19.

ANTIBIOTIC POLICY

Antibiotics Policy & Antibiogram

1. Purpose
The principal aim of an antibiotic policy is to promote rational antibiotic use. Antibiotic
restriction should lead to a reduction of resistance, decreased cost and improved patient
care. The aim of implementing this policy throughout the Hospital is to ensure that
antibiotics are used appropriately. This should result in more effective treatment of
infections so that patient outcomes are optimized. In addition appropriate antibiotic use
should minimize the risk of healthcare-associated infections occurring and this produces
benefits for patients and for service delivery and clinical outcomes.

2. Scope
All Patient Care Units

3. Responsibility for implementation

Overall responsibility of implementation of this policy is of the Infection Control Team under
the monitoring and supervision of Infection Control Committee.

4. Policy
4.1. Better definition of empiric treatment and duration of such treatment. Antibiotics
usage shall be monitored for checking the sensitivity pattern amongst
microorganisms. Discourage inappropriate combination antibiotic therapy unless
indicated.
4.2. Microbiology department shall generate a monthly report on sensitivity pattern of
microorganisms towards antibiotics in use. This report shall be circulated to all
consultants every six months in the form of an antibiogram. Consultants shall use
information from this microbiological report to structure their empiric antibiotic
treatment.
4.3. Consultants shall consider using the antibiotic sensitivity report.
4.4. The copy of the report shall also be send to pharmacy. Pharmacy shall monitor
the dispensing of antibiotic and keep a record of antibiotic usage. Any
discrepancy in usage with the report generated by microbiology department shall
be brought in to the notice of infection control committee. Antibiotic audit will
be implemented to check irrational use of antibiotics.
4.5. Infection control committee shall monitor the implementation of this policy and
rational use of antibiotic.

5. Restriction on antibiotic usage

5.1. The infection control committee can introduce restriction on the use of antibiotics as
an essential component of infection control program or to influence antibiotic
prescribing, in specific clinical areas where there are significant problems with
healthcare-associated infections. Antibiotic restrictions will only be implemented
with the aim of healthcare associated infections.
5.2. Following practices shall be followed while prescribing antibiotics:
 Good practices for use of antibiotics:
5.2.1. Consider whether or not the patient actually requires an antibiotic.
5.2.2. Avoid treating colonized patients who are not actually infected.
5.2.3. In general, do not change antibiotic therapy if the clinical condition is improving.
5.2.4. If there is no clinical response within 72 hours, the clinical diagnosis, the choice
of antibiotic and/or the possibility of a secondary infection should be
reconsidered.
5.2.5. Give the antibiotic for the minimum length of time that is effective.
5.2.6. Consider the use of pharmacy “stop” policies, where drugs written up for a
specified period and are then only continued if a new prescription is issued.
5.2.7. For surgical prophylaxis start the antibiotic with induction of anesthesia and
continue for a maximum of 24 hours only. Antibiotics could be continued in case
of high risk patient group. It is the discretion of the clinician to take this decision.

Note: Before prescribing any antimicrobial, the Consultant will confirm the choice with the
consultant/microbiologist.

Table: I Antibiotic prophylaxis.:

Procedure Usual Preferred Alternate Comments
Organism Prophylaxis prophylaxis
s
Angiography S.aureus Cefazolin 2gm. (IV) Cefotaxime Patients undergoing
(MSSA) x 1 dose 2gm. (IV) x 1 sterile vascular
Or dose procedures do not
Ceftriaxone Or require prophylactic
1gm. (IV) x 1 dose Ceftizoxime antibiotics. Strictly
2gm. (IV) x 1 adhere to sterile
dose procedures rules

Angioplasty S. Aureus Cefazolin 2gm. (IV) Cefotaxime Administer

(MSSA) x3 doses 2 gm. (IV) x 3 immediately prior to
(8 hrly) doses procedure. Repeat 2
Or (8 hrly) more doses 8 hourly.
Ceftriaxone 1gm. Or
(IV) x3 doses Ceftizoxime
(8 hrly) 2 gm. (IV) x 3
doses(8 hrly)

Table: II
CABG/
Prophyla Initial Dose/ Remar
THORACIC Frequency
xis Dose Time ks
SURGERY
I line Cefotaxime 2gm immediately to be followe 1gm till
prophylax before repeated d by 8hrly patient
is procedure after 3hrs if is
procedure is delined
 prolonged
Cefuroxime 1.5gm
Or
1.5gm 8hrly
Amikacine
Plus single dose
500mg
to be
till
alternate immediately repeated
followe 1gm patient
prophylax Cefazolin 2gm before after 3hrs if
d by 8hrly is
is procedure procedure is
delined
prolonged
1gm
Or Ceftriaxone 2gm
8hrly
Amikacine
Plus single dose
500mg

CABG (INHOUSE)
to be
Cefotaxime till
I line immediately repeated
2gm/ followe 1gm patient
prophylax before after 3hrs if
Cefipime/ d by 8hrly is
is procedure procedure is
Augmentin delined
prolonged
Cefuroxime 1.5gm
Or
1.5gm 8hrly
Amikacin
Plus 500mg single dose
(if high risk)
to be
till
alternate immediately repeated
Cefazolin 2gm followe 1gm patient
prophylax before after 3hrs if
or levoflox d by 8hrly is
is procedure procedure is
delined
prolonged
1gm
Or Ceftriaxone 2gm
8hrly
Amikacine
Plus 500mg single dose
(if High risk)
Linezolid/
teicoplanin(MRS
A suspect)
VALVE REPLACEMENT
to be
till
I line immediately repeated
followe 1gm patient
prophylax Cefotaxime 2gm before after 3hrs if
d by 8hrly is
is procedure procedure is
delined
prolonged
 Cefuroxime 1.5gm
Or
1.5gm 8hrly
immediately
vancomycin
before
1gm
procedure
If MRSA
Or linezolid 600mg single dose suspect
ed
to be
till
alternate immediately repeated
followe 1gm patient
prophylax Cefazolin 2gm before after 3hrs if
d by 8hrly is
is procedure procedure is
delined
prolonged
1gm
Or Ceftriaxone 2gm
8hrly
immediately
vancomycin
before
1gm
procedure
If MRSA
Or Linezolid 600mg single dose suspect
ed

FOR PAEDIATRIC PROCEDURES

to be
till
I line immediately repeated 25mg/
Cefotaxime followe patient
prophylax before after 3hrs if kg
50mg/kg d by is
is procedure procedure is 8hrly
delined
prolonged
25mg/
Cefuroxime
Or kg
50mg/kg
8hrly
Amikacine
Plus single dose
25mg/kg
to be
till
alternate immediately repeated 25mg/
Cefazolin followe patient
prophylax before after 3hrs if kg
50mg/kg d by is
is procedure procedure is 8hrly
delined
prolonged
25mg/
Ceftriaxone
Or kg
50mg/kg
8hrly
Aminoglycoside
Plus single dose
25mg/kg
 OTHER SURGICAL CATEGORIES:
No. Category First Line
1 Abdominal surgeries( No infection)
A Cholecystectomy
B Cefoperazone+sulbactum
Abdominal surgeries( H/o
past hospitalization in the
last year, high risk)
C Cefoperazone+sulbactum/
Urology(clean)
(High Risk Case)
D Urology(infected)
E Head and Neck surgeries
F Breast surgeries
G Orthopaedic
surgeries( Arthroscopy,fra
cture etc)
H Orthopaedic
surgeries(TKR)
I Gynec surgeries
Alternative
Cefazoline/ Ceftriaxone Cefuroxime/Ceftrixone
+
Aminoglycoside /Metranidazole +
Aminoglycoside/Clindamycin
If high risk, carbapenums
+ may be added
Aminoglycoside /Metranidazole
Piperacillin+tazobactum/
levofloxacin Ciprofloxacin
+ +
Aminoglycoside Aminoglycoside
Cefoperazone+sulbactum/ Piperacillin+tazobactum/
levofloxacin Ciprofloxacin
+ +
Aminoglycoside + Aminoglycoside +
Carbapenum Carbapenum
Cefazolin/Ceftriaxone Cefoperazone+uslbactum/
+ Piperacillin tazobactum
Clindamycin/Aminoglycosides +
Metronidazole/Clindamycin
Cefazolin/Ceftriaxone Augmentin / Floroquinolone
+ +
Linezolid (if MRSA suspected) Vancomycin(if MRSA
suspected)
Cefazolin/Ceftriaxone Augmentin / Floroquinolone
+ +
Linezolid (if MRSA suspected) Vancomycin (if MRSA
suspected)
Ceftizoxime/Cefuroxime Cefoperazone-sulbactum/
Plus Floroquinolone
Amikacin Plus aminoglycoside
Linezolid(Suspect MRSA, previous (In case of bilateral TKR)
hospitalization)
Cefazoline/ Ceftriaxone Piperacillin+tazobactum/
+ Levofloxacin
Aminoglycoside /Metranidazole +
Aminoglycoside
Important :

The antibiotic is a guideline for surgeons. Clinical findings and situations may require addition or
deletion of antibiotics. The policy is also framed with the consideration of hospital antibiogram.
Changes may be made as and when a significant change in pattern and clinical condition of the
patient is noted. Prophylaxis is meant tobe given only before the surgery, if the need arises it may
be converted to early therapy. This decision is at the discretion of the clinician.

OTHER ANTIBIOTIC POLICIES :

2 Meningitis post neuro Ceftrixone / Cefotaxime (If ESBL Cefotaxime / Imepenum (if
Surgical / Trauma Amp C : Meropenem) + no neuro risk)
Vancomycin +
Vancomycin
3 Shunt Infection Vancomycin (Till MRSA Excluded) Linezolid
4 Primary / contiguous Brain Ceftrixone / Cefotaxime + Metrogyl Pen G + Metrogyl
abscess
5 Post-surgical / Trauma Ceftraixone / Cefotaxime + Vanco till MRSA excluded in
abscess Vancomycin / Cloxacillin post Brain surgery
6 AOM / Acute sinusitis Amoxycillin +clavulanate / Ceftriaxone /Augmentin
Cefuroxime
7 Malignant Otitis extrena Ciprofloxacin Ceftazidime /piperacillin

8 Chronic sinusitis Amoxy + Clavulanic acid Respiratory Floroquinolone

9 Streptococcal Pharyngitis Amoxycillin 1st generation
Cephalosporin / macrolide
10 AECB Amoxyciliin + Clavulanic acid Cefuroxime
11 Community acquired Amoxycyline / macrolide Respiratory floroquinolone
pneumonia CAP-OPD
12 CAP in patient (non ICU) Amoxycillin + Clavulanate / Ceftriaxone + macrolide

13 Cap –ICU IV Ceftriaxone + macrolide / Respiratory FQ If .Pseudo is a

concern Pip Tazo + Ciproflox.
In case of Aspiration amox / clavulanate + Respiratory FQ

14 Lung abscess Clindamycin Pip Tazo / amox Clave /Amp sulb

15 Infective Endocarditis : Pen G / Amp + Clox
Native valve +Genta , Prosthetic
Vanco + gentamycin (as per clinical
valve Vanco +
protocol)
gentamycin +
RIfampicin
16 Acute Osteomylitis Cloxacillin Cefazolin / Levo and Rifampicin /
Clindamycin
17 Pyoderma Localized – mupirocin / Fusidic acid, Widespread – 1 st generation
Ceph / amoxicillin+ Clavulanic acid / macrolide /Ampiclox
 18 Cellulitis (Non diabetic) Cefazolin /linezolid(if Augmentin / Vancomycin (if MRSA is
MRSA is suspected) suspected)
19 Necrotizing Fascitis Ceftrixone & Piperacillin
clindamycin +tazobactum/Ticarcillin+Clavulanate /
imipenem
20 Septic artheritis Levoflox / Ceftrixone Ciproflox / Cloxacillin
21 Enteric fever Sick-Ceftrixone Out patient- Cefixime / Azithro / Cotrimoxazole /
High dose: quinolones
22 Dysentery Ciprofloxacin Ceftrixone
23 Liver abscess Ceftriaxone / Ticarcillin+ clavulanic acid / Piperacillin+
Cefotaxime and Tazobactum
Metronidazole
24 Acute Cholangitis Cefoperazone and metronidazole/ Ceftrixone and metronidazole

25 Acute appendicitis Ceftrixone / Ciproflox and metronidazole

Cefotaxime and
Metronidazole
26 Secondary peritonitis Ceftriaxone / Ciprofloxacin and metronidazole
Cefotaxime and
Metronidazole
27 Primary peritonitis Ceftriaxone / Piperacillin+ Tazobactum
Cefotaxime
28 Cystitis Norflox / Ciproflox Cotrimoxazole
29 Pyelonephritis Ciproflox / Amikacin / floroquinolone
Cefotaxime

It should be Noted :
1. The prophylaxis and policy is defined for guidance and rational use of antibiotics.

2. It is the privilege of the treating consultant to use a higher antibiotic/an antibiotic

not listed above if he/she feels is safer and lifesaving for the patient.

3. It is recommended to deescalate, if possible the antibiotic after the culture report is

received.

4. In case staphylococcus aureus is suspected please cover MRSA till the microbiology
report is received. If MSSA the de-escalation may be done.

References:
5.2.7.1. Dipiro J, et al. “Pharmacotherapy: A Pathophysiologic Approach”. 6th ed.
McGraw-Hill company inc; 1999.

5.2.7.2. Braunwald E, fauci A, et.al. “Harison’s manual of medicine”. 15th ed. McGraw-
Hill company inc; 2002.

5.2.7.3. Brunton L, et al. “Goodman & Gilman's the pharmacological basis of

therapeutics”. 11th Ed. McGraw-Hill company inc; 2006.
 6. Antibiogram
No Organism >50% sensitive drugs Remarks
1 E.Coli Amikacin
Colistin E.coli due to plasmids has a
Meropenem tendency to change its
Imepenem sensitivity pattern during
Timentin therapy. A repeat culture after a
Gentamycin week is recommended.
Piperacillin-Tazobactum
2 Klebseilla Pneumonaie Ertapenem
Timentin
Meropenem
Imipenem
Cefipime
Amikacin
3 Pseudomonas Cefipime Pseudomonas due to plasmids
Aeruginosa has a tendency to change its
Piperacillin-Tazobactum sensitivity pattern during
PiperacillinColistin therapy. A repeat culture after a
Amikacin week is recommended.
4 S.Aureus Vancomycin
Linezolid
Teicoplanin
Imipenem Please note , MRSA may be
covered at initiation of therapy
Meropenem
and if patient has previous
Ertapenem
history, but please deescalate if
Amikacin culture grows MSSA.
Clindamycin
Rifampicin
Ticarcillin-clavulanic acid
5 Acinetobacter Spp. Cefipime
Colistin
Note :
 The yearly antibiogram pattern is formulated as per the culture sensitivity reports for
the year 2013. Common bacteria and antibiotics that have shown > 50% sensitivity
are listed.
 The PK-PD have to be taken into consideration before selecting the drug.
 This is the local epidemiology of the hospital and a guidance document for initiating
antibiotics in case HAI is suspected before culture-sensitivity report.
 Department of Infection control recommends if possible de-escalation of antibiotic
after the culture and sensitivity report is received
 Important aspect this time is loss of floroquinolones which is a very important group
 in clinical therapy. Please use them rationally so that they take a firm place in our
antibiogram of 2014.
 The Infection control department is at your service. Please do not hesitate to solve
your queries.
Rational use of antibiotics is the need of the hour...
Please Contribute!!!

Restricted Antibiotic Guidelines

Restricted antibiotics are those antimicrobial agents, which should not be used or which are
restricted by the hospital formulary to be used in the empirical therapy of any infection. The
purpose of enlisting of restricted antibiotic is to keep certain antibiotics in reserve only to be
used if culture and cross sensitivity reports are positive for that specific antibiotic. These
restricted antibiotics are mainly the newer molecules in the market and certain old
molecules specified for certain specific use.

These restricted antibiotics are never used as a first line therapy. Since the drug resistant
and the drug sensitivity of microorganisms differ in different regions, the list of restricted
antibiotics for hospitals in different geographical regions differ. Therefore every hospital has
to frame its own list of restricted antibiotics. This will not only help in overcoming drug
resistance problem but also a good patient prognosis in various life threatening infections.

The restricted antibiotic guidelines are a step towards the upgradation in the antibiotic
policies of hospitals. To solve the purpose of reducing antibiotic resistance, antibiotic policies
are framed by many multispeciality and tertiary healthcare centers.

The following Antibiotics are consider as restricted or high end antibiotics.

1. Quinolones: I/V Ciprofloxacin, Oflxacin, Levofloxacin, Gatifloxacin, Moxifloxacin,
Lomifloxacin, Sparfloxacin.
2. Carbapenems: Imimpenem/Cilastatin, Meropenem,Ertapenam, Doripenem
3. Glycopeptides: Vancomycin, Teicoplanin
4. Tigecycline
5. Linezolid
6. Colistin
7. Polymyxin B
8. Daptomycin
9. IV Metreogyl
10. Voriconazole
11. Griseofulvin
12. Pipercillin/Tazobactum
13. Clindmycin
14. Ceftriaxone