NHS Antibiotic PDF

Information for Clinicians
Microbiology Department
Guideline for the Empirical Treatment of Infections in Adults

______________________________________________________________________
Appropriate prescribing of antibiotics
Decision to prescribe
The use of antibiotics carries significant risks to the patient and the decision to prescribe
an antibiotic should always be clinically justified following a risk-benefit assessment. Do
not start antibiotics in the absence of clinical evidence of bacterial infection unless the
patient is gravely ill and sepsis is part of the differential diagnosis. If the clinical picture
is not clear and the patient is stable, it may be possible to wait, monitor the patient
clinically and review with laboratory results.
If there is evidence/suspicion of sepsis, use local guidelines to initiate broad spectrum

antibiotic treatment within one hour of diagnosis (or as soon as possible) in patients with
life threatening infections. Delay in starting adequate antibiotic therapy in severe
infection is associated with increased morbidity and mortality. Individual patient and
drug-specific factors to consider in all cases include:
• previous antimicrobial history
• previous colonisation or infection with multi-resistant organisms
• allergies and other side effects (including risk of Clostridium difficile infection)
• contraindications and cautions
• availability of and absorption by oral route
Appropriate specimens for microscopy, culture and sensitivity should be obtained prior
to commencing antibiotics wherever possible but do not delay starting treatment in
patients who are severely ill.
Minimising the use of broad-spectrum antibiotics

The use of broad-spectrum antibiotic agents is a major factor in inducing C. difficile
infection. In addition there is evidence to show an association between total
antimicrobial use and use of some specific classes of antibiotics with higher MRSA
prevalence. Clinicians should avoid the use of cephalosporins, quinolones, broad-
spectrum penicillins (including amoxicillin) and clindamycin unless there are clear
clinical indications for their use.
Broad-spectrum antibiotics should be restricted to the treatment of serious infections
when the pathogen is not known or when other effective agents are unavailable.
Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 1 of 26
© Royal United Hospital Bath NHS Trust
Documentation
The clinical indication, duration or review date, route and dose should be clearly
documented in the patient’s medical notes and on the drug chart.
Reasons for any deviations from empirical treatment guidelines should be recorded in
the patient’s medical notes.
Allergies must be recorded in the patient’s medical notes and on the front of the drug
chart and anaesthetic record, along with the nature of the reaction.
Review of antibiotic treatment

Review the clinical diagnosis and the continuing need for antibiotics by 48 hours then
daily with a clear plan of action - the “Antimicrobial Prescribing Decision”. The five
Antimicrobial Prescribing Decision options are:
1. Stop antibiotics if there is no evidence of infection
2. Switch IV to Oral
3. Change antibiotics – ideally to a narrower spectrum – or broader if required
4. Continue and review again after a further 24 hours
5. Outpatient Parenteral Antibiotic Therapy (OPAT)
It is essential that the review and subsequent decision is clearly documented in the
medical notes. Treatment with antibiotics should not continue beyond 7 days (IV and
oral) unless recommended by a local guideline or microbiologist.
Department of Health Guidance recommend a Start Smart - then Focus approach for all
antibiotic prescriptions
Start smart is:

• Do not start antibiotics in the absence of clinical evidence of bacterial infection
• If there is evidence/suspicion of bacterial infection, use local guidelines to initiate
prompt effective antibiotic treatment
• Document on drug chart and in medical notes: clinical indication, duration or review
date, route and dose
• Obtain cultures first
• Prescribe single dose antibiotics for surgical prophylaxis; where antibiotics have
been shown to be effective
Then focus is:

• Review the clinical diagnosis and the continuing need for antibiotics by 48 hours and
make a clear plan of action - the “Antimicrobial Prescribing Decision”
• The five Antimicrobial Prescribing Decision options are:
- Stop antimicrobials
- Switch IV to Oral
- Change,
- Continue
- Outpatient Parenteral Antibiotic Therapy (OPAT).
Intravenous or oral therapy
Intravenous (IV) therapy should only be used for patients with severe infections,
patients who have a focus of infection requiring high doses of antibiotics, patients who
are unable to take or absorb oral antibiotics, and when there are no alternative suitable
oral agents.
IV antibiotics should be reviewed on a daily basis and, if appropriate, the patient

switched to an oral equivalent within 24 hours of meeting switch criteria.
Oral switch criteria are:
• temperature < 37.5 °C for 24 hours

• signs and symptoms of infection are improving
• inflammatory markers are decreasing
• patient able to tolerate oral food and fluids
• absence of on-going or potential problem of absorption
• oral formulation or suitable oral alternative is available
Exceptions to this include some serious infections where exceptionally high antibiotic
tissue concentrations are essential (e.g. meningitis, infective endocarditis) or following
microbiological advice.

Using this guideline
This antibiotic policy gives initial empirical treatment only but should be used
discriminately with consideration of contra-indications, interactions and previous culture
results. Doses are based on normal hepatic and renal function in a 70kg man and
may require adjustment. Durations are given as a guide but should be evaluated
based on the condition being treated & the clinical response. Antibiotics should be
reviewed and rationalised with microbiology results and clinical progress.
• Vancomycin and Gentamicin - Always check levels at appropriate intervals and

adjust dose / dosage interval accordingly. See “Guidelines for the dosing and
monitoring of Gentamicin, Vancomycin and Teicoplanin” for further advice. Do not
use Gentamicin for more than 7 days without discussion with a Microbiologist.
• Penicillin allergy - patients with a history of anaphylaxis, urticarial rash or a rash
immediately after penicillin administration (type 1 allergy) should not receive a
penicillin, cephalosporin or other beta-lactam antibiotic. Check before prescribing if
you are unsure which class an antibiotic belongs to. Discuss alternative antibiotic
treatment with a Microbiologist if a suitable one is not given in the policy.
• MRSA - If a patient has been in hospital for more than five days, has previously
been known to be colonised with MRSA, or is at risk for MRSA colonisation (e.g.
recent hospital admission or resident in a Nursing or Residential home) consider
using Vancomycin or Teicoplanin.
• Extended Spectrum Beta-Lactamase (ESBL) producers, Vancomycin Resistant
Enterococci (VRE) and other multi-resistant organisms - If a patient has been
previously colonized or infected with a multi resistant organism or may have risk
factors for colonisation (e.g. recurrent urinary tract infections, admitted from a
nursing home or a long term catheter in situ) an alternative antibiotic regime may be
necessary– discuss with Microbiology.
• Tetanus - for further information see ‘Immunisation Against Infectious Diseases -
The Green Book’ December 2006, Chapter 30: Tetanus.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAn
dGuidance/DH_079917

Empirical Treatment Guidelines
Adult Empirical Treatment Guidelines: Sepsis (antibiotics should be initiated within 1 hour of diagnosis)
Infection Antibiotic Treatment IV Option Comments
Community-acquired Co-amoxiclav 1.2g tds & If neutropenia or suspected neutropenia,

sepsis of unknown Gentamicin 5mg/kg od see Neutropenic Sepsis Guideline
origin, meningitis not +/- Metronidazole 500mg tds if
suspected anaerobic infection suspected If ESBL producer or other multi-resistant
organism present, or if concern regarding
Penicillin allergy: clinical response or renal function, discuss with
Teicoplanin 600mg 12 hourly for Microbiology
first 3 doses then 600mg od &
Gentamicin 5mg/kg od Discuss all cases with Microbiology within 24
+/-Metronidazole 500mg tds if hours
anaerobic infection suspected
Hospital acquired Discuss with Microbiology

sepsis
Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval
accordingly. See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”
Adult Empirical Treatment Guidelines: CNS Infections
Infection Antibiotic Treatment IV Option Comments

Ceftriaxone 4g od Consider adjunctive dexamethasone
Suspected Bacterial (0.15 mg/kg 4 hourly for 2–4 days with the first
Meningitis Add Amoxicillin 2g dose administered 10–20 min before, or at least
4 hourly if patient >50 years old or if concomitant with, the first dose of antimicrobial
immunocompromised or pregnant therapy) in adults with suspected or proven
pneumococcal meningitis
Discuss with Microbiology if recent
travel abroad or penicillin allergy Discuss all suspected cases with a
Microbiologist
Inform relevant Health Protection Unit (via

switchboard)
Send EDTA blood sample for Meningococcal

and Pneumococcal PCR
Treat for 14-21 days
Suspected HSV Aciclovir 10mg/kg tds
encephalopathy Dose reduction required if Inform relevant Health Protection Unit (via
eGFR<50 switchboard)
CSF should be sent for viral PCR

Adult Empirical Treatment Guidelines: Genitourinary
• Previous urine culture results should guide empirical therapy
• Review with urine culture results
• Urine dipsticks are often positive in elderly patients and treatment may not be indicated – see UTI in the Non
Catheterised Older Adult Guidelines
Infection Antibiotic Treatment Total Additional Comments
Duration
Trimethoprim 200mg po bd
Uncomplicated 3 days Nitrofurantoin is contra-indicated
UTI in If recent Trimethoprim use or known in patients with eGFR <20ml/min
women (See UT Trimethoprim resistant isolate: and may be ineffective if eGFR
I in the non Co-amoxiclav 625mg po tds 20-60ml/min
catheterised
Older Adult Penicillin allergy: Nitrofurantoin 50mg po qds Discuss with Microbiology if
Guidelines there is high risk of, or previous
Trimethoprim 200mg po bd infection/ colonisation with a
UTI in 7 days VRE, ESBL producing isolate, or
men (See UTI If recent Trimethoprim use or known other multi-resistant organism
in the non Trimethoprim resistant isolate:
catheterised Co-amoxiclav 625mg po tds
Older Adult
Guidelines Penicillin allergy: Nitrofurantoin 50mg po qds
Repeat MSU 7 days after

Mild UTI in Cefalexin 500mg po bd 7 days completion of antibiotics as test
pregnancy of cure
IV treatment: Oral treatment:
Co-amoxiclav Co-amoxiclav 625mg
Pyelonephritis 1.2g tds & single tds 10-14 Discuss with Microbiology if
dose of days there is high risk of, or previous
Gentamicin infection/ colonisation with a
5mg/kg VRE, ESBL producing isolate, or
Penicillin allergy: Penicillin allergy: other multi-resistant organism
Ciprofloxacin Ciprofloxacin 500mg bd 7 days
500mg po bd (7 days treatment only
& single dose of required if ciprofloxacin Review oral switch with culture
Gentamicin used) results and clinical progress
5mg/kg iv
Amoxicillin1g tds Discuss with Microbiology if
Urinary Catheter & Gentamicin Oral treatment not 7 days there is high risk of, or
Infection 5mg/kg od recommended for previously infection/ colonisation
(Urinary empirical treatment with a VRE, ESBL producer, or
symptoms, other multi-resistant organism
fever, sepsis, ↑ Penicillin allergy:
inflammatory Gentamicin Consider catheter change once
markers). 5mg/kg once daily antibiotic known to be active
& single dose of against isolate
Vancomycin 1g
Please ensure that symptoms
are clearly indicated on the
request form for CSU culture
Adult Empirical Treatment Guidelines: Genitourinary

Infection Antibiotic Treatment Total Additional Comments
Duration
Asymptomatic No treatment required Urinalysis for leukocytes &
bacterial nitrites is non-specific in CSUs
colonisation of
urinary catheter
Epididymo- Ceftriaxone 500mg im single dose &

orchitis STI Doxycycline 100mg po bd for 14 days 14 days Refer to GUM
suspected OR
If likely due to chlamydia or other non-
gonococcal organisms:
Doxycycline 100mg po bd or
Ofloxacin 200mg po bd
OR
If severe epididymo-orchitis or features
of bacteraemia, Ceftriaxone 1g iv od &
Gentamicin 5mg/kg iv od for 3-5 days
until fever subsides, and then review
with culture
OR
Ofloxacin 200mg po bd
Epididymo- If systemically well
orchitis STI not Ciprofloxacin 500mg po bd
suspected 10 days
If severe epididymo-orchitis or features
suggestive of bacteraemia, Ceftriaxone
1g iv od & Gentamicin 5mg/kg iv od for
3-5 days until fever subsides, and then
review with culture results
Bacterial Ciprofloxacin 500mg po bd 28 days If STI suspected, refer to GUM

Prostatitis STI not
suspected Review with culture results
Urethritis, Epididymo-orchitis, Prostatitis:

If STI suspected refer to GUM for investigation and treatment (Ext 4558)
Out of hours take (1) urethral swab for gonorrhoea culture (2) first void urine or urethral swab for chlamydia and
gonorrhoea NAAT (3) MSU for culture, and then start antibiotics. Refer to GUM for follow up.
Change of long term indwelling urethral catheter in males
• Prophylactic antibiotics are recommended in patients with a history of catheter-associated urinary tract
infection following catheter change, or if catheter change likely to be traumatic.
• Be guided by culture results of pre-change CSU (please state indication for culture clearly on request form).
If empirical cover necessary, give Gentamicin 1.5mg/kg iv or im
Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval
accordingly. See ”Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”
Adult Empirical Treatment Guidelines: Infective Endocarditis (IE)

Infection Antibiotic Treatment IV Comments
Option
Infective Endocarditis: indolent Amoxicillin 2g iv 4 hourly & Discuss all suspected cases with a
presentation Gentamicin 1mg/kg (ideal body Microbiologist within 24hours,
weight) iv bd particularly if critically ill
It is preferable to wait for blood Take 3 sets of blood cultures from

culture results before separate venepunctures before
commencing treatment commencing treatment
Send a clotted sample for baseline

atypical endocarditis serology
Infective Endocarditis: acute Vancomycin iv dosed
presentation (or indolent according to local guidelines & TARGET LEVELS in treatment of IE:
presentation with penicillin allergy) Gentamicin 1mg/kg (ideal body • Vancomycin:
with no risk factors for weight) iv bd. If eGFR <45 use Pre-dose 10-15mg/l but higher
multi-resistant bacteria Ciprofloxacin 750mg po bd/ levels may be required (discuss
400mg iv bd 12 hourly instead with Microbiology)
of Gentamicin
• Gentamicin:
Infective Endocarditis: prosthetic Vancomycin dosed according Pre-dose: <1mg/l
heart valve or suspected MRSA to local guidelines & Post dose 3-5mg/l
Gentamicin 1mg/kg ideal body
weight 12 hourly & rifampicin
300-600mg 12 hourly po/iv
(use lower dose of rifampicin if
severe renal impairment)

Adult Empirical Treatment Guidelines: Respiratory Tract
CURB-65 Guidelines to determine management of Community Acquired Pneumonia (CAP)
Markers of Severity
Confusion: new disorientation in person place or time or MTS of 8 or less
Urea: raised >7mmol/L
Respiratory rate raised ≥30/min
Blood pressure: systolic <90mmHg and/or diastolic ≤ 60mmHg
65 years old or above
0-1 2 3 or more
Low Severity Moderate Severity High Severity
Infection Antibiotic Antibiotic Treatment Oral Total Additional Comments

Treatment IV Option Duration
Option
Non-severe Treat as low severity Community Acquired 5 days
exacerbations of Pneumonia
COPD
Low severity Amoxicillin 1g tds Amoxicillin 500mg tds 5 days Use IV only if unable to
CAP Penicillin allergy or Penicillin allergy or recent swallow or absorb orally
recent Amoxicillin: Amoxicillin: If there is a high clinical
Based on Clarithromycin Doxycycline suspicion of pneumonia
clinical 500mg po/iv bd 200mg on day 1 then 100mg caused by atypical
judgement and od pathogens (including
CURB-65 OR legionella) add
continue Clarithromycin Clarithromycin 500mg bd to
500mg bd if switching from IV Amoxicillin
Moderate Amoxicillin 1g tds Amoxicillin 500mg tds 7-10 days Treat with Co-amoxiclav 1.2g
severity CAP & Clarithromycin & Clarithromycin 500mg bd iv tds instead of Amoxicillin if
500mg po/iv bd recent Amoxicillin use in the
Penicillin allergy: Penicillin allergy: Doxycycline community
Vancomycin dosed 200mg day 1 and then
according to local 100mg od Send urine for legionella
guidelines & OR antigen
Clarithromycin continue Clarithromycin
500mg po/iv bd 500mg bd if switching from IV
High severity Co-amoxiclav 1.2g Follow on from iv treatment: 7 - 10 If MRSA pneumonia
CAP tds Co-amoxiclav 625mg tds & days suspected add iv
& Clarithromycin Clarithromycin 500mg bd Vancomycin
Use iv 500mg iv bd
treatment Penicillin allergy: Follow on from iv treatment if Send urine for legionella
initially Vancomycin dosed Penicillin allergy: antigen and pneumococcal
according to local Doxycycline 200mg on day 1 antigen
guidelines & then 100mg od
Clarithromycin
500mg iv bd (if pre-
existing chest
disease, consider
using Ciprofloxacin
in place of
Clarithromycin)
Infection Antibiotic Antibiotic Treatment Oral Total Additional Comments
Treatment IV Option Duration
Option
Aspiration Co-amoxiclav 1.2g Amoxicillin 500mg po tds 5-10 days
pneumonia tds Note that in the first 48 hours
(inpatient < 48 Penicillin allergy: post aspiration, the patient
hours) Clarithromycin 500mg po/iv BD & may present with chemical
Metronidazole po/iv tds pneumonitis for which
Co-amoxiclav 1.2g Co-amoxiclav 625mg tds 5-10 days antibiotics are not indicated
Aspiration tds
pneumonia If suspected lung abscess,
(inpatient >48 Penicillin allergy: necrotising pneumonia or
hours) Clarithromycin 500mg po/iv BD & patient very unwell , discuss
Metronidazole po/iv tds with Microbiology
Infective Discuss with Discuss with Respiratory/ According Empirical therapy depends
exacerbation of Respiratory/ Microbiology to clinical upon culture results. Two
bronchiectasis, Microbiology response agents may be required.
CF or other
suppurative lung
condition
Cefuroxime 1.5g Amoxicillin 500mg tds & 5 -10 Send urine for legionella
CAP pregnancy tds & Clarithromycin 500mg bd days antigen
or breast Clarithromycin
feeding 500mg po / iv bd Treat with Co-amoxiclav
Penicillin allergy: Penicillin allergy: 625mg po tds instead of
Discuss with Clarithromycin 500mg bd Amoxicillin if recent
Microbiology Discuss with Microbiology if Amoxicillin use in the
concerns community
Co-amoxiclav 1.2g Co-amoxiclav 625mg tds 7 - 10 Add Vancomycin iv dosed
HAP tds days according to local
(Hospital < 5 Penicillin allergy: Penicillin allergy: guidelines if MRSA
days and no Vancomycin iv Discuss with Microbiology suspected
previous dosed according to
antibiotics) local guidelines Send legionella urinary
& Ciprofloxacin po antigen and discuss with
500mg bd (or Microbiology if any history
400mg iv bd if oral suggestive of legionella
route not
appropriate) If not responding to therapy,
discuss with Microbiology
Piperacillin- Discuss with Microbiology 7 - 10 Add Vancomycin iv dosed

HAP tazobactam 4.5g days according to local
(Hospital > 5 tds guidelines if MRSA
days or previous Penicillin allergy: suspected or patient very
Co-amoxiclav) Vancomycin iv unwell
dosed according to
local guidelines Send urine for legionella
& Ciprofloxacin po antigen
500mg bd (or
400mg iv bd if oral If not responding to therapy,
route not discuss with Microbiology
appropriate)
Vancomycin and Gentamicin – check levels at appropriate intervals and adjust dose/dosage interval accordingly.
See “Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”
Adult Empirical Treatment Guidelines: ENT
Infection Antibiotic Antibiotic Total Duration Additional Comments

Treatment IV Treatment Oral
Option Option
Tonsillitis/ Quinsy Benzylpenicillin Penicillin V 500mg 10 days Consider infectious

1.2g qds qds mononucleosis
Penicillin allergy: Penicillin allergy: Add Metronidazole 500mg iv

Clarithromycin Clarithromycin tds if quinsy
500mg bd 500mg po bd
Ceftriaxone 2g iv Follow on from iv 10-14 days Add Metronidazole 500mg iv

Epiglottitis od treatment: tds if abscess
Co-amoxiclav
625mg tds
Penicillin allergy: Penicillin allergy:
Discuss with Discuss with
Microbiology Microbiology
Co-amoxiclav 1.2g Co-amoxiclav 5-7 days Use iv only if unable to

Acute sinusitis tds 625mg tds swallow or absorb po
antibiotic
Penicillin allergy: OR
Doxycycline 200mg
po on day 1 then Doxycycline 200mg
100mg po od on day 1 then
100mg od
Flucloxacillin 1g Flucloxacillin According to
Acute severe otitis qds 500mg qds clinical
externa response
Penicillin allergy or Penicillin allergy:
MRSA suspected: Doxycycline 200mg
Vancomycin iv on day 1 then
dosed according to 100mg od
local guidelines
Piperacillin- Discuss with According to Add Teicoplanin 600mg iv

Invasive otitis tazobactam 4.5g Microbiology clinical 12 hourly for first 3 doses
externa tds & Gentamicin response then 600mg iv od if MRSA
5mg/kg iv od isolated or suspected
Penicillin allergy:
Discuss with
Microbiology

Adult Empirical Treatment Guidelines: Bone and Joint
Infection Antibiotic Total Duration Additional

Treatment Comments
IV Option
*********Always try to take appropriate specimens for culture prior to antibiotic therapy*********
Septic arthritis Flucloxacillin 2g iv Consider gonorrhoea If MRSA isolated or

native joint qds & Gentamicin suspected, discuss
5mg/kg iv od Please discuss with Microbiology within 1 week with Microbiology
Penicillin allergy:
Vancomycin iv Treatment usually requires 2 weeks iv then 4 Rationalise therapy
dosed according weeks oral antibiotics based on results of
to local guidelines deep tissue culture
& Ciprofloxacin results
750mg po bd
Acute Flucloxacillin 2g iv Please discuss with Microbiology within 1 week
osteomyelitis qds & Gentamicin
5mg/kg iv od
Chronic Discuss individual case with Microbiology
osteomyelitis
Diabetic foot with If sepsis, Piperacillin-tazobactam 4.5g iv If MRO suspected, discuss with Microbiology
possible tds. Add Vancomycin iv dosed according
underlying to local guidelines if MRSA is suspected If not septic, discuss with Microbiology
osteomyelitis
Liaise with Diabetic Foot Team
Penicillin allergy: Discuss with
Microbiology
Suspected Vancomycin iv dosed according to local Continue antibiotics until culture results are
prosthetic joint guidelines. available, then review treatment with Microbiology
infection
Add Piperacillin-tazobactam 4.5g iv tds if
previous or suspected infection with Gram
negative organisms or patient septic or
sinus present
Penicillin allergy: Discuss with

Microbiology
Open fracture with See Antibiotic Guideline: Surgical Prophylaxis in

and without Adults
significant
contamination
“Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”

Adult Empirical Treatment Guidelines: Skin and Soft Tissue
Infection Antibiotic Treatment IV Antibiotic Treatment Total Additional Comments

Option Oral Option Duration
Human or Co-amoxiclav 1.2g tds Co-amoxiclav 625mg tds 7 days Check tetanus status and
animal bite discuss with Microbiology if
Penicillin allergy: Penicillin allergy: human bite or concern
Ciprofloxacin 400mg iv bd Ciprofloxacin 500-750mg regarding rabies
& Clindamycin 600mg iv bd & Clindamycin 300-
qds 450mg qds
Cellulitis Flucloxacillin 1g qds Flucloxacillin 500mg qds 5 - 7 days Only if severe consider adding
Clindamycin 300-450mg po
qds to Flucloxacillin /
Penicillin allergy or MRSA Penicillin allergy:
Vancomycin
suspected: Vancomycin iv Doxycycline 200mg po on
(substitute if on Doxycycline)
dosed according to local day 1 then 100mg po od
guidelines
Bursitis Flucloxacillin 1g qds Flucloxacillin 500mg qds 7 days
Penicillin allergy or MRSA Penicillin allergy:

suspected: Vancomycin iv Doxycycline 200mg po on
dosed according to local day 1 then 100mg po od
guidelines
Mastitis Flucloxacillin 1g qds Flucloxacillin 500mg qds 5-7days
OR OR
consider Co-amoxiclav consider Co-amoxiclav
1.2g tds if breastfeeding, 625mg tds if
post- operative or recent breastfeeding, post -
Flucloxacillin operative or recent
Flucloxacillin
Penicillin allergy or MRSA Penicillin allergy or MRSA
suspected: Vancomycin iv suspected:
dosed according to local Discuss with Microbiology
guidelines
Co-amoxiclav 1.2g tds Co-amoxiclav 625mg tds 7 -10 If MRSA is suspected add
Moderate- days Vancomycin iv dosed
severe If severe consider adding according to local guidelines
cellulitis in Clindamycin 300-450mg
association po qds Liaise with Diabetic Foot Team
with diabetes Penicillin allergy: Penicillin allergy:
or post GI Clindamycin 600mg iv qds Discuss with Microbiology
surgery & Ciprofloxacin 750mg po
bd (or 400mg iv bd if oral
route not appropriate)
Necrotising Meropenem 1g tds Not appropriate According If suspected get an URGENT
Fasciitis & Clindamycin 600mg iv to clinical surgical opinion and discuss
qds response with a Microbiologist
& Metronidazole 500mg
tds & single dose If MRSA is suspected add
Gentamicin 5mg/kg Vancomycin iv dosed
according to local guidelines

Adult Empirical Treatment Guidelines: Skin and Soft Tissue
Infection Antibiotic Treatment IV Antibiotic Total Additional Comments
Option Treatment Oral Duration
Option
Severe pre Ceftriaxone 2g bd Discuss with According Discuss with Microbiology,
septal and Microbiology to clinical Ophthalmology and ENT
orbital cellulitis Penicillin allergy or MRSA Penicillin allergy or response
suspected: Discuss with MRSA suspected: Consider urgent imaging
Microbiology Discuss with
Microbiology
Cellulitis Flucloxacillin 1g qds Flucloxacillin 500mg According Consider possibility of a deep
surrounding +/- Metronidazole 500mg qds +/- to clinical seated infection and referral to
ulcer or tds Metronidazole response Tissue Viability
pressure sore 400mg tds
OR
Co-amoxiclav 625mg
tds
Penicillin allergy or MRSA Penicillin allergy or
suspected: Vancomycin iv MRSA suspected:
dosed according to local Doxycycline 200mg
guidelines +/- on day 1 then 100mg
Metronidazole 500mg tds od +/- Metronidazole
400mg tds
Ulcer or Pressure relief and topical wound care should be adequate
pressure sore
with no
evidence of
cellulitis
Adult Empirical Treatment Guidelines: Gynaecology
Infection Antibiotic Antibiotic Total Additional Comments

Treatment IV Treatment Oral Duration
Option Option
PID (low risk Ceftriaxone Ofloxacin 14 days Pregnancy: Use Erythromycin instead of
gonococcal) 2g od & 400mg bd & Doxycycline
Metronidazole Metronidazole
500mg tds & 400mg bd Refer to GUM
Doxycycline
100mg po bd Anaerobes are of greater importance in severe
PID; Metronidazole may be discontinued in
PID (high risk Ceftriaxone 2g IM ceftriaxone 14 days patients with mild or moderate PID who are
gonococcal) od & 500mg single unable to tolerate it.
Metronidazole dose then
500mg tds & Doxycycline
Doxycycline 100mg po bd &
100mg po bd Metronidazole
400mg po bd

Adult Empirical Treatment Guidelines: Intra-abdominal Infections
Infection Antibiotic Treatment IV Antibiotic Total Additional Comments
Option Treatment Oral Duration
Option
Amoxicillin 1g tds & Co-amoxiclav 625mg 5 - 7 days Continue IV for 5-7 days if
Appendicitis, Metronidazole 500mg tds & tds & Metronidazole peritoneal contamination
diverticulitis Gentamicin 5mg/kg od 400mg tds
or peritonitis OR Review with culture results
If eGFR <45, treat with prior to switching to oral
Piperacillin-tazobactam 4.5g therapy
tds & Metronidazole 500mg
iv tds
Teicoplanin 600mg 12 hourly Ciprofloxacin 500 mg
for 3 doses then 600mg od & bd & Metronidazole
Metronidazole 500mg tds & 400mg tds
Gentamicin 5mg/kg od
OR
If eGFR <45, discuss with
Microbiology
Amoxicillin 1g tds & Co-amoxiclav 625mg 7 days
Cholecystitis Metronidazole 500mg tds & tds & Metronidazole
and Gentamicin 5mg/kg od 400mg tds
Cholangitis OR
If eGFR <45, treat with
Piperacillin-tazobactam 4.5g
iv tds & Metronidazole
500mg iv tds
Teicoplanin 600mg 12 hourly Ciprofloxacin 500 mg
for 3 doses then 600mg od & bd & Metronidazole
Metronidazole 500mg tds & 400mg tds
OR
Microbiology
Piperacillin/ tazobactam 4.5g Not appropriate 7 days Add Gentamicin 5mg/ kg
Severe tds& Metronidazole od if septic
Pancreatitis 500mg iv tds
with infected Note:
necrosis Penicillin allergy: Discuss Infected necrosis is rare in
with Microbiology the first week. Infection is
presumed when there is
extraluminal gas in the
pancreatic and/or
peripancreatic tissues or
when FNA is positive for
bacteria and / or fungi on
Gram stain and culture.

Adult Empirical Treatment Guidelines: Intra-abdominal Infections
Infection Antibiotic Treatment IV Antibiotic Treatment Total Additional Comments
Option Oral Option Duration
Piperacillin/ tazobactam
Spontaneous 4.5g iv tds Be guided by culture 5-7 days
Bacterial results
Peritonitis Penicillin allergy: Discuss
with Microbiology
Piperacillin/ tazobactam
Variceal 4.5g iv tds 5-7 days
haemorrhage
with cirrhosis Penicillin allergy:
Teicoplanin 600mg 12
hourly for 3 doses then
600mg od &
OR
Microbiology
“Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin”

References
British National Formulary 65th edition. March- September 2013.
Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare

Associated Infection (ARHAI). Antimicrobial Stewardship: “Start Smart – Then Focus”.
2011.
Scottish Intercollegiate Guidelines Network. Management of suspected bacterial urinary

tract infection in adults. Clinical Guideline 88. Updated July 2012.
British Society for Sexual Health and HIV. Management of epididymo-orchitis (2010)
http://www.bashh.org/documents/3546.pdf
British Society for Sexual Health and HIV. United Kingdom National guideline for the
management of prostatitis (2008)
IDSA Guidelines. Practice Guidelines for the Management of Bacterial Meningitis. Clin
Infect Dis 2004; 39:1267–84
http://cid.oxfordjournals.org/content/39/9/1267.full
Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of
the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob
Chemother 2012; 67: 269–289.
http://jac.oxfordjournals.org/content/67/2/269.full.pdf+html
British Thoracic Society. Guidelines for the Management of Community Acquired

Pneumonia in Adults. Thorax 2009, Vol 64 Supplement III
http://www.brit-thoracic.org.uk/Portals/0/Guidelines/Pneumonia/CAPGuideline-full.pdf
IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and
Adults. Clin Infect Dis. 2012 doi: 10.1093/cid/cir1043
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html
Repanos C, Mukherjee P, Alwahab Y. Role of microbiological studies in management of

peritonsillar abscess J Laryngol Otol. 2009;123(8):877-9. doi:
10.1017/S0022215108004106. Epub 2008 Dec 4.
.
IDSA Guidelines. Practice Guidelines for the Diagnosis and Management of Group A
Streptococcal Pharyngitis. Clin Infect Dis 2002; 35:113–25.
http://cid.oxfordjournals.org/content/35/2/113.full.pdf+html
SIGN Guideline 117. April 2010. Management of sore throat and indications for
tonsillectomy, A national clinical guideline.
http://www.sign.ac.uk/pdf/sign117.pdf

BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen
joint in adults. Rheumatology 2006; 45 (8): 1039-1041.
http://rheumatology.oxfordjournals.org/content/45/8/1039.full.pdf+html
British Society for Sexual Health and HIV. UK National Guideline for the Management of
Pelvic Inflammatory Disease (2011).
http://www.bashh.org/documents/3572.pdf
IDSA Guidelines. Practice Guidelines for the Diagnosis and Management of Skin and
Soft-tissue. Clin Infect Dis. 2005;41:1373-406.
UK Guidelines for the Management of Acute Pancreatitis. Gut 2005;54:iii1-iii9

doi:10.1136/gut.2004.057026
http://gut.bmj.com/content/54/suppl_3/iii1.full
AASLD Practice Guidelines. Prevention and Management of Gastroesophageal

Varices and Variceal Hemorrhage in Cirrhosis. Hepatology 2007; 46 (3).
http://www.aasld.org/practiceguidelines/documents/bookmarked%20practice%20guideli
nes/prevention%20and%20management%20of%20gastro%20varices%20and%20hem
orrhage.pdf
Jalan R and Hayes PC.UK Guidelines on the management of patients with variceal
haemorrhage in cirrhotic patients.
Gut 2000;46:iii1-iii15 doi:10.1136/gut.46.suppl_3.iii1
http://gut.bmj.com/content/46/suppl_3/iii1.full
IDSA Guideline. Diagnosis and Management of Complicated Intra-abdominal Infection

in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious
Diseases Society of America. Clin Infect Dis 2010;50:133-64.
EASL clinical practice guidelines on the management of ascites, spontaneous bacterial

peritonitis, and hepatorenal syndrome in cirrhosis. Journal of Hepatology 2010; 53:397-
417.
http://www.easl.eu/assets/application/files/21e21971bf182e5_file.pdf
Classification of acute pancreatitis—2012: revision of the Atlanta classification and

definitions by international consensus. Banks et al. Gut 2013;62:102–111.

Related documents
• Guidelines for the dosing and monitoring of Gentamicin, Vancomycin and

Teicoplanin
• Guidelines for UTI in Elderly
• Neutropenic Sepsis Guideline
• Antibiotic Guidelines: Paediatric and Neonatal
• Control of Infection Strategy
• Antibiotic prescribing Policy
• Antibiotic Guideline: Surgical Prophylaxis in Adults
List of abbreviations
CAP Community Acquired Pneumonia
CF Cystic Fibrosis
CSU Catheter sample of urine
ESBL Extended Spectrum Beta-Lactamase
HAP Hospital Acquired Pneumonia
HSV Herpes Simplex Virus
IE Infective Endocarditis
MRO Multi-resistant organisms
MSU Mid- stream urine
NAAT Nucleic Acid Amplification Test
OPAT Outpatient Parenteral Antibiotic Therapy
PID Pelvic Inflammatory Disease
STI Sexually Transmitted Infection
VRE Vancomycin Resistant Enterococci

Appendix 1: Guidance on Penicillin Allergies
Penicillin Containing Antibiotics:

Amoxicillin
Augmentin (Co-amoxiclav contains amoxicillin & clavulanic acid )
CONTRA-INDICATED Flucloxacillin
Penicillin G (benzylpenicillin)
Penicillin V (phenoxymethyl-penicillin)
Piperacillin + tazobactam (Tazocin)
Cephalosporins:
Crossover allergy possible Cefalexin(s) Cefaclor(s) Cefuroxime(s)
(up to 6.5%): Cefotaxime(s) Ceftazidime(s) Cefixime(s)
Avoid if history of immediate hypersensitivity to Cefradine(s) Ceftriaxone(s)
penicillin. Use with caution if non-severe allergy (e.g.
minor rash only)
Other beta-lactam antibiotics :
Aztreonam(s) Ertapenem(s) Meropenem(s)
®
Non Beta-lactam antibiotics:

®
Amikacin Doxycycline Oxytetracycline
(s)
Azithromycin Erythromycin Rifampicin
®
CONSIDERED SAFE Chloramphenicol Gentamicin Sodium Fusidate
(s) (s) (s)
Ciprofloxacin Levofloxacin Teicoplanin
(s) ®
Clarithromycin Linezolid Trimethoprim
(s) (s)
Clindamycin Metronidazole Tobramycin
(s) (s) (s)
Colistin Minocycline Vancomycin
(s)
Co-trimoxazole Nitrofurantoin

Date of Issue: 2013 Page: 20 of 26
Page 20 of 26
Appendix 2: Prescribing and monitoring once daily Gentamicin in adults
The standard treatment dose is 5mg/kg,

The standard prophylaxis dose is 3mg/kg
No single dose of Gentamicin should normally exceed 520mg
Neutropenic sepsis dose is 6mg/kg, max dose at discretion of prescribing clinician
Figure 1 Suggested gentamicin doses of 5mg/kg according to height and weight in MALE patients,
taking into account a correction factor for obese patients
Male
6' 5 280 320 320 360 400 400 440 440 480 480 480 480 480 480 520 520 520 520 520 520 520 520 520 520 520 520 520
6' 4 280 320 320 360 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520 520 520 520 520 520
6' 3 280 320 320 360 400 400 440 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520 520 520 520 520
6' 2 280 320 320 360 400 400 440 440 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520 520 520 520
6' 1 280 320 320 360 400 400 440 440 440 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520 520 520
6' 0 280 320 320 360 400 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520 520 520
5' 11 280 320 320 360 400 400 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520 520
Height in feet
5' 10 280 320 320 360 400 400 400 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520
5' 9 280 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520
5' 8 280 320 320 360 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520
5' 7 280 320 320 360 360 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520
5' 6 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520
5' 5 280 320 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520
5' 4 280 320 320 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520
5' 3 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520
5' 2 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520
5' 1 280 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520
5' 0 280 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520
60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190
Actual weight in kg
Figure 2 Suggested gentamicin doses of 5mg/kg according to height and weight in FEMALE
patients, taking into account a correction factor for obese patients
Female
6' 3 200 240 240 280 320 320 360 400 400 440 440 440 440 440 440 480 480 480 480 520 520 520 520 520 520
6' 2 200 240 240 280 320 320 360 400 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520
6' 1 200 240 240 280 320 320 360 400 400 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520
6' 0 200 240 240 280 320 320 360 400 400 400 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520
5' 11 200 240 240 280 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520
5' 10 200 240 240 280 320 320 360 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520
Height in feet
5' 9 200 240 240 280 320 320 360 360 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520
5' 8 200 240 240 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520
5' 7 200 240 240 280 320 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480
5' 6 200 240 240 280 320 320 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480
5' 5 200 240 240 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480
5' 4 200 240 240 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480
5' 3 200 240 240 280 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480
5' 2 200 240 240 280 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480
5' 1 200 240 240 240 240 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440
5' 0 200 240 240 240 240 240 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440
4' 11 200 240 240 240 240 240 240 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440
4' 10 200 200 200 240 240 240 240 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440
45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
Actual weight in kg

Date of Issue: 2013
Page 21 of 26
Dosing interval and monitoring
Gentamicin is cleared predominantly via the kidneys and the dosage interval needs to
be increased in patients with impaired renal function.
Renal Suggested Dose Time First assay Do I give next dose

Function eGFR interval time before assay results
2
(ml/min/1.73m ) available?
Normal > 60 24 hours Check level 24 In patients <65 years

hours post old, with good urine
dose output give 2nd dose
without waiting for result
In patients >65 years

old, wait for result
before giving 2nd dose
Impaired 30-60 Dependent Check level 24 Wait for result before

on levels hours post giving any further doses
dose
Severe < 30 Discuss with microbiology

Impairment
• Take pre dose levels up to one hour before the second dose is given
• Patients >65 years old, or with abnormal renal function or poor urine output: the pre
dose gentamicin level must be ≤1mg/litre before any further dose is given
• For patients with normal and stable renal function check pre dose level twice weekly
• For patients with abnormal renal function, check the pre dose gentamicin level
before each dose
Renal function must be checked regularly. If renal function deteriorates, more frequent
monitoring may be needed, the dosing interval may need to be increased or
discontinuation of therapy may be required. Discuss alternative antibiotics with a
Microbiologist.

Date of Issue: 2013
Page 22 of 26
Prescribing and Monitoring of Vancomycin
Normal renal function:
Age Vancomycin Dose Dose Frequency
(years)
<65 1000mg 12 hourly
65-75 750mg 12 hourly
>75 500mg 12 hourly
Check levels pre dose levels at 3rd or 4th dose and give dose
Assay twice weekly if pre-dose levels <15mg/l and renal function stable
Impaired renal function:

Renal Suggested Age Vancomycin Dose Dose
Impairment eGFR (years) Frequency
(ml/min/1.73m2)
Mild to moderate 45-60 >75 1000mg measure

level at 24h
and await the
All ages 1000mg result before
Moderate or <45 giving the
Severe next dose
Pre dose level should be <15mg/l. Consider dose reduction (e.g. to 750mg OD) if higher
Renal function must be checked regularly. If renal function deteriorates more frequent
monitoring may be needed.
Aim for pre-dose levels 5-15mg/l (aim for 10-15mg/l for serious or deep seated
infections)

Date of Issue: 2013
Page 23 of 26
Document Control Information
Consultation Schedule
Name and Title of Individual Date
Consulted
Dr Paul Lyons, Consultant Neurologist 12/9/13
Dr Dominic Williamson, Consultant in Emergency Medicine 12/9/13
Dr Philip Kaye, Consultant in Emergency Medicine 12/9/13
Dr Chris Dyer, Consultant Geriatrician 12/9/13
Dr Arnold Fernandes, Consultant in GU Medicine 2/8/13
Dr Kate Horn, Consultant in GU Medicine 2/8/13
Dr Anu Garg, Consultant Physician 12/9/13
Dr Mark Mallet, Consultant Physician 12/9/13
Dr John Linehan, Consultant Gastroenterologist 12/9/13
Dr Ben Colleypriest, Consultant Gastroenterologist 25/9/13
Dr Mark Farrant, Consultant Gastroenterologist 25/9/13
Dr Julia Maltby, Consultant Gastroenterologist 25/9/13
Dr Jonathan Quinlan, Consultant Gastroenterologist 25/9/13
Dr Rob Lowe, Consultant Cardiologist 12/9/13
Dr Jacob Easaw, Consultant Cardiologist 12/9/13
Dr Vidan Masani, Consultant Respiratory Physician 12/9/13
Dr Adam Malin, Consultant Respiratory Physician 12/9/13
Dr Tony Robinson, Consultant Physician 12/9/13
Dr Marc Atkin, Consultant Physician 12/9/13
Dr Kim Gupta, Consultant Anaesthetist 12/9/13
Dr Andy Georgio, Consultant Anaesthetist 12/9/13
Mr Simon Gregg-Smith, Consultant Orthopaedic Surgeon 12/9/13
Mr Steve Pope, Consultant Orthopaedic Surgeon 12/9/13
Mr John Budd, Consultant Surgeon 12/9/13
Mr Stephen Dalton, Consultant Colorectal Surgeon 12/9/13
Mr Mike Williamson, Consultant Colorectal Surgeon 12/9/13
Ms Catherine Ashworth, Clinical Director ENT 12/9/13
Mr David Walker, Consultant Gynaecologist 12/9/13
Mr Jon McFarlane, Consultant Urologist 12/9/13
Mr Richard Antcliff, Consultant Ophthalmic Surgeon 12/9/13
The following people have submitted responses to the consultation process:

Name and Title of Individual Date
Responded
Miss Nicola Lawrence, Consultant Breast Surgeon 20/9/13
Mr Richard Sutton, Consultant Breast Surgeon 18/9/13
Mr Nick Johnson, Consultant Gynaecologist 16/9/13
Mr Rick Porter, Consultant Gynaecologist 18/9/13
Mr David Walker, Consultant Gynaecologist 17/9/13
Mr Mike Williamson, Consultant Colorectal Surgeon 18/9/13
Date of Issue: 2013
Page 24 of 26
Mr John Budd, Consultant Surgeon 12/9/13
Dr Philip Kaye, Consultant in Emergency Medicine 18/9/13
Miss Claire Taylor, Consultant in Emergency Medicine 17/9/13
Dr Mark Mallet, Consultant Physician 13/9/13
Dr Adam Malin, Consultant Respiratory Physician 16/9/13
Dr Rob Lowe, Consultant Cardiologist 12/9/13
Dr Jacob Easaw, Consultant Cardiologist 12/9/13
Dr Vidan Masani, Consultant Respiratory Physician 12/9/13
Dr Kate Horn, Consultant in GU Medicine 2/8/13
Dr Arnold Fernandes, Consultant in GU Medicine 2/8/13
Mr Neil Bradbury, Consultant Orthopaedic Surgeon 17/9/13
Mr Steve Pope, Consultant Orthopaedic Surgeon 18/9/13
Mr Allister Trezies, Consultant Orthopaedic Surgeon 7/10/13
Name of Committee/s (if applicable) Date of

Committee

Date of Issue: 2013
Page 25 of 26
Ratification Assurance Statement
Dear
Please review the following information to support the ratification of the below named
document.
Name of Guideline: Guideline for the Empirical Treatment of Infections
Name of author: Wendy Fletcher and Teh Li Chin
Job Title: Antimicrobial Pharmacist and Consultant Microbiologist

I, the above named author, confirm that:
• The Guideline presented for ratification describes best practise known to me at the time
of the development of the guideline.
• I will bring to the attention of my clinical director or line manger any information which
may affect the validity of this Guideline as soon as this becomes known to me;
• I have undertaken appropriate consultation on this Guideline and have considered all
responses.
• I acknowledge that the policy will be kept under review, and that I may be asked to refine
the guideline. If no interim changes are required it will then be formally reviewed on its
documented review date.
Signature of Author: Date: 21/11/2013

Name of Person
Ratifying this Guideline: William Hubbard
Job Title: Head of Medicine
Signature: Date: 21/11/2013
To the person approving this Guideline:

Please ensure this page has been completed correctly, then print, sign and
post this page only to: The Policy Coordinator, John Apley Building.
The whole guideline must be sent electronically to: ruh-tr.policies@nhs.net

Date of Issue: 2013
Page 26 of 26

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Information for Clinicians

Guideline for the Empirical Treatment of Infections in Adults

Appropriate prescribing of antibiotics

If there is evidence/suspicion of sepsis, use local guidelines to initiate broad spectrum

Minimising the use of broad-spectrum antibiotics

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

Review of antibiotic treatment

Start smart is:

Then focus is:

IV antibiotics should be reviewed on a daily basis and, if appropriate, the patient

Oral switch criteria are:

• temperature < 37.5 °C for 24 hours

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

• Vancomycin and Gentamicin - Always check levels at appropriate intervals and

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

Infection Antibiotic Treatment IV Option Comments

Community-acquired Co-amoxiclav 1.2g tds & If neutropenia or suspected neutropenia,

Hospital acquired Discuss with Microbiology

Adult Empirical Treatment Guidelines: CNS Infections

Infection Antibiotic Treatment IV Option Comments

Inform relevant Health Protection Unit (via

Send EDTA blood sample for Meningococcal

CSF should be sent for viral PCR

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

Repeat MSU 7 days after

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

Epididymo- Ceftriaxone 500mg im single dose &

Bacterial Ciprofloxacin 500mg po bd 28 days If STI suspected, refer to GUM

Urethritis, Epididymo-orchitis, Prostatitis:

Adult Empirical Treatment Guidelines: Infective Endocarditis (IE)

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

It is preferable to wait for blood Take 3 sets of blood cultures from

Send a clotted sample for baseline

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

Low Severity Moderate Severity High Severity

Infection Antibiotic Antibiotic Treatment Oral Total Additional Comments

Piperacillin- Discuss with Microbiology 7 - 10 Add Vancomycin iv dosed

Infection Antibiotic Antibiotic Total Duration Additional Comments

Tonsillitis/ Quinsy Benzylpenicillin Penicillin V 500mg 10 days Consider infectious

Penicillin allergy: Penicillin allergy: Add Metronidazole 500mg iv

Ceftriaxone 2g iv Follow on from iv 10-14 days Add Metronidazole 500mg iv

Co-amoxiclav 1.2g Co-amoxiclav 5-7 days Use iv only if unable to

Piperacillin- Discuss with According to Add Teicoplanin 600mg iv

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

Infection Antibiotic Total Duration Additional

Septic arthritis Flucloxacillin 2g iv Consider gonorrhoea If MRSA isolated or

Penicillin allergy: Discuss with

Open fracture with See Antibiotic Guideline: Surgical Prophylaxis in

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

Infection Antibiotic Treatment IV Antibiotic Treatment Total Additional Comments

Penicillin allergy or MRSA Penicillin allergy:

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

Adult Empirical Treatment Guidelines: Gynaecology

Infection Antibiotic Antibiotic Total Additional Comments

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0

British National Formulary 65th edition. March- September 2013.

Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare

Scottish Intercollegiate Guidelines Network. Management of suspected bacterial urinary

British Thoracic Society. Guidelines for the Management of Community Acquired

Repanos C, Mukherjee P, Alwahab Y. Role of microbiological studies in management of

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0