ICU INFECTION MANAGEMENT GUIDANCE

• Antibiotic regimes have been chosen to minimise risk of C. difficile infection and resistance (in particular gram negative bacteria - see national guidance) • Antibiotics should always be reviewed when sensitivities are available • Document plan for antibiotic duration or review in notes and medicine chart prior to discharge from ICU

(options for penicillin allergy are in brackets) EMPIRICAL TREATMENT

st Community Acquired 1 line Co-amoxiclav + Clarithromycin (Levofloxacin) nd Pneumonia 2 line Piperacillin/tazobactam + Clarithromycin (Discuss with Microbiologist)

Amoxicillin + Metronidazole (Co-trimoxazole + Metronidazole) Aspiration Pneumonia Non severe

or Early Post-op Pneumonia Severe Follow HAP guidance below

st Hospital Acquired 1 line Amoxicillin + Gentamicin + Metronidazole (Vancomycin + Gent + Metro)

For patients with reduced renal function have had 72hours of gentamicin and still require IV Pneumonia (including VAP) or

therapy replace gentamicin with Aztreonam. nd 2 line Piperacillin/tazobactam (Vanc + Ciprofloxacin + Metro)

st Amoxicillin + Gentamicin + Metronidazole (Vancomycin + Gent + Metro) Intra-abdominal Sepsis 1 line

For patients with reduced renal function or have had 72hours of gentamicin and still require IV

therapy replace gentamicin with Aztreonam. nd 2 line Piperacillin/tazobactam (Vanc + Ciprofloxacin + Metro)

Severe SBP (click here) Piperacillin/tazobactam

Necrotising Pancreatitis (click here) Piperacillin/tazobactam

Aspiration Pneumonia Prophylaxis Not recommended

DIRECTED THERAPY - ORGANISM OR SENSITIVITIES KNOWN • Try to use narrowest spectrum agent • Co-trimoxazole can be used for non severe: • intra-abdominal infections • hospital acquired pneumonia • UTI • ESBL infections including UTI, hospital acquired pneumonia and intra-abdominal infections o Use temocillin instead of meropenem • Multiresistance and/or allergy and carbapenem required then if possible: o Use Ertapenem instead of Meropenem . For coliforms e.g. E. coli, Klebsiella but NOT Pseudomonas aeruginosa . Ertapenem may reduce selective pressure on meropenem-resistant P. aeruginosa • Proven MRSA HAP/VAP o Use Linezolid

Notes on Antibiotic Dosing, Monitoring, Administration and Antibacterial Activity • Refer to SPC, renal drug handbook or contact pharmacist regarding dosage adjustments if ↓ renal function Aztreonam • Provides gram negative cover including Pseudomonas but not ESBLs. No gram +ve or anaerobic cover. • 2g tds or qds (adjust dose for renal function). For dosing guidance click here. Ciprofloxacin • Additional warnings have been released following reviews of serious and disabling effects. • Update on Fluoroquinolone (FQ) Warnings. Gentamicin • For dosing guidance click here (MS Excel compatible online dosage calculator also available at this link) Vancomycin • Often given by continuous infusion - click here • If given by intermittent infusion always aim for the recommended higher trough level of 15-20mg/l • Seek advice on dosing in renal replacement therapy (local guidance in development) Piperacillin/tazobactam • Recommended administration by 30 minute infusion but if fluid restricted can be given as bolus (unlicensed) • For severe infection or if patient neutropenic use 4.5g qds • Does not require the addition of metronidazole as anaerobic activity is very good Temocillin • Provides gram negative cover including ESBLs (at 2g bd dose) but not Pseudomonas or Acinetobacter Tigecycline • Is an option for intra-abdominal infection but discuss all other possible options with Microbiologist before prescribing and monitor patient closely - see warning re increased mortality risk (link) Linezolid • Refer to local prescribing and monitoring guidance - click here

Developed by: ICU/Microbiology/Pharmacy Approved by: Antimicrobial Management Group, October 2016 Review: Feb 2021