Empirical Antimicrobial Therapy Prescribing Guidance For Adults

Guidance for initial hospital therapy in adults.
Specialist units may have separate policies

Empirical Antimicrobial Therapy Prescribing Guidance for Adults
STOP AND THINK BEFORE YOU GIVE ANTIBIOTIC THERAPY! Antibiotics are overused in the elderly (particularly patients with urinary catheters or suspected UTIs) and in patients with viral or non-infective exacerbations
of COPD. Always obtain cultures and consider delay in therapy unless there is a clear anatomical site of infection with high probability of bacterial aetiology, sepsis or clinical deterioration. Check previous microbiology
results. Doses quoted are for patients without renal or hepatic impairment, please adjust if necessary. Consider cautions, contra-indications and drug interactions.
ORAL THERAPY USUALLY RECOMMENDED IMPORTANT NOTES

Lower Respiratory Tract Urinary Tract Gastro-Intestinal Skin/Soft Tissue
REVIEW ANTIBIOTIC THERAPY
GUIDANCE ICONS
Limited soft tissue infection DAILY:
Pneumonia Lower Respiratory Tract Lower UTI/cystitis – female Gastroenteritis
Infection (LRTI) – define Oral Flucloxacillin 1g 6hrly Gentamicin/Vancomycin - see
CURB65 score:
diagnosis (e.g. acute bronchitis,
Antibiotics if symptoms + No antibiotic usually required.
If true penicillin allergy
STOP? ** prescribing guidance on intranet
Confusion (new onset), Urea >7, RR>30, diast BP<60 positive urinalysis. Consider
exacerbation COPD, CAP) and Clostridium difficile Oral Clarithromycin 500mg
or syst BP<90, age >65yrs. delaying antibiotic therapy Aztreonam If eGFR < 30mL/min (CKD>4)
Additional adverse features: hypoxia (SAO2 <92%) or multilobar treat accordingly pending urine culture.
associated diarrhoea 12hrly SIMPLIFY? or known/ suspected AKI consider
consolidation or cavitation on x-ray. Exacerbation of COPD Catheter specimen of urine is Stop/simplify concomitant Duration 7 - 14 days. § aztreonam IV as alternative to gentamicin
antibiotics and gastric acid
Low Severity Community Acquired Pneumonia (CAP) Antibiotics only if purulent
unreliable.
Caution with these antibiotics suppressive therapy if possible. Infected bite SWITCH? – see dosing information on intranet
sputum and raised WCC or Human or animal bite
# IffullIVguideline
Co-trimoxazole not available - see
CURB65 score: 0-1 in patients with CKD ≥3 or at Refer to full guidance for list
Oral Amoxicillin 1g 8hrly
CRP. Use 1st line antibiotic
risk of hyperkalaemia. of severity factors.
Oral Co-amoxiclav 625mg DOCUMENT! for advice
unless recent hospitalisation or 8hrly
or Non-severe: oral
recent antibiotic. Trimethoprim 200mg 12hrly Second line or in penicillin
Oral Doxycycline 200mg stat then 100mg daily. Metronidazole 400mg 8hrly
Mild to Moderate Severity
or
Nitrofurantoin 100mg m/r Severe or no improvement
allergy Clostridium difficile infection (CDI) risk.
Duration 5 days – consider extending if symptoms not im- Oral Doxycycline 100mg
proved after 3 days. Oral Amoxicillin 1g 8hrly 12hrly or 50mg i/r 6hrly after 5 days of Metronidazole; 12hrly Use the following antibiotics with caution in high risk patients e.g. frail elderly,
Duration 3 days. oral Vancomycin 125mg +Metronidazole 400mg 8hrly
Moderate Severity CAP If true penicillin allergy 6hrly (add IV Metronidazole immunosupressed, prolonged hospital stay, previous CDI, recent antibiotics.
Doxycyline 200mg stat then Uncomplicated UTI - men Duration 7 days
CURB65 score: = 2 500mg 8hrly if ileus or
100mg daily. As above duration 7 days. hypotension)
High risk antibiotics: clindamycin, ceftriaxone, ceftazidime, ciprofloxacin,
Oral/IV Amoxicillin 1g 8hrly Diabetic Foot Infection
Duration 5 days. levofloxacin, co-amoxiclav, clarithromycin, meropenem.
+ oral Clarithromycin 500mg 12hrly (until atypical excluded) UTI in Pregnancy Total duration 10 days. Refer to protocol on Diabetes
If true penicillin allergy Nitrofurantoin 100mg m/r Recurrent CDI – discuss with Grampian Guidance intranet
microbiology / ID page.
oral Doxycycline monotherapy 100mg 12 hrly Severe Infective
12hrly or 50mg i/r 6hrly URGENT IV THERAPY
or if IV required, treat as per CURB65 >3 (Avoid in 3rd trimester)
Exacerbation of COPD or
Total duration 5-7 days – consider extending if symptoms not Co-trimoxazole 960mg IV# Trimethoprim 200mg 12hrly Intra-abdominal Sepsis Moderate to severe cellulitis
improved after 3 days. Sepsis - Source Unknown CNS Infection Endocarditis
12hrly
Switch to oral
(Avoid in 1st trimester) Gentamicin ** IV
+ Metronidazole 500mg 8hrly
Flucloxacillin 1-2g 6hrly IV
(use 2g if BMI>30)
If 1st line options unsuitable Sepsis - Source Unknown IV therapy to be Possible infective endocarditis
Co-trimoxazole 960mg 12hrly Cefalexin 500mg 12hrly IV
High Severity CAP or Switch to oral administered URGENTLY on
+ Amoxicillin 1g 8hrly IV Flucloxacillin 1g 6hrly Amoxicillin 1g 8hrly IV Seek senior specialist advice.
CURB65 score: ≥3:
No Previous Antibiotic
Doxycycline 200mg stat then
100mg 12 hrly when condition
Duration 7 days.
If true penicillin allergy or If true penicillin allergy or if
+ Gentamicin ** IV
+/- Metronidazole 500mg
arrival at hospital and after
blood cultures. Indolent:
Complicated UTI gentamicin not appropriate MRSA likely Amoxicillin 2g IV 4hrly
IV Amoxicillin 1g 8hrly improves. 8hrly IV (add if anaerobic cover CT scan before LP if seizures,
(renal tract abnormality)
+ Second line
Oral Co-trimoxazole 960mg
Co-trimoxazole 960mg
12hrly IV#
Vancomycin IV
Switch to oral
** required) reduced GCS, papilloedema, + (optional) Gentamicin IV
as per synergistic dosing
Oral Clarithromycin 500mg 12hrly (until atypical excluded) Clarithromycin 500mg 12hrly + Metronidazole 500mg 8hrly In true penicillin allergy or CNS signs or
12hrly Doxycycline 100mg 12hrly immunosuppression. protocol
IV then switch to oral when IV known MRSA
Switch to oral Second line
Doxycycline monotherapy 100mg 12 hrly
condition improves.
Ciprofloxacin 500mg oral Switch to oral Total duration 7-14 days. Gentamicin ** IV Seek ID/microbiology advice. Severe sepsis, acute
or
Total duration 7 days. 12hrly Metronidazole 400mg 8hrly Suspected necrotising + Vancomycin ** IV presentation or penicillin allergy:
Amoxicillin 1g 8 hrly Duration 7-14 days.
+
Doxycycline 100-200mg daily
fasciitis or severe or rapidly
progressive infection in an
8hrly IV
Meningitis Vancomycin ** IV
Hospital acquired Ceftriaxone 2g 12hrly IV + Gentamicin IV as per
+ Clarithromycin 500mg 12hrly (until atypical excluded) or IVDU Consider aztreonam§ IV as
Pneumonia synergistic dosing protocol
Previous Antibiotics Metronidazole 400mg 8hrly alternative to gentamicin. If true penicillin allergy
Early (≤4 days of admission) Catheter-related UTI EARLY DEBRIDEMENT/
Chloramphenicol 12.5-25mg/
Co-amoxiclav 1.2g 8hrly IV + EXPLORATION IS ESSENTIAL Intra-cardiac prosthesis:
Treat as for CAP Antibiotics are not indicated
+ Clarithromycin 500mg 12hrly Oral/IV (until atypical excluded)
Late (>5 days of admission) unless evidence of systemic
12hrly Flucloxacillin 2g 6hrly IV Neutropenic Sepsis kg 6hrly IV
If age >55 to cover Listeria
Vancomycin ** IV
Switch to oral infection e.g. pyrexia, loin + Benzylpenicillin 2.4g 6hrly IV Standard risk patients: + Gentamicin IV as per
Non-severe Total duration 3-5 days. + Amoxicillin 2g 4hrly IV
Doxycycline monotherapy 100mg 12hrly
Amoxicillin oral 1g 8hrly
pain, raised WCC or acute
confusion in elderly. If
+ Gentamicin ** IV
+ Clindamycin IV 600mg-1.2g
Piperacillin/Tazobactam 4.5g
6hrly IV or in penicillin allergy
synergistic dosing protocol
+ Rifampicin 300-600mg
If true penicillin allergy
Co-trimoxazole 960mg 12hrly IV#
If true penicillin allergy systemic infection likely 6-8hrly In mild penicillin allergy
+ Vancomycin IV ** oral / IV 12hrly
Doxycycline oral 100mg treat as complicated UTI or Ceftazidime 2g 8hrly IV Give Dexamethasone IV for
or pyelonephritis depending on Biliary Sepsis Switch to oral
12hrly (In severe penicillin allergy see 4 days
Levofloxacin 500mg 12hrly IV clinical symptoms. Remove/ Flucloxacillin 500mg-1g 6hrly FURTHER ADVICE
or Amoxicillin 1g 8hrly IV below)
+ Amoxicillin 500mg-1g 8hrly Duration 7 days for
Switch to oral
Doxycycline monotherapy 100mg 12hrly
Co-trimoxazole oral 960mg
12hrly
replace catheter following 1st
or 2nd dose of antibiotic.
+ Gentamicin ** IV
Clindamycin 600mg 8hrly High risk patients: meningococcal, 14 days for Can be obtained from the
Duty Microbiologist or Clinical
or Total duration 5 days. 8hrly IV In penicillin allergy: Add Gentamicin ** IV to pneumococcal
Pharmacist or the ID Unit
Co-trimoxazole 960mg 12hrly Pyelonephritis / Urosepsis If true penicillin allergy or
Vancomycin IV **
+ Clindamycin 600mg-1.2g
options above Refer to full guidance for further
information.
Aberdeen Royal Infirmary.
Severe Septic shock or severe Infection Control advice may be
Total duration (IV plus oral) 7-10 days Co-amoxiclav IV 1.2g 8hrly Gentamicin ** IV (NB: if gentamicin not appropriate
IV 6-8hrly penicillin allergy in Standard / given by the duty microbiologist.
+ Gentamicin ** IV if life reduced or unstable renal
function give single dose 12hrly IV#
+ Gentamicin ** IV
Switch to oral options
High risk patients Encephalitis
Aciclovir 10mg/kg 8hrly IV The full antibiotic guidelines and
threatening. +/- Metronidazole 500mg Meropenem 1g 8hrly IV
Aspiration Pneumonia Switch to oral Co-amoxiclav only then review with ID or depending on sensitivities. policies can be found on the
microbiology) 8hrly IV Consider aztreonam§ IV as Duration 14 - 21 days intranet at:
If oral antibiotics appropriate, 625mg 8 hrly. Duration: micro/ID advice alternative to gentamicin. (if confirmed).
+ Amoxicillin 1g IV 8hrly Switch to oral www.nhsgrampian.org/gjf -
Oral Amoxicillin 1g 8hrly If true penicillin allergy Switch to oral option guided Doxycycline 100-200mg daily Chapter 5 Infections.
+ Oral Metronidazole 400mg 8hrly Levofloxacin 500mg (IV or by microbiology sensitivities. +/- Metronidazole 400mg
oral) 12hrly Post-operative infection – “Clean sites” Post-operative infection – “Dirty sites” e.g.
If IV required, 8hrly Abdominal, Female genital tract, Head/Neck Produced by the NHS Grampian
In penicillin allergy Flucloxacillin 500mg-1g 6hrly IV or oral Antimicrobial Management Team
IV Amoxicillin 1g 8hrly Total duration 7-10 days. Ciprofloxacin 500mg oral (or or
In penicillin allergy Co-trimoxazole 960mg IV# 12hrly
+ IV Metronidazole 500mg 8hrly If MRSA likely add 400mg IV) 12hrly. Co-trimoxazole 960mg November 2018.
+/- Metronidazole 500mg IV 8hrly
If true penicillin allergy Vancomycin ** IV as per Total duration 7 days (if
12hrly Vancomycin IV ** as per protocol
Switch to oral
Review November 2021.
Clarithromycin 500mg 12hrly (oral or IV) protocol. +/- Metronidazole 400mg Switch to oral
urinary tract abnormality 8hrly Co-trimoxazole 960mg 12hrly
+ Metronidazole 8hrly (oral 400mg or IV 500mg) consider 10-14 days). Co-trimoxazole 960mg 12hrly
Total duration 10-14 days +/- Metronidazole 400mg 8hrly
Total duration 7 days.
Total duration 7 days. Total duration 10-14 days Version 6
ZA03441 CGD180364

Empirical Antimicrobial Therapy Prescribing Guidance For Adults

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Empirical Antimicrobial Therapy Prescribing Guidance For Adults

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Guidance for initial hospital therapy in adults.

Specialist units may have separate policies

ORAL THERAPY USUALLY RECOMMENDED IMPORTANT NOTES

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