CLINICAL GUIDELINE

Infection Management Guidelines in

Adults

A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient
characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased
susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good
practice to record these and communicate them to others involved in the care of the patient.

Version Number: 7
Does this version include
Yes
changes to clinical advice:
Date Approved: 17th November 2020

Date of Next Review: 30th November 2023

Lead Author: Ysobel Gourlay

Approval Group: Antimicrobial Utilisation Committee

Important Note:

The Intranet version of this document is the only version that is maintained.
Any printed copies should therefore be viewed as ‘Uncontrolled’ and as such, may not necessarily contain the
latest updates and amendments.
Infection Management Guidelines Empirical Antibiotic Therapy in Adults
STOP AND THINK BEFORE ANTIBIOTIC THERAPY: 1 in 5 antibiotic courses associated with adverse events including C.difficile, drug interactions/ toxicity, device related infections and S. aureus bacteraemia. THINK SEPSIS if NEWS ≥ 5. Send samples to microbiology before starting antibiotics. RECORD antibiotic indication on kardex.
REVIEW patient and results. RECORD clinical response and prescription daily. Can you SIMPLIFY, SWITCH or STOP ? If Clinical improvement + eating/drinking + deep seated/complex infection not suspected then IVOST and RECORD duration of remaining oral therapy. RECORD the STOP date for oral antibiotic - score kardex at appropriate date.
REVIEW all IV antibiotics DAILY and RECORD review date. INFORM patient of reason for antibiotic and likely duration.
NB Doses recommended based on normal renal/liver function - see BNF or Renal handbook for dosing advice. For info on antibiotic contra-indications, cautions and monitoring see BNF.

Definition of SEPSIS: INFECTION (includes Systemic Inflammatory Response Syndrome (SIRS*) WITH evidence of ORGAN HYPOPERFUSION (≥ 2 of: Confusion, < 15 GCS or Resp Rate ≥ 22/ min or Systolic BP ≤ 100 mm Hg).
Ensure SEPSIS 6 within one hour: 1. Blood cultures (& any other relevant samples), 2. IV Antibiotic administration, 3. Oxygen to maintain target saturation, 4. Measure lactate, 5. IV fluids, 6. Monitor urine output hourly.
*SIRS indicated by Temp < 36°C or > 38°C, HR > 90 bpm, RR> 20/ min & WCC < 4 or > 12 x109/ L. SIRS is not specific to bacterial infection (also viral & non-infective causes).

Lower Respiratory Tract Infections Skin/ Soft Tissue Infections Gastrointestinal Infections Urinary Tract Infections Bone/ Joint Infections Severe Systemic Infection
CNS Infections Immunocompromised Patient
Source Unknown
Infective Exacerbation COPD Gastroenteritis UTI in Pregnancy Septic arthritis/
Mild skin/soft tissue infection Osteomyelitis Prosthetic joint
Antibiotics only if purulent sputum (send for culture along with viral gargle) Confirm travel history/ other risk factors See NHS GGC Obstetric guidance Urgent Blood Cultures then IV Antimicrobial Therapy within ONE hour
Oral Flucloxacillin 1g 6 hrly infection
Dual antibiotic therapy not recommended & increases risk of harm Antibiotics not usually required
or if true penicillin/beta-lactam allergy
Oral ▲Doxycycline 200mg as a one-off single dose then 100mg daily and may be deleterious in E.coli O157 Obtain blood cultures prior to
Oral Co-trimoxazole 960mg 12 hrly Consider viral causes including Lower UTI/cystitis antibiotic therapy. If not acutely Community or Healthcare Immunocompromised Patient
or Oral Amoxicillin 500mg 8 hrly or Oral ■ Clarithromycin 500mg 12 hrly or Oral ▲Doxycycline 100mg 12 hrly LP safe without CT scan UNLESS:
COVID-19 Don’t treat asymptomatic bacteriuria. unwell/septic, also obtain synovial associated sepsis where Chemotherapy < 3 weeks,
Duration 5 days seizures, GCS ≤ 12, CNS signs,
Duration 5 days Obtain urine culture prior to antibiotic. fluid/deep tissue samples prior to source unknown high dose steroids (e.g. prednisolone
papilloedema or immunosuppression.
C. difficile infection (CDI) In women often self-limiting, consider antibiotic therapy. If CT: Blood cultures and antibiotics Review all anatomical systems, > 15mg/day for > 2 weeks), other
Suspected COVID-19 pneumonia See NHS GGC CDI guidance delayed prescribing.
Native joint BEFORE CT scan. perform CXR and consider other immunosuppressants (e.g. anti-TNF,
Antibiotics NOT usually required Treat before lab confirmation if Antibiotics if significant symptoms IV Flucloxacillin 2g 6 hrly imaging/ laboratory investigations cyclophosphamide), Stem cell/solid
suspected. Discontinue if toxin negative Oral Nitrofurantoin 50mg 6 hrly Use Meningitis/ Encephalitis order set organ transplant or primary
Antibiotics only if COPD with purulent sputum (treat as above) or suspected Consider and test for COVID-19
Moderate / Severe Cellulitis or Oral Trimethoprim 200mg 12 hrly If MRSA suspected or if true on Trakcare, Blood and CSF Glucose. immunodeficiency
bacterial pneumonia with Chest X-Ray changes (treat as Pneumonia below) No severity markers LP contraindicated if: Brain shift, Review diagnosis DAILY
Consider stopping antibiotics following review and positive Consider OPAT/ ambulatory care Oral Metronidazole 400mg 8 hrly Duration: Females 3 days, Males 7 days penicillin/beta-lactam allergy
rapid GCS reduction, Resp/ cardiac Add cover for S.aureus infection if;
SARS-CoV-2 result (consult local management pathway). (Do not use suspension) If eGFR < 30 mL/min/1.73 m2 IV Vancomycin** healthcare associated, recent
compromise, severe sepsis, rapidly
If requires inpatient management: • Nitrofurantoin contraindicated If considered high risk for hospitalisation, post-op wound/ line Neutropenic Sepsis
IV Flucloxacillin 2g 6 hrly
Any severity marker or evolving rash, infection at LP site,
• Trimethoprim use with caution may  K+ Gram negative infection e.g. related, PWID
Uncertain if LRTI/ UTI first recurrence of CDI and decrease renal function. Monitor immunocompromised, recurrent UTI
coagulopathy, thrombocytopenia, Neutrophils ≤ 0.5 x 109 / L + fever
If MRSA suspected or if true penicillin/ beta- Add cover for MRSA infection if;
Send MSSU, sputum and viral gargle Oral Vancomycin 125mg 6 hrly anticoagulant drugs (temperature > 38°C or 37.5°C on 2
lactam allergy or sickle cell disease recent MRSA carrier or previous infection
▲
Duration 10 days occasions 30 min apart) / hypothermia
Oral Co-trimoxazole 960mg 12 hrly or Oral Doxycycline 100mg 12 hrly IV Vancomycin** ADD IV Gentamicin**∆ (max 4 days) Add cover for Streptococcal infection if; < 36°C OR chills, shivers, sweats or other
If enteral feeding tube use Vancomycin Upper UTI
Do NOT prescribe Co-amoxiclav pharyngitis/erythroderma/hypotension symptoms suggestive of infection.
If rapidly progressive (see full NHS GGC CDI guidance) Duration and IVOST: discuss
Review/ clarify diagnosis at 48 hours Add IV Clindamycin 600mg 6 hrly Obtain urine for culture prior to
with microbiology at 72 hours. All patients who have received recent
Intra-abdominal sepsis
antibiotic. Exclude pneumonia if Possible bacterial meningitis
Duration if diagnosis remains uncertain MAXIMUM 5 days Duration 7-10 days (IV/oral) loin/back pain Usually 4 - 6 weeks (IV/oral) if chemotherapy and who exhibit any of
diagnosis confirmed. IV Ceftriaxone 2g 12 hrly Source unknown the symptoms above are presumed to
IV Amoxicillin 1g 8 hrly
Non-severe/without sepsis or if true penicillin/beta-lactam allergy IV Amoxicillin 1g 8 hrly be neutropenic and septic.
Pneumonia + IV/Oral Metronidazole 500/400mg 8 hrly Prosthetic joint
+ IV Gentamicin**∆ (max 4 days) ) Oral▲■Ciprofloxacin 500mg 12 hrly IV Chloramphenicol 25mg/kg (max 2g) + IV Gentamicin**∆ (max 4 days)
IV Vancomycin** 6 hrly
Hospital Acquired If eGFR < 20 mL/min/1.73 m2 or Oral Trimethoprim 200mg 12 hrly if If S.aureus suspected
Community Acquired Suspected Necrotising Fasciitis + IV Gentamicin**∆ (max 4 days) ADD IV Flucloxacillin 2g 6 hrly Immunocompromised
Pneumonia (HAP) sensitive organism. If age ≥ 60 years, immunosuppressed,
Pneumonia (CAP) Consider in SSTI with disproportionate
IV Piperacillin/Tazobactam 4.5g 12 hourly
Duration and IVOST: discuss with pregnant, alcohol excess, liver disease If MRSA suspected or if true penicillin/ with fever BUT normal
(Monotherapy) Duration 7 days
Assess for SEPSIS Diagnosis of HAP is difficult and it is often pain or presence of acute organ microbiologist at 72 hours or if listeria meningitis suspected: beta-lactam allergy neutrophils AND source of
If true penicillin/beta-lactam allergy Trimethoprim see above re  eGFR
Calculate CURB 65 score: over-diagnosed. Consider other causes of dysfunction/ hypoperfusion ADD IV Amoxicillin 2g 4 hrly to IV Vancomycin** infection identified
• Confusion (new onset) clinical deterioration including hypotension. IV Vancomycin ** UROSEPSIS/ Pyelonephritis Diabetic foot infection/ Ceftriaxone + IV Gentamicin**∆ (max 4 days) Manage as per infection management
including hospital-onset COVID-19 + IV/Oral Metronidazole 500/400mg 8 hrly with fever
• Urea > 7 mmol/L
and review diagnosis early.
Seek urgent surgical/
+ IV Gentamicin**Δ (max 4 days)
osteomyelitis or if true penicillin/beta-lactam allergy
If severe Streptococcal infection suspected guidelines based on anatomical source.
• RR ≥ 30 breaths/ min orthopaedic review. IV Gentamicin**∆ (max 4 days)
Seek senior advice. Assess severity If eGFR < 20mL/min/1.73 m2 Assess ulcer size, probes to bone, ADD IV Co-trimoxazole 30mg/kg 6 hrly ADD IV Clindamycin 600mg 6 hrly Neutropenic sepsis or
• BP – diastolic ≤ 60 mmHg or based on CURB 65 score. Urgent DEBRIDEMENT/ If eGFR < 20 mL/min/1.73 m2 neuropathy, peripheral vascular disease, to Chloramphenicol
▲■
IV/Oral Ciprofloxacin If eGFR < 20 mL/min/1.73 m2 REPLACE Immunocompromised with fever
systolic < 90 mmHg EXPLORATION may be required Oral ▲■Ciprofloxacin MRSA risk. For outpatient therapy
If within 4 days of admission + IV/Oral Metronidazole 500/400mg 8 hrly IF BACTERIAL MENINGITIS STRONGLY Gentamicin with Oral/IV ▲■Ciprofloxacin and source of infection unknown;
• Age ≥ 65 years IV Flucloxacillin 2g 6 hrly Duration 7 days consult diabetic clinic guidelines
Treat as for CAP Total Duration 5 days (IV/oral) SUSPECTED ADD IV Dexamethasone (See guideline Initial Management of
+ IV Benzylpenicillin 2.4g 6 hrly IV Flucloxacillin 2g 6 hrly 10mg 6 hrly (for 4 days) and refer to ID Duration: Review with response/
Non-severe CAP If ≤ 7 days post hospital discharge + IV Metronidazole 500mg 8 hrly Assuming source control micro results at 72 hours Neutropenic Sepsis or Sepsis of Unknown
or ≥ 5 days after admission: + IV/Oral Metronidazole Duration of antibiotics: Source in Immunocompromised Adults)
CURB 65 score: ≤ 2 (and no sepsis) + IV Clindamycin 1.2g 6 hrly Biliary tract infection Catheter related UTI 500/400mg 8 hrly Discuss with Micro/ID
Non-severe HAP + IV Gentamicin**∆ (max 4 days)
As above except metronidazole not If SEPSIS or SIRS ≥2 Add
NEWS ≤ 6 Standard Risk
Oral Amoxicillin 500mg 8 hrly Remove/ replace catheter and send IV Piperacillin/Tazobactam 4.5g 6 hourly
Oral therapy recommended If MRSA suspected or if true penicillin/
or Oral ▲Doxycycline 200mg as a routinely required unless severe urine for culture. Don’t treat IV Gentamicin**∆ (max 4 days) If MRSA colonised/ line infection or sign of skin
Oral ▲Doxycycline 100mg 12 hrly beta-lactam allergy
asymptomatic bacteriuria
one-off single dose then 100mg daily If MRSA suspected or if true penicillin/beta- and soft tissue infection
or Oral Co-trimoxazole 960mg 12 hrly REPLACE Flucloxacillin Pancreatitis
or Oral ■ Clarithromycin 500mg 12 hrly lactam allergy Possible viral meningitis ADD IV Vancomycin**
Duration 5 days + Benzylpenicillin with IV Vancomycin** Does not require antibiotic therapy Symptomatic bacteriuria without
Duration 5 days unless complicated by cholangitis. sepsis IV Vancomycin** Usually diagnosed after empirical
Or if true penicillin/ beta-lactam allergy
Severe HAP Rationalise therapy within 48-72 hours
IV Gentamicin**∆ (max 4 days)
Severe CAP IV Co-trimoxazole 960mg 12 hrly Give single dose of IV Gentamicin**∆ + IV/Oral Metronidazole management and exclusion of bacterial Possible Infective Endocarditis
Based on: response, microbiology results + IV Vancomycin**
CURB 65 score ≥ 3 (or if allergy IV Co-amoxiclav 1.2g 8 hrly) infection specialist review Spontaneous bacterial immediately prior to catheter removal 500/400mg 8 hrly meningitis. Viral meningitis does NOT Always seek senior specialist advice and
+ IV Gentamicin**∆ (max 4 days) peritonitis or if IV route not available give single require antiviral prescription unless refer to cardiology.
or CAP (with any CURB 65 score) Duration 10 days (IV/oral) If SEPSIS or SIRS ≥2 Add immunocompromised. NEWS ≥ 7 High Risk
PLUS sepsis syndrome: See BNF for dosing of or as per infection specialist dose of oral ▲■Ciprofloxacin 500mg
Ascites PLUS peritoneal white cell count 30 minutes before catheter change. IV Gentamicin**∆ (max 4 days) Discuss with ID. Native heart valve IV Piperacillin/Tazobactam 4.5g 6 hourly
co-trimoxazole in renal impairment IV Amoxicillin 2g 4 hrly
IV/oral ■ Clarithromycin 500mg 12 hrly
if eGFR < 20 mL/min/ 1.73 m2 contact > 500/mm3 or > 250 neutrophils/mm3 If eGFR 10-30 mL/min/1.73 m2 (Metronidazole oral bioavailability Confusion or reduced consciousness = + IV Gentamicin**∆ (max 4 days)
PLUS either: infection specialist If not receiving co-trimoxazole ▲■
Ciprofloxacin 500mg single dose 80- 100%) Encephalitis NOT meningitis + IV Flucloxacillin 2g 6 hrly if < 85kg If MRSA colonised/ line infection or sign of skin
prophylaxis: If eGFR < 20 mL/min/1.73 m2 REPLACE (4 hrly if ≥ 85kg) and soft tissue infection
IV Amoxicillin 1g 8 hrly Duration 5 days (IV/oral) Infected human/animal bite Symptomatic bacteriuria with sepsis Possible viral encephalitis + IV Gentamicin ∆ (#synergistic dosing)
IV/Oral Co-trimoxazole 960mg 12 hourly As above and treat as per Gentamicin with Oral/IV ▲■Ciprofloxacin ADD IV Vancomycin**
or if requiring HDU/ ICU level care If critically ill discuss with infection specialist Non-severe bite Consider if confusion or reduced level
If receiving co-trimoxazole prophylaxis: pyelonephritis/ culture results. Duration/IVOST If MRSA/ resistant organisms suspected or if Or if true penicillin/ beta-lactam allergy
IV Co-amoxiclav 1.2g 8 hrly Oral Co-amoxiclav 625mg 8 hrly consciousness in suspected CNS infection.
IV Co-amoxiclav 1.2g 8 hrly Discuss with Micro/ID true penicillin/beta-lactam allergy IV Gentamicin**∆ (max 4 days)
If true penicillin/beta-lactam allergy or or if true penicillin/beta-lactam allergy Duration 7 days (IV/oral) Ensure CSF viral PCR is requested.
Aspiration pneumonia + IV Vancomycin**
Legionella strongly suspected Oral Doxycycline 100mg 12 hrly
▲ or if true penicillin/beta-lactam allergy May not be possible to differentiate IV Vancomycin**
Vascular graft infection + IV ▲■Ciprofloxacin 400mg 8 hourly
This is a chemical injury and does not + Oral Metronidazole 400mg 8 hrly from bacterial meningo-encephalitis. + IV Gentamicin ∆ (#synergistic dosing)
Oral/IV ▲■ Levofloxacin 500mg 12 hrly Oral /IV▲■Ciprofloxacin 500/400mg 12 hrly
monotherapy
indicate antibiotic treatment. Reserve + IV Vancomycin** Suspected prostatitis IV Flucloxacillin 2g 6hrly IV Aciclovir 10mg/kg 8 hrly Prosthetic heart valve Patients with Stem Cell Transplant
Duration 5 days (treatment)
antibiotics for those who fail to Consider in all men with lower + IV Gentamicin**∆ (max 4 days) See BNF for dosing in renal impairment. IV Vancomycin** or receiving chemotherapy for
(NB oral bioavailability 99 – 100 %) 3 days (prophylaxis) Duration 7 days (IV/oral)
improve within 48 hrs post aspiration. UTI symptoms If MRSA suspected or if true penicillin/beta- + IV Gentamicin ∆ (#synergistic dosing)
Duration 5 days (IV/oral) Discuss further management with ID/ Acute Leukaemia
IV Amoxicillin 1g 8 hrly Severe bite Decompensated Chronic liver lactam allergy
Legionella 10-14 days Refer to Urology virology. May require repeat LP or Discuss with Infection specialist NEWS ≤ 6 See High Risk treatment above.
Consider surgical review. IV Vancomycin**
or if true penicillin/beta-lactam allergy Disease with Sepsis Oral ▲■Ciprofloxacin 500mg 12 hrly neuro-imaging to establish diagnosis. within 72 hours NEWS ≥ 7 Critical Risk
IV Co-amoxiclav 1.2g 8 hrly + IV Gentamicin**∆ (max 4 days)
IV Clarithromycin 500mg 12 hrly
■
Unknown Source or Oral Trimethoprim 200mg 12 hrly Discuss duration/IVOST further Duration: Discuss with ID
#
See Synergistic Gentamicin for Endocarditis See Neutropenic Sepsis guidelines
+ IV Metronidazole 500mg 8 hrly or if true penicillin/beta-lactam allergy
IV Piperacillin/Tazobactam 4.5g 8 hourly if sensitive organism. management with Infection specialist in Adults guideline on StaffNet for dosing
Duration 5 days (IV/oral) IV Vancomycin** or if true penicillin/beta-lactam allergy Duration 14 days
+ Oral Metronidazole 400mg 8 hrly Oral /IV▲■Ciprofloxacin 500/400mg 12 hrly
+ Oral Ciprofloxacin 500mg 12 hrly
▲■
+ IV Vancomycin** !! Important Antibiotic Drug Interactions & Safety Information !!
**Gentamicin/ **Vancomycin If creatinine not available give gentamicin as follows:

• 323874 v1.0
Gentamicin / Vancomycin adult dosing calculators Actual Body Gentamicin Actual Body Gentamicin
Duration 7 days (IV/oral) Duration 7 days (IV/oral)
▲
Doxycycline/ Quinolone: reduced absorption with iron, calcium, magnesium & some nutritional supplements. See BNF (Appendix1) or see
are available via ‘Clinical Info’ icon on staff intranet Weight Dose Weight Dose pharmacy for advice.
/ GGC Medicines App. Use GGC Prescribing,
Administration, Monitoring charts < 40 kg 5 mg/kg 60 - 69 kg 320 mg ■
Clarithromycin/ Quinolone: risk of serious drug interactions see BNF (appendix 1) or seek pharmacy advice. May also prolong the QTc
Vancomycin If creatinine not available give 40 - 49 kg 240 mg 70 - 79 kg 360mg interval, avoid (where possible) if other QTc risk factors.
Vancomycin loading dose as per actual body weight
50 - 59 kg 280mg ≥ 80 kg 400 mg
▲■
Quinolones e.g. Ciprofloxacin, Levofloxacin Stop treatment at first signs of a serious adverse reaction (e.g. tendonitis), prescribe with caution for
Gentamicin ∆ Avoid Gentamicin in
decompensated liver disease or myasthenia gravis NB If CKD5 give 2.5 mg/kg (max 180 mg) people over 60 years and avoid co administration with a corticosteroid. See BNF for dosing advice in reduced renal function.

FURTHER ADVICE: Duty Microbiologist, Clinical/ Antimicrobial Pharmacist, Infectious Disease (ID) Unit at QEUH, local Respiratory Unit (for RTI) or from the Adult Therapeutic Handbook. Infection Control advice may be given by the Duty Microbiologist. NHS GGC Antimicrobial Utilisation Committee; Nov 2020 Expires Nov 2023, Updates: www.ggcformulary.scot.nhs.uk/Guidelines