October 2017 19 - Antimicrobial Policy for Adults The Rotherham NHS Foundation Trust Barnsley Hospital NHS Foundation Trust
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The Rotherham NHS Foundation Trust
Barnsley Hospital NHS Foundation Trust
Antimicrobial Policy
for Adults
Do not use antimicrobials unless absolutely essential
October 2017 19
Penicillin Allergy
Allergy Status [1]
• Always ask for a description of the reaction experienced.
• Document in notes and on the medicine chart: The Name of medicine,
the signs, symptoms and severity of the reaction, and the date when the
reaction occurred
• If there are no allergies document "None Known"
• If allergy status is not known document "Allergy status unconfirmed".
Action must be taken to confirm the allergy status by the end of the
following day.
• Diarrhoea is a results of change in bowel flora and not an allergic reaction
PENICILLIN ALLERGY Do not use any Beta-lactams
Penicillins Cephalosporins
LIFE-THREATENING Amoxicillin Cefalexin
IMMEDIATE Benzylpenicillin Cefotaxime
eg anaphylaxis Co-amoxiclav Ceftazidime
Co-fluampicil Ceftriaxone
angioedema Flucloxacillin Cefuroxime
urticaria HeliClear®
(contains amoxicillin, for H pylori eradication)
rash – florid, blotchy
Temocillin
Penicillin V
Piperacillin with Tazobactam
Carbapenems
Imipenem
Meropenem
PENICILLIN ALLERGY Use with caution cephalosporins,
carbapenems and monobactams
NOT LIFE-THREATENING Cross-reactivity in 10% of patients allergic
DELAYED to penicillin
eg simple rash
Cephalosporins Carbapenems
- non confluent, Cefalexin Imipenem
- non pruritic Cefotaxime Meropenem
- restricted to small area Ceftazidime
Ceftriaxone
Cefuroxime
PENICILLIN ALLERGY Safe to use
Amikacin Gentamicin
ALL TYPES Azithromycin Metronidazole
Aztreonam* Nitrofurantoin
Ciprofloxacin Ofloxacin
Clarithromycin Sodium fusidate
*Aztreonam may be less Clindamycin Teicoplanin
likely than other beta lactams Colomycin Tetracycline
to cause hypersensitivity in Co-trimoxazole Tigecycline
penicillin sensitive patients. Daptomycin Tobramycin
Microbiology may advise Doxycycline Trimethoprim
but do not use where there is a Erythromycin Vancomycin
history of ceftazidime allergy. [2] Fosfomycin
For antibiotics not listed or for further information, please contact:
Barnsley Rotherham
Ward Clinical pharmacist Bleep Bleep
Microbiologist 2749, 4986 4742, 7712
Medicines Information 2857 4126
Antimicrobial Policy for Adults 2017 19 Page 3
Table of contents
ANTIMICROBIAL TREATMENT
ABBREVIATIONS 5
INTRODUCTION 6
PRINCIPLES OF ANTIMICROBIAL PRESCRIBING 7
EARLY WARNING SCORE CHARTS 8-9
ESSENTIAL FACTS 10
PRESCRIBING ON THE DRUG CHART 10
ADVICE/SBAR REPORTING 10
ANTIMICROBIAL USE AND RESTRICTIONS 11
APPROPRIATE USE OF IV AND ORAL ANTIMICROBIALS 12
RESPIRATORY TRACT INFECTIONS 14
COMMUNITY–ACQUIRED 14
HOSPITAL–ACQUIRED PNEUMONIA 16
CHRONIC LUNG DISEASE 17
MYCOBACTERIAL 17
URINARY TRACT INFECTIONS 18-19
SEPTICAEMIA 20
COMMUNITY–ACQUIRED 20
HOSPITAL–ACQUIRED 20
INFECTIVE ENDOCARDITIS 21
EMPIRICAL (Organism not known) 21
TARGETED (Organism known) 22-24
CENTRAL NERVOUS SYSTEM 25
MENINGITIS 25
ENCEPHALITIS 25
BRAIN ABSCESS 25
SKIN AND SOFT TISSUE INFECTIONS 26
BACTERIAL 26-27
SURGICAL SITE INFECTION 28
DERMATOPHYTE 29
CANDIDA 29
VIRAL 30
ARTHROPOD INFESTATIONS 30
DIABETIC FOOT ULCER 31-32
BONE AND JOINT INFECTIONS 33
ENT INFECTIONS 34
ORAL AND MAXILLOFACIAL INFECTIONS 35
EYE INFECTIONS 35
OBSTETRIC AND GYNAECOLOGICAL INFECTIONS 36
SEXUALLY TRANSMITTED INFECTIONS 37-38
HAEMATOLOGICAL INFECTIONS 39
Page 4 Antimicrobial Policy for Adults 2017 19
GASTROINTESTINAL INFECTIONS 40-41
C.DIFFICILE ASSOCIATED DIARRHOEA 42
MRSA DECOLONISATION AND FOLLOW UP OF PATIENTS 43
ANTIMICROBIAL PROPHYLAXIS
SURGICAL PROPHYLAXIS 44
PRINCIPLES OF SURGICAL PROPHYLAXIS 44
HEAD AND NECK - INTRACRANIAL 45
HEAD AND NECK 45
FACIAL 46
EAR, NOSE AND THROAT 47
OPHTHALMOLOGY 47
THORAX 48
HEPATOBILIARY 48
LOWER GASTROINTESTINAL 49
ABDOMEN 49
SPLEEN 49
GI ENDOSCOPY AND PEG PROPHYLAXIS 50
GYNAECOLOGICAL 52
UROLOGY 53
LIMB 54
MEDICAL PROPHYLAXIS 55
MENINGOCOCCAL DISEASE / MENINGITIS CONTACTS 55
HAEMOPHILUS INFLUENZAE TYPE b CONTACTS 55
PREVENTION OF PNEUMOCOCCAL INFECTIONS
(ASPLENIC PATIENTS & SICKLE CELL DISEASE) 55
TUBERCULOSIS PROPHYLAXIS 55
PROPHYLAXIS AGAINST ENDOCARDITIS 56
REFERENCES 57
APPENDICES 61
Therapeutic Drug Monitoring 61
APPENDIX A Gentamicin High Dose Regimen 62
APPENDIX B Gentamicin Conventional Dose Regimen 64
APPENDIX C Amikacin 65
APPENDIX D Tobramycin 66
APPENDIX E Teicoplanin 67
APPENDIX F Vancomycin 70
APPENDIX G Splenectomy Guidelines 71
APPENDIX H Doses in renal impairment 73
APPENDIX I Types of Antimicrobials 76
CONTACT NUMBERS and AUTHORS 77
CONTACTING MICROBIOLOGIST 78
SEPSIS SIX CHECKLIST 79
Copyright © 2017 Barnsley Hospital NHS Foundation Trust
Copyright © 2017 The Rotherham NHS Foundation Trust
Antimicrobial Policy for Adults 2017 19 Page 5
ABBREVIATIONS
BASHH British Association of Sexual Health and HIV
bd twice daily
BSAC British Society for Antimicrobial Chemotherapy
BTS British Thoracic Society
CCDC Consultant in Communicable Disease Control
CDI Clostridium difficile infection
CMV Cytomegalovirus
CRP C Reactive protein
CSF Cerebrospinal fluid
CSU Catheter specimen urine
ERCP Endoscopic retrograde colangiopancreatography
ESBL Extended Spectrum Beta Lactamase
FBC Full blood count
HACEK Haemophilus species, Actinobacillus actinomycetemcomitans,
Cardiobacterium hominis, Eikenella corrodens and Kingella species
HDU High dependancy unit
HIV Human immunodeficiency virus
HPA Health Protection Agency
HSV Herpes simplex virus
i/m Intramuscular
ITU Intensive therapy unit
i/v Intravenous
kg kilogram
mg milligram
mL millilitre
m/r Modified release
MRSA Meticillin Resistant Staphylococcus Aureus
MSU Mid stream urine
NICE National Institute for Health and Clinical Excellence
od once daily
P alternative in penicillin allergy
PEG Percutaneous endoscopic gastrostomy
PHE Public Health England
PID Pelvic inflammatory disease
PR per rectum
p/v per vaginum
qds four times daily
SBP Spontaneous bacterial peritonitis
SIGN Scottish Intercollegiate Guidelines Network
STI Sexually transmitted infections
tds three times daily
U&E Urea and electrolytes
UTI Urinary tract infection
VZV Varicella-zoster virus
WCC White cell countPage 6 Antimicrobial Policy for Adults 2017 19
Antimicrobial Policy ANTIMICROBIAL RESISTANCE-
(The Path of Least Resistance)
There is a growing national and international concern
Introduction about the increasing resistance of micro-organisms to
antimicrobial agents (House of Lords Select Committee
The aim of these guidelines is to optimise antimicrobial on Science and Technology, Standing Medical Advisory
prescribing within both The Rotherham NHS Committee 1998).[7] This resistance is an inevitable
Foundation Trust and Barnsley Hospital NHS Foundation consequence of antimicrobial use by Darwinian
Trust. Antimicrobials are over-prescribed in many health selection pressure. Resistance makes infections more
institutions and both these hospitals are not exempt. difficult, and often more expensive to treat and may
These guidelines would not only attempt to provide the increase complications and length of hospital stay. The
best quality of care to manage patients with infections Chief Medical Officer has highlighted the importance
but also to reduce microbial resistance, healthcare of prudent use of antimicrobials, i.e. appropriate choice,
associated infections and overall cost. The prudent use dose and duration of antimicrobial therapy in his report
of antimicrobials in order to minimise the emergence of “Winning Ways” (December 2003).[4]
resistance has also been emphasised by the House of In general, the more broad-spectrum antimicrobials
Lords and Department of Health (1998). [3] are more likely to be associated with the emergence
of resistance and health care associated infections
The Chief Medical Officer in his report “Winning Ways” including Clostridium difficile. Furthermore some of the
(December 2003) [4] has set out a clear direction on less broad-spectrum antimicrobials such as ciprofloxacin
the actions required to reduce the level of healthcare can select for emergence of MRSA
associated infections and to curb the proliferation
of antimicrobial-resistant organisms. Furthermore,
antimicrobial usage has also been addressed in some
of the domains of the Saving Lives Toolkit [5] and
ANTIMICROBIAL ASSOCIATED
more recently the Infection Control Code of Practice DIARRHOEA
(September 2006) [6] has set standards for appropriate
antimicrobial prescribing. Antimicrobial usage particularly the more broad-
spectrum ones may lead to diarrhoea and Clostridium
difficile colitis.
The aim of both hospitals is therefore not to use
the more broad-spectrum antimicrobials such
as cephalosporins – ceftriaxone/cefotaxime and
carbepenems and minimise the use of cefuroxime
particularly in Elderly patients.Antimicrobial Policy for Adults 2017 19 Page 7
PRINCIPLES OF
ANTIMICROBIAL PRESCRIBING
Before prescribing antimicrobials, consider the
following 10 points:
1. Do not start antimicrobial therapy unless there is
clear evidence of infection
2. Take a thorough drug allergy history
3. Initiate prompt effective antibiotic treatment
within ONE hour of diagnosis (or as soon as
possible) in patients with severe sepsis or life
threatening infections.
4. Avoid inappropriate use of broad spectrum
antibiotics.
5. Obtain culture prior to commencing therapy where
possible (but do not delay therapy)
6. Check for previous microbiology results and history
of MRSA/ESBL/CPE/ Clostridium difficile
7. Comply with local antimicrobial prescribing
guidance
8. Document clinical indication (and disease severity
if appropriate), drug name, dose and route on drug
card and in clinical notes *
9. Include a review/stop date or duration on the
prescription
10. Document the exact indication on the drug chart
(rather than stating long term prophylaxis) for
clinical prophylaxis
* Based on Start Smart then Focus - Antimicrobial
Stewardship Toolkit for English Hospitals updated
March 2015 [8]Page 8 Antimicrobial Policy for Adults 2017 19 Early warning score chart Barnsley
Antimicrobial Policy for Adults 2017 19 Page 9 Early warning score chart Rotherham
Page 10 Antimicrobial Policy for Adults 2017 19
ESSENTIAL FACTS ADVICE
• Encourage oral antimicrobials whenever possible. Advice can always be obtained from the Department
of Medical Microbiology. There is a 24 hour and 7 day
• Use IV antimicrobials only in serious infections or
service, both technical and clinical, available for the
when patients are unable to take oral medication.
investigation, treatment, and prevention of infections.
• After 48-72 hrs of IV therapy review the patient Pharmacists may be contacted for dosage, therapeutic
and consider switching to oral medication. drug monitoring and medicines information.
• Generally a total of 5 days of antimicrobial therapy
Before contacting for advice:
should suffice for uncomplicated infections.
• Assess the patient
• Review antimicrobials and clinical progress on • Know the admitting diagnosis
a daily basis in the light of current microbiology • Read the most recent medical and nursing notes
results. • Have appropriate documents available eg Nursing
• Once the aetiological agent is identified, switch and Medical Records, PAR (Patient at risk), MEWS/
the broad spectrum therapy to a targeted narrow NEWS (early warning charts), Prescription Charts,
spectrum agent. Allergies, IV fluids, Resuscitation status
• Communicate using the SBAR Reporting Tool.
SBAR Reporting Tool
PRESCRIBING ON THE Source: Springfield hospital, Springfield, Vermont
DRUG CHART Situation
• State your name and unit/ward
• Check for genuine allergy • I am calling about patient’s name and age
• Check for history of Clostridium difficile diarrhoea, • The reason I am calling is…
CPE, ESBL producing, MRSA and other resistant
organisms Background
• Document • State the admission diagnosis/working diagnosis and
• Duration or review date date of admission
• Indication • Relevant medical history including family history;
• The CODE for Restricted Antimicrobials in the underlying condition/ co morbidities
section ‘Additional Instructions’ • A brief summary of treatment to date;
current antimicrobial therapy and duration;
recent antimicrobial use (within the last month if
ADHERENCE TO THE POLICY possible)
• History of C.difficile diarrhoea / CPE / ESBL / MRSA /
This will be monitored on a daily basis on the wards and
other resistant organisms
as a rolling programme of audits by the directorates,
• Previous microbiology results
microbiology and the pharmacy departments, as
• Infective markers
recommended by Infection Control Code of Practice, [6]
• Travel history
NICE Guideline 15 :antimicrobial stewardship : systems
and processes for effective antimicrobial medicine use
Assessment
[9] 'Saving Lives’ [10] and 'Start Smart Then Focus' [8]
State your assessment of the patient
• Allergies
• Renal function
• Hepatic function
Recommendations/Actions
• I would like (state what you would like to see done)
• Determine timescale
• Is there anything else I should do?
• Record name and phone or bleep number of contact
• Patient concerns, expectations and wishes
Don’t forget to document the call!Antimicrobial Policy for Adults 2017 19 Page 11
Antimicrobial use and restrictions
Please contact Consultant Microbiologist when considering protected (red and yellow) antimicrobials.
Antimicrobials Permitted Indications
Amikacin iv
Red -
Amoxicillin oral iv Code required
Amphotericin iv at all times, unless
Azithromycin oral for permitted
indications.
Aztreonam iv Aspiration pneumonia (page 16), biliary infections (page 40), hospital acquired sepsis (page 20),
pyelonephritis (page 19) Surgical prophylaxis (GI endoscopy page 50) See relevant page
Benzylpenicillin iv for further details
Caspofungin iv
Cefalexin oral UTI in pregnancy (page 18) Yellow -
Code required
Cefotaxime iv Bacterial meningitis, brain abscess (page 25), encephalitis (page 25) endocarditis (page 24)
within 48
Ceftazidime iv hours unless
Ceftriaxone iv Epididymo-orchitis (page 38), haemophilus influenzae type b contacts (page 55), meningitis contacts (page for permitted
im 55), PID (page 36) uncomplicated gonorrhoea (page 37)
indication.
Cefuroxime iv Community acquired pneumonia (page 14), community acquired sepsis (page 20), oral and maxillofacial see relevant page
surgery infections (page 35), pyelonephritis (page 19), surgical prophylaxis
(pages 45, 47, 52, 53 )
for further details
Chloramphenicol oral iv Bacterial meningitis (page 25), ophthalmic preparations (page 35 and 47)
Ciprofloxacin oral iv biliary infections (page 40), bites (page 27), enteric fever (page 40), epididymo-orchitis (page 19), gonorrhoea Green -
(page 37), haematology (page 39), meningitis contacts (page 55), necrotising fasciitis (page 27), obstetrics No Code needed
and gynaecology post op sepsis (page 36), pneumonia (page 14), prostatitis (page 19), pyelonephritis (page Prescribing
19) SBP, (page 41), surgical prophylaxis (pages 50, 51, 53),
permitted
Clarithromycin oral iv
according to the
Clindamycin oral iv Bites (page 27), maxillofacial surgery infections (page 35), necrotising fasciitis (page 27), obstetrics and
gynaecology post op sepsis (page 36) periorbital cellulitis (page 35) quinsy
Antimicrobial
(page 34) oral and surgical prophylaxis (pages 45, 46, 47, 52) Policy
Co-amoxiclav oral iv
Co-trimoxazole oral iv
Dalbavancin iv
Documentation:
Daptomycin iv
Doxycycline oral
Health care record
Ertapenem iv Document microbiologist
Erythromycin oral iv advice
• The CODE
Ethambutol oral
• Review or stop
Flucloxacillin oral iv
date
Fluconazole oral iv
Medicines Chart
Fosfomycin Antimicrobial, route,
Fusidic acid oral Osteomyelitis and septic arthritis (page 33) dose, dose times plus
Sodium fusidate • The CODE
Gentamicin iv • Indication
Isoniazid oral • Review or stop
Levofloxacin oral Weston park patients only
date
Linezolid oral iv
Meropenem iv Endocarditis (page 21) Haematology (page 39)
Metronidazole oral
Nitrofurantoin oral
Ofloxacin oral
Penicillin V oral
Pivmecillinam oral
Piperacillin/ iv Hospital acquired pneumonia (page 16) Sepsis (page 20) Cellulitis (page 26) necrotising fasciitis (page 27) diabetic
tazobactam foot ulcer (page 32) Neutropenic Sepsis (page 39) Surgical prophylaxis (page 51)
Septic arthritis (page 33)
Pyrazinamide oral
Rifampicin oral iv Legionella pneumonia, post influenza/ staphyloccal pneumonia (page 15) tuberculosis (page 18) endocarditis (page 21
and 23) meningitis contacts and Haemophilus (page 55)
Teicoplanin iv Pneumonia (pages 15, 16) Sepsis (MRSA page 20) Cellulitis (page 26) Necrotising fasciitis and Infected leg ulcers (page
27) Surgical site infection (page 28) Diabetic foot (page 32) Osteomyelitis and septic arthritis (page 33) Neutropenic
Sepsis (page 39) Surgical prophylaxis (pages 45, 46, 47, 48, 49, 50, 51, 52 and 54)
Temocillin iv
Tigecycline iv
Tobramycin iv nebulised
Trimethoprim oral
Vancomycin Oral oral
(for C Diffiicle)
Vancomycin iv Endocarditis (page 21 and 23)
Voriconazole ivPage 12 Antimicrobial Policy for Adults 2017 19
GUIDELINE FOR THE APPROPRIATE USE OF INTRAVENOUS AND
ORAL ANTIMICROBIALS FOR ADULTS
Most patients DO NOT require i/v antibiotics. The majority of those who do will only need for 48-72 hours
INDICATIONS FOR IV ANTIBIOTICS
If sepsis is suspected refer to Sepsis Six checklist on page 79
1. Sepsis (2 or more of the following)
- temperature >38o C or 90 beats/min
- respiratory rate >20 breaths/min
- WCC >12 x 10 9/L orSTART SMART GUIDANCE [8] GUIDANCE ON GOOD CLINICAL
ANTIMICROBIAL PRESCRIBING
Right drug, Right dose, Right time, Right duration...
Every patient
Clinical review
Then focus and decision at
START SMART
48 to 72 hours
Clinical review, check
• Take history of relevant allergies microbiology, make a
• Initiate prompt effective antibiotic clear plan and
treatment within one hour of diagnosis
document decision
(or as soon as possible) in patients
with severe sepsis or life threatening
infections
• Comply with local prescribing guidance
• Document clinical indication and 1. STOP 2. I/V oral switch 3. Change 4. continue 5. Community
disease severity if appropriate, dose and IV therapy
route on drug chart and in clinical notes
Antimicrobial Policy for Adults 2017 19
• Include review/stop date or duration
• Obtain cultures prior to commencing
therapy where possible (but do not
delay therapy)
• Check previous microbiology results Document all decisions
including alert organisms
Page 13
Adapted from Start Smart then Focus -
Antimicrobial Stewardship toolkit for English hospitals [8]Page 14 Antimicrobial Policy for Adults 2017 19
RESPIRATORY TRACT INFECTIONS - Community-acquired
IMPORTANT Before prescribing antimicrobials
• History of C.difficile diarrhoea / CPE / ESBL / MRSA / Take appropriate samples
other resistant organisms – contact Microbiologist • Sputum in all cases if possible
• Check for previous microbiology results • Blood culture in severe
• Treatment duration (i/v or oral) 5 days unless specified pneumonia
• Sepsis – start antibiotics within an hour of diagnosis. Prescribe in STAT section of • Urine Legionella and
drug chart. Refer to Sepsis Six checklist on page 79 pneumococcal antigen in
• Consider referral to vascular access team if patient is suitable for moderate to severe infection
community IV pathway.
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Pneumonia [16, 17]
Streptococcus Review microbiology
pneumoniae
Definition: sign and syptoms of Send acute and convalescent
lower respiratory tract infection Mycoplasma sera for atypical serology
and radiological evidence of pneumoniae
consolidation on chest X-ray
Haemophilus
influenzae
Assess severity*
If low to moderate severity and Chlamydia sp.
no consolidation on chest x-ray
consider using empirical sepsis Legionella sp.
guidance on page 20
Start antibiotics within 4 hours of
presentation
Low severity Amoxicillin oral P Penicillin allergy:
CURB65 score 0-1 500 mg – 1 g tds for 5 days
If treated with Amoxicillin prior Doxycycline oral
200mg stat then 100- 200mg od
to admission or
Clarithromycin oral Clarithromycin oral or i/v
500 mg bd for 5 days 500 mg bd
Moderate severity Start antibiotics immediately Send blood cultures and sputum
CURB65 score 2 Amoxicillin oral
500 mg – 1 g tds P Penicillin allergy:
plus Omit Amoxicillin
Clarithromycin oral
500 mg bd Total duration 5 days
Give i/v if needed
High severity Start antibiotics immediately: P Penicillin allergy
CURB65 score 3-5 Co-amoxiclav i/v 1.2g tds plus Non-life threatening and less than
Clarithromycin i/v 500mg bd 65 years old
Cefuroxime i/v
*CURB65 score
De-escalate in view of sputum and/or 1.5 g tds
1 point for each blood culture results plus
Confusion Clarithromycin i/v
Urea >7 mmol/L 500 mg bd
Respiratory rate ≥ 30 / min Life threatening or older than
Blood pressure: 65 years old
Systolic < 90 mmHg Teicoplanin i/v
Diastolic ≤ 60 mmHg 6mg/kg (appendix Ei)
Age ≥ 65 years plus
Ciprofloxacin i/v 400mg bd
Micro code is required the
following day
Pneumonia continued overleaf
Total duration 7-10 daysAntimicrobial Policy for Adults 2017 19 Page 15
RESPIRATORY TRACT INFECTIONS - Community-acquired
IMPORTANT Before prescribing antimicrobials
• History of MRSA/ ESBL/ Clostridium difficile – contact Microbiologist Take appropriate samples
• Check for previous microbiology results • Sputum in all cases if possible
• Treatment duration (i/v or oral) 5 days unless specified • Blood culture in severe
• Sepsis – start antibiotics within an hour of diagnosis. Prescribe in STAT section of drug chart pneumonia
Refer to Sepsis Six checklist on page 79
• Consider referral to vascular access team if patient is suitable for
community IV pathway.
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Pneumonia, continued Confirmed Benzylpenicillin i/v P Penicillin allergy:
Streptococcus 1.2 g qds discuss with Microbiologist
pneumoniae
Confirmed MRSA Teicoplanin i/v
6mg/kg (appendix Ei)
addition of sodium fusidate or
rifampicin may be advised by
microbiologist
Duration: as advised by
Microbiologist
Primary Atypical Mycoplasma Clarithromycin oral Take appropriate samples,
Pneumonia pneumoniae*/** 500 mg bd including samples for serology
i/v If severe vomiting and urine antigen for Legionella
[16, 17] Chlamydia
pneumoniae*/**
Chlamydia Doxycycline oral *Infection control procedures
psittaci** 200 mg first dose then 100 mg bd should be undertaken
for 14 days
**Locally notifiable disease
Coxiella Tetracycline is the drug of choice. to PHE (Public Health England)
burnetti*/** Seek advice from Consultant
Microbiologist
Legionella Clarithromycin i/v
pneumophila** 500 mg bd
Rifampicin or
Ciprofloxacin may need to be Duration at least 2 weeks
added in severe cases
Discuss with microbiologist
Post-Influenza / Confirmed Flucloxacillin i/v P Penicillin allergy:
Staphylococcus aureus Staphylococcus 2g qds Teicoplanin i/v
Pneumonia aureus plus 6mg/kg (appendix Ei - pg 68)
Rifampicin oral initially plus
600mg bd Rifampicin oral initially
[13] Give i/v if needed 600mg bd
Give i/v if needed
Total duration 2-3 weeksPage 16 Antimicrobial Policy for Adults 2017 19
RESPIRATORY TRACT INFECTIONS - Hospital-acquired pneumonia
IMPORTANT Before prescribing antimicrobials
• History of C.difficile diarrhoea / CPE / ESBL / MRSA / Take appropriate samples
other resistant organisms – contact Microbiologist • Sputum in all cases if possible
• Check for previous microbiology results • Blood cultures
• Treatment duration (i/v or oral) 5 days unless specified
• Sepsis – start antibiotics within an hour of diagnosis. Prescribe in STAT section
of drug chart. Refer to Sepsis Six checklist on page 79
Hospital acquired Pneumonia:
Definition – Pneumonia occurring > 48 hr after admission and excluding any infection that is incubating at the time of admission.
Diagnosis of HAP is difficult. Following Criteria will help in identifying patients in whom pneumonia should be considered.
1. Purulent sputum
2. Increased oxygen requirement
3. Temperature
4. WCC >10 x 10 9/L orAntimicrobial Policy for Adults 2017 19 Page 17
CHRONIC LUNG DISEASE
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Infective exacerbation of Viruses 80% Doxycycline oral Tetracycline allergy or
chronic obstructive pulmonary Streptococcus 200mg first dose then contraindicated:
disease pneumoniae 100-200mg od for 5days Amoxicillin oral
500mg tds for 5 days
Haemophilus If failed on doxycycline
influenzae therapy
dyspnoea Amoxicillin oral
purulence Moraxella 500mg to 1g tds
catarrhalis If patient fails to respond to therapy
sputum volume then discuss with microbiology To review on day 5 – longer
treatment may be required in
(18) some circumstances e.g. until
sputum becomes mucoid for at
least 24 hours
Bronchietasis Haemophilus Check previous Microbiology and take Seek advice from Microbiologist
influenzae a sputum sample before prescribing any
Infections in chronic lung diseases Staphylococcus antibiotic.
are treated with broad spectrum Pseudomonas spp
antibiotics for a prolonged Duration 7 days for initial treatment
duration. the resulting collateral subsequent therapy as guided by
damage of this practice must Microbiology
be appreciated and taken into
consideration when deciding the
type and duration of antimicrobial
agent.
(19)
References
Chronic obstructive pulmonary disease in over 16s: diagnosis and management NICE guidelines [CG101]
Published date: June 2010
The British Thoracic Society Bronchiectasis (non-CF) guideline group (2010) Guideline for non - CF Branchiectasis Thorax
65 (i) 1-58
RESPIRATORY TRACT INFECTIONS - Mycobacterial
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Tuberculosis Mycobacterium Doses based on patient weight Please refer to TB policy
tuberculosis
[20] First 2 months of quadruple therapy Infection control risk –
Mycobacterium either Rifater® oral for appropriate isolation and
bovis (combination of isoniazid, rifampicin infection control precautions
and pyrazinamide)
Mycobacterium plus Refer to Consultant Chest
africanum Ethambutol oral Physician and Infection Control
or Team
Voractiv®
(Combination of isoniazid, rifampicin,
pyrazinamide and ethambutol)
Followed by 4 months of double
therapy Notify Public Health Doctor
Rifinah® oral
(combination of isoniazid and
rifampicin)
Atypical Mycobacterial Mycobacterium Consult Microbiology for susceptibility Seek advice from Consultant
Infection avium intracellulare details Microbiologist and Chest
Physician
Mycobacterium
kansasii No need for isolation or
notification
Mycobacterium
malmoense etc.Page 18 Antimicrobial Policy for Adults 2017 19
URINARY TRACT INFECTIONS [12,13,21]
IMPORTANT Before prescribing antimicrobials
• History of CPE/MRSA/ ESBL/ Clostridium difficile – contact Microbiologist Take appropriate samples
• Check for previous microbiology results • MSU for culture and
sensitivities
• Sepsis – start antibiotics within an hour of diagnosis. Prescribe in STAT section of drug chart
Refer to Sepsis Six checklist on page 79
Lower UTI
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Women (non pregnant) E coli 1st line >85% of coliforms sensitive to
Simple cystitis Klebsiella sp. *Nitrofurantoin oral nitrofurantoin.
(No fever, no loin pain) Proteus sp. 50 to 100 mg 6 hourly for 3 days 70% sensitive to trimethoprim
Enterococci
MRSA 2nd line Send MSU for culture and
Trimethoprim oral sensitivities
200 mg bd for 3 days
*Avoid in renal impairment
(eGFRAntimicrobial Policy for Adults 2017 19 Page 19
URINARY TRACT INFECTIONS [12,13,21]
IMPORTANT Before prescribing antimicrobials
• History of CPE/MRSA/ ESBL/ Clostridium difficile – contact Microbiologist Take appropriate samples
• Check for previous microbiology results • MSU for culture and
sensitivities
• Sepsis – start antibiotics within an hour of diagnosis. Prescribe in STAT section of drug chart
Refer to Sepsis Six checklist on page 79
Upper UTI
Pyelonephritis E coli and other If less than 50 years of age Pregnancy
Loin pain/fever Gram negative Ciprofloxacin oral Cefuroxime i/v 1.5g tds
organisms 500 mg bd
predominantly i/v if needed 400 mg bd P Penicillin allergy >50 years
of age
If older than 50 years of age
Co-amoxiclav oral 625mg tds or Aztreonam i/v
1.2g i/v tds. 1g tds
If life threatening sepsis If life threatening sepsis
Consider adding single dose consider adding single
**Gentamicin i/v dose **Gentamicin i/v
High Dose (Appendix A) High Dose (Appendix A) and then
and then review review
Aztreonam - caution in
Total duration 10 – 14 days Ceftazidime allergy
Review treatment in light of cultures Caution
and sensitivities CIPROFLOXACIN ENCOURAGES
THE EMERGENCE OF MRSA
AND C. difficile
**Gentamicin levels:
(Appendix A)
Complicated UTI E coli and other Seek advice from Microbiologist please check previous
Renal calculi Gram negative microbiology
Urinary catheter organisms
Urological abnormality predominantly
Recurrent UTI
Surgery etc.
Prostatitis E coli and other 1st line Seek advice from Consultant
Gram negative Ciprofloxacin oral Microbiologist and Urologist
organisms 500 mg bd for 4 weeks
predominantly (i/v 200 – 400 mg bd Refer to Urologist for advice on
if needed) specimen collection
2nd line Caution
Trimethoprim oral 200mg bd CIPROFLOXACIN ENCOURAGES
for 4 weeks THE EMERGENCE OF MRSA
AND C. difficile
Epididymo-orchitis Ciprofloxacin oral
Urinary source 500 mg bd 10 days
If STI suspected refer to page 38Page 20 Antimicrobial Policy for Adults 2017 19
SEPSIS [22]
• It is important to establish the primary source of septicaemia in order to shed light on the most
probable organisms and the underlying pathology.
• Blood culture should be taken BEFORE commencing antimicrobial therapy.
• Sepsis – start antibiotics within an hour of diagnosis. Prescribe in STAT section of drug chart and inform nursing staff
Refer to Sepsis Six checklist on page 79
IMPORTANT Before prescribing antimicrobials
• History of CPE/MRSA/ ESBL/ C.difficile – contact Microbiologist Take appropriate samples
• Check for previous microbiology results • Blood cultures
• Normally treatment duration (iv or oral) 5 days unless specified • Urine
• Sputum
Community-acquired
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Source unknown Empirical *Co-amoxiclav i/v Take appropriate samples
1.2 g tds
Review treatment in light of If severe add P Penicillin allergy:
cultures and sensitivities Metronidazole i/v Non-life threatening:
500 mg tds Cefuroxime i/v 1.5 g tds
UTI is the commonest cause
*If Co-amoxiclav used in the past Life threatening and Elderly:
4 weeks Teicoplanin i/v
Piperacillin/tazobactam i/v 6mg/kg (appendix Ei - pg 68)
4.5 g tds plus
Ciprofloxacin oral
500 mg bd
If life threatening sepsis i/v if needed 400 mg bd
Consider adding single dose
**Gentamicin i/v If severe add
High Dose (Appendix A) Metronidazole i/v
and then review 500 mg tds
If MRSA or line infection add If life threatening sepsis
Teicoplanin i/v Consider adding single dose
6mg/kg (appendix Ei - pg 68) **Gentamicin i/v
High Dose (Appendix A)
and then review
**Gentamicin levels:
(Appendix A)
Hospital-acquired
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Source unknown Wide range of Piperacillin–tazobactam i/v P Penicillin allergy:
hospital organisms 4.5 g tds Non-life threatening:
Teicoplanin i/v
If life threatening sepsis 6mg/kg (appendix Ei - pg 68)
Consider adding single dose Aztreonam i/v 1-2g tds
**Gentamicin i/v Aztreonam - caution in
High Dose (Appendix A) Ceftazidime allergy
and then review
If life threatening sepsis
Consider adding single dose
If MRSA or line infection add
**Gentamicin i/v
Teicoplanin i/v
6mg/kg (appendix Ei - pg 68) High Dose (Appendix A)
and then review
Life threatening allergy
or If previously grown resistant
organism (ESBL, AmpC) contact
microbiologist
**Gentamicin levels:
(Appendix A)Antimicrobial Policy for Adults 2017 19 Page 21
INFECTIVE ENDOCARDITIS – Empirical (Organism not known) [23]
• Discuss treatment with Consultant Cardiologist and Microbiologist
IMPORTANT • History of CPE/MRSA/ ESBL/ C.difficile – contact Take appropriate samples
Before prescribing Microbiologist THREE sets of blood cultures from
antimicrobials • Check for previous microbiology results different sites and at different times
• Modify as soon as culture and sensitivities are available PRIOR to antimicrobial therapy
• Consider referral to vascular access team
if patient is suitable for community IV pathway
IMPORTANT Gentamicin & Vancomycin
• Review treatment every 3 days
Therapeutic drug • Renal impairment – discuss with Microbiologist
monitoring • Discuss duration with Microbiologist
• Monitor blood levels (Appendices B & F)
• Inform patient of potential side effects
• Monitor renal function 3 times a week (hearing, balance and renal impairment)
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Native valve Empirical Flucloxacillin i/v Treatment should be started
Acute presentation 2g 4-6 hourly (i.e. 8 to 12g daily) as soon as blood cultures are
Use 4 hourly regimen if weight is collected for acute presentation
greater than 85kg
plus P Penicillin allergy:
*Gentamicin i/v see below
80 mg 12 hourly
Modify according to culture and
Native valve Empirical Amoxicillin i/v sensitivities. If negative contact
Indolent (Subacute) 2g 4 hourly Consultant Cardiologist and
presentation Microbiologist
A second agent may be required
please discuss with microbiology. *Gentamicin levels:
Pre dose (trough):Page 22 Antimicrobial Policy for Adults 2017 19
ENDOCARDITIS – Targeted (Organism known) [23]
Discuss treatment with Consultant Cardiologist and Microbiologist
IMPORTANT • History of CPE/MRSA/ ESBL/ C.difficile – contact Take appropriate samples
Before prescribing Microbiologist THREE sets of blood cultures from
antimicrobials • Treatment duration depends on the organism and patient different sites and at different times
factors. Must be discussed with Microbiologist/Cardiologist PRIOR to antimicrobial therapy
• Consider referral to vascular access team if patient
is suitable for community IV pathway
IMPORTANT Gentamicin & Vancomycin
Therapeutic drug • Renal impairment – discuss with Microbiologist • Inform patient of potential side effects
monitoring • Monitor blood levels (Appendices B & F) (hearing, balance and renal impairment)
• Monitor renal function 3 times a week • Discuss with Microbiologist before
• Review treatment every 3 days continuing for longer than 2 weeks
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Native valve endocarditis Viridans Commence with P Penicillin allergy:
Streptococcal Endocarditis Streptococci Benzylpenicillin i/v Consult Microbiologist
Streptococcus bovis 2.4 g 4 hourly
(six times a day) *In patients with renal
plus impairment antibiotic dose
*Gentamicin i/v needs to be modified
80 mg 12 hourly
*Gentamicin levels
Pre dose (trough):Antimicrobial Policy for Adults 2017 19 Page 23
ENDOCARDITIS – Treatment of known organisms (Continued) [23]
Discuss treatment with Consultant Cardiologist and Microbiologist
IMPORTANT • History of CPE/MRSA/ ESBL/ C.difficile – contact Take appropriate samples
Before prescribing Microbiologist THREE sets of blood cultures from
antimicrobials • Check for previous microbiology results different sites and at different times
• Treatment duration depends on the organism and patient PRIOR to antimicrobial therapy
factors. Must be discussed with Microbiologist/Cardiologist
• Consider referral to vascular access team if patient
is suitable for community IV pathway
IMPORTANT Gentamicin & Vancomycin
Therapeutic drug • Renal impairment – discuss with Microbiologist • Inform patient of potential side effects
monitoring • Monitor blood levels (Appendices B & F) (hearing, balance and renal impairment)
• Monitor renal function 3 times a week • Discuss with Microbiologist before
• Review treatment every 3 days continuing for longer than 2 weeks
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Native Valve Staphylococcus Flucloxacillin i/v Discuss with Microbiologist for
Staphylococcus aureus aureus 2 g every 4- 6 hours for additional antimicrobials
endocarditis 4-6 weeks
use 4 hourly regime if weight is P Penicillin allergy: see below
greater than 85kg
P Penicillin allergy *Vancomycin i/v *Vancomycin dose needs to be
or 1 g 12 hourly adjusted according to the renal
MRSA endocarditis MRSA plus function
Rifampicin oral
300-600 mg bd Discuss with Microbiologist
use lower dose if creatinine clearance
is less than 30mL/min *Vancomycin levels:
Duration at least 6 weeks -consult Pre dose (trough) 15–20 mg/L
Microbiologist (Appendix F)
Intracardiac prosthesis Staphylococcus tFlucloxacillin i/v Discuss with Consultant
Staphylococcus aureus aureus 2 g every 4- 6 hours for Cardiologist and Microbiologist
endocarditis plus
ttRifampicin oral
300-600 mg 12 hourly **Gentamicin levels:
plus Pre dose (trough):Page 24 Antimicrobial Policy for Adults 2017 19
ENDOCARDITIS – Treatment of known organisms (Continued) [23]
Discuss treatment with Consultant Cardiologist and Microbiologist
IMPORTANT • History of CPE/MRSA/ ESBL/ C.difficile – contact Take appropriate samples
Before prescribing Microbiologist THREE sets of blood cultures from
antimicrobials • Check for previous microbiology results different sites and at different times
• Treatment duration depends on the organism and patient PRIOR to antimicrobial therapy
factors. Must be discussed with Microbiologist/Cardiologist
• Consider referral to vascular access team If patient
is suitable for community IV pathway
IMPORTANT Gentamicin & Vancomycin
Therapeutic drug • Renal impairment – discuss with Microbiologist • Inform patient of potential side effects
monitoring • Monitor blood levels (Appendices B & F) (hearing, balance and renal impairment)
• Monitor renal function 3 times a week • Discuss with Microbiologist before
• Review treatment every 3 days continuing for longer than 2 weeks
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Endocarditis due to other Coagulase negative Treatment depends upon Seek advice from Microbiologist
organisms staphylococci susceptibility
HACEK organisms
Aerobic Gram
negative organisms
Fungi etc.
Gram negative organisms E. coli Cefotaxime i/v Discuss with Consultant
Klebsiella 1g tds Cardiologist and Microbiologist
Gram negative plus
bacilli *Gentamicin i/v
80 mg 12 hourly *Gentamicin levels:
Pre dose (trough):Antimicrobial Policy for Adults 2017 19 Page 25
CENTRAL NERVOUS SYSTEM INFECTIONS [13]
IMPORTANT Before prescribing antimicrobials Take appropriate samples
• Blood cultures
• CSF
• History of CPE/MRSA/ ESBL/ Clostridium difficile – contact Microbiologist
• Throat swabs for virolology
• Check for previous microbiology results and bacteriology
• All cases where a diagnosis of meningocccal disease is suspected should be promotly • EDTA blood for PCR
notified to the CCDC without waiting for microbiological confirmation • Stool for enteroviruses
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Bacterial meningitis Neisseria Initially: Medical emergency
meningitidis Ceftriaxone i/v Start antibiotics immediately,
Streptococcus 2g bd then inform Microbiology
pneumoniae and CCDC** for prophylaxis
Haemophilus Immunocompromised or of close contacts in case of
influenzae type b Age>65 years: meningococcal and
Consider Listeria sp.– haemophilus infection
add Amoxicillin i/v
2g 4 hourly. *Please advise patients on
Steroid use in Meningitis avoiding risk in the future
Consider adjunctive treatment Duration: P Penicillin allergy:
with dexamethasone (particularly Neisseria meningitidis 7 days
Life threatening:
if pneumococcal meningitis Streptococcus pneumoniae 14 days
chloramphenicol iv
suspected in adults) preferably Haemophilus influenzae 10 days
25mg/kg every 6 hours.
starting before or with first
Confirmed Listeria* Amoxicillin i/v Maximum 6g per day
dose of antibacterial, but
2g 4 hourly for 3 weeks Discuss with consultant
no later than 12 hours after
plus microbiologist after 48 hours.
starting antibacterial; avoid
*Gentamicin i/v Monitor for bone marrow
dexamethasone in septic shock,
High dose (Appendix A) suppression
meningococcal septicaemia, or
Review after 7 days – discuss with Inform Hospital Infection Control
if immunocompromised, or in
Microbiologist Team
meningitis following surgery.*
*Gentamicin levels:
* British National formulary No 73 accessed (Appendix A)
via medicines complete on 11 May 2017
**CCDC – 09.00 - 17.00
Tel: 0114 3211177
Out of hours via switchboard
All other organisms Discuss with Consultant
including Microbiologist
Mycobacterium
tuberculosis
Viral meningitis Enteroviruses Most commonly caused by enterovirus Send stool and throat swabs for
which causes a self limiting disease viral culture. Seek advice from
which no treatment is required Consultant Microbiologist
Herpes virus
eg high temperture Aciclovir i/v 10 mg / kg 8 hourly for PCR will confirm presence of
and focal 14-21 days. Use ideal body weight if enteroviruses
Neurological signs patient is obese.
Encephalitis Commonest agent Empirically to start Discuss with Consultant
Herpes simplex Ceftriaxone i/v Microbiologist
Signs of diffuse or focal virus (HSV) 2g bd
All bacterial agents plus PCR on the CSF will confirm HSV
neurological symptoms such as
causing meningitis, Aciclovir i/v infection
drowsiness
Varicella zoster 10 mg/kg per dose every 8 hours
seizures virus (VZV), CMV, for 14 to 21 days Do not switch to oral aciclovir
confusion Toxoplasma and
fungi Add if immunocompromised or
Age > 65 years
Amoxicillin i/v
2 g 4 hourly
Brain abscess Depends on source Start with Discuss with Microbiologist
of abscess Cefotaxime i/v
2g qds Treatment modified according
plus to the nature of organism and
Metronidazole i/v clinical manifestation
500 mg tdsPage 26 Antimicrobial Policy for Adults 2017 19
SKIN AND SOFT TISSUE INFECTIONS – Bacterial
IMPORTANT Before prescribing antimicrobials Take appropriate samples
• Pus and aspirate when
• History of CPE/MRSA/ ESBL/ Clostridium difficile – contact Microbiologist available
• Check for previous microbiology results • Wound swabs
• Treatment duration (iv or oral) 5 days unless specified • Blood cultures
• Consider referral to vascular access team if patient is suitable for community
IV pathway
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Impetigo: Staphylococcus Topical therapy may suffice Contact Microbiologist for
MILD Localised aureus Hydrogen peroxide cream 1% further advice
Beta haemolytic (Crystacide® ) apply 2-3 times daily
[12] (group A,C,G)
Streptococci
P Penicillin allergy:
Spreading Flucloxacillin oral or I/V
500 mg to 1g qds Clarithromycin oral or i/v
500 mg bd
P Penicillin allergy:
SEVERE Flucloxacillin i/v
1 to 2 g qds Teicoplanin i/v
plus 6mg/kg (appendix Ei - pg 68)
Benzylpenicillin i/v Contact microbiologist for review
1.8 g qds
Change to oral antibiotics (as for
mild infection) after satisfactory
clinical response
Total duration 5 days
Erysipelas Beta haemolytic Benzylpenicillin i/v Consider oral Amoxicillin
(group A,C,G) 1.8 g qds following adequate clinical
[12] Streptococci or response
For less severe infection
Amoxicillin oral P Penicillin allergy:
500 mg to 1g tds Clarithromycin oral or i/v
500 mg bd
Duration 7 to 10 days
Cellulitis: Beta haemolytic Flucloxacillin oral P Penicillin allergy:
MILD (group A,C,G) 500 mg to 1g qds Clarithromycin oral
[12,13] Streptococci 500 mg bd
Staphylococcus
aureus
MODERATE / SEVERE Benzylpenicillin i/v High dose i/v antimicrobials
1.8 g qds are necessary initially
plus P Penicillin allergy:
Flucloxacillin i/v
1 to 2 g qds Teicoplanin i/v
Review with microbiology results 6mg/kg (appendix Ei - pg 68)
Consider oral only after
satisfactory response/
SEVERE As above plus Piperacillin/ tazobactam i/v microbiology
In high risk patients MRSA 4.5 g tds
eg Diabetics Infection or plus Review treatment after 5 days.
Immunocompromised colonisation Teicoplanin i/v Some patients may need a
or if no response to high dose 6mg/kg (appendix Ei - pg 68) longer course eg 10-14 days
benzylpenicillin and flucloxacillinAntimicrobial Policy for Adults 2017 19 Page 27
SKIN AND SOFT TISSUE INFECTIONS – Bacterial
IMPORTANT Before prescribing antimicrobials Take appropriate samples
• Pus and aspirate when
• History of CPE/ MRSA/ ESBL/ Clostridium difficile – contact Microbiologist available
• Check for previous microbiology results • Wound swabs
• Treatment duration (iv or oral) 5 days unless specified • Blood cultures
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Necrotising fasciitis Type 1 Surgical Emergency Debridement: Seek urgent
or severe Group A Mixed organisms requiring frequent high dose advice from General Surgeon
Streptococcal cellulitis antibiotics & debridement
Type 2 P Penicillin allergy:
[13] Group A Commence Commence with
Streptococci (if renal function normal): Clindamycin i/v
Benzylpenicillin i/v 1.2g 6 hourly plus
2.4 g 4 hourly Ciprofloxacin i/v
plus 400mg bd plus
Clindamycin i/v Teicoplanin i/v
1.2 g 6 hourly 6mg/kg (appendix Ei - pg 68)
plus and seek microbiology advice
Ciprofloxacin i/v immediately
400mg bd
Contact Microbiologist within 24 Infection control precautions and
hours isolation should be followed
Infected leg ulcers or Wide range of Co-amoxiclav i/v 1.2g tds or oral
pressure sores organisms (usually 625mg tds may be used in the first
Skin ulcers will usually be polymicrobial) instance.
colonised by many organisms. including If MRSA suspected add
Significance is established by Staphylococcus Teicoplanin i/v
clinical signs of infection i.e. aureus 6mg/kg (appendix Ei - pg 68)
spreading cellulitis, discharge or Steptococci
sepsis and type of organism. Anaerobes
Contact Tissue Viability Team
Diabetic foot ulcer See Pages 31-32
[25,26,27]
Bites [12, 13] Anaerobes Prevention of infection: P Penicillin allergy:
Streptococci Clindamycin oral
Animal and Human Pasteurella Co-amoxiclav oral 300mg qds
Multocida 625mg tds 7 days Plus
Surgical toilet most important Ciprofloxacin oral
Human bite: Antimicrobial prophylaxis advised for: 500mg bd
For animal bites: Mouth Flora Puncture wound, bite involving hand, Both for 7 days
Assess tetanus and rabies risk including HACEK foot, face, joint, tendon, ligament, Caution
organsims immunocompromised, diabetics, CIPROFLOXACIN
For human bites: elderly and asplenic patients ENCOURAGES THE
Assess HIV/Hepatitis B&C risk EMERGENCE OF MRSA
Refer to Blood- borne policy for
appropriate prophylaxis
Inpatient treatment of infection:
Co-amoxiclav i/v
1.2g tds P Penicillin allergy:
Clindamycin i/v
900mg qds
Plus
Ciprofloxacin oral
500mg bdPage 28 Antimicrobial Policy for Adults 2017 19
SKIN AND SOFT TISSUE INFECTIONS – Surgical site infection
IMPORTANT Before prescribing antimicrobials Take appropriate samples
• Pus and aspirate when
• History of CPE/ MRSA/ ESBL/ Clostridium difficile – contact Microbiologist available
• Check for previous microbiology results • Wound swabs
• Treatment duration (iv or oral) 5 days unless specified • Blood cultures
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Following clean surgery Staphylococcus Flucloxacillin i/v Mild erythema does not require
aureus 1- 2 g qds antimicrobials
Streptococci or
[12] oral 500mg to 1g qds P Penicillin allergy:
In severe cases seek advice from Clarithromycin i/v or oral
Consultant Microbiologist 500 mg bd
Duration 7 to 10 days
MRSA Doxycycline oral
Less serious 200 mg first dose then 100 mg bd for Check for tetracycline sensitivity
7 to 10 days
More serious Teicoplanin i/v Duration: discuss with
or unable to take 6mg/kg (appendix Ei - pg 68) Microbiologist
oral
Following contaminated Staphylococcus Seek advice from Microbiologist The mainstay of treatment is
surgery aureus surgical intervention
MRSA
[12] Coliforms
AnaerobesAntimicrobial Policy for Adults 2017 19 Page 29
SKIN AND SOFT TISSUE INFECTIONS – Dermatophyte [8]
IMPORTANT Before prescribing antimicrobials
Take appropriate samples
• Skin scrapings
• Nail clippings
• Hair
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Skin infections in general Trichophyton sp. For limited infections Skin scrapings should be
Epidermophyton Clotrimazole cream 1% sent to Microbiology
sp. Apply 2 - 3 times a day
Microsporum sp or
Miconazole cream 2%
Apply twice daily
Scalp ringworm and extensive As above Terbinafine oral Check LFT's initially prior to
tinea infections 250 mg od for at least 4 weeks starting treatment thereafter
or, if failed every 2 weeks
Itraconazole oral (pulsed)
200mg od for a 7 day course
repeat after 21 days for 3 courses
Pityriasis versicolor Malassezia furfur Topical In recurrent cases seek advice
Selenium sulphide shampoo from Dermatologist.
(Selsun®)
Use as a lotion (diluted with water)
and leave for 30 minutes or overnight.
Repeat 2-7 times over 2 weeks
Nail infections Trichophyton sp. Terbinafine oral Nail clippings should be sent to
Epidermophyton sp 250 mg od Microbiology
6 weeks - 3 months Check LFT's prior to
starting treatment and
every 2 weeks thereafter.
SKIN AND SOFT TISSUE INFECTIONS – Candida
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Dermal candidiasis Candida albicans Topical Duration of therapy will depend
Candida glabrata Clotrimazole cream 1% on the clinical condition
Candida tropicalis Apply bd - tds
etc or
Miconazole cream 2%
Apply bd
Systemic
Fluconazole oral
50 mg od for 2-4 weeks
(for up to 6 weeks in tinea pedis)Page 30 Antimicrobial Policy for Adults 2017 19
SKIN AND SOFT TISSUE INFECTIONS – Viral [11]
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Herpes simplex Herpes simplex Aciclovir cream 5% Take swab for viral pcr
virus Apply to lesions at first sign of attack
5 times a day for 5 days
For more serious infection
Aciclovir oral
200 mg 5 times a day
for 5 days
Chickenpox Varicella-zoster Aciclovir oral Take swab for viral pcr
Inpatients & Complicated virus 800 mg 5 times a day
Chickenpox (such as for 7 days
pneumonia and pregnancy)
In severe infections
Aciclovir i/v
5 –10 mg/kg 8 hourly
followed by oral – total 7 days
Herpes zoster Varicella-zoster Aciclovir oral Take swab for viral pcr
virus 800 mg 5 times a day
for 7 days
or
Famciclovir oral
500 mg tds for 7 days
SKIN AND SOFT TISSUE INFECTIONS – Arthropod infestations
INFECTION ORGANISMS ANTIMICROBIALS COMMENTS
Scabies Sarcoptes scabiei Ist choice Consult with Dermatologist to
Permethrin 5% cream confirm diagnosis
Apply over the whole body, including
face, neck, scalp and ears and wash Inform Infection Control Team
off after 8 -12 hours.
Repeat after 7 days Infection Control procedures
should be followed
2nd choice
Malathion 0.5% aqueous liquid If evidence of cross infection
Apply over the whole body (i.e. 2 cases or more) then
and wash off after 24 hours all patients & staff should be
Repeat after 7 days treated
(Unlicensed Use)
All members of the affected
Norwegian scabies Ivermectin oral household should be treated,
- A more serious paying particular attention to
scabies usually (Named Patient) the web of the fingers and toes
affecting the 200 micrograms/kg and brushing under the ends
Immuno- single dose of nails
compromised
Only after dermatology or
microbiology recommendation
Head Lice Pediculus capitis Malathion 0.5% aqueous liquid Two applications 7 days apart
Apply to dry hair and scalp, to prevent lice emerging from
leave on for 12 hours, rinse and dry eggs that survive the first
Repeat after 7 days (unlicenced use) applicationGuidelines for the management of diabetic patients with an infected foot ulcer and /or infected foot
Before prescribing antimicrobials - check history of MRSA or Pseudomonas
Infection Signs and symptoms, Investigations Treatment Antimicrobials
Wound bed Check Allergy Status
Minor infections • Superficial Deep wound swab • Cleanse and debride the wound 1st line
• Bed: yellow/ grey Foot examination, to include vascular before obtaining specimen(s) for culture Flucloxacillin oral 1g qds
• Delayed healing / non healing and neurological assessment • Inspection of wound on admission or out of
Localised erythema, Warmth & • Friable and marked hours on the ward P Penicillin allergy
swelling around ulcer (< 3cm) granulation Wound assessment • Wound / callus debridement by experienced Clarithromycin oral 500mg bd
• New areas of breakdown or practitioner
necrosis Blood glucose • Pressure relief Add Metronidazole oral 400 mg tds,
[25,26,27] • Bridging of soft tissue and Temperature • Wound management – antimicrobials if wound malodorous
epithelium Pulse and BP • Moisture balance
• Odour • Ongoing evaluation based on clinical 2nd line
findings Co-amoxiclav oral 625 mg tds
• Patient education
Wound swab results should be obtained as soon as
Referrals possible. Prescribed antimicrobials should be checked
All patients with infected diabetic foot ulcers against sensitivity results, and changed accordingly.
to the Multi-disciplinary Diabetic Foot Care Do not use prolonged antibiotic treatment (more than
Team 14 days) for treatment of mild soft tissue diabetic foot
infection.
Moderate infections • Deep tissue ulceration As for minor infection • Same as minor infections, except Co-amoxiclav i/v 1.2 g tds
+ /- undermined edges plus antimicrobials
Intense widespread erythema, +/- penetrates to bone Bloods: • Hospitalisation Add Metronidazole oral 400 mg tds,
Antimicrobial Policy for Adults 2017 19
swelling and heat (> 3cm), • Wound breakdown or satellite FBC, U&Es, WCC • Non-weight bearing if wound malodorous
+/- bony involvement, areas CRP • May also require surgical debridement
+/- ischaemia, • Extreme purulent discharge Blood cultures P Penicillin allergy
+/- lymphangitis, • Malodour Urgent referrals Contact Microbiologist
regional lymphadenitis • Increased pain X-ray 1. Diabetologist / Multidisciplinary
malaise, • Swelling, induration Diabetic Foot Care team Modify antimicrobial therapy according to culture and
flu-like symptoms--pyrexia, • Crepitus Urgent arterial Doppler - if absent or sensitivities.
tachycardia, rigors and erratic • Sausage shaped toe(s) weak foot pulses 2. Vascular Surgeons
glucose levels (indicating osteomyelitis) If peripheral vascular disease confirmed If colonised with MRSA or pseudomonas or has
BUT • Blue discolouration of skin due or cannot be excluded had recent antibiotic use then seek advice from
HAEMODYNAMICALLY to ischaemia or tissue microbiologist
STABLE destruction
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