20

2017

August 2017 1
 PRINCESS ROYAL UNIVERSITY HOSPITAL
ANTIMICROBIAL TREATMENT GUIDELINES FOR ADULTS
Version 7 - August 2017
This version of the guidance replaces Version 6 published in August 2016

Contents
1. INTRODUCTION ....................................................................................................................3
2. PENICILLIN ALLERGY ..............................................................................................................5
3. INTRAVENOUS (IV) TO ORAL (PO) SWITCH POLICY ............................................................6
4A. INPATIENT SEPSIS PATHWAY - UPDATED .........................................................................7
4B. NEUTROPENIC SEPSIS .........................................................................................................8
5. ANTIMICROBIAL TREATMENT GUIDANCE.............................................................................9
i. Sepsis and Central Nervous System Infections .......................................................................9
ii. Lower Respiratory Tract Infections .......................................................................................11
iii Eye, Ear, Nose and Throat Infections ...................................................................................13
iv. Gastro Intestinal Infection ....................................................................................................15
v. Clostridium difficile Infection (CDI) ........................................................................................16
vi. A. Diagnosis Algorithm UTI – NEW SECTION .....................................................................17
vi. B Urinary Tract Infections – UPDATED ...............................................................................18
vii. Infective Endocarditis: Initial empirical treatment – UPDATED ...........................................19
viii. Genito-Urinary Infections ....................................................................................................20
ix. Infections of the Skin, Soft Tissues, Joints and Bones .........................................................21
6. ANTIMICROBIAL PROPHYLAXIS IN MEDICINE ....................................................................22
7. OUTPATIENT PARENTERAL ANTIBIOTIC THERAPY (OPAT) FOR CELLULITIS ................23
8. OUTPATIENT PARENTERAL ANTIBIOTIC THERAPY (OPAT) FOR PYELONEPHRITIS .....24
9. FEVER IN THE RETURNED TRAVELLER ..............................................................................25
10. GENTAMICIN – ONCE DAILY DOSING ................................................................................27
11. AMIKACIN ONCE DAILY DOSING ........................................................................................29
12. VANCOMYCIN INTERMITTENT INFUSIONS .......................................................................30
13. FORMULAE ...........................................................................................................................32
14. USEFUL CONTACTS ............................................................................................................32
August 2017 2
1. INTRODUCTION
This guidance is for use at PRUH site only; there is separate guidance in use at Denmark Hill site.
This version of the guidance replaces Version 6 published in August 2016
AIMS OF THE GUIDELINES:
 To provide recommendations on the initial, empirical treatment of common infections
 To promote the safe, prudent and cost effective use of antimicrobials
 To prevent the emergence of antimicrobial resistance and Health Care Associated Infections

ANTIMICROBIAL PRESCRIBING: START SMART THEN FOCUS

This guidance follows the Department of Health Antimicrobial Stewardship principles of “Start Smart then Focus”. The
algorithm below summarises Start Smart then focus, Antimicrobial prescribing principles

CHOICE OF ANTIMICROBIAL - consider the following:

 Use knowledge of the common pathogens at the likely source of infection
 Use the most narrow-spectrum antimicrobial(s) appropriate for the infection being treated
 Review recent microbiology results, and the presence of hospital associated organisms e.g. MRSA and multi-resistant
organisms
 Serious infections will require IV therapy, e.g. severe sepsis, bacterial meningitis, neutropenic sepsis, osteomyelitis,
endocarditis, necrotising fasciitis and septic arthritis
 Some antimicrobials require Therapeutic Drug Monitoring e.g. Vancomycin, Gentamicin, Amikacin and sometimes
Chloramphenicol
 Other factors to consider:
o recent antimicrobial history
o patient’s body weight (or Adjusted Body Weight)
August 2017 3
 o allergies
o liver and renal impairment
o pregnancy/breast feeding
o drug interactions with concomitant medication
 Drug doses are intended only as a guide. For further details regarding drug information, such as dose adjustments in
renal or liver impairment, contra-indications, interactions, precautions, adverse effects and safety in pregnancy please
refer to the current BNF, product literature, Ward Pharmacist or Antimicrobial Pharmacist.

Responsibilities
This Guideline applies to all prescribers at the Princess Royal University Hospital and supersedes all previous Adult
Antimicrobial Treatment Guidelines. When deviation from the Guideline is clinically indicated, the rationale for
this deviation must be evidence based and clearly documented in the patient’s notes.
All prescribers are responsible for maintaining awareness of the content of this Guideline, and for ensuring their practice
complies with the Guideline and related policies which are available on the Intranet.

Contacting Medical Microbiology Consultants for Advice:

The Medical Microbiology Consultants Advice service is in high demand during and out of hours. Therefore before
contacting Microbiology Consultant:-
 discuss the patient with a senior member of your own team
 check whether the information you are seeking is in the PRUH Antimicrobial Treatment Guidelines or the BNF.
 check to see if there is already Medical Microbiology advice in the notes or handover
 make sure you have the relevant information to hand because you will be asked in detail about relevant medical
history, current clinical findings, current observations, any recent significant changes, results of relevant
laboratory and imaging investigations, antimicrobial history (including drug names, start and stop dates, and
allergic reactions with type of reaction if known)

After the consultation:-

 Record the plan in the EPR or notes and ensure it is handed over.
Antimicrobial Key Performance Indicators (KPI):
The Trust monitors antimicrobial prescribing; this is an imperative measure in reducing emergence of antibiotic resistance
and hospital acquired infections such as C. difficile associated diarrhoea. The Antimicrobial KPI audit is undertaken each
month to assess prescribing against Antimicrobial KPIs. All antimicrobial prescriptions must state the indication and
stop/review date and must be assessed for IV to PO switch at no later than 48 hours after the first dose. Antimicrobials
must be prescribed in line with approved Trust Guidelines or be approved by Medical Microbiology.

Restricted Antimicrobials
Unless part of an approved Trust Guideline, the following antimicrobials are only to be prescribed with Medical
Microbiology approval. The microbiologist who approved the prescription will provide an “Authorisation Code” which must
be documented on the drug chart/patient notes.

Ambisome, Caspofungin, Voriconazole, Posaconazole – (unless critical care or Haem-Onc patient)

Amikacin, Gentamicin for more than 5 days
Daptomycin
Carbapenems (unless Critical Care Unit, HDU or Haem-Onc)
Cephalosporins (unless for suspected or proven bacterial meningitis, CF or neurosurgery)
Ciprofloxacin and other Quinolones
Clindamycin
Flucytosine
Linezolid (unless intensive care areas, with consultant approval)
Piperacillin-Tazobactam (Tazocin)
Teicoplanin – contact Microbiology for dosing and monitoring
Temocillin
Tigecycline
Valganciclovir
Vancomycin

August 2017 4
2. PENICILLIN ALLERGY
Drugs colour coded RED are contraindicated in patients with a penicillin allergy
Drugs colour coded ORANGE should be used with caution in patients with a penicillin allergy
Drugs colour coded GREEN may be used safely in patients with a penicillin allergy.

Endorse all drug allergies clearly on the drug chart and in the notes with details of the reaction

Penicillin Containing
antimicrobials
CONTRA-
Penicillin Allergy
LIFE-THREATENING
Amoxicillin
Benzylpenicillin
INDICATED
. anaphylaxis, angioedema Cefalexin
Co-amoxiclav (Augmentin®)
History of Penicillin Flucloxacillin
Allergy with Phenoxymethylpenicillin
LIFE-THREATENING (Penicillin V)
REACTION Pivmecillinam (Mecillinam)
e.g. anaphylaxis, Tazocin® (Piperacillin+ Tazobactam)
angioedema, urticaria, Temocillin
immediate rash Timentin® (Ticarcilin + Clavulanic
acid)

Other Beta-Lactam
antimicrobials
USE WITH
Aztreonam Ceftriaxone
CAUTION Cefadroxil Cefuroxime
History of Non-Severe Cefixime Ertapenem
Penicillin Allergy (e.g. Cefotaxime Imipenem
delayed/minor rash). Avoid Cefradine Meropenem
if serious penicillin allergy Ceftaroline
(e.g. anaphylaxis/ Ceftazidime
angioedema, urticaria)

Non Beta-lactam
antimicrobials
Not an exhaustive list

Amikacin Linezolid
Azithromycin Levofloxacin
Ciprofloxacin Metronidazole
CONSIDERED
Chloramphenicol Minocycline
SAFE
In patients with Clarithromycin Moxifloxacin
Penicillin Allergy Clindamycin Nitrofurantoin
For use in patients
(Remember to consider Colisitin Rifampicin
allergic to penicillin
allergies to other Co-trimoxazole Sodium Fusidate
antimicrobials) Daptomycin Teicoplanin
Doxycycline Tigecycline
Erythromycin Tobramycin
Fusidic acid Trimethoprim
Gentamicin Vancomycin

August 2017 5
 3. INTRAVENOUS (IV) TO ORAL (PO) SWITCH POLICY
Evidence suggests that limiting IV antibiotic therapy to a maximum of 48 hours can reduce nursing time, drug costs,
adverse drug reactions, and even the length of inpatient stay. Patients receiving IV antibiotic therapy should be
converted to a suitable oral alternative when all the criteria listed below are met.
Inclusion criteria Exclusion criteria
 48 hrs IV antimicrobial therapy  All patients on ITU
 Oral drug formulation available or suitable  Patients with neutropenic sepsis
substitute  CNS infection (meningitis, encephalitis, brain abscess)
 Able to swallow & tolerate oral fluids  Severe cellulitis
 Normal GI absorption (no diarrhoea/vomiting)  Endocarditis
 Temperature <38°C  Central line infections (line in-situ)
 Patient has clinically improved  Immunosuppression
 Signs of infection are improving (e.g. WCC)  Deep abscess, lung abscess
 No unexplained tachycardia (i.e. the HR is  Empyema
<100bpm)  Ascending cholangitis
 IV treatment not indicated (see exclusion criteria)  Necrotising fasciitis
 Osteomyelitis*, septic arthritis* - *Not absolute exclusions.
Seek Micro advice.
 On advice of medical microbiologist

Focused IV to PO Switching Policy

IV Ciprofloxacin and IV Clarithromycin are subject to a specific focused IV to oral switch policy, with less restrictive
inclusion and exclusion criteria.

Inclusion criteria• Patient is able to swallow and tolerate oral fluids Exclusion criteria
• Patient has normal GI absorption (no diarrhoea, vomiting etc.)
• Patient has a temperature <38°C On the advice of a Medical Microbiologist
• Patient does not have an unexplained tachycardia (i.e. HR >100 bpm)

The process for pharmacists to change prescriptions, inform prescribers and document this in the notes is the
same for all IV to PO switches.
Please Note: dosages and frequency may need adjustment in patients with renal impairment.
Consult your Pharmacist for further advice.
Standard Intravenous Recommended Switch to Oral Additional Information
Antimicrobial Regimen Antimicrobial
Amoxicillin Amoxicillin 500mg-1g TDS ~ 90% oral bioavailability
Benzylpenicillin Amoxicillin 500mg-1g TDS Phenoxymethylpenicillin (Penicillin V) should be
avoided due to erratic absorption
Ceftriaxone No oral product available, contact Medical Microbiology
Ciprofloxacin Ciprofloxacin 500mg BD Discuss IV use with Microbiology/Pharmacy
70-80% oral bioavailability
Clarithromycin Clarithromycin 500mg BD Only 55% oral bioavailability but tissue conc. achieved
IV: 30 x price of oral satisfactory (>MICs). High risk of thrombophlebitis if IV
preparation used
Clindamycin Clindamycin 150mg-450mg QDS ~ 90% oral bioavailability
Co- amoxiclav Co-amoxiclav 625mg TDS ~ 70% oral bioavailability
(Augmentin®)
Flucloxacillin Flucloxacillin 500mg-1g QDS ~ 80% oral bioavailability on empty stomach
Gentamicin No oral product available, contact Medical Microbiology
Meropenem No oral product available, contact Medical Microbiology
Metronidazole Metronidazole 400mg TDS Or rectal 1g TDS for 3 days, then 1g BD. Switch to oral
therapy when possible
Rifampicin Rifampicin 300mg-600mg BD AVOID IV: 100% oral bioavailability
Sodium Fusidate Sodium Fusidate 500mg TDS AVOID IV: high risk of thrombophlebitis and jaundice,
95% oral bioavailability
Piperacillin/tazobactam No oral product available, contact Medical Microbiology
(Tazocin®)
Vancomycin Oral Vancomycin is not systemically absorbed. The oral route is restricted only for the
treatment of severe C. difficile

August 2017 6
4A. INPATIENT SEPSIS PATHWAY - UPDATED

August 2017 7
 4B. NEUTROPENIC SEPSIS

August 2017 8
5. ANTIMICROBIAL TREATMENT GUIDANCE
i. Sepsis and Central Nervous System Infections
INFECTION FIRST LINE PENICILLIN ALLERGIC DURATION COMMENTS
Fever in the Returned
See Section 8 and also Viral Haemorrhagic Fever Guidelines on the KCH intranet If suspected; isolate patient and discuss with Microbiology
Traveller
Community acquired Co-amoxiclav IV 1.2g TDS  Ensure the first dose of antimicrobials is administered
plus Gentamicin IV STAT then within an hour of patient presenting
Systemic

(within 72hours of Gentamicin IV

(unknown
Sepsis*

source)

admission) review plus Vancomycin IV Review after  Appropriate cultures including blood cultures must be
Hospital acquired Piperacillin/tazobactam plus Metronidazole 500mg IV 24 hours taken before starting antimicrobials
(72hrs or more after 4.5g IV TDS plus Gentamicin TDS  Review must be carried out within 24 hours
admission) IV MAX 2 doses  In septic shock, review and de-escalate treatment after
Severe Sepsis/Septic Shock Amikacin IV OD 24 hours or consult Microbiology
Meropenem 1g IV TDS Review after
Recent hospital admission or plus Vancomycin IV
plus Vancomycin IV 48 hours  Also see Section 4: Think Sepsis (pages 7 and 8)
inpatient for >72 hours plus Metronidazole 500mg IV
+ Gentamicin
(unknown source) TDS
Piperacillin/tazobactam  If a patient is known or suspected to be MRSA
4.5g IV TDS plus Gentamicin Teicoplanin IV 400mg positive (e.g. recent hospital admission, residence
IV OD MAX 2 doses (if >70Kg: 6mg/kg) every 12 hours in nursing home), appropriate antimicrobial cover
Neutropenic Sepsis MUST include IV Vancomycin
for 3 doses then OD
See separate Neutropenic Review after
If MILD penicillin allergy: plus Gentamicin IV
Sepsis guideline 24 hours *If clinical suspicion of Meningitis/CNS infections use
Meropenem 1g IV TDS +/- Ciprofloxacin 400mg IV BD
plus Gentamicin IV STAT (Only of benefit if patient is not on Ceftriaxone 2g IV BD
then review Ciprofloxacin prophylaxis)

Chloramphenicol 25mg/kg IV Duration will  Take blood cultures and EDTA blood for bacterial PCR
QDS (reduce dose as soon as depend on  Send urgent CSF if not contraindicated but DO NOT
Ceftriaxone 2g IV BD culture results DELAY IV ANTIMICROBIALS
clinically indicated. See separate
and on clinical  Send blood glucose at the same time as CSF
Central Nervous System Infections

Chloramphenicol guidelines)
If Listeriosis is suspected (patient response  Is patient immunocompromised? TB meningitis
immunocompromised or >50 suspected? Seek advice from GUM team, chest
Acute Meningitis If Listeriosis is suspected (patient
years of age) 7 days when consultant and Microbiology, as appropriate
immunocompromised or elderly)
ADD Amoxicillin 2g IV QDS no organism
contact Microbiology consultant  Notify all cases to the Consultant in Communicable
for treatment advice isolated Disease Control at the Public Health England (see
section 15)
If no contraindications, consider Dexamethasone 10mg IV QDS when bacterial
meningitis is suspected. First dose should be given prior to or at the same time  If patient has had multiple, recent courses of
as the 1st dose of antimicrobials. Continue for 2 - 4 days antimicrobials or has come from an area where
penicillin resistant S. pneumoniae is common (e.g.
14-21 days if Eastern & Southern Europe, America or the Far East),
If encephalitis suspected (Confusion, seizures or altered state of
Encephalitis HSV or VZV add Vancomycin IV
consciousness) ADD Aciclovir 10mg/kg IV TDS
confirmed  See Section 6 for prophylaxis of contacts (or Click here)
>90% caused by Enteroviruses and no treatment is necessary.  Meningitis and encephalitis: all suspected and
Viral Meningitis
Rarely caused by Herpes viruses where aciclovir can be used if there are signs of confirmed cases require isolation in a side room and
encephalitis (Confusion, seizures or altered state of consciousness) barrier nursing with respiratory precautions for at least
48 hours of antimicrobials

August 2017 9
 LOWER RESPIRATORY TRACT INFECTIONS
Management of Community Acquired Pneumonia (CAP) in Adults
Adapted from Guidelines for the Management of CAP in Adults: update 2009. British Thoracic Society.

Triage/Initial Assessment suggestive of CAP

Result of CXR reviewed by clinician

NO CONSOLIDATION CONSOLIDATION

Re-assess and consider Does the patient meet

alternative diagnosis criteria of CAP?

Yes No
Consider other diagnoses

Treat according to clinical

judgment and CURB-65 score

CURB-65 0-1 CURB-65 3-5

Low severity CURB-65 2 High severity
Medium
severity

Treat according to CAP

treatment guidelines

August 2017 10
ii. Lower Respiratory Tract Infections

INFECTION FIRST LINE PENICILLIN ALLERGIC DURATION COMMENTS

Community Acquired Pneumonia (CAP):
if patient presents within 5 days of hospital admission
Assess patient according to CURB-65 severity score and document in the notes:
Score 1 point if each of the following is present:
 Confusion; new onset
 Urea >7mmol/L
 Respiratory rate ≥30/min
 Blood pressure: SBP<90 or DBP ≤60mmHg
 65: Age ≥ 65 years
Community Acquired
Pneumonia (CAP) If a patient is known or suspected to be MRSA positive
Amoxicillin 500mg PO TDS
CURB-65: 0-1 (e.g. recent hospital admission, residence in nursing
Doxycycline 200mg PO OD home), appropriate antimicrobial cover MUST include
OR if unable to tolerate oral: 5-7 days IV Vancomycin
Community Acquired Clarithromycin 500mg IV BD*
Amoxicillin 1g PO TDS + Please send:
Pneumonia (CAP)
Doxycycline 200mg PO OD
CURB-65: 2  blood cultures
 sputum
 urine for legionella & pneumococcal antigen test
 pleural fluid if present
Co-amoxiclav 1.2g IV TDS 7-10days  CURB-65 ≥ 3 send viral swabs (nose and throat) for
Community Acquired Vancomycin IV
respiratory viral PCR
Pneumonia (CAP) plus
Plus IV
CURB-65: 3-5 Clarithromycin 500mg
antimicrobials  Young patients with life threatening illness may have a
OR critically ill patients IV or PO BD
Doxycycline 200mg PO OD to be reviewed low CURB-65
with If critically ill add :
CAP
OR
Gentamicin IV (review after 48
daily  *Clarithromycin is thrombophlebetic intravenously so
Clarithromycin 500mg IV or (see page 6: IV convert to oral as soon as possible.
hours)
PO BD to PO switch)  Consider TB as alternative diagnosis

If patient presents during the influenza season, consider anti-viral treatment according to following protocol ‘Respiratory Virus and Atypical Bacterial Infections:
Treatment and Infection Control Protocol for all Sites’:
http://kcgs/Documents/Respiratory%20Virus%20and%20Atypical%20Bacterial%20Infections%20Treatment%20and%20Infection%20Control%20Protocol.pdf

August 2017 11
Hospital Acquired Pneumonia (HAP)
if patient presents >5 days after hospital admission
Hospital Acquired If poor clinical If a patient is known or suspected to be MRSA
Amoxicillin 1g IV TDS positive (e.g. recent hospital admission, residence in
Pneumonia plus improvement
(No recent history of iv after 48 hours, nursing home), appropriate antimicrobial cover
Gentamicin IV MUST include IV Vancomycin
antimicrobial use/ ICU or Vancomycin IV consider
hospital admission) plus alternative
diagnosis Please send:
Ciprofloxacin IV 200mg BD or Ciprofloxacin IV 200mg BD or  blood cultures
Hospital Acquired 500mg PO BD 500mg PO BD
Pneumonia 5-7 days  sputum
plus
(Previous iv antimicrobials  urine for legionella & pneumococcal antigen test
Flucloxacillin 1g IV QDS  pleural fluid if present
or ICU admission)
Or 0.5-1g PO QDS
Vancomycin IV
plus Confirm by evidence of consolidation on CXR
Co-amoxiclav 1.2g IV TDS
Healthcare associated Clarithromycin 500mg
plus
pneumonia (i.e. nursing IV or PO BD 5-7 days
Doxycycline 200mg PO OD
home) If critically ill add :
Gentamicin IV (review after 48
hours)
Amoxicillin 1g IV TDS Vancomycin IV
48 hours then
plus Gentamicin IV plus Gentamicin IV
Aspiration Pneumonia review
plus Metronidazole 500mg IV TDS plus Metronidazole 500mg IV TDS

Infective Exacerbation of Antimicrobial should be used to treat exacerbation with a

Doxycycline 200mg PO OD 7 days
COPD history of increased amount of purulent sputum

Pulmonary Tuberculosis
Refer to the Respiratory Physicians

August 2017 12
iii Eye, Ear, Nose and Throat Infections
INFECTIONS
Tonsillitis - Majority viral (90%
resolve in 7 days without antibiotics)
Bacterial causes:  haemolytic
Streptococci (BHS) e.g. groups A,C
&G
Quinsy/Peri-tonsilar Abscess
 haemolytic Streptococci (BHS) e.g.
groups A,C & G, Anaerobes
Acute Otitis Media (AOM) Common
in children and usually
Viral in origin.
 Haemolytic Streps, Haemophilus
influenzae, Moraxella catarrhalis
Acute Mastoiditis
Commonly caused by: Strep.
pneumoniae, Haemophilus influenzae,
or Moraxella catarrhalis. Less common
causes are Group A Streptococci,
and Staph. aureus.
Acute Otitis Externa (AOE)
S. aureus,  Haemolytic Streps,
Fungi including Aspergillus sp. , and
Pseudomonas may be isolated
Necrotising/Malignant Otitis
Externa
Cause: As AOE, plus anaerobes
August 2017
FIRST LINE CHOICE
If 3 or more of the following, give antibiotics: temp ≥38°C, absence of cough,
swollen anterior cervical nodes, tonsillar swelling/pus
Phenoxymethylpenicillin 500mg PO
QDS
Benzylpenicillin 1.2g IV QDS
plus Metronidazole 500mg IV TDS
Stepdown: Co-amoxiclav 625mg PO
TDS
Amoxicillin 500mg TDS
Second line
Co-amoxiclav 625mg PO TDS
Non-severe: Co-amoxiclav 625mg PO
TDS
Severe: Co-amoxiclav IV
1.2g TDS
Mild: Locorten Vioform eardrops or Aluminium Acetate ear drops
Severe: Flucloxacillin 500mg PO
QDS
Piperacillin/tazobactam 4.5g IV QDS
plus Gentisone® HC eardrops:
3 drops TDS for 7-14 days
Oral Stepdown:
Ciprofloxacin 500mg PO BD
PENICILLIN ALLERGIC
Clarithromycin 500mg PO
BD
Clindamycin 1.2g IV QDS
Stepdown:
Clindamycin 300mg PO
TDS
Clarithromycin 500mg PO
BD
Discuss with Microbiology
Clarithromycin 500mg PO
BD
Discuss with Microbiology
COMMENTS
Modified Centor Score system can be used.
www.mdcalc.com to assess antibiotic usage, based upon
age, lymphadenopathy, absence of cough, fever and
7 – 10 tonsillar exudates.
days Antibiotic usage has been shown to prevent quinsy and
otitis media
 Abscess formation (between the tonsil and lateral
pharyngeal wall) as a complication of acute
tonsillitis/pharyngitis. Usually unilateral.
7 – 10
 Pain can be severe, associated with otalgia, trismus,
days dysphagia and drooling of saliva. Patient usually pyrexial
and systemically unwell.
 Refer to ENT
 Send Throat swab and drained pus
60% resolve without antibiotics within 24 hours
Consider referral to ENT in cases of treatment failure
5 days
AOM is rare in adults and referral to a specialist should be
considered on clinical grounds
A complication of AOM, presented with otalgia, tenderness
over the mastoid antrum +/- narrowing of external ear canal
 CT or MRI scan is required to confirm the diagnosis
2-4  Send a sample: post-auricular abscess or mastoid cavity
weeks following surgical drainage
 Chronic mastoditis may follow. Chronic suppurative otitis
media (cholesteatoma); surgical intervention is usually
the treatment of choice.
7 days Keep ear clean and dry
If persistent and extending outside the ear canal, start
antibiotics and refer to a specialist
5 days. Swimmer’s ear may require Ciprofloxacin (adults only)
4-6  Surgical debridement is often required, consider referral
Weeks to ENT if symptoms extend outside the ear
 Ensure swabs are taken prior to starting topical therapy
 Assess for any bone and intracranial extension
 All cases to be discussed with microbiology
 Switch to orals based on clinical assessment and
microbiological results
13
Peri-Chondritis
Infective causes: Pseudomonas
aeruginosa, Staph. aureus and 
Haemolytic Streps
Non-infective causes: autoimmune
and trauma
Sinusitis
As AOM, plus anaerobes,
Pseudomonas
Acute Epiglotitis
Periorbital (pre-septal)/Facial
Cellulitis
Causes include Staphylococcus
aureus, Group A streptococci,
Streptococcus pneumoniae +/-
anaerobes, or rarely Haemophilus
influenzae
EYE INFECTIONS
Acute Conjunctivitis
(adults or children)
Viral, Staph. aureus,
Beta Haemolytic Streps,
Pneumococci,
Haemophilus influenzae
August 2017
Ciprofloxacin 500mg PO BD
Plus Flucloxacillin 500mg PO QDS
Amoxicillin 500mg PO TDS
If persistent or severe worsening of
symptoms
Co-amoxiclav 625mg PO TDS
Ceftriaxone 2g IV BD
Stepdown PO: discuss with
Microbiology
Co-amoxiclav 1.2g IV TDS
OR
Cefuroxime 1.5g IV TDS
plus
Metronidazole 400mg PO TDS or
500mg IV TDS
Note most conjunctivitis is viral – consider if antimicrobial treatment is required
65% resolve on placebo
Chloramphenicol 0.5% eye drops OR 1% eye ointment QDS. (OTC)
Fusidic Acid 1% eye drops BD (only active against staphylococci, no Gram negative activity).
Discuss with Microbiology
Doxycycline 200mg PO Stat
then 100mg OD daily
OR
Clarithromycin 500mg PO
BD
Chloramphenicol
25 mg/ kg IV QDS
(Contact Microbiology)
Vancomycin IV
plus
Ciprofloxacin 500mg PO
BD
plus
Metronidazole 400mg PO
TDS or 500mg IV TDS
OR
7 days
Consider if antibiotic treatment is necessary. If evidence
of purulent nasal discharge after 5-7 days:
7 days Consider ENT referral for drainage of chronic infections
 Immediate and Urgent anaesthetist referral is crucial
in management
 Life threatening condition requires urgent ENT
referral.
 Usually caused by H. influenzae but also Group A
7 days Streptococcus, Pneumococcus
 If IV Chloramphenicol used refer to separate
guidelines as plasma concentration monitoring and
dose adjustment may be necessary.
 Acute eyelid erythema and oedema, sometimes with
associated pain, conjunctivitis, and excessive eye
watering and blurred vision
10 – 14 Give IV until all swelling and redness subside, then
days complete oral course of a suitable antibiotic, e.g. Co-
amoxiclav or Clarithromycin with Metronidazole
 refer to ENT, Ophthalmology and seek microbiology
advice
Continue treatment for 2 days
after resolution of symptoms but
for a maximum of 7 days`
14
iv. Gastro Intestinal Infection

INFECTION FIRST LINE PENICILLIN ALLERGIC DURATION COMMENTS

Metronidazole 500mg IV TDS If a patient is known or suspected to be MRSA

Intra-abdominal sepsis - not
post operative (e.g. peritonitis,
diverticulitis, biliary sepsis)
Cirrhotic patients with Intra-
abdominal sepsis/SBP
not post-operative (e.g.
peritonitis, diverticulitis, biliary
sepsis, variceal bleeding)
Post-operative abdominal
sepsis (nosocomial)
Gentamicin IV
plus Metronidazole 500mg IV TDS
plus Amoxicillin 1g IV TDS
Co-amoxiclav 1.2g IV TDS
plus
Ciprofloxacin 500mg PO BD
If known or suspected MRSA ADD
Vancomycin IV
(Use Ciprofloxacin 400mg IV BD
only if patient NBM or not absorbing
oral medication)
Co-amoxiclav 1.2g IV TDS
plus Gentamicin* IV
If known or suspected MRSA ADD
Vancomycin IV
plus Gentamicin IV positive (e.g. recent hospital admission,
+/- Vancomycin IV residence in nursing home), prescribe
5 days then
antimicrobials according to penicillin allergic
review
When switching to oral check regimen
culture results, discuss with When switching to oral treatment:
microbiology or pharmacy Contact Medical Microbiology for advice
 Patients with cirrhosis may not manifest
Metronidazole 500mg IV TDS sepsis with classical SIRS pattern - a low
plus threshold for antimicrobials is required
Vancomycin IV  Patients with decompensated cirrhosis
plus (jaundice, encephalopathy, worsening renal
Review after 48
Ciprofloxacin 500mg PO BD function, new onset of ascites and variceal
hours
bleeding) should be considered to be septic
Maximum 7 days
until proven otherwise
(Use Ciprofloxacin 400mg IV  Caution with Gentamicin due to risk of hepato-
BD only if patient NBM or not renal failure
absorbing oral medication)  Send blood and urine cultures and ascites if
present
*Review need for Gentamicin daily
Metronidazole 500mg IV TDS
5 days then
plus Gentamicin* IV
review
plus Vancomycin IV

Antimicrobials not required in acute pancreatitis with no evidence of infection. Treat as per intra-abdominal sepsis (see above) if treatment
Acute Pancreatitis
required. Duration to be decided on individual basis: contact the Microbiologist to discuss
Duration  Surgical debridement is essential
Meropenem 1g IV TDS Metronidazole 500mg IV TDS
dependent on  Urgent surgical and ITU referral
Acute Necrotising Pancreatitis plus Gentamicin IV
management.  Contact Microbiology for early referral
If known or suspected MRSA ADD plus Vancomycin IV
Vancomycin IV
Regular review.  Review antimicrobials with culture results
 Isolate patient
Acute Gastroenteritis usually
Usually self-limiting and No antibacterial treatment required  Send stool sample
caused by viruses,
campylobacter, salmonella,
If evidence of systemic symptoms or patient severely ill N/A  Infective gastroenteritis is a notifiable disease;
Contact Medical Microbiology for advice notify Public Health if cultured
shigella
 Maintain electrolyte and fluid balance

August 2017 15
v. Clostridium difficile Infection (CDI)
INFECTION
Clostridium difficile
associated diarrhoea
Mild to Moderate
Non-Pregnant
Severe and/or pregnant
e.g. ≥ 1 of white cell count >15 x
109/L, rise in serum creatinine
>50% above baseline, evidence
of severe colitis abdo/radiological
signs), temperature >38.5ºC
Life Threatening Infection
i.e. hypotension, partial or
complete ileus, clinical or CT
evidence of toxic megacolon or
severe colitis
2nd Episode/ relapsing CDI
(Non-Pregnant patients)
August 2017
FIRST LINE
Metronidazole
400mg PO TDS
Vancomycin*
125mg-250mg PO QDS.
Microbiology. Fidaxomicin
If at risk of recurrence
contact Medical Microbiology
non-pregnant patients
Vancomycin* up to 500 mg
PO QDS (via nasogastric
tube if needed) Plus
Metronidazole
500mg IV TDS
AND contact Consultant
Microbiologist
Fidaxomicin 200mg PO BD
SECOND LINE DURATION COMMENTS
All Suspected / Positive cases should be discussed
with Infection Prevention and Control Team
Vancomycin* S Suspect that a case may be infective where there
10-14 days
125mg PO QDS is no clear alternative cause for diarrhoea.
I Isolate the patient and consult with the Infection
Prevention and Control Team while determining the
cause of the diarrhoea.
G Gloves and aprons must be used for all contacts
with the patient and their environment.
H Hand washing with soap and water should be
carried out before and after each contact with the
patient and the patient’s environment.
T Test the stool for pathogens, by sending
Contact Medical specimens immediately
10-14 days
may be indicated for  Review patients with C difficile infection at least
daily for signs of progression and seek
gastroenterology and/or surgical opinion in
severe infection
 If symptoms not improved after 5 days discuss
with microbiology
 Stop the precipitating antibiotics unless absolute
clinical need
 Review PPI’s and stop if possible
Contact Medical  Stop laxatives
10-14 days
Microbiology  Be alert for features of life-threatening infection.
 The absence of diarrhoea does not necessarily
exclude a diagnosis of C. difficile infection if other
features are present e.g. high WBC count or fever
without an alternative cause. Refer to the full C.
difficile management
guideline on the Kingsweb Infection Resources
Pages http://kweb/kwiki/Infection_Resources
10 days
*Vancomycin –Use injection orally. Vancomycin
capsules reserved ONLY for TTA/outpatients
16
vi. A. Diagnosis Algorithm UTI
– NEW SECTION
Lower UTI Diagnosis Algorithm

Is the patient catheterised?

Catheterised Not catheterised

Does the patient have signs of infection?
 Fever/rigors or Classic symptoms of UTI Nonspecific symptoms No symptoms
 Suprapubic/renal angle tenderness or e.g. Dysuria, Frequency, e.g. elderly with New Onset e.g. Smelly/Cloudy urine
 Delirium Lower Abdominal Pain Confusion,
AND consider other causes first
 Other source of infections must be excluded
UTI Unlikely
 Do not routinely
Yes No dipstick or send for
UTI Likely UTI Unlikely Dipstick MSU sample culture
 Urine dipstick not  Urine dipstick not  Reassess if patient
useful useful becomes symptomatic
 Send Urine for  Do not send Nitrate & Leucocytes Nitrate & Leucocytes Nitrate & Leucocytes  If culture positive but
MC&S cultures Both positive One positive only Both Negative asymptomatic, see
asymptomatic
bacteriuria box below
UTI Likely Possible UTI UTI unlikely
Assess for sepsis & - Continue to  Send MSU for M C &S  Send MSU for M  Reassess for other
treat according to Monitor the patient  Assess for sepsis and C&S causes of
PRUH Antimicrobial - Do not start  Await M C&S result symptoms
treat according to the
Guidelines antibiotics PRUH Antimicrobial before treatment  Do not treat unless
Guidelines unless signs of sepsis signs of sepsis
present
Asymptomatic Bacteriuria
Asymptomatic bacteriuria is the detection of bacteria in the urine with absence of symptoms. Please note:
 It is very common in the elderly
 Not related to increase morbidity or mortalities
 Antibiotics do not improve outcomes but increase risks of Clostridium difficile and antibiotic resistance
August 2017
 Please Do not send urine for culture on patients who do not have symptoms
17
vi. B Urinary Tract Infections – UPDATED
Lower Urinary Tract
Infections (Cystitis)
Lower Urinary Tract
Infections (Cystitis) in
pregnancy
Upper Urinary Tract
infections (Pyelonephritis)
Catheter associated UTI
(Ca-UTI)
Urinary Catheterisation
Asymptomatic bacteriuria
August 2017
1st Line Nitrofurantoin 50mg PO QDS (avoid if eGFR <45ml/min)  Collect urine sample before starting antimicrobials
2nd Line Pivmecillinam 400 mg PO STAT, then 200 mg TDS  Antimicrobial resistance is common: review
treatment once sensitivity results available
Female: 3 days  *Nitrofurantoin is contraindicated in the last 4
If patient not responding, give a STAT dose of Gentamicin IV until Male: 7 days weeks of pregnancy
culture and sensitivity results are available  **Trimethoprim is contra-indicated in the first
trimester
Trimethoprim 200mg PO BD may only be used if known sensitive  Trimethoprim can inhibit tubular secretion of
creatinine and should be considered as a
Nitrofurantoin* 100mg PO QDS contributor if there is an elevation in serum
(avoid if eGFR <45ml/min) creatinine
Cefalexin 500mg PO TDS 7 days  Pivmecillinam: Has gram negative action only.
OR Trimethoprim** 200mg PO BD Contraindicated if impaired transit through the
(If known sensitive) oesophagus (risk of ulceration). Concomitant use of
valproate and valproic acid must be avoided
Co-amoxiclav 1.2g IV TDS
Gentamicin IV
plus Gentamicin IV If patient does not require admission, consider
then review when sensitivities are 10-14 days
then review when sensitivities Ciprofloxacin 500mg PO BD
available
are available
Best Practice Guide:
All catheters become colonised with bacteria. A positive urine dipstick or the presence  Avoid unnecessary catheterisation
of an organism in a catheter specimen of urine is not an indication for treatment without  Remove urinary catheters as soon as possible
evidence of clinical infection e.g. ↑ temp, WCC or CRP  Do not send routine catheter urines for testing and
do not start antimicrobials if urine cloudy or smelly
If patient has Ca-UTI and/or purulent catheter exit site discharge change or remove with  Dipstick testing should not be used to diagnose
Gentamicin 160mg IV or IM STAT UTIs in catheterised patients
 Send catheter urines only if patient is symptomatic
OR as part of a septic screen
See Section 6: Antimicrobial Prophylaxis in Medicine
Asymptomatic bacteriuria: treat only if pregnant
Asymptomatic bacteriuria in the elderly is common; antimicrobial treatment can be more harmful than beneficial and should NOT be offered
18
vii. Infective Endocarditis: Initial empirical treatment – UPDATED
INFECTION
Community Acquired
Native Valve or Late
Prosthetic Valve (≥ 12
months) Infective
Endocarditis
Early Prosthetic Valve
Infective Endocarditis
(<12months) or healthcare
associated
(Also pacemaker, other
implanted foreign material)
August 2017
FIRST LINE
Amoxicillin 2g IV 4hrly plus
Flucloxacillin 2g IV 4hrly plus
Gentamicin IV 3mg/kg OD*
Treat as in pen allergy if Known
or at Risk of MRSA
Vancomycin IV
plus Gentamicin IV 3mg/kg OD*
plus Rifampicin 300-600mg PO BD (IV route only if unable to tolerate
oral)
PENICILLIN ALLERGIC/
DURATION COMMENTS
MRSA KNOWN OR SUSPECTED
 Take blood cultures (3 sets, plus a serum sample)
before antimicrobials
Vancomycin IV  Indolent presentation (>1 week of duration): if
plus Gentamicin IV 3mg/kg OD* patient is stable it is reasonable to await blood
culture results before starting antimicrobials
Duration to be  Seek an urgent cardiology review
advised on  Monitor LFTs, FBC and CRP
individual  Discuss with Microbiologist (see contact details in
patient basis section 14)
by  Review antimicrobials when blood cultures results
Microbiology available
but usually  Monitor gentamicin levels as per guidelines
4-6 weeks  * Discuss with Microbiology or Pharmacy if impaired
renal function (CrCl < 30mL/min)
 NB: For overweight and obese individuals (<20%
over Ideal Body Weight), dosing and creatinine
clearance should be calculated using Adjusted
Body Weight (see formulae in Section 13)
19
 viii. Genito-Urinary Infections

REFER all acute GU patients to Sexual Health Clinic. The patient should attend GUM clinic the following morning.
 All sexually active patients should be offered screening for Sexually Transmitted Infections (STI) and HIV
 Ensure pregnancy test for all female patients
 See Antimicrobial Treatment and Prophylaxis Guidelines for Obstetrics and Gynaecology
INFECTION FIRST LINE PENICILLIN ALLERGIC DURATION COMMENTS

Ceftriaxone 500mg IM STAT
Pelvic Inflammatory Disease
plus Doxycycline 100mg PO BD
Mild to moderate infection
plus Metronidazole 400mg PO BD
Pregnant
Doxycycline 100mg PO BD
plus Metronidazole 400mg PO BD
plus Spectinomycin 2g IM STAT if
suspected STI
 EXCLUDE pregnancy before treating as an out-patient
 PID is extremely rare in pregnancy
 If patient penicillin allergic, determine details and if non-
severe penicillin allergy, e.g. delayed onset of rash,
consider 1st line antimicrobials

Ceftriaxone 2g IV OD Clindamycin 900mg IV TDS Total 14  Before starting antimicrobials, send:

Non-

Pelvic Inflammatory days o MSU

plus Doxycycline 100mg PO BD plus Gentamicin IV OD
Disease o Screen for Chlamydia and Gonorrhoea
plus Metronidazole 400mg PO BD plus Spectinomycin 2g IM STAT if
Severe infection  IV to oral switch in accordance with IV to oral switch
suspected STI
e.g. pyrexia >38°C, policy
Pregnant

clinical signs of tubo  Metronidazole may be stopped after 5 days

feeding
/Breast

Ceftriaxone 2g IV OD
ovarian abscess, signs
plus Erythromycin 500mg PO QDS
of pelvic peritonitis
plus Metronidazole 400mg PO BD
Switch to
 Spectinomycin is an unlicensed medicine and
Clindamycin 450mg PO QDS
requires importing.

Epididymo-orchitis likely Sexually
transmitted pathogen (urethral
discharge, recent partner change)
Epididymo-orchitis likely Enteric
organisms (recent instrumentation/
catheterisation)
Ceftriaxone 1g IV OD plus Gentamicin IV OD then switch to oral agents
Acute Prostatitis
For patients suitable for oral therapy: Ciprofloxacin 500mg PO BD
Chronic Prostatitis
Acute Genital Herpes
August 2017
 Start antimicrobials after sending MSU and urethral
Ceftriaxone 500g IM STAT 10-14 swab
plus Doxycycline 100mg PO BD days  All patients with sexually transmitted epididymo-orchitis
should be screened for STI
 All patients with urinary tract pathogen confirmed
epididymo-orchitis should be investigated for structural
10
Ciprofloxacin 500mg PO BD abnormalities and urinary tract obstruction by a
days
urologist
 In young males, consider possibility of mumps orchitis
Start antimicrobials immediately after sending MSU & BC
28 Review according to sensitivity results
days Treatment of acute/chronic prostatitis could be switched
to Trimethoprim 200mg BD for 28 days in patients with
28 Ciprofloxacin allergy, previous or high risk C. difficile or
Ciprofloxacin 500mg PO BD history of epilepsy
days
 Take viral (green top) swabs from base of
lesions/scrapings from genital ulcers. Place samples in
viral transport medium immediately after collection
Aciclovir 200mg PO five times daily
 Treatment should be initiated within 5 days of the start of
(use Aciclovir 400mg 5 times daily in severe infections or
5 days the episode
immunocompromised patients)
 Consider prescribing regular analgesia and topical
lidocaine ointment 5% (apply when required) for all
patients
20
ix. Infections of the Skin, Soft Tissues, Joints and Bones
INFECTION
Non-severe Cellulitis
Severe Cellulitis
(includes any cellulitis of the
hand or face)
Necrotising Fasciitis
(Group A Streptococci)
Fever, severe pain, swelling
and redness
Synergistic Gangrene
e.g. Fournier’s
Animal or Human Bite
Severe Animal or Human
Bite (severe cellulitis
following animal or human
bite)
Septic Arthritis/
Acute Osteomyelitis
Septic Arthritis/
Acute Osteomyelitis and
MRSA is a possibility
Prosthetic Joint Infections
August 2017
FIRST LINE PENICILLIN ALLERGIC DURATION COMMENTS
Flucloxacillin 500mg PO QDS Clarithromycin 500mg PO BD
7-14 days
If known or suspected MRSA  Wound swab if broken skin
Doxycycline 200mg PO STAT then 100mg BD  Draw demarcation lines
Flucloxacillin 1g IV QDS  Blood culture when appropriate
OR
Vancomycin IV 7-14 days
If known or suspected MRSA
Vancomycin IV
 Surgical debridement is essential
Duration
Meropenem 1g IV TDS Vancomycin IV  Urgent surgical and ITU referral
dependant on
plus Clindamycin 1.2g IV QDS plus Clindamycin 1.2g IV QDS  Contact Microbiology for early referral
management
+/- Gentamicin IV plus Gentamicin IV
Regular review  Consider the addition of IVIG
 Review antimicrobials with culture results
Doxycycline 200mg OD
Co-amoxiclav 625mg PO TDS  Clean wound thoroughly
plus Metronidazole 400mg PO TDS
 Assess risk of tetanus
Ciprofloxacin 500mg PO BD 7 days  Human bites, assess HIV / Hepatitis B & C risk
Co-amoxiclav 1.2g IV TDS plus Vancomycin IV  Consider rabies prophylaxis for bites from animals
plus Metronidazole 400mg PO TDS in endemic countries
Septic Arthritis
Flucloxacillin 2g IV QDS
 Send joint aspirate and BC before starting
antimicrobials. Culture results essential to
If patient elderly, frail, has a Vancomycin IV Usually 14 days
determine treatment
history of recurrent UTIs or recent IV
 Gonococcus should be considered in young and
abdominal surgery add Total of 6 weeks
sexually active patients
Gentamicin IV
Osteomyelitis
 Send BC in acute haematogenous osteomyelitis
Vancomycin IV  Consider addition of Sodium Fusidate if isolate is
If patient elderly, frail, has a history of recurrent UTIs or recent abdominal sensitive
surgery ADD Gentamicin IV
 Surgical debridement is essential
 Take multiple specimens (5 x cultures and 5 x
Review with histology)
Vancomycin IV plus Gentamicin IV
Microbiology  Give antimicrobials AFTER sampling
 Change to appropriate antimicrobials once
organisms have been identified
21
6. ANTIMICROBIAL PROPHYLAXIS IN MEDICINE

INDICATION FIRST LINE PENICILLIN ALLERGIC COMMENTS

Phenoxymethylpenicillin Erythromycin 250mg PO BD

Asplenia/Sickle Cell Please refer to : “Spleen: Prevention and Treatment of Infection in Patients with Absent
(Pen V) (or 500mg PO OD if
Disease or Dysfunctional Spleen” on Intranet
250 - 500mg PO BD compliance issues)

 Inform Public Health England, Health Protection Team for contact tracing and
prophylaxis advice of close contacts

Close contacts of a
Phenoxymethylpenicillin
case of invasive
Group A
Streptococcal (GAS)
disease
Meningococcal
Chemoprophylaxis:
Should be offered to
close contacts,
irrespective of
vaccination status, that
require public health
action (see comments)
Close contacts of
Haemophilus
influenza type B
Change or removal of
long term urinary
catheter
Insertion/removal of
urinary catheter in If catheter or catheter exit site is colonised with S.aureus or a
painless (chronic)
urinary retention
Removal of urinary
catheter if urine or
meatus colonised
with S.aureus
Prophylaxis should be offered to Mother and baby if either develop invasive GAS
disease in the first 28 days of baby’s life
(Pen V) Azithromycin 500mg PO OD
500mg PO QDS for 5 days
Close contacts with symptoms suggestive of localised GAS infection (i.e. sore throat,
for 10 days
fever, skin infection) within 30 days of the diagnosis in an index patient should be
advised to seek urgent medical attention and be treated accordingly
Please refer to Antimicrobial management of invasive Group A Streptococcal disease
and of close contacts
 Inform Public Health England, Health Protection Team for contact tracing and
prophylaxis
 Chemoprophylaxis of close/household contacts that have accompanied the
In Adults (including Pregnancy) : patient and are in the hospital should be agreed with the HPU
Ciprofloxacin 500mg PO as a single dose (First line)  Health Care Workers (HCWs) only need prophylaxis if direct facial exposure to
OR respiratory secretions (e.g. inserting an airway, suctioning without a mask)
Rifampicin 600mg PO BD for two days HCWs must reduce the possibility of exposure by wearing surgical masks and
using closed suction when carrying out airway management procedures
 If patients with meningococcal disease are treated with IV Benzylpenicillin then
prophylaxis is required to eliminate nasopharyngeal carriage
 Inform Public Health England, Health Protection Team for contact tracing and
Rifampicin 600mg PO OD for 4 days prophylaxis
 Ensure Hib vaccination up-to-date
Best Practice Guide:
 Avoid unnecessary catheterisation
Gentamicin 160mg IV or IM STAT  Remove urinary catheters as soon as possible
 Do not send routine catheter urines for testing and do not start antimicrobials if
urine cloudy or smelly
history of MRSA ADD Doxycycline 200mg PO STAT  Dipstick testing should not be used to diagnose UTIs in catheterised patients
 Send catheter urines only if patient is symptomatic OR as part of a septic screen

August 2017 22
 7. OUTPATIENT PARENTERAL ANTIBIOTIC THERAPY (OPAT) FOR CELLULITIS
Class I Class II Class III Class IV
Patients have no sign of Patient has two or more SIRS Sepsis with SIGNS of Severe life threatening
systemic toxicity, have no criteria: ORGAN DISFUNCTION, such infection like necrotizing
uncontrolled co-morbidities T: <36 or >38 °C as acute confusion, new need fasciitis.
HR >90 BPM for O2 to keep SpO2>90%,
Treat as an Out-Patient with RR>20 BPM hypotension (BP <90/60) or -Rapid progression of
antibiotics WCC: <4 or >12x10 /L
9
lactate >2mmol/L erythema,
st
1 Line: OR -Severe pain and
but NO SIGNS of ORGAN Unstable co-morbidities that -Symptoms out of
Flucloxacillin 500mg PO QDS DYSFUNCTION may interfere with response to proportion to clinical
OR treatment signs
If penicillin allergic or
Systemically well but with a co- OR
suspected MRSA: Dual
morbidity such as: Limb threatening infection due
Therapy:
 Peripheral vascular disease to vascular compromise
Doxycycline 200mg STAT then
100mg BD PLUS  Chronic venous insufficiency
Trimethoprim 200mg PO BD  Morbid obesity

Treat for 7-14 days & review Consider for OPAT Requires admission for IV Antibiotics and
rd
on the 3 day regular monitoring – See PRUH
Antimicrobial Treatment Guidelines

Class I Class II
If oral treatment failure after 3 days: Discuss Referrals must be agreed by ED or Ambulatory Unit
with ED/AU/ Microbiology Consultant – consider Consultant/ SpR
OPAT Exclusions
- Hand cellulitis – Refer to Orthopaedics
- Peri-orbital cellulitis – Refer to ENT/ Maxillofacial
- Confusion – Refer to MEDICS
- Cellulitis following contamination with fresh/salty
water: discuss with a microbiologist
- IVDU – Refer to MEDICS
- Animal bites/facial cellulitis– see notes below
- Diabetic ulcers – Refer to Medics

Age No PENCILLIN ALLERGY PENICILLIN ALLERGY or Know/at Risk of

MRSA infection
Over 70

Dual Therapy Dual Therapy

Years

1- Teicoplanin* Dose as below - for 3-5 days 1- Teicoplanin* Dose as below - for 3-5 days
PLUS PLUS
2- Flucloxacillin 1g PO QDS for 10 days 2- Doxycycline 200mg STAT then 100mg PO BD
NOTE: When switching to dual oral therapy for 10 days
70 Years
Under

Ceftriaxone 2g IV OD for 3-5 days 1- Trimethoprim 200mg PO BD

FOLLOWED BY (when appropriate) PLUS
Flucloxacillin 1g PO QDS for 10 days 2- Doxycycline 100mg PO BD

Assess progression regularly. Remember to check culture results when available and adjust treatment accordingly

*Doses of Teicoplanin : 800mg IV OD on day 1 (Loading dose) Then dose according to body weight, 18-24 hours after loading
dose, <70kg 400 mg OD, 70-100kg 600mg OD, >100kg 800mg OD
Doses of Teicoplanin in Renal Impairment: Give standard loading dose to all patients as above. If Creatinine Clearance (CrCl)= 20-
50ml/min: dose as in normal renal function (as above), If CrCl= 10-20ml/min then give loading dose as above followed by a dose every
24-48 hours. If CrCl=<10ml/min then give loading dose as above then give 200mg-400mg every 48-72 hours
Consider Co-amoxiclav 625mg TDS for mild human/animal wound bites or facial cellulitis (no peri-orbital involvement). Discuss with
Microbiology of allergic to penicillin
Follow the steps below when starting treatment
 Laboratory Investigations: FBC, U&Es, CRP- additionally send swabs if wound or pus present – before starting the antibiotics
 Mark the cellulitic area, in order to assess response to treatment – before starting the antibiotics
 ED/AU Consultant or Senior review to confirm suitability for OPAT
 Give first dose of IV antibiotics according to guidelines above
 Prescribe subsequent IV doses and follow up with oral antibiotics according to OPAT pathway
 Complete ‘Transfer to UCC care’ checklist on OPAT pathway
 Photocopy ED or AU notes and give to the patient with referral letter and information pack
 Inform the patient to Contact the PRUH UCC (Tel. 01689 863050) to book an appointment for the following days of IV antibiotic
 Green: Safe to use in Penicillin allergy, Orange: can be used in minor Penicillin allergy, Red: Do not use in Penicillin allergy
August 2017 23
 8. OUTPATIENT PARENTERAL ANTIBIOTIC THERAPY (OPAT) FOR PYELONEPHRITIS

PRUH Pyelonephritis OPAT pathway

 Clinical diagnosis of pyelonephritis requiring IV antibiotics

 Send MSU (before the start of Antibiotics) and check if there are any previous results
 Document urine dipstick and pregnancy status
 Blood for U&E, FBC and CRP

Is the patient eligible for ambulatory care? i.e. fulfil the Ambulatory Care
Admission criteria and
 Clinically stable
 Physically and mentally able

No Yes

Refer to Medicine Refer to Ambulatory Care Unit

Treat according to the PRUH Is the eGFR>60ml/min?

Antibiotic Treatment Guidelines

Yes No

Gentamicin - dose as per guidelines Discuss with duty

Monitor level according to guidance (see Trust Consultant Microbiologist
Antimicrobial Guidelines) Ext. 64287
Consider side effects and contraindications

24 hours : check urine Microscopy

If no WBC re-consider diagnosis

2-3 days

Check result for an oral antibiotic option.

Treat for 10 – 14 days in total

If culture results are not known refer to the duty

Consultant Microbiologist Ext. 64287

Discuss with Microbiology if resistance. Review culture results after 3 days and treat accordingly. Patients
generally require 2-3 days of IV antibiotic treatment and changed to oral when sensitivities are known.
August 2017 24
 9. FEVER IN THE RETURNED TRAVELLER
Table 1: Common or important causes of fever associated w ith geographical area and specific
risk factors. See also Zika virus guidelines on KCH intranet.

Detailed travel history

• Travel destination(s) (table1), including the particular area within a country, duration of stay, date of return in
relation to onset of symptoms including countries visited in transit.
• Whether urban or rural areas were visited, purpose of travel (to indicate any occupational exposure), standard of
accommodation, contact with animals.
• Pre-travel vaccination, type and adherence to malarial prophylaxis, illness of any travel companions.
• History of sexual activity and any non-prescribed or illicit drug use.
Thorough clinical examination
• Is there an obvious source or cause for the fever? Localising symptoms and signs may give a clue as to the
underlying diagnosis. A large proportion of febrile returning travellers will have ordinary infections such as
pneumonia or urinary sepsis.
• Are there any manifestations of sepsis, shock or haemorrhage? Possibility of bacterial sepsis (e.g. enteric fever,
meningococcal sepsis), severe and complicated malaria, dengue haemorrhagic fever and viral haemorrhagic
fevers. Nurse in strict isolation and contact the microbiology consultant.
• The timing of symptoms in relation to travel and date of return can exclude certain imported diagnoses and make
others more likely (table 2).
AREA/RISK FACTOR COMMON OCCASIONAL RARE BUT IMPORTANT
Viral Haemorrhagic F ever,
Dengue, Acute
Malaria, Rickettsial other Arbovirus (e.g. Rift
Schistosomiasis,
Sub-Saharan Africa infections, HIV, Enteric Valley, W est Nile, Yellow
Meningococcal
Fever (typhoid fever) fever), Histoplasmosis,
Disease
Visceral Leishmaniasis,
North Africa, Middle
East and Brucellosis Visceral Leishmaniasis
Mediterranean
Eastern Europe and
Lyme disease Tick Borne E ncephalitis
Scandinavia

South and Central Enteric Fever, Dengue, Chikungunya, Visceral Congo-Crimean

Asia Malaria Leishmaniasis Haemorrhagic Fever

Enteric Fever, Dengue, Scrub typhus, Melioidosis,

South East Asia Leptospirosis
Malaria, Chikungunya Penicilliosis

North Australia Ross River virus Melioidosis

Leptospirosis,
Latin America and Dengue, Malaria, Enteric Yellow fever, hanta virus,
Histoplasmosis,
Caribbean Fever Chagas disease
Coccidiomycosis
Lyme disease,
Histoplasmosis,
Ehrlichiosis, W est Nile
North America Coccidiomycosis,
Fever
Rocky Mountain
Spotted f ever
Game park Tick Typhus Trypanosomiasis, Anthrax

Fresh w ater Acute Schistosomiasis,

exposure Leptospirosis
Penicilliosis,
Tuberculosis, Non - Visceral
Histoplasmosis,
HIV typhoid Salmonella, Leishmaniasis, STI
Coccidiomycosis,
Amoebiasis (e.g. syphilis)
Blastomycosis

August 2017 25
 Table 2: Typical incubation period
Short  Acute gastroenteritis  Arboviral infections
(<10 days)  Respiratory tract infection (including (Dengue, Chikungunya)
influenza)  Rickettsial infections
 Meningitis  Borrellia
Medium  Malaria (Plasmodium falciparum)  Viral Haemorrhagic Fever
(10-21 days)  HIV  Typhoid
 CMV/EBV  Brucellosis, Leptospirosis
Long  Malaria (including Plasmodium  Tuberculosis
(>21 days) falciparum)  HIV, Viral hepatitis
 Amoebic liver abscess  Visceral leishmaniasis

Fever in the Returned Traveller

In those returning from the tropics malaria must always be excluded.

All febrile patients should have urgent blood film and/or rapid diagnostic tests (RDT) for malaria performed
regardless of whether or not malaria prophylaxis has been taken. Three thick films / RDTs over 72 hours (as an
outpatient if appropriate) should be performed to exclude malaria with confidence.
Other tests: two sets of blood cultures before starting antibiotics, FBC, U&E, CRP, LFTs.
HIV should be considered from all settings. Remember, patients may have more than one diagnosis.

Malaria film negative and Malaria film positive

obvious source? (e.g. A severity assessment must
pneumonia, pyelopnephritis) be done for all patients with
malaria.

Yes No
o
Are there any Follow Malaria Assessment
Investigations and manifestations of sepsis,
treatment according to and Treatment Algorithm and
shock or hemorrhage? UK Malaria Treatment
guidelines
Guidelines on Trust Intranet

Yes Yes and

Consider bacterial sepsis (e.g. Symptomatic within 21 days
enteric fever, meningococcal of leaving high risk areas of
sepsis), dengue hemorrhagic western and central Africa?
fever, leptospirosis

Appropriate investigations
according to clinical
suspicion (blood cultures,
Consider Viral
serology)
Haemorrhagic Fever
See Trust Guidance
on KCH intranet
Start empirical treatment
based on epidemiological
probability of infection whilst
waiting for results to return

August 2017 26
10. GENTAMICIN – ONCE DAILY DOSING

 Gentamicin is a narrow-spectrum, bactericidal antimicrobial and works synergistically with beta-lactam antimicrobials
and is active against most Gram negative organisms.
 Great care must be taken to ensure that the correct dose for your patient is prescribed.
 Once daily Gentamicin will ensure maximum efficacy and minimum risk of toxicity.
 It is crucial that trough levels of Gentamicin are measured to ensure that accumulation and resulting toxicity does not
occur.
 Whenever possible, treatment should not exceed 5 days without specialist advice.
 Ototoxicity and nephrotoxicity are significant side effects. Refer to the current BNF for a complete list of cautions,
contra-indications and side-effects.
 Check patient is not prescribed other nephrotoxic drugs, e.g. IV furosemide and if so, dose cautiously with close
monitoring or use alternative antimicrobial if possible.
 Contra-indication: Aminoglycoside may impair neuromuscular transmission and should not be given to patients with
myasthenia gravis.

EXCLUSION CRITERIA for once daily Gentamicin:

 Endocarditis (see also page 16 and 26), ascites, severe burns (>20% of the total body surface area) and cystic
fibrosis.

If Gentamicin is indicated for these patients a multiple dosing regimen should be used.

Dosing

1) Do not prescribe more than one dose in a 24 hour period. Always confirm when the last dose was administered before
prescribing another dose.
2) Weigh your patient (kg) and calculate Ideal Body Weight (IBW). If your patient is obese (>20% over IBW), calculate
Adjusted Body Weight (see Section 13 “Formulae”)
3) Calculate patient’s creatinine clearance using Cockcroft-Gault equation (see formulae on page 29 or use “Dose
Calculator” on Trust Intranet).
4) Dose patient according to algorithm.

Gentamicin Dose Calculator on Intranet

Gentamicin “Dose Calculator” for Once daily dosing regimen is available on intranet
click here

Administration
Dilute Gentamicin dose in 100ml Sodium Chloride 0.9% or Glucose 5% and administer as an intravenous infusion over
30-60 minutes.

Monitoring
Refer to “Key Responsibilities Regarding Administration and Monitoring of Gentamicin for Adults" (on intranet under
antimicrobial guidelines).

 Patients receiving only a single “STAT” dose of Gentamicin do not require monitoring.
 Monitor patients receiving regular Gentamicin and interpret Gentamicin levels according to the algorithm (including
serum creatinine and urea).
 Complete Therapeutic Drug Monitoring (TDM) stickers and attach to the drug chart when prescribing Gentamicin.
 The exact time of Gentamicin sample collection (using 24 hour clock) must be recorded on the laboratory request (and
TDM sticker).

rd
Check renal function every 3 day and daily for levels >1mg/L.
 Audiometry testing is recommended if treatment >2/52.
 Review need for Gentamicin on a daily basis.

August 2017 27
 Once Daily Gentamicin Dosing and Monitoring
You can also use the Dose Calculator on the Intranet

Creatinine Clearance (ml/min) Dose and frequency of Gentamicin

>80 5.0 mg/kg every 24 hours

60-80 4.0 mg/kg every 24 hours

40-60 3.5 mg/kg every 24 hours

30-40 2.5 mg/kg every 24 hours

20-30 4.0 mg/kg every 48 hours

< 20 Seek specialist advice

Attach Therapeutic Drug Monitoring Sticker to drug chart and complete

FOR ALL PATIENTS, TAKE A TROUGH LEVEL BEFORE THE SECOND DOSE
(i.e. 0-4 hours before second dose is due)
Remember to check time of last dose carefully - consult A&E clerking, stat side of drug chart, anaesthetic
records and time the following dose accordingly

WAIT for LEVEL before administering next dose

Level Action
<1mg/L Continue current dosing regimen. Monitor level twice weekly if CrCl stable.

Confirm level taken at correct time. If not, repeat level.

Confirm correct dose prescribed for weight and renal function.
1-2mg/L
Consider dose reduction or extend interval between doses, e.g. every 48-72 hours.
Check trough level before next dose and ensure <1mg/L before next dose.

Confirm level taken at correct time. Withhold until level <1mg/L then consider dose
>2mg/L
reduction or extend interval between doses. Contact Pharmacist for advice.

August 2017 28
11. AMIKACIN ONCE DAILY DOSING

 Amikacin is a restricted antimicrobial. It is only indicated when recommended by Microbiology OR as indicated by

these Guidelines
 Great care must be taken to ensure that the correct dose for your patient is prescribed
 Amikacin is active against most Gram negative organisms, once daily dosing ensures maximum efficacy and
minimises risk of toxicity.
 Whenever possible, treatment should not exceed 7 days without specialist advice.
 Ototoxicity and nephrotoxicity are significant side effects. Refer to the current BNF for a complete list of cautions,
contra-indications and side-effects.
 Check patient is not prescribed other nephrotoxic drugs, e.g. IV furosemide and if so, dose cautiously with close
monitoring or use alternative antimicrobial if possible.
 Contra-indication: Aminoglycoside may impair neuromuscular transmission and should not be given to patients
with myasthenia gravis.
Exclusion Criteria for once daily amikacin:
 Patients with ascites, severe burns (>20% of the total body surface area) and cystic fibrosis.
 If amikacin is indicated for these patients, seek Microbiology advice.
Dosing
1. Weigh your patient. If your patient is obese (>20% over ideal body weight), calculate Adjusted Body Weight (see
Formulae- section 13)
2. Calculate patient’s Creatinine Clearance using Cockroft-Gault equation (see Formulae on Section 13)
3. Dose patient according to table below: The total dose must not exceed 1.5g/day, round dose to the nearest
125mg.

Creatinine Once Daily

Ideal time for trough Acceptable
Clearance Amikacin Dose Monitoring frequency
level to be taken plasma level
(ml/min) (mg/kg)
Twice weekly for patients
>50 15 Trough level:
with stable renal function
<5mg/L
18-24 hours post dose Alternate days for the elderly
Peak Level:
and patients with poor renal
50-20 10 Not required
function

<20 Discuss with Medical Microbiology

Please note- guidance on dosing may vary in critically ill patients on ICU, discuss with Medical
Microbiology
Administration
Dilute required dose to a 2.5mg/ml solution with 100ml Sodium Chloride 0.9% or Glucose 5% and administer as an
intravenous infusion over 60 minutes.
Monitoring
 Patients receiving only one dose (STAT dose) of Amikacin do not usually require monitoring.
 Complete a Therapeutic Drug Monitoring sticker with details of when a level should be taken and the actual time
the level is taken, using the 24 hour clock.

rd
Check renal function every 3 day, audiometry testing is recommended if treatment >2/52
 In patients with stable renal function, subsequent doses can be given without waiting for the level.

Ideal sampling time: Take sample 18 – 24 hours post dose:

Levels (mg/L) Trough level Interpretation
Less than 5mg/L Continue at current dose

Confirm levels taken at correct time and not through the infusion line. Withhold
More than 5mg/L dose, repeat level 18-24 later and discuss with Microbiology.
Give dose only when level <5mg/L.

August 2017 29
12. VANCOMYCIN INTERMITTENT INFUSIONS

You can also use the VANCOMYCIN dose calculator on the intranet

 Vancomycin is active against Gram positive organisms, including MRSA.

 Loading doses of Vancomycin enable therapeutic levels to be achieved rapidly but trough levels of Vancomycin
need to be measured to ensure accumulation and toxicity does not occur.
 Advice should be sought from Pharmacy before dosing Vancomycin in patients receiving dialysis.
 Oral Vancomycin is not absorbed and should only be used to treat C.difficile disease.
 Refer to the current BNF for a complete list of cautions, contra-indications and side-effects.

Dosing
1) Weigh your patient (in kg). Determine and administer loading dose (see next page).
2) Calculate patient’s creatinine clearance using Cockroft-Gault equation (see formulae on page 27 or use dose
calculator on Trust Intranet).
3) Dose patient according to Maintenance dose table (see next page)

Administration
 Exact time of administration must be recorded on the drug chart next to initials (using 24 hour clock)
 Vancomycin should always be administered peripherally or centrally as a slow intravenous infusion in either
Sodium Chloride 0.9% or Glucose 5% solution.
 This should be administered at a rate not exceeding 10 mg/minute (rapid administration must be avoided as this
results in flushing and a transient rash over the neck and shoulders -red man syndrome).

Monitoring
Refer to “Key Responsibilities Regarding Administration and Monitoring of Vancomycin for Adults" (on intranet under
Antimicrobial Guidelines).

 Monitor patients receiving regular Vancomycin according to the algorithm (including creatinine, urea and FBC -
neutropenia and thrombocytopenia can occur after prolonged therapy).
 Use Therapeutic Drug Monitoring (TDM) stickers when prescribing Vancomycin.
 The exact time of Vancomycin sample collection (using 24 hour clock) must be recorded on the laboratory request
(and TDM sticker)
 Monitor renal function regularly.
 Review need for Vancomycin on a daily basis.

August 2017 30
 Step-wise Guide to Prescribing and Monitoring Intravenous Vancomycin
(not for use in Critical Care patients)

i. Prescribe loading dose on STAT section of drug chart

Patient’s Actual Body

<60kg 60-90kg >90kg
Weight

Loading Dose: 1.5g in

1g in 250ml 2g in 500ml
Diluents Sodium Chloride 500ml over 3
over 2 hours IV over 4 hours IV
0.9% or Glucose 5% hours IV

ii. Calculate Creatinine Clearance – see page 27

iii. Select maintenance dose based on CrCl. Prescribe on regular side of drug chart.
First maintenance dose to be prescribed one dosage interval after loading dose

Maintenance Dose Table

CrCl (ml/min) Dose Dose Interval Administration (IV)
(hours)
>110 1.5g 12 500ml over 3hrs
90-110 1.25g 12 250ml over 2.5hrs
75-89 1g 12 250ml over 2 hrs
55-74 750mg 12 250ml over 1.5hrs
40-54 500mg 12 250ml over 1.5hrs
30-39 750mg 24 250ml over 1.5hrs
20-29 500mg 24 100ml over 1 hr
<20 500mg 48 100ml over 1 hr

iv. Taking Levels

a. Take pre-dose level before the third dose (for 12 hourly regimes) or before the second dose (for 24 or 48
hourly regimes)
b. Do not wait for this level to return, give the next dose. It is important to continue dosing and not omit any
doses. Check results prior to the following dose
c. Repeat levels every 3 days if renal function stable
d. Repeat levels following any dosage adjustment
e. Monitor serum creatinine daily
v. Interpret level according to table below
Trough Level Interpretation and maintenance dose adjustments
Pre-dose (trough)
Maintenance dose adjustment
level
Less than 5mg/L Confirm all doses given. If they have, move up two maintenance doses
5-10mg/L Confirm all doses given. If they have, move up one maintenance doses
Continue at current dose (unless MRSA pneumonia, Osteomyelitis, CNS
10-20mg/L infection, endocarditis and bacteraemia -discuss with Microbiology
consultant)
20-25mg/L Move down one maintenance dose without omitting any doses
25-30mg/L Omit next dose and move down two maintenance doses
Withhold Vancomycin. Repeat levels daily and seek advice from
>30mg/L
Pharmacy/Microbiology. Make sure level has not been taken through infusion line

August 2017 31
13. FORMULAE

Creatinine Clearance
CrCl (ml/min) = 140-Age(yrs) x Weight (kg) X 1.23 (Male) or 1.04 (Female)
(Cockcroft-Gault
Serum creatinine (µmol/L)
equation)
Ideal Body Weight Male: 50kg + (2.3 x number inches > 5ft) in kg
(IBW) Females: 45.5kg + (2.3 x number inches > 5ft) in kg
Obesity Adjustment:
Adjusted Body Weight IBW + 0.4 (actual body weight – IBW) in kg
(ABW)

14. USEFUL CONTACTS

Microbiology Consultant: For Clinical Queries/Consultations:

01689 864287 (Ext. 64287)
Office Hours You will be directed to voicemail if the line is busy. You may
(Monday to Friday: 09:00 – 17:30) leave your name and contact details or try again later

Out of Hours Via PRUH Switch Board

Antimicrobial Pharmacist
Office Hours Page KH2805 (Internal: 737*, external: via switchboard)
* NB pager number will change after November 2017
Out of Hours If urgent contact the on–call pharmacist via switchboard

Infection Prevention Team

Office Hours 01689 863459 or 01689 863460
Out of Hours Contact the Microbiology Consultant via PRUH switchboard

Microbiology Laboratory based at Princess Royal University Hospital

Result Enquiry (normal working hours only) ext. 64269 Serology 64250
Urgent Samples e.g. CSF, joint fluid

From 9am to 5:30pm weekdays Ext 64343

Out of Hours
Contact Biomedical Scientist on call via PRUH
Switchboard

Public Health England/ Health Protection Unit

Office Hours 0344 326 2052
Our of Hours PRUH Switchboard
Tel: 020 3456 7891 and ask for the On-call Tropical Medicine
Hospital for Tropical Disease Registrar

August 2017 32