Antimicrobial Policy for Adults (2017-19)

The Rotherham NHS Foundation Trust Barnsley Hospital NHS Foundation Trust

Antimicrobial Policy for Adults

Do not use antimicrobials unless absolutely essential

October 2017 19 Penicillin Allergy

Allergy Status [1] • Always ask for a description of the reaction experienced. • Document in notes and on the medicine chart: The Name of medicine, the signs, symptoms and severity of the reaction, and the date when the reaction occurred • If there are no allergies document "None Known" • If allergy status is not known document "Allergy status unconfirmed". Action must be taken to confirm the allergy status by the end of the following day. • Diarrhoea is a results of change in bowel flora and not an allergic reaction

PENICILLIN ALLERGY Do not use any Beta-lactams

Penicillins Cephalosporins LIFE-THREATENING Amoxicillin Cefalexin IMMEDIATE Benzylpenicillin Cefotaxime eg anaphylaxis Co-amoxiclav Ceftazidime Co-fluampicil Ceftriaxone angioedema Flucloxacillin Cefuroxime urticaria HeliClear® rash – florid, blotchy (contains amoxicillin, for H pylori eradication) Temocillin Penicillin V Piperacillin with Tazobactam

Carbapenems Imipenem Meropenem

PENICILLIN ALLERGY Use with caution cephalosporins, carbapenems and monobactams NOT LIFE-THREATENING Cross-reactivity in 10% of patients allergic DELAYED to penicillin eg simple rash Cephalosporins Carbapenems - non confluent, Cefalexin Imipenem - non pruritic Cefotaxime Meropenem - restricted to small area Ceftazidime Ceftriaxone Cefuroxime

PENICILLIN ALLERGY Safe to use Amikacin Gentamicin ALL TYPES Azithromycin Metronidazole Aztreonam* Nitrofurantoin Ciprofloxacin Ofloxacin Clarithromycin Sodium fusidate *Aztreonam may be less Clindamycin Teicoplanin likely than other beta lactams Colomycin Tetracycline to cause hypersensitivity in Co-trimoxazole Tigecycline penicillin sensitive patients. Daptomycin Tobramycin Microbiology may advise Doxycycline Trimethoprim but do not use where there is a Erythromycin Vancomycin history of ceftazidime allergy. [2] Fosfomycin

For antibiotics not listed or for further information, please contact:

Barnsley Rotherham Ward Clinical pharmacist Bleep Bleep Microbiologist 2749, 4986 4742, 7712 Medicines Information 2857 4126 Antimicrobial Policy for Adults 2017 19 Page 3

Table of contents

ANTIMICROBIAL TREATMENT

ABBREVIATIONS 5 INTRODUCTION 6 PRINCIPLES OF ANTIMICROBIAL PRESCRIBING 7 EARLY WARNING SCORE CHARTS 8-9 ESSENTIAL FACTS 10 PRESCRIBING ON THE DRUG CHART 10 ADVICE/SBAR REPORTING 10 ANTIMICROBIAL USE AND RESTRICTIONS 11 APPROPRIATE USE OF IV AND ORAL ANTIMICROBIALS 12 RESPIRATORY TRACT INFECTIONS 14 COMMUNITY–ACQUIRED 14 HOSPITAL–ACQUIRED PNEUMONIA 16 CHRONIC LUNG DISEASE 17 MYCOBACTERIAL 17 URINARY TRACT INFECTIONS 18-19 SEPTICAEMIA 20 COMMUNITY–ACQUIRED 20 HOSPITAL–ACQUIRED 20 INFECTIVE ENDOCARDITIS 21 EMPIRICAL (Organism not known) 21 TARGETED (Organism known) 22-24 CENTRAL NERVOUS SYSTEM 25 MENINGITIS 25 ENCEPHALITIS 25 BRAIN ABSCESS 25 SKIN AND SOFT TISSUE INFECTIONS 26 BACTERIAL 26-27 SURGICAL SITE INFECTION 28 DERMATOPHYTE 29 CANDIDA 29 VIRAL 30 ARTHROPOD INFESTATIONS 30 DIABETIC FOOT ULCER 31-32 BONE AND JOINT INFECTIONS 33 ENT INFECTIONS 34 ORAL AND MAXILLOFACIAL INFECTIONS 35 EYE INFECTIONS 35 OBSTETRIC AND GYNAECOLOGICAL INFECTIONS 36 SEXUALLY TRANSMITTED INFECTIONS 37-38 HAEMATOLOGICAL INFECTIONS 39 Page 4 Antimicrobial Policy for Adults 2017 19

GASTROINTESTINAL INFECTIONS 40-41 C.DIFFICILE ASSOCIATED DIARRHOEA 42

MRSA DECOLONISATION AND FOLLOW UP OF PATIENTS 43

ANTIMICROBIAL PROPHYLAXIS

SURGICAL PROPHYLAXIS 44 PRINCIPLES OF SURGICAL PROPHYLAXIS 44 HEAD AND NECK - INTRACRANIAL 45 HEAD AND NECK 45 FACIAL 46 EAR, NOSE AND THROAT 47 OPHTHALMOLOGY 47 THORAX 48 HEPATOBILIARY 48 LOWER GASTROINTESTINAL 49 ABDOMEN 49 SPLEEN 49 GI ENDOSCOPY AND PEG PROPHYLAXIS 50 GYNAECOLOGICAL 52 UROLOGY 53 LIMB 54

MEDICAL PROPHYLAXIS 55 MENINGOCOCCAL DISEASE / MENINGITIS CONTACTS 55 HAEMOPHILUS INFLUENZAE TYPE b CONTACTS 55 PREVENTION OF PNEUMOCOCCAL INFECTIONS (ASPLENIC PATIENTS & SICKLE CELL DISEASE) 55 TUBERCULOSIS PROPHYLAXIS 55

PROPHYLAXIS AGAINST ENDOCARDITIS 56

REFERENCES 57

APPENDICES 61 Therapeutic Drug Monitoring 61 APPENDIX A Gentamicin High Dose Regimen 62 APPENDIX B Gentamicin Conventional Dose Regimen 64 APPENDIX C Amikacin 65 APPENDIX D Tobramycin 66 APPENDIX E Teicoplanin 67 APPENDIX F Vancomycin 70 APPENDIX G Splenectomy Guidelines 71 APPENDIX H Doses in renal impairment 73 APPENDIX I Types of Antimicrobials 76

CONTACT NUMBERS and AUTHORS 77

CONTACTING MICROBIOLOGIST 78

SEPSIS SIX CHECKLIST 79

ABBREVIATIONS

BASHH British Association of Sexual Health and HIV bd twice daily BSAC British Society for Antimicrobial Chemotherapy BTS British Thoracic Society CCDC Consultant in Communicable Disease Control CDI Clostridium difficile infection CMV Cytomegalovirus CRP C Reactive protein CSF Cerebrospinal fluid CSU Catheter specimen urine ERCP Endoscopic retrograde colangiopancreatography ESBL Extended Spectrum Beta Lactamase FBC Full blood count HACEK Haemophilus species, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens and Kingella species HDU High dependancy unit HIV Human immunodeficiency virus HPA Health Protection Agency HSV Herpes simplex virus i/m Intramuscular ITU Intensive therapy unit i/v Intravenous kg kilogram mg milligram mL millilitre m/r Modified release MRSA Meticillin Resistant Staphylococcus Aureus MSU Mid stream urine NICE National Institute for Health and Clinical Excellence od once daily P alternative in penicillin allergy PEG Percutaneous endoscopic gastrostomy PHE Public Health England PID Pelvic inflammatory disease PR per rectum p/v per vaginum qds four times daily SBP Spontaneous bacterial peritonitis SIGN Scottish Intercollegiate Guidelines Network STI Sexually transmitted infections tds three times daily U&E Urea and electrolytes UTI Urinary tract infection VZV Varicella-zoster virus WCC White cell count Page 6 Antimicrobial Policy for Adults 2017 19

Antimicrobial Policy ANTIMICROBIAL RESISTANCE- (The Path of Least Resistance)

There is a growing national and international concern Introduction about the increasing resistance of micro-organisms to antimicrobial agents (House of Lords Select Committee The aim of these guidelines is to optimise antimicrobial on Science and Technology, Standing Medical Advisory prescribing within both The Rotherham NHS Committee 1998).[7] This resistance is an inevitable Foundation Trust and Barnsley Hospital NHS Foundation consequence of antimicrobial use by Darwinian Trust. Antimicrobials are over-prescribed in many health selection pressure. Resistance makes infections more institutions and both these hospitals are not exempt. difficult, and often more expensive to treat and may These guidelines would not only attempt to provide the increase complications and length of hospital stay. The best quality of care to manage patients with infections Chief Medical Officer has highlighted the importance but also to reduce microbial resistance, healthcare of prudent use of antimicrobials, i.e. appropriate choice, associated infections and overall cost. The prudent use dose and duration of antimicrobial therapy in his report of antimicrobials in order to minimise the emergence of “Winning Ways” (December 2003).[4] resistance has also been emphasised by the House of In general, the more broad-spectrum antimicrobials Lords and Department of Health (1998).[3] are more likely to be associated with the emergence of resistance and health care associated infections The Chief Medical Officer in his report “Winning Ways” including Clostridium difficile. Furthermore some of the (December 2003)[4] has set out a clear direction on less broad-spectrum antimicrobials such as ciprofloxacin the actions required to reduce the level of healthcare can select for emergence of MRSA associated infections and to curb the proliferation of antimicrobial-resistant organisms. Furthermore, antimicrobial usage has also been addressed in some ANTIMICROBIAL ASSOCIATED of the domains of the Saving Lives Toolkit[5] and more recently the Infection Control Code of Practice DIARRHOEA (September 2006)[6] has set standards for appropriate antimicrobial prescribing. Antimicrobial usage particularly the more broad- spectrum ones may lead to diarrhoea and Clostridium difficile colitis.

The aim of both hospitals is therefore not to use the more broad-spectrum antimicrobials such as cephalosporins – ceftriaxone/cefotaxime and carbepenems and minimise the use of cefuroxime particularly in Elderly patients. Antimicrobial Policy for Adults 2017 19 Page 7

PRINCIPLES OF ANTIMICROBIAL PRESCRIBING

Before prescribing antimicrobials, consider the following 10 points:

1. Do not start antimicrobial therapy unless there is clear evidence of infection

2. Take a thorough drug allergy history

3. Initiate prompt effective antibiotic treatment within ONE hour of diagnosis (or as soon as possible) in patients with severe sepsis or life threatening infections.

4. Avoid inappropriate use of broad spectrum antibiotics.

5. Obtain culture prior to commencing therapy where possible (but do not delay therapy)

6. Check for previous microbiology results and history of MRSA/ESBL/CPE/ Clostridium difficile

7. Comply with local antimicrobial prescribing guidance

8. Document clinical indication (and disease severity if appropriate), drug name, dose and route on drug card and in clinical notes *

9. Include a review/stop date or duration on the prescription

10. Document the exact indication on the drug chart (rather than stating long term prophylaxis) for clinical prophylaxis

* Based on Start Smart then Focus - Antimicrobial Stewardship Toolkit for English Hospitals updated March 2015 [8] Page 8 Antimicrobial Policy for Adults 2017 19

Early warning score chart Barnsley Antimicrobial Policy for Adults 2017 19 Page 9

Early warning score chart Rotherham Page 10 Antimicrobial Policy for Adults 2017 19

ESSENTIAL FACTS ADVICE

• Encourage oral antimicrobials whenever possible. Advice can always be obtained from the Department of Medical Microbiology. There is a 24 hour and 7 day • Use IV antimicrobials only in serious infections or service, both technical and clinical, available for the when patients are unable to take oral medication. investigation, treatment, and prevention of infections. • After 48-72 hrs of IV therapy review the patient Pharmacists may be contacted for dosage, therapeutic and consider switching to oral medication. drug monitoring and medicines information. • Generally a total of 5 days of antimicrobial therapy Before contacting for advice: should suffice for uncomplicated infections. • Assess the patient • Review antimicrobials and clinical progress on • Know the admitting diagnosis a daily basis in the light of current microbiology • Read the most recent medical and nursing notes results. • Have appropriate documents available eg Nursing • Once the aetiological agent is identified, switch and Medical Records, PAR (Patient at risk), MEWS/ the broad spectrum therapy to a targeted narrow NEWS (early warning charts), Prescription Charts, spectrum agent. Allergies, IV fluids, Resuscitation status • Communicate using the SBAR Reporting Tool.

SBAR Reporting Tool PRESCRIBING ON THE Source: Springfield hospital, Springfield, Vermont DRUG CHART Situation • State your name and unit/ward • Check for genuine allergy • I am calling about patient’s name and age • Check for history of Clostridium difficile diarrhoea, • The reason I am calling is… CPE, ESBL producing, MRSA and other resistant organisms Background • Document • State the admission diagnosis/working diagnosis and • Duration or review date date of admission • Indication • Relevant medical history including family history; • The CODE for Restricted Antimicrobials in the underlying condition/ co morbidities section ‘Additional Instructions’ • A brief summary of treatment to date; current antimicrobial therapy and duration; recent antimicrobial use (within the last month if ADHERENCE TO THE POLICY possible) • History of C.difficile diarrhoea / CPE / ESBL / MRSA / This will be monitored on a daily basis on the wards and other resistant organisms as a rolling programme of audits by the directorates, • Previous microbiology results microbiology and the pharmacy departments, as • Infective markers recommended by Infection Control Code of Practice, [6] • Travel history NICE Guideline 15 :antimicrobial stewardship : systems and processes for effective antimicrobial medicine use Assessment [9] 'Saving Lives’ [10] and 'Start Smart Then Focus' [8] State your assessment of the patient • Allergies • Renal function • Hepatic function

Recommendations/Actions • I would like (state what you would like to see done) • Determine timescale • Is there anything else I should do? • Record name and phone or bleep number of contact • Patient concerns, expectations and wishes

Don’t forget to document the call! Antimicrobial Policy for Adults 2017 19 Page 11 Antimicrobial use and restrictions Please contact Consultant Microbiologist when considering protected (red and yellow) antimicrobials.

Antimicrobials Permitted Indications

Amikacin iv Red - Amoxicillin oral iv Code required Amphotericin iv at all times, unless Azithromycin oral for permitted indications. Aztreonam iv Aspiration pneumonia (page 16), biliary infections (page 40), hospital acquired sepsis (page 20), pyelonephritis (page 19) Surgical prophylaxis (GI endoscopy page 50) See relevant page Benzylpenicillin iv for further details Caspofungin iv Cefalexin oral UTI in pregnancy (page 18) Yellow - Code required Cefotaxime iv Bacterial meningitis, brain abscess (page 25), encephalitis (page 25) endocarditis (page 24) within 48 Ceftazidime iv hours unless Ceftriaxone iv Epididymo-orchitis (page 38), haemophilus influenzae type b contacts (page 55), meningitis contacts (page for permitted im 55), PID (page 36) uncomplicated gonorrhoea (page 37) indication. Cefuroxime iv Community acquired pneumonia (page 14), community acquired sepsis (page 20), oral and maxillofacial see relevant page surgery infections (page 35), pyelonephritis (page 19), surgical prophylaxis (pages 45, 47, 52, 53 ) for further details Chloramphenicol oral iv Bacterial meningitis (page 25), ophthalmic preparations (page 35 and 47) Ciprofloxacin oral iv biliary infections (page 40), bites (page 27), enteric fever (page 40), epididymo-orchitis (page 19), gonorrhoea Green - (page 37), haematology (page 39), meningitis contacts (page 55), necrotising fasciitis (page 27), obstetrics No Code needed and gynaecology post op sepsis (page 36), pneumonia (page 14), prostatitis (page 19), pyelonephritis (page Prescribing 19) SBP, (page 41), surgical prophylaxis (pages 50, 51, 53), permitted Clarithromycin oral iv according to the Clindamycin oral iv Bites (page 27), maxillofacial surgery infections (page 35), necrotising fasciitis (page 27), obstetrics and gynaecology post op sepsis (page 36) periorbital cellulitis (page 35) quinsy Antimicrobial (page 34) oral and surgical prophylaxis (pages 45, 46, 47, 52) Policy Co-amoxiclav oral iv Co-trimoxazole oral iv Dalbavancin iv Documentation: Daptomycin iv Doxycycline oral Health care record Ertapenem iv Document microbiologist Erythromycin oral iv advice • The CODE Ethambutol oral • Review or stop Flucloxacillin oral iv date Fluconazole oral iv Medicines Chart Fosfomycin Antimicrobial, route, Fusidic acid oral Osteomyelitis and septic arthritis (page 33) dose, dose times plus Sodium fusidate • The CODE Gentamicin iv • Indication Isoniazid oral • Review or stop date Levofloxacin oral Weston park patients only Linezolid oral iv Meropenem iv Endocarditis (page 21) Haematology (page 39) Metronidazole oral Nitrofurantoin oral Ofloxacin oral Penicillin V oral Pivmecillinam oral Piperacillin/ iv Hospital acquired pneumonia (page 16) Sepsis (page 20) Cellulitis (page 26) necrotising fasciitis (page 27) diabetic tazobactam foot ulcer (page 32) Neutropenic Sepsis (page 39) Surgical prophylaxis (page 51) Septic arthritis (page 33) Pyrazinamide oral Rifampicin oral iv Legionella pneumonia, post influenza/ staphyloccal pneumonia (page 15) tuberculosis (page 18) endocarditis (page 21 and 23) meningitis contacts and Haemophilus (page 55) Teicoplanin iv Pneumonia (pages 15, 16) Sepsis (MRSA page 20) Cellulitis (page 26) Necrotising fasciitis and Infected leg ulcers (page 27) Surgical site infection (page 28) Diabetic foot (page 32) Osteomyelitis and septic arthritis (page 33) Neutropenic Sepsis (page 39) Surgical prophylaxis (pages 45, 46, 47, 48, 49, 50, 51, 52 and 54) Temocillin iv Tigecycline iv Tobramycin iv nebulised Trimethoprim oral Vancomycin Oral oral (for C Diffiicle) Vancomycin iv Endocarditis (page 21 and 23) Voriconazole iv Page 12 Antimicrobial Policy for Adults 2017 19

GUIDELINE FOR THE APPROPRIATE USE OF INTRAVENOUS AND ORAL ANTIMICROBIALS FOR ADULTS Most patients DO NOT require i/v antibiotics. The majority of those who do will only need for 48-72 hours

INDICATIONS FOR IV ANTIBIOTICS If sepsis is suspected refer to Sepsis Six checklist on page 79

1. Sepsis (2 or more of the following) - temperature >38o C or <36o C - heart rate >90 beats/min - respiratory rate >20 breaths/min - WCC >12 x 109/L or <4 x 109/L - CURB65 score 3–5 2. Febrile with neutropenia (WCC <1.0 x 109 /L) 3. Specific indications which require high dose i/v therapy e.g. endocarditis, septic arthritis, osteomyelitis, meningitis, necrotising fasciitis, disease specific scoring system 4. Positive blood cultures in the past 24 hours 5. Oral route compromised e.g. - unconscious - vomiting - nil by mouth - reduced absorption (diarrhoea or steatorrhoea) - mechanical swallowing disorder 6. No oral formulation available

Have the indications for commencing or continuing i/v antibiotics been met? (review daily)

YES NO

Start or Continue with i/v Start or Consider switch to antimicrobial Refer to the appropriate Policy or discuss ORAL antimicrobial/dose • Continue to monitor closely with microbiologist • Review need for i/v therapy If necessary Continue to monitor patient’s again after 24 hours progress following change to oral therapy

Standard TOTAL duration i/v+oral (days) ANTIMICROBIALS Intravenous Oral Infective exac. of COPD 5 - 7 (specify duration on Medicines Chart) Pneumonia, uncomplicated 5 Pneumonia, severe 7 - 10 Amoxicillin 500 mg – 1g tds UTI, uncomplicated 3 Benzylpenicillin Amoxicillin 500mg - 1g tds Pyelonephritis 14 Clarithromycin 500 mg bd Cellulitis 10-14 Co-amoxiclav 625 mg tds Flucloxacillin 500 mg – 2 g qds Meropenem Discuss with microbiologist Metronidazole 400 mg tds Piperacillin /tazobactam Discuss with microbiologist Teicoplanin Discuss with microbiologist Vancomycin Discuss with microbiologist Antimicrobial Policy for Adults 2017 19 Page 13 5. Community5. IV therapy 4. continue 3. Change3. Clinical check review, microbiology, make a clear plan and document decision Clinical review Clinical and decision at 48 hours 72 to Document all decisions 2. I/V switch oral GUIDANCE ON GOOD CLINICAL ON GOOD GUIDANCE ANTIMICROBIAL PRESCRIBING Right drug, Right dose, Right time, Right duration... Right drug, time, Right Right dose, Right Every patient 1. STOP Then focus START SMART START Take history of relevant allergies relevant of history Take prompt effectiveInitiate antibiotic diagnosis of hour one within treatment patients in possible) (or as soon as threatening life or sepsis severe with infections guidance prescribing local with Comply and indication Document clinical dose and severity appropriate, if disease notes clinical in chart and drug on route Include review/stop date or duration to commencing Obtain prior cultures (but do not possible where therapy delay therapy) alert organisms including START SMART GUIDANCE [8] SMART GUIDANCE START - Focus then Smart Start from Adapted Antimicrobial Stewardship toolkit for English hospitals [8] results microbiology previous Check • • • • • • • Page 14 Antimicrobial Policy for Adults 2017 19

RESPIRATORY TRACT INFECTIONS - Community-acquired

IMPORTANT Before prescribing antimicrobials

• History of C.difficile diarrhoea / CPE / ESBL / MRSA / Take appropriate samples other resistant organisms – contact Microbiologist • Sputum in all cases if possible • Check for previous microbiology results • Blood culture in severe • Treatment duration (i/v or oral) 5 days unless specified pneumonia • Sepsis – start antibiotics within an hour of diagnosis. Prescribe in STAT section of • Urine Legionella and drug chart. Refer to Sepsis Six checklist on page 79 pneumococcal antigen in • Consider referral to vascular access team if patient is suitable for moderate to severe infection community IV pathway.

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Pneumonia [16, 17] Streptococcus Review microbiology pneumoniae Definition: sign and syptoms of Send acute and convalescent lower respiratory tract infection Mycoplasma sera for atypical serology and radiological evidence of pneumoniae consolidation on chest X-ray Haemophilus influenzae Assess severity* If low to moderate severity and Chlamydia sp. no consolidation on chest x-ray consider using empirical sepsis Legionella sp. guidance on page 20

Start antibiotics within 4 hours of

presentation

Low severity Amoxicillin oral P Penicillin allergy: CURB65 score 0-1 500 mg – 1 g tds for 5 days

If treated with Amoxicillin prior Doxycycline oral 200mg stat then 100- 200mg od to admission or Clarithromycin oral Clarithromycin oral or i/v 500 mg bd for 5 days 500 mg bd

Moderate severity Start antibiotics immediately Send blood cultures and sputum CURB65 score 2 Amoxicillin oral 500 mg – 1 g tds P Penicillin allergy: plus Omit Amoxicillin Clarithromycin oral 500 mg bd Total duration 5 days Give i/v if needed

High severity Start antibiotics immediately: P Penicillin allergy CURB65 score 3-5 Co-amoxiclav i/v 1.2g tds plus Non-life threatening and less than Clarithromycin i/v 500mg bd 65 years old Cefuroxime i/v *CURB65 score De-escalate in view of sputum and/or 1.5 g tds 1 point for each blood culture results plus Confusion Clarithromycin i/v Urea >7 mmol/L 500 mg bd Respiratory rate ≥ 30 / min Life threatening or older than Blood pressure: 65 years old Systolic < 90 mmHg Teicoplanin i/v Diastolic ≤ 60 mmHg 6mg/kg (appendix Ei) Age ≥ 65 years plus Ciprofloxacin i/v 400mg bd Micro code is required the following day

Pneumonia continued overleaf Total duration 7-10 days Antimicrobial Policy for Adults 2017 19 Page 15

RESPIRATORY TRACT INFECTIONS - Community-acquired

IMPORTANT Before prescribing antimicrobials

• History of MRSA/ ESBL/ Clostridium difficile – contact Microbiologist Take appropriate samples • Check for previous microbiology results • Sputum in all cases if possible • Treatment duration (i/v or oral) 5 days unless specified • Blood culture in severe • Sepsis – start antibiotics within an hour of diagnosis. Prescribe in STAT section of drug chart pneumonia Refer to Sepsis Six checklist on page 79 • Consider referral to vascular access team if patient is suitable for community IV pathway.

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Pneumonia, continued Confirmed Benzylpenicillin i/v P Penicillin allergy: Streptococcus 1.2 g qds discuss with Microbiologist pneumoniae

Confirmed MRSA Teicoplanin i/v 6mg/kg (appendix Ei)

addition of sodium fusidate or rifampicin may be advised by microbiologist Duration: as advised by Microbiologist

Primary Atypical Mycoplasma Clarithromycin oral Take appropriate samples, Pneumonia pneumoniae*/** 500 mg bd including samples for serology i/v If severe vomiting and urine antigen for Legionella [16, 17] Chlamydia pneumoniae*/**

Chlamydia Doxycycline oral *Infection control procedures psittaci** 200 mg first dose then 100 mg bd should be undertaken for 14 days **Locally notifiable disease Coxiella Tetracycline is the drug of choice. to PHE (Public Health England) burnetti*/** Seek advice from Consultant Microbiologist

Legionella Clarithromycin i/v pneumophila** 500 mg bd Rifampicin or Ciprofloxacin may need to be Duration at least 2 weeks added in severe cases Discuss with microbiologist

Post-Influenza / Confirmed Flucloxacillin i/v P Penicillin allergy: Staphylococcus aureus Staphylococcus 2g qds Teicoplanin i/v Pneumonia aureus plus 6mg/kg (appendix Ei - pg 68) Rifampicin oral initially plus 600mg bd Rifampicin oral initially [13] Give i/v if needed 600mg bd Give i/v if needed Total duration 2-3 weeks

Page 16 Antimicrobial Policy for Adults 2017 19

RESPIRATORY TRACT INFECTIONS - Hospital-acquired pneumonia

IMPORTANT Before prescribing antimicrobials

Hospital acquired Pneumonia: Definition – Pneumonia occurring > 48 hr after admission and excluding any infection that is incubating at the time of admission. Diagnosis of HAP is difficult. Following Criteria will help in identifying patients in whom pneumonia should be considered. 1. Purulent sputum 2. Increased oxygen requirement 3. Temperature 4. WCC >10 x 109/L or <4 x 109/L 5. New or persistent infiltrate on chest x-ray, which is otherwise unexplained Presence of 3 or more criteria indicates high probability of pneumonia and antibiotic therapy is indicated in these patients.

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Hospital acquired P Penicillin allergy: Pneumonia Teicoplanin i/v 6mg/kg (appendix Ei - pg 68) Early onset Streptococcus Co-amoxiclav i/v plus (<5 days after admission) pneumoniae 1.2 g tds Ciprofloxacin oral No previous antibiotic therapy Haemophilus 500 mg bd and no risk factors influenzae i/v if needed 400 mg bd Staphylococcus aureus

Early onset In addition to Piperacillin/tazobactam i/v *Risk factors: (<5 days after admission) above organisms 4.5 g tds Recent hospital admission With previous antibiotic Recent use of co-amoxiclav therapy and risk factors* E.Coli, Klebsiella Add if MRSA positive Positive culture for Pseudomonas Acinetobacter Teicoplanin i/v Immunocompromised Pseudomonas 6mg/kg (appendix Ei - pg 68) MRSA

Late onset E.Coli, Klebsiella Piperacillin/tazobactam i/v If previous sample positive tailor (>5 days after admission) Acinetobacter 4.5 g tds the antibiotics according to the With previous antibiotic Pseudomonas sensitivity. therapy MRSA Add if MRSA positive Any treatment longer than 5 Teicoplanin i/v days should be discussed with 6mg/kg (appendix Ei - pg 68) micro

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Aspiration Pneumonia Wide range of If no previous hospital admission P Penicillin allergy: Most likely to be chemical organisms Amoxicillin i/v Aztreonam i/v pneumonitis. including 500 mg tds 1g tds anaerobes plus plus If no consolidation on chest Metronidazole i/v Teicoplanin i/v xray then consider stopping 500 mg tds 6mg/kg (appendix Ei - pg 68) antimicrobials. plus If previous hospital admission or metronidazole i/v hospital acquired 500mg tds Co-amoxiclav i/v Aztreonam - caution in 1.2 g tds Ceftazidime allergy Review in the light of cultures Change to oral at 48 hours Total duration 5 days Antimicrobial Policy for Adults 2017 19 Page 17

CHRONIC LUNG DISEASE INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Infective exacerbation of Viruses 80% Doxycycline oral Tetracycline allergy or chronic obstructive pulmonary Streptococcus 200mg first dose then contraindicated: disease pneumoniae 100-200mg od for 5days Amoxicillin oral 500mg tds for 5 days Haemophilus If failed on doxycycline influenzae therapy dyspnoea Amoxicillin oral purulence Moraxella 500mg to 1g tds catarrhalis If patient fails to respond to therapy sputum volume then discuss with microbiology To review on day 5 – longer treatment may be required in (18) some circumstances e.g. until sputum becomes mucoid for at least 24 hours

Bronchietasis Haemophilus Check previous Microbiology and take Seek advice from Microbiologist influenzae a sputum sample before prescribing any Infections in chronic lung diseases Staphylococcus antibiotic. are treated with broad spectrum Pseudomonas spp antibiotics for a prolonged Duration 7 days for initial treatment duration. the resulting collateral subsequent therapy as guided by damage of this practice must Microbiology be appreciated and taken into consideration when deciding the type and duration of antimicrobial agent.

(19)

References Chronic obstructive pulmonary disease in over 16s: diagnosis and management NICE guidelines [CG101] Published date: June 2010 The British Thoracic Society Bronchiectasis (non-CF) guideline group (2010) Guideline for non - CF Branchiectasis Thorax 65 (i) 1-58 RESPIRATORY TRACT INFECTIONS - Mycobacterial

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Tuberculosis Mycobacterium Doses based on patient weight Please refer to TB policy tuberculosis [20] First 2 months of quadruple therapy Infection control risk – Mycobacterium either Rifater® oral for appropriate isolation and bovis (combination of isoniazid, rifampicin infection control precautions and pyrazinamide) Mycobacterium plus Refer to Consultant Chest africanum Ethambutol oral Physician and Infection Control or Team Voractiv® (Combination of isoniazid, rifampicin, pyrazinamide and ethambutol) Followed by 4 months of double therapy Notify Public Health Doctor Rifinah® oral (combination of isoniazid and rifampicin)

Atypical Mycobacterial Mycobacterium Consult Microbiology for susceptibility Seek advice from Consultant Infection avium intracellulare details Microbiologist and Chest Physician Mycobacterium kansasii No need for isolation or notification Mycobacterium malmoense etc.

Page 18 Antimicrobial Policy for Adults 2017 19

URINARY TRACT INFECTIONS [12,13,21]

IMPORTANT Before prescribing antimicrobials

Women (non pregnant) E coli 1st line >85% of coliforms sensitive to Simple cystitis Klebsiella sp. *Nitrofurantoin oral nitrofurantoin. (No fever, no loin pain) Proteus sp. 50 to 100 mg 6 hourly for 3 days 70% sensitive to trimethoprim Enterococci MRSA 2nd line Send MSU for culture and Trimethoprim oral sensitivities 200 mg bd for 3 days *Avoid in renal impairment (eGFR <60 mL/minute)

Men** As above Antibiotics as above **Investigate further for Duration 7 days underlying pathology

Pregnancy As above Cefalexin oral P Penicillin allergy: 500 mg tds for 7 days Seek advice from Microbiologist

Review therapy according to culture and sensitivity

Recurrent UTI

Two or more confirmed infections E coli and other First line prophylaxis with : *Avoid in renal impairment (eGFR in the last 12 months Gram negative nitrofurantoin oral 50mg* once daily at <45 mL/minute) organisms night as long as the isolate is sensitive. Decision of long term prophylaxis predominantly Where this is not suitable then discuss should be made in conjunction with Microbiology with the microbiologist after 3 months initial treatment.

Upper UTI

See next page Antimicrobial Policy for Adults 2017 19 Page 19

URINARY TRACT INFECTIONS [12,13,21]

IMPORTANT Before prescribing antimicrobials

• History of CPE/MRSA/ ESBL/ Clostridium difficile – contact Microbiologist Take appropriate samples • MSU for culture and • Check for previous microbiology results sensitivities • Sepsis – start antibiotics within an hour of diagnosis. Prescribe in STAT section of drug chart Refer to Sepsis Six checklist on page 79 Upper UTI Pyelonephritis E coli and other If less than 50 years of age Pregnancy Loin pain/fever Gram negative Ciprofloxacin oral Cefuroxime i/v 1.5g tds organisms 500 mg bd predominantly i/v if needed 400 mg bd P Penicillin allergy >50 years of age If older than 50 years of age Co-amoxiclav oral 625mg tds or Aztreonam i/v 1.2g i/v tds. 1g tds

If life threatening sepsis If life threatening sepsis Consider adding single dose consider adding single **Gentamicin i/v dose **Gentamicin i/v High Dose (Appendix A) High Dose (Appendix A) and then and then review review Aztreonam - caution in Total duration 10 – 14 days Ceftazidime allergy

Review treatment in light of cultures Caution and sensitivities CIPROFLOXACIN ENCOURAGES THE EMERGENCE OF MRSA AND C. difficile

**Gentamicin levels: (Appendix A) Complicated UTI E coli and other Seek advice from Microbiologist please check previous Renal calculi Gram negative microbiology Urinary catheter organisms Urological abnormality predominantly Recurrent UTI Surgery etc.

Prostatitis E coli and other 1st line Seek advice from Consultant Gram negative Ciprofloxacin oral Microbiologist and Urologist organisms 500 mg bd for 4 weeks predominantly (i/v 200 – 400 mg bd Refer to Urologist for advice on if needed) specimen collection

2nd line Caution Trimethoprim oral 200mg bd CIPROFLOXACIN ENCOURAGES for 4 weeks THE EMERGENCE OF MRSA AND C. difficile

Epididymo-orchitis Ciprofloxacin oral Urinary source 500 mg bd 10 days

If STI suspected refer to page 38 Page 20 Antimicrobial Policy for Adults 2017 19

SEPSIS [22]

• It is important to establish the primary source of septicaemia in order to shed light on the most probable organisms and the underlying pathology. • Blood culture should be taken BEFORE commencing antimicrobial therapy. • Sepsis – start antibiotics within an hour of diagnosis. Prescribe in STAT section of drug chart and inform nursing staff Refer to Sepsis Six checklist on page 79

IMPORTANT Before prescribing antimicrobials

• History of CPE/MRSA/ ESBL/ C.difficile – contact Microbiologist Take appropriate samples • Check for previous microbiology results • Blood cultures • Normally treatment duration (iv or oral) 5 days unless specified • Urine • Sputum Community-acquired

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Source unknown Empirical *Co-amoxiclav i/v Take appropriate samples 1.2 g tds Review treatment in light of If severe add P Penicillin allergy: cultures and sensitivities Metronidazole i/v Non-life threatening: 500 mg tds Cefuroxime i/v 1.5 g tds UTI is the commonest cause *If Co-amoxiclav used in the past Life threatening and Elderly: 4 weeks Teicoplanin i/v Piperacillin/tazobactam i/v 6mg/kg (appendix Ei - pg 68) 4.5 g tds plus Ciprofloxacin oral 500 mg bd If life threatening sepsis i/v if needed 400 mg bd Consider adding single dose **Gentamicin i/v If severe add High Dose (Appendix A) Metronidazole i/v and then review 500 mg tds

If MRSA or line infection add If life threatening sepsis Teicoplanin i/v Consider adding single dose 6mg/kg (appendix Ei - pg 68) **Gentamicin i/v High Dose (Appendix A) and then review **Gentamicin levels: (Appendix A) Hospital-acquired INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Source unknown Wide range of Piperacillin–tazobactam i/v P Penicillin allergy: hospital organisms 4.5 g tds Non-life threatening: Teicoplanin i/v If life threatening sepsis 6mg/kg (appendix Ei - pg 68) Consider adding single dose Aztreonam i/v 1-2g tds **Gentamicin i/v Aztreonam - caution in High Dose (Appendix A) Ceftazidime allergy and then review If life threatening sepsis Consider adding single dose If MRSA or line infection add **Gentamicin i/v Teicoplanin i/v 6mg/kg (appendix Ei - pg 68) High Dose (Appendix A) and then review Life threatening allergy or If previously grown resistant organism (ESBL, AmpC) contact microbiologist **Gentamicin levels: (Appendix A) Antimicrobial Policy for Adults 2017 19 Page 21

INFECTIVE ENDOCARDITIS – Empirical (Organism not known) [23]

• Discuss treatment with Consultant Cardiologist and Microbiologist

IMPORTANT • History of CPE/MRSA/ ESBL/ C.difficile – contact Take appropriate samples Before prescribing Microbiologist THREE sets of blood cultures from antimicrobials • Check for previous microbiology results different sites and at different times • Modify as soon as culture and sensitivities are available PRIOR to antimicrobial therapy • Consider referral to vascular access team if patient is suitable for community IV pathway

IMPORTANT Gentamicin & Vancomycin • Review treatment every 3 days Therapeutic drug • Renal impairment – discuss with Microbiologist • Discuss duration with Microbiologist monitoring • Monitor blood levels (Appendices B & F) • Inform patient of potential side effects • Monitor renal function 3 times a week (hearing, balance and renal impairment)

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Native valve Empirical Flucloxacillin i/v Treatment should be started Acute presentation 2g 4-6 hourly (i.e. 8 to 12g daily) as soon as blood cultures are Use 4 hourly regimen if weight is collected for acute presentation greater than 85kg plus P Penicillin allergy: *Gentamicin i/v see below 80 mg 12 hourly Modify according to culture and Native valve Empirical Amoxicillin i/v sensitivities. If negative contact Indolent (Subacute) 2g 4 hourly Consultant Cardiologist and presentation Microbiologist A second agent may be required please discuss with microbiology. *Gentamicin levels: Pre dose (trough): <1mg/L If not acutely septic antimicrobial 1 hour Post dose (peak): therapy maybe withheld until culture 3 – 5 mg/L results are known. (i.e. not the usual therapeutic levels) Native valve Acute presentation with risk Empirical Vancomycin i/v **Vancomycin levels: factors for multiresistant 1g 12 hourly (Appendix F) Enterobacteriace plus Pre dose (trough): 15 – 20 mg/L or Meropenem i/v Pseudomonas 2g 8 hourly

P Penicillin allergy Empirical **Vancomycin i/v or 1g 12 hourly Intra-cardiac prosthesis plus or Rifampicin oral Suspected MRSA 300-600 mg 12 hourly use lower dose if creatinine clearance is less than 30mL/min plus *Gentamicin i/v 80 mg 12 hourly Page 22 Antimicrobial Policy for Adults 2017 19

ENDOCARDITIS – Targeted (Organism known) [23] Discuss treatment with Consultant Cardiologist and Microbiologist

IMPORTANT • History of CPE/MRSA/ ESBL/ C.difficile – contact Take appropriate samples Before prescribing Microbiologist THREE sets of blood cultures from antimicrobials • Treatment duration depends on the organism and patient different sites and at different times factors. Must be discussed with Microbiologist/Cardiologist PRIOR to antimicrobial therapy • Consider referral to vascular access team if patient is suitable for community IV pathway

IMPORTANT Gentamicin & Vancomycin Therapeutic drug • Renal impairment – discuss with Microbiologist • Inform patient of potential side effects monitoring • Monitor blood levels (Appendices B & F) (hearing, balance and renal impairment) • Monitor renal function 3 times a week • Discuss with Microbiologist before • Review treatment every 3 days continuing for longer than 2 weeks

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Native valve endocarditis Viridans Commence with P Penicillin allergy: Streptococcal Endocarditis Streptococci Benzylpenicillin i/v Consult Microbiologist Streptococcus bovis 2.4 g 4 hourly (six times a day) *In patients with renal plus impairment antibiotic dose *Gentamicin i/v needs to be modified 80 mg 12 hourly *Gentamicin levels Pre dose (trough): <1mg/L 1 hr Post dose (peak): 3 – 5 mg/L i.e. not the usual therapeutic levels

Duration may vary with the clinical course of the disease Discuss with Microbiologist once weekly and prior to any antibiotic change

Enterococcal endocarditis Gentamicin- Amoxicillin i/v P Penicillin allergy: sensitive or low 2 g 4 hourly Consult Microbiologist level resistant (six times a day) *Dose should be adjusted Enterococci plus according to the renal function *Gentamicin i/v 80 mg 12 hourly *Gentamicin levels: Pre dose (trough): <1mg/L Duration 4-6 weeks 1 hour Post dose (peak): 3 – 5 mg/L Gentamicin- Amoxicillin i/v i.e. not the usual therapeutic resistant 2 g 4 hourly levels). Enterococci (six times a day) Monotherapy 8-12 weeks

Streptomycin i/m Streptomycin levels: Added if strain is sensitive Seek advice from Microbiology 7.5 mg/kg once daily

Dual therapy 6 weeks Antimicrobial Policy for Adults 2017 19 Page 23

ENDOCARDITIS – Treatment of known organisms (Continued) [23] Discuss treatment with Consultant Cardiologist and Microbiologist

IMPORTANT • History of CPE/MRSA/ ESBL/ C.difficile – contact Take appropriate samples Before prescribing Microbiologist THREE sets of blood cultures from antimicrobials • Check for previous microbiology results different sites and at different times • Treatment duration depends on the organism and patient PRIOR to antimicrobial therapy factors. Must be discussed with Microbiologist/Cardiologist • Consider referral to vascular access team if patient is suitable for community IV pathway

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Native Valve Staphylococcus Flucloxacillin i/v Discuss with Microbiologist for Staphylococcus aureus aureus 2 g every 4- 6 hours for additional antimicrobials endocarditis 4-6 weeks use 4 hourly regime if weight is P Penicillin allergy: see below greater than 85kg

P Penicillin allergy *Vancomycin i/v *Vancomycin dose needs to be or 1 g 12 hourly adjusted according to the renal MRSA endocarditis MRSA plus function Rifampicin oral 300-600 mg bd Discuss with Microbiologist use lower dose if creatinine clearance is less than 30mL/min *Vancomycin levels: Duration at least 6 weeks -consult Pre dose (trough) 15–20 mg/L Microbiologist (Appendix F)

Intracardiac prosthesis Staphylococcus tFlucloxacillin i/v Discuss with Consultant Staphylococcus aureus aureus 2 g every 4- 6 hours for Cardiologist and Microbiologist endocarditis plus ttRifampicin oral 300-600 mg 12 hourly **Gentamicin levels: plus Pre dose (trough): <1mg/L **Gentamicin i/v 1 hour Post dose (peak): 80 mg 12 hourly 3 – 5 mg/L Duration 6 weeks - consult i.e. not the usual therapeutic Microbiologist levels).

Intracardiac prosthesis *Vancomycin i/v Duration may vary with the 1g 12 hourly clinical course of the disease P Penicillin allergy MRSA plus Discuss with Microbiologist or ttRifampicin oral MRSA endocarditis 300-600 mg 12 hourly tFlucloxacillin i/v plus use 4 hourly regime if weight is **Gentamicin i/v greater than 85kg 80 mg 12 hourly Duration 6 weeks - consult ttRifampicin oral Microbiologist use lower dose if creatinine clearance is less than 30mL/min Page 24 Antimicrobial Policy for Adults 2017 19

ENDOCARDITIS – Treatment of known organisms (Continued) [23] Discuss treatment with Consultant Cardiologist and Microbiologist

IMPORTANT • History of CPE/MRSA/ ESBL/ C.difficile – contact Take appropriate samples Before prescribing Microbiologist THREE sets of blood cultures from antimicrobials • Check for previous microbiology results different sites and at different times • Treatment duration depends on the organism and patient PRIOR to antimicrobial therapy factors. Must be discussed with Microbiologist/Cardiologist • Consider referral to vascular access team If patient is suitable for community IV pathway

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Endocarditis due to other Coagulase negative Treatment depends upon Seek advice from Microbiologist organisms staphylococci susceptibility HACEK organisms Aerobic Gram negative organisms Fungi etc.

Gram negative organisms E. coli Cefotaxime i/v Discuss with Consultant Klebsiella 1g tds Cardiologist and Microbiologist Gram negative plus bacilli *Gentamicin i/v 80 mg 12 hourly *Gentamicin levels: Pre dose (trough): <1mg/L 1 hour Post dose (peak): HACEK organisms Haemophilus Ceftriaxone i/v 3 – 5 mg/L species, 2 g od i.e. not the usual therapeutic Actinobacillus or levels). actinomycete- Cefotaxime i/v mcomitans, 1g tds Duration may vary with the Cardiobacterium plus clinical course of the disease hominis, *Gentamicin i/v Discuss with Microbiologist Eikenella corrodens 80 mg 12 hourly Kingella species Antimicrobial Policy for Adults 2017 19 Page 25

CENTRAL NERVOUS SYSTEM INFECTIONS [13] IMPORTANT Before prescribing antimicrobials Take appropriate samples • Blood cultures • CSF • History of CPE/MRSA/ ESBL/ Clostridium difficile – contact Microbiologist • Throat swabs for virolology • Check for previous microbiology results and bacteriology • All cases where a diagnosis of meningocccal disease is suspected should be promotly • EDTA blood for PCR notified to the CCDC without waiting for microbiological confirmation • Stool for enteroviruses

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Bacterial meningitis Neisseria Initially: Medical emergency meningitidis Ceftriaxone i/v Start antibiotics immediately, Streptococcus 2g bd then inform Microbiology pneumoniae and CCDC** for prophylaxis Haemophilus Immunocompromised or of close contacts in case of influenzae type b Age>65 years: meningococcal and Consider Listeria sp.– haemophilus infection add Amoxicillin i/v 2g 4 hourly. *Please advise patients on Steroid use in Meningitis avoiding risk in the future Consider adjunctive treatment Duration: P Penicillin allergy: Neisseria meningitidis 7 days with dexamethasone (particularly Life threatening: Streptococcus pneumoniae 14 days if pneumococcal meningitis chloramphenicol iv Haemophilus influenzae 10 days suspected in adults) preferably 25mg/kg every 6 hours. starting before or with first Maximum 6g per day dose of antibacterial, but ConfirmedListeria* Amoxicillin i/v Discuss with consultant no later than 12 hours after 2g 4 hourly for 3 weeks microbiologist after 48 hours. starting antibacterial; avoid plus Monitor for bone marrow dexamethasone in septic shock, *Gentamicin i/v suppression meningococcal septicaemia, or High dose (Appendix A) Inform Hospital Infection Control if immunocompromised, or in Review after 7 days – discuss with Team meningitis following surgery.* Microbiologist *Gentamicin levels: * British National formulary No 73 accessed (Appendix A) via medicines complete on 11 May 2017 **CCDC – 09.00 - 17.00 Tel: 0114 3211177 Out of hours via switchboard All other organisms Discuss with Consultant including Microbiologist Mycobacterium tuberculosis

Viral meningitis Enteroviruses Most commonly caused by enterovirus Send stool and throat swabs for which causes a self limiting disease viral culture. Seek advice from which no treatment is required Consultant Microbiologist Herpes virus eg high temperture Aciclovir i/v 10 mg / kg 8 hourly for PCR will confirm presence of and focal 14-21 days. Use ideal body weight if enteroviruses Neurological signs patient is obese. Encephalitis Commonest agent Empirically to start Discuss with Consultant Herpes simplex Ceftriaxone i/v Microbiologist Signs of diffuse or focal virus (HSV) 2g bd All bacterial agents plus PCR on the CSF will confirm HSV neurological symptoms such as causing meningitis, Aciclovir i/v infection drowsiness Varicella zoster 10 mg/kg per dose every 8 hours seizures virus (VZV), CMV, for 14 to 21 days Do not switch to oral aciclovir confusion Toxoplasma and fungi Add if immunocompromised or Age > 65 years Amoxicillin i/v 2 g 4 hourly Brain abscess Depends on source Start with Discuss with Microbiologist of abscess Cefotaxime i/v 2g qds Treatment modified according plus to the nature of organism and Metronidazole i/v clinical manifestation 500 mg tds Page 26 Antimicrobial Policy for Adults 2017 19

SKIN AND SOFT TISSUE INFECTIONS – Bacterial

IMPORTANT Before prescribing antimicrobials Take appropriate samples • Pus and aspirate when • History of CPE/MRSA/ ESBL/ Clostridium difficile – contact Microbiologist available • Check for previous microbiology results • Wound swabs • Treatment duration (iv or oral) 5 days unless specified • Blood cultures • Consider referral to vascular access team if patient is suitable for community IV pathway

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Impetigo: Staphylococcus Topical therapy may suffice Contact Microbiologist for MILD Localised aureus Hydrogen peroxide cream 1% further advice Beta haemolytic (Crystacide®) apply 2-3 times daily [12] (group A,C,G) Streptococci

Spreading Flucloxacillin oral or I/V P Penicillin allergy: 500 mg to 1g qds Clarithromycin oral or i/v 500 mg bd

SEVERE Flucloxacillin i/v P Penicillin allergy: 1 to 2 g qds Teicoplanin i/v plus 6mg/kg (appendix Ei - pg 68) Benzylpenicillin i/v Contact microbiologist for review 1.8 g qds Change to oral antibiotics (as for mild infection) after satisfactory clinical response

Total duration 5 days Erysipelas Beta haemolytic Benzylpenicillin i/v Consider oral Amoxicillin (group A,C,G) 1.8 g qds following adequate clinical [12] Streptococci or response For less severe infection Amoxicillin oral P Penicillin allergy: 500 mg to 1g tds Clarithromycin oral or i/v 500 mg bd Duration 7 to 10 days

Cellulitis: Beta haemolytic Flucloxacillin oral P Penicillin allergy: MILD (group A,C,G) 500 mg to 1g qds Clarithromycin oral [12,13] Streptococci 500 mg bd Staphylococcus aureus MODERATE / SEVERE Benzylpenicillin i/v High dose i/v antimicrobials 1.8 g qds are necessary initially plus P Penicillin allergy: Flucloxacillin i/v 1 to 2 g qds Teicoplanin i/v Review with microbiology results 6mg/kg (appendix Ei - pg 68) Consider oral only after satisfactory response/ As above plus SEVERE Piperacillin/ tazobactam i/v microbiology In high risk patients MRSA 4.5 g tds eg Diabetics Infection or plus Review treatment after 5 days. Immunocompromised colonisation Teicoplanin i/v Some patients may need a or if no response to high dose 6mg/kg (appendix Ei - pg 68) longer course eg 10-14 days benzylpenicillin and flucloxacillin Antimicrobial Policy for Adults 2017 19 Page 27

SKIN AND SOFT TISSUE INFECTIONS – Bacterial

IMPORTANT Before prescribing antimicrobials Take appropriate samples • Pus and aspirate when • History of CPE/ MRSA/ ESBL/ Clostridium difficile – contact Microbiologist available • Check for previous microbiology results • Wound swabs • Treatment duration (iv or oral) 5 days unless specified • Blood cultures

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Necrotising fasciitis Type 1 Surgical Emergency Debridement: Seek urgent or severe Group A Mixed organisms requiring frequent high dose advice from General Surgeon Streptococcal cellulitis antibiotics & debridement Type 2 P Penicillin allergy: [13] Group A Commence Commence with Streptococci (if renal function normal): Clindamycin i/v Benzylpenicillin i/v 1.2g 6 hourly plus 2.4 g 4 hourly Ciprofloxacin i/v plus 400mg bd plus Clindamycin i/v Teicoplanin i/v 1.2 g 6 hourly 6mg/kg (appendix Ei - pg 68) plus and seek microbiology advice Ciprofloxacin i/v immediately 400mg bd Contact Microbiologist within 24 Infection control precautions and hours isolation should be followed

Infected leg ulcers or Wide range of Co-amoxiclav i/v 1.2g tds or oral pressure sores organisms (usually 625mg tds may be used in the first Skin ulcers will usually be polymicrobial) instance. colonised by many organisms. including If MRSA suspected add Significance is established by Staphylococcus Teicoplanin i/v clinical signs of infection i.e. aureus 6mg/kg (appendix Ei - pg 68) spreading cellulitis, discharge or Steptococci sepsis and type of organism. Anaerobes Contact Tissue Viability Team

Diabetic foot ulcer See Pages 31-32 [25,26,27]

Bites [12, 13] Anaerobes Prevention of infection: P Penicillin allergy: Streptococci Clindamycin oral Animal and Human Pasteurella Co-amoxiclav oral 300mg qds Multocida 625mg tds 7 days Plus Surgical toilet most important Ciprofloxacin oral Human bite: Antimicrobial prophylaxis advised for: 500mg bd For animal bites: Mouth Flora Puncture wound, bite involving hand, Both for 7 days Assess tetanus and rabies risk including HACEK foot, face, joint, tendon, ligament, Caution organsims immunocompromised, diabetics, CIPROFLOXACIN For human bites: elderly and asplenic patients ENCOURAGES THE Assess HIV/Hepatitis B&C risk EMERGENCE OF MRSA Refer to Blood- borne policy for appropriate prophylaxis Inpatient treatment of infection:

Co-amoxiclav i/v 1.2g tds P Penicillin allergy: Clindamycin i/v 900mg qds Plus Ciprofloxacin oral 500mg bd Page 28 Antimicrobial Policy for Adults 2017 19

SKIN AND SOFT TISSUE INFECTIONS – Surgical site infection

IMPORTANT Before prescribing antimicrobials Take appropriate samples • Pus and aspirate when • History of CPE/ MRSA/ ESBL/ Clostridium difficile – contact Microbiologist available • Check for previous microbiology results • Wound swabs • Treatment duration (iv or oral) 5 days unless specified • Blood cultures

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Following clean surgery Staphylococcus Flucloxacillin i/v Mild erythema does not require aureus 1- 2 g qds antimicrobials Streptococci or [12] oral 500mg to 1g qds P Penicillin allergy: In severe cases seek advice from Clarithromycin i/v or oral Consultant Microbiologist 500 mg bd

Duration 7 to 10 days

MRSA Doxycycline oral Less serious 200 mg first dose then 100 mg bd for Check for tetracycline sensitivity 7 to 10 days

More serious Teicoplanin i/v Duration: discuss with or unable to take 6mg/kg (appendix Ei - pg 68) Microbiologist oral

Following contaminated Staphylococcus Seek advice from Microbiologist The mainstay of treatment is surgery aureus surgical intervention MRSA [12] Coliforms Anaerobes Antimicrobial Policy for Adults 2017 19 Page 29

SKIN AND SOFT TISSUE INFECTIONS – Dermatophyte [8]

IMPORTANT Before prescribing antimicrobials

Take appropriate samples • Skin scrapings • Nail clippings • Hair

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Skin infections in general Trichophyton sp. For limited infections Skin scrapings should be Epidermophyton Clotrimazole cream 1% sent to Microbiology sp. Apply 2 - 3 times a day Microsporum sp or Miconazole cream 2% Apply twice daily

Scalp ringworm and extensive As above Terbinafine oral Check LFT's initially prior to tinea infections 250 mg od for at least 4 weeks starting treatment thereafter or, if failed every 2 weeks

Itraconazole oral (pulsed) 200mg od for a 7 day course repeat after 21 days for 3 courses Pityriasis versicolor Malassezia furfur Topical In recurrent cases seek advice Selenium sulphide shampoo from Dermatologist. (Selsun®) Use as a lotion (diluted with water) and leave for 30 minutes or overnight. Repeat 2-7 times over 2 weeks

Nail infections Trichophyton sp. Terbinafine oral Nail clippings should be sent to Epidermophyton sp 250 mg od Microbiology 6 weeks - 3 months Check LFT's prior to starting treatment and every 2 weeks thereafter.

SKIN AND SOFT TISSUE INFECTIONS – Candida

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Dermal candidiasis Candida albicans Topical Duration of therapy will depend Candida glabrata Clotrimazole cream 1% on the clinical condition Candida tropicalis Apply bd - tds etc or Miconazole cream 2% Apply bd

Systemic Fluconazole oral 50 mg od for 2-4 weeks (for up to 6 weeks in tinea pedis) Page 30 Antimicrobial Policy for Adults 2017 19

SKIN AND SOFT TISSUE INFECTIONS – Viral [11]

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Herpes simplex Herpes simplex Aciclovir cream 5% Take swab for viral pcr virus Apply to lesions at first sign of attack 5 times a day for 5 days

For more serious infection Aciclovir oral 200 mg 5 times a day for 5 days Chickenpox Varicella-zoster Aciclovir oral Take swab for viral pcr Inpatients & Complicated virus 800 mg 5 times a day Chickenpox (such as for 7 days pneumonia and pregnancy) In severe infections Aciclovir i/v 5 –10 mg/kg 8 hourly followed by oral – total 7 days Herpes zoster Varicella-zoster Aciclovir oral Take swab for viral pcr virus 800 mg 5 times a day for 7 days or Famciclovir oral 500 mg tds for 7 days

SKIN AND SOFT TISSUE INFECTIONS – Arthropod infestations

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Scabies Sarcoptes scabiei Ist choice Consult with Dermatologist to Permethrin 5% cream confirm diagnosis Apply over the whole body, including face, neck, scalp and ears and wash Inform Infection Control Team off after 8 -12 hours. Repeat after 7 days Infection Control procedures should be followed 2nd choice Malathion 0.5% aqueous liquid If evidence of cross infection Apply over the whole body (i.e. 2 cases or more) then and wash off after 24 hours all patients & staff should be Repeat after 7 days treated (Unlicensed Use) All members of the affected Norwegian scabies Ivermectin oral household should be treated, - A more serious paying particular attention to scabies usually (Named Patient) the web of the fingers and toes affecting the 200 micrograms/kg and brushing under the ends Immuno- single dose of nails compromised Only after dermatology or microbiology recommendation

Head Lice Pediculus capitis Malathion 0.5% aqueous liquid Two applications 7 days apart Apply to dry hair and scalp, to prevent lice emerging from leave on for 12 hours, rinse and dry eggs that survive the first Repeat after 7 days (unlicenced use) application Antimicrobial Policy for Adults 2017 19 Page 31

400 mg tds, 400 mg tds, P P possible. Prescribed antimicrobials should be checked against sensitivity results, and changed accordingly. Do not use prolonged antibiotic treatment (more than days) treatment for mild soft of 14 tissue diabetic foot infection. 1st line 1st Flucloxacillin 1g oral qds Penicillin allergy 500mgClarithromycin oral bd oral Metronidazole Add if wound malodorous line 2nd Co-amoxiclav mg tds oral 625 swabWound results should be obtained as soon as Co-amoxiclav i/v g tds 1.2 oral Metronidazole Add if wound malodorous Penicillin allergy Contact Microbiologist Modify and culture antimicrobial to therapy according sensitivities. If colonised with MRSA or pseudomonas or has from advice seek then use antibiotic recent had microbiologist Antimicrobials Allergy Check Status

hours on the ward / callus debridement• Wound experienced by practitioner • Pressure relief management• Wound – antimicrobials • Moisture balance • Ongoing evaluation based on clinical findings education Patient • Referrals All patients with infected diabetic ulcers foot the Multi-disciplinaryto Diabetic Foot Care Team antimicrobials • Hospitalisation • Non-weight bearing • May also surgical require debridement Urgent referrals Diabetologist / Multidisciplinary1. Diabetic Foot team Care Surgeons Vascular 2. If peripheral vascular disease confirmed or cannot be excluded • Same as minor infections, except • Cleanse and debride• Cleanse the wound before obtaining specimen(s) for culture • Inspection wound of on admission or out of Treatment As minor for infection plus Bloods: U&Es,FBC, WCC CRP Blood cultures X-ray Urgent arterial Doppler - if absent or pulses foot weak Deep wound swab Foot examination, include vascular to neurologicaland assessment assessment Wound Blood glucose Temperature Pulse and BP Investigations

Extreme purulent discharge Malodour Increased pain Swelling, induration Crepitus Sausage shaped toe(s) Blue discolouration skin due of Deep tissue ulceration or breakdown satellite Wound Superficial Bed: yellow/ grey Delayed healing / non healing marked and Friable New or breakdown areas of Bridging soft of tissue and Odour

areas • • • • • • (indicating osteomyelitis) • ischaemia to or tissue destruction • + /- undermined edges +/- penetrates bone to • Signs and symptoms, and Signs bed Wound • • • • granulation • necrosis • epithelium •

Intense widespread erythema,Intense swelling and heat 3cm), (> +/- bony involvement, +/- ischaemia, +/- lymphangitis, lymphadenitis regional malaise, flu-like symptoms--pyrexia, tachycardia, rigors and erratic glucose levels BUT HAEMODYNAMICALLY STABLE Infection infectionsMinor Localised erythema, & Warmth swelling around 3cm) ulcer (< [25,26,27] Moderate infections Before prescribing antimicrobials - check history MRSA of or Pseudomonas Guidelines for the management of diabetic patients with an infected foot ulcer and ulcer with foot an infected patients the management of diabetic for Guidelines /or foot infected Page 32 Antimicrobial Policy for Adults 2017 19 Initially: Piperacillin/tazobactam i/v plus g tds 4.5 i/v Teicoplanin Discuss with Microbiologist the following day 6mg/kg (appendix - pg 68) Ei If osteomyelitis is suspected (appendix 12mg/kg - pg 69) Eii Antimicrobials Allergy Check Status

HDU / ITU • As moderate for infection antimicrobials Intravenous • scale sliding • Insulin and i/v fluids • Monitor blood glucose hourly Immediate to: referral surgeons Vascular 1. possible for radical debridement/ reconstruction amputation / Diabetologist 2. • If hypotensive - aggressive i/v fluid therapy scoring • PAR • Most patients will transfer to require Treatment As moderate for infection ALWAYS: Blood and cultures wound swab also arterialConsider blood gasses Consider: dopplers,Urgent Arteriogram MRA Investigations

Present as above marked plus Large infected areas of Localised fluctuance and Pyrexia Acute ischaemia present may

Signs and symptoms, and Signs bed Wound as a red / leg foot a or have white appearance with purplish mottling with absent and foot possibly and foot possibly popliteal pulses • necrosis (dry) or gangrene (wet) • sloughy tissue • expression pus of with gas the in • Crepitus soft tissues on X-ray • Purplish discolouration the of skin indicating subcutaneous necrosis • • (Third edition)

- Presenting as Severe Infections Severe emergency clinical haemodynamically Patient - unstable Limb ischaemia and / or Septicaemia and / or early warning Triggering score References: References: Edmonds ME, Foster VM (2014) Managing the diabetic foot Wiley-Blackwell S (2010) Kumar Holt T, ABC diabetes of (6th Edition) books BMJ Wiley-Blackwell/ Antimicrobial Policy for Adults 2017 19 Page 33

BONE AND JOINT INFECTIONS [11,12,13]

IMPORTANT Before prescribing antimicrobials Take appropriate samples • Blood cultures • History of CPE / MRSA/ ESBL/ Clostridium difficile – contact Microbiologist • Other orthopaedic samples • Check for previous microbiology results when possible • Treatment duration may be several weeks, according to the microbiology • Wound swabs • Tailor therapy according to culture results • Cultures from septic foci Consider referral to vascular access team if patient is suitable for community IV pathway.

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS ACUTE OSTEOMYELITIS Staphylococcus Flucloxacillin i/v Blood culture and other relevant Non-high risk patients aureus 2 g qds orthopaedic samples should be Others for at least 1-2 weeks in the taken before initiation of therapy Anaerobes first instance, followed by oral therapy for a total of 6-8 weeks. P Penicillin allergy: Seek advice from consultant Teicoplanin i/v Microbiologist 12mg/kg (appendix Eii - pg 69)

Addition of *sodium fusidate may Modify according to culture and be advised by Microbiologist sensitivities

As above plus Seek advice from consultant Discuss with Microbiologist High risk patients Gram-Negative Microbiologist organisms Monitor response with CRP

High dose Sodium fusidate Known MRSA Teicoplanin i/v • NEVER USE ON ITS OWN 12mg/kg (appendix Eii - pg 69) • Seek Microbiologists advice if plus oral not possible *Sodium fusidate oral • Monitor LFTs twice weekly Tablets 500 mg tds (= Suspension Fusidic acid *Sodium fusidate should not be 750 mg tds) administered with statin drugs due to interaction. Seek advice from pharmacist SEPTIC ARTHRITIS Staphylococcus Flucloxacillin i/v i/v therapy for at least 2 weeks aureus 2 g qds followed by oral therapy for total NATIVE JOINT Beta haemolytic plus of 4-6 weeks Streptococci Benzylpenicillin i/v 1.8 g qds

Known MRSA Teicoplanin i/v *Sodium fusidate or Penicillin allergy 12mg/kg (appendix Eii - see pg 69) • NEVER USE ON ITS OWN plus • Seek Microbiologists advice if *Sodium fusidate oral oral not possible Tablets 500 mg tds • Monitor LFTs twice weekly (= Suspension Fusidic acid 750 mg tds) Sodium fusidate should not be Contact Microbiologist as soon administered with statin drugs as possible due to interaction. Seek advice from pharmacist SEPTIC ARTHRITIS Wide range of Obtain cultures and ideally Appropriate sampling and organisms await results before initiation of identification of infecting agent PROSTHETIC JOINT antimicrobial but if acutely septic or is crucial for successful treatment haemodynamically unstable Collaborative management start on P Penicillin allergy between Orthopaedic Surgeon Teicoplanin i/v Teicoplanin i/v and Microbiologist 12mg/kg (appendix Eii - see pg 69) 12mg/kg (appendix Eii - pg 69) plus plus Piperacillin/tazobactam i/v Ciprofloxacin oral 4.5g tds 750 mg bd and contact Microbiologist as soon i/v if needed 400 mg bd as possible Page 34 Antimicrobial Policy for Adults 2017 19

ENT INFECTIONS [12, 13]

IMPORTANT • History of CPE / MRSA/ ESBL/ C.difficile – contact Take appropriate samples Before prescribing Microbiologist • Pus and aspirate when antimicrobials • Check for previous microbiology results possible • Wound swabs • Treatment duration (iv or oral) 5 days unless specified • Blood cultures

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Tonsillitis / Pharyngitis Majority viral If severe P Penicillin allergy: Group A Benzylpenicillin i/v Clarithromycin oral beta haemolytic 1.2 g qds for 48 hours followed by 500 mg bd Streptococci Amoxicillin oral 500 mg tds

Total duration: 10 days Peritonsillar Abscess As above Benzylpenicillin i/v P Penicillin allergy: (Quinsy) + / - 1.8 g qds for 48 hours Clindamycin IV Anaerobes plus 1.2g qds Metronidazole oral 400 mg tds

Change to Co-amoxiclav oral 625 mg tds

Total duration: 10 days Otitis Many are viral May not be infective. Often respond According to culture and Externa Staphylococcus to careful cleansing and topical sensitivity aureus steroids Group A, C or G If malignant otitis or spreading Streptococci cellulitis contact Microbiologist Anaerobes

Acute Otitis Media Viral Amoxicillin oral P Penicillin allergy: (1st episode) Streptococcus 1 g tds for Doxycycline oral Mainly viral. 80% resolve pneumoniae 5-7 days 200 mg first dose then without antimicrobials Haemophilus 100 mg od influenzae Chronic or Discharging Streptococcus Consult Microbiologist and treat Swab should be taken for culture Otitis Media pneumoniae according to culture results Haemophilus influenzae Staphylococcus aureus Acute Sinusitis Viral Amoxicillin i/v P Penicillin allergy: (Rhinogenic origin) Streptococcus 1g tds for 5 days Doxycycline oral Mainly viral. Symptomatic benefit pneumoniae or 200 mg first dose then of antimicrobials is small Haemophilus Amoxicillin oral 100 mg od influenzae 500mg tds for 5 days

Acute Sinusitis As above + Co-amoxiclav oral P Penicillin allergy: (Dental origin) Wide range 625 mg tds for 7 days Doxycycline oral of organisms 200 mg first dose then including: If severe 100 mg od Streptococci, Co-amoxiclav i/v viridans 1.2 g tds Streptococci Anaerobes Antimicrobial Policy for Adults 2017 19 Page 35

ORAL AND MAXILLOFACIAL SURGERY INFECTIONS

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Acute infections including Oral and upper Co-amoxiclav i/v Discuss with Microbiologist tissue space abscesses respiratory flora 1.2 g tds P Penicillin allergy secondary to dental sepsis usually for 5-7 days Non life threatening etc. initially Cefuroxime i/v 1.5g tds plus Metrondazole i/v 500mg tds

Life threatening penicillin allergy initially Clindamycin i/v 1.2g qds

Then tailor according to culture and sensitives

EYE INFECTIONS [11, 12]

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Conjunctivitis Staphylococcus Chloramphenicol Second line aureus 0.5% eye drops Fusidic acid m/r eye drops 1% Haemophilus 2 hourly during the day and 1% Apply bd influenzae ointment at night for 5 days Streptococcus pneumoniae Group A C G Streptococci

Chlamydia, Seek advice from Consultant viruses, fungi, Ophthalmologist protozoa, helminths Periorbital cellulitis Benzylpenicillin i/v Take conjunctival swabs 1.8 g qds plus P Penicillin allergy: Flucloxacillin i/v Clindamycin i/v 1 g qds 1.2q qds Usual duration 7 to 10 days usual duration 7 to 10 days

Following clinical improvement consider switching to oral as guided by culture and sensitivities

Deep seated eye infection Wide range of Depends on organism isolated and Seek advice from Consultant Post-operative eye infection organisms antibiotic susceptibility Ophthalmologist Post-injury eye infection

Endophthalmitis Collaboration between Consultant Ophthalmologist and Microbiologist is essential Page 36 Antimicrobial Policy for Adults 2017 19

OBSTETRIC AND GYNAECOLOGICAL INFECTIONS

IMPORTANT Before prescribing antimicrobials

• History of CPE / MRSA/ ESBL/ Clostridium difficile – contact Microbiologist Take appropriate samples • Check for previous microbiology results • Blood cultures • Wound swab • Treatment duration (i/v or oral) 5 days unless specified • HVS or endocervical swab • Sepsis – start antibiotics within an hour of diagnosis. Prescribe in STAT section of drug chart Refer to Sepsis Six checklist on page 79

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Post-operative sepsis Coliforms Co-amoxiclav i/v Send specimens to Microbiology Group B 1.2 g tds - blood culture, urine, and Streptococci or wound swabs Anaerobes Co-amoxiclav oral 625 mg tds P Penicillin allergy: Clindamycin i/v 1.2g qds plus Ciprofloxacin i/v 400mg bd or Oral 500mg bd

Post-partum sepsis As above As above

Pelvic inflammatory disease Neisseria *Ceftriaxone i/v *Discontinue i/v therapy (PID) gonorrhoea 2 g od 24 hours after clinical Chlamydia plus improvement and switch to oral Acute Admissions trachomatis Doxycycline oral Mycoplasma 100 mg bd for 14 days P Penicillin allergy: [29] hominis plus life threatening: Ureaplasma Metronidazole oral *Clindamycin i/v urealyticum 400 mg bd for 14 days 900 mg tds Coliforms plus Group B **Gentamicin i/v Streptococci High Dose (Appendix A) Anaerobes (Wide range Oral switch of mixtures of Clindamycin oral organisms) 450 mg qds for 14 days plus Metronidazole oral 400 mg bd for 14 days

**Gentamicin levels: (Appendix A)

Outpatient Regime As above Ofloxacin oral If Ofloxacin is not available or 400 mg bd for 14 days contraindicated: plus Ceftriaxone i/m Metronidazole oral 500mg single dose 400 mg bd for 14 days plus Doxycycline oral 100mg bd for 14 days plus Metronidazole oral 400mg bd for 14 days Antimicrobial Policy for Adults 2017 19 Page 37

SEXUALLY TRANSMITTED INFECTIONS

PATIENTS DIAGNOSED STI

• Encourage patients to attend GU Medicine for additional screening. Take appropriate samples • Sexual partners may also require treatment

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Uncomplicated gonorrhoea Neisseria Ceftriaxone i/m Screen for co-incident sexually gonorrhoea 500mg single dose transmitted disease plus [30] Azithromycin oral 1gm single dose

P Penicillin allergy if life threatening: NON-PREGNANT Azithromycin oral 2 g single dose (unlicensed) or Ciprofloxacin oral 500mg single dose when infection is known or anticipated to be quinolone sensitive PREGNANT Spectinomycin i/m (Named Patient) 2 g single dose plus Azithromycin oral 1gm single dose

Uncomplicated chlamydia Chlamydia NON-PREGNANT Screen for co-incident sexually infection trachomatis types Azithromycin oral transmitted disease (D-K) 1 g single dose [12, 31] or PREGNANT Doxycycline oral refer to GU medicine 100 mg bd for 7 days

Bacterial vaginosis Gardnerella NON-PREGNANT PREGNANT vaginalis Metronidazole oral Metronidazole oral [32] Prevotella sp 2 g single dose 400 mg bd for 7 days Mycoplasma or (High dose 2 g contraindicated) hominis 400 mg bd for 7 days or Mobilincus sp or Balance Activ gel 1 application Balance Activ gel 1 application at at night for 7 nights night for 7 nights Metronidazole allergy or contraindicated: Clindamycin 2% cream intravaginal 5 g at night for 7 nights or oral 300 mg twice daily for 7 days or Balance Activ gel 1 application at night for 7 nights Page 38 Antimicrobial Policy for Adults 2017 19

SEXUALLY TRANSMITTED INFECTIONS (Continued)

PATIENTS DIAGNOSED STI

• Encourage patients to attend GU Medicine for additional screening Take appropriate samples • Sexual partners may also require treatment

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Trichomoniasis Trichomonas NON-PREGNANT Refer to GU Medicine vaginalis Metronidazole oral [33] 2 g single dose PREGNANCY or Metronidazole oral Metronidazole oral 400 mg bd for 7 days 400 mg bd for 7 days (High dose 2 g contraindicated) Primary genital herpes Herpes simplex Aciclovir oral Refer to GU medicine virus 400mg tds for 5 days

Genital warts Human papilloma Topical therapies available in Wart Please refer to GU Medicine virus Treatment Clinic

Candida vaginitis (Thrush) Candida albicans Clotrimazole p/v For frequent recurrent episodes, Other Candida 500 mg pessary single dose please refer to GU Medicine species Alternative treatment Fluconazole oral 150 mg single dose Epididymo-orchitis Neisseria Ceftriaxone i/m Please refer to GU Medicine for Most probably STI related gonorrhoea 500mg single dose contact tracing and counselling Chlamydia sp. plus [35] Doxycycline 100mg bd 10-14 days

If gonorrhea infection has been excluded Doxycycline 100mg bd 10-14 days or Ofloxacin 200mg bd 14 days

If urinary source Most probably due Ciprofloxacin oral Refer to previous urinary culture to bowel organisms 500 mg bd 10 days results

HIV Seek specialist advice from GU Medicine Antimicrobial Policy for Adults 2017 19 Page 39

HAEMATOLOGICAL INFECTIONS

These patients suffer from various haematological immuno-compromising conditions such as acute and chronic leukaemias, myelomas etc. Neutropaenic patients whether disease or chemotherapy induced are at highest risk of acquiring infection. Refer to Sepsis Six checklist on page 79.

IMPORTANT Before prescribing antimicrobials

• History of CPE/C difficile / MRSA/ ESBL – contact Microbiologist Take appropriate samples • Check for previous microbiology results • Blood cultures – central • Treatment duration – as advised by Consultant Microbiologist line & peripheral site

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Non-neutropaenic patients Wide range See relevant section in the policy with clinical signs of of organisms infection depending on site of infection

Neutropaenic patients Wide range of Piperacillin/Tazobactam i/v Blood cultures should be (neutrophils < 1.0 x 109 /L) organisms: 4.5g qds obtained from with a temperature greater Coliforms • central line o than 38 C or other signs or Pseudomonas sp. If oral ulceration present consider • peripheral site symptoms consistent with Staphylococcus fungal and herpes viral infection. clinically significant sepsis. aureus send swabs and discuss with Patient should be in protective Streptococci Microbiologist. isolation

When oral can be given switch to P Penicillin allergy: Ciprofloxacin oral 500mg bd Teicoplanin i/v plus Amoxycillin oral 6mg/kg (appendix Ei - pg 68) 500mg tds plus *Gentamicin i/v High Dose (see Appendix A)

Seek advice from If NO response within Haematologist and 24 – 48 hours then change to: Microbiologist

Teicoplanin i/v May require Amikacin or 6mg/kg (appendix Ei - pg 68) Tobramycin depending on plus the organism isolated. Please Meropenem i/v see protocol for serum level 1g tds monitoring (Appendix C and D) If NO response following second regimen after 48 hours then rule out *Gentamicin level systemic fungal infection. Contact (Appendix A) Consultant Microbiologist

Intravascular-catheter Coagulase- Teicoplanin i/v As above associated infection whether negative 6mg/kg (appendix Ei - pg 68) plus neutropaenic or not Stapylococci plus take swab from catheter exit Staphylococcus *Gentamicin i/v site aureus High Dose Diphtheroids (see Appendix A) Coliforms Page 40 Antimicrobial Policy for Adults 2017 19 GASTRO-INTESTINAL INFECTIONS IMPORTANT Before prescribing antimicrobials

• History of CPE / MRSA/ ESBL/ Clostridium difficile – contact Microbiologist Take appropriate samples • Check for previous microbiology results • Treatment duration – as advised by Consultant Microbiologist

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS Acute gastro-enteritis Salmonella sp. Usually NOT required Cases should be barrier nursed. Shigella sp. May be necessary in invasive Campylobacter sp. salmonellosis Food poisoning is a notifiable Viruses disease

Antibiotic associated Clostridium difficile See chart on page 42 STOP other antimicrobials if diarrhoea possible [37] If no response after treatment seek advice from Microbiologist Enteric fever Salmonella typhi Ciprofloxacin oral If cannot take oral Salmonella 500 mg bd for 14 days consider i/v initially paratyphi 400 mg bd

Biliary infections Coliforms Co-amoxiclav i/v P Penicillin allergy - Gram negative 1.2 g tds If less than 65 years old Cholangitis or organisms CiprofloxacinP i/v Cholecystitis oral 625 mg tds 400mg bd or oral 500mg bd plus Metronidazole i/v 500mg tds or oral 400mg tds

If greater than 65 years old Aztreonam i/v 1 to 2g tds plus Metronidazole i/v 500mg tds or oral 400mg tds

Eradication of Helicobacter 1st line P *Penicillin allergy: Helicobacter pylori pylori Triple therapy, Replace Amoxicillin with all Twice daily for 7 days Metronidazole oral Clarithromycin oral 400 mg bd and [38] 500 mg bd Reduce Clarithromycin dose to plus 250 mg bd Amoxicillin* oral 1 g bd Do not use clarithromycin or plus metronidazole if used in the past Lansoprazole oral year for any infection (Rotherham) 30 mg bd 2nd line Omeprazole oral In consultation with (Barnsley) Gastroenterologist 20 mg bd

Liver Abscess Coliforms Empirical treatment until results are Seek advice from Microbiologist Streptococci available: Send aspirate and blood culture Anaerobes Initially for microbiology culture and Co-amoxiclav i/v review treatment when results 1.2g tds available

Duration of treatment usually 8-12 weeks Antimicrobial Policy for Adults 2017 19 Page 41

GASTRO-INTESTINAL INFECTIONS

INFECTION ORGANISMS ANTIMICROBIALS COMMENTS

Diverticulitis Polymicrobial Co-amoxiclav i/v P Penicillin allergy: Patients with uncomplicated 1.2g tds Gentamicin i/v diverticulitis (See appendix A high dose) (defined as CT confirmed plus pancreatitis left sided disease Metronidazole i/v without abscess, free air or Duration 5 days 500mg tds fistula with or without fever and elevated inflammatory markers) If elderly or renal impairment can be treated conservatively Aztreonam i/v without antimicrobials. 1g tds Plus Metronidazole i/v 500mg tds

Appendicitis Coliforms Co-amoxiclav i/v Take blood culture or sample as Streptococci 1.2g tds appropriate Anaerobes P Penicillin allergy: Gentamicin iv (See appendix A high dose) Duration 5 days plus Metronidazole i/v 500mg tds

If elderly or renal impairment Aztreonam i/v 1g tds Plus Metronidazole i/v 500mg tds

Spontaneous Bacterial Treatment Co-amoxiclav i/v P penicillin allergy - Peritonitis (SBP) 1.2g tds Ciprofloxacin i/v 400mg bd unless evidence of previous resistant plus An ascitic neutrophil count of organisms Metronidazole i/v >250 cells/mm3 with or without 500mg tds a positive ascitic fluid culture and in the absence of a surgically In patients with advanced treatable, intra-abdominal source hepatic insufficiency a dosage of infection reduction with serum level monitoring is necessary

Patients recovering from Prophylaxis Co-trimoxazole oral If sulphonamide or trimethoprim spontaneous bacterial 960mg od allergy Co-amoxiclav oral peritonitis (SBP) Creatinine Clearance: 375mg od 15 – 30 ml/min 480mg oral OD Creatinine Clearance: Less than 15 ml/min, avoid use of Co-trimoxazole.

- Monitor full blood count (FBC) every 6 weeks

Prophylaxis for life or until disappearance of ascites or transplant Page 42 Antimicrobial Policy for Adults 2017 19

C.difficile diarrhoea [37]

Clostridium Difficile infection (CDI) 1st episode

Diarrhoea AND one of the following: Positive C difficile toxin OR results of C difficile toxin test pending AND clinical suspicion of CDI

Review and discontinue non C difficile antibiotics where appropriate to allow normal intestinal flora to be re-established Stop proton pump inhibitor unless clinically indicated Stop anti-motility medicines Suspected cases must be isolated

Symptoms/signs: Mild to moderate Symptoms/signs: severe CDI 9 o CDI WCC >15 x 10 /L, acute rising creatinine, T>38.5 C or Oral Vancomycin signs/symptoms of severe colitis 125 mg qds 14 days Oral Vancomycin 250mg qds 14 days

Daily Assessment Daily Assessment Including review of fluid/electrolytes Including review of fluid/electrolytes

Diarrhoea should resolve in 1-2 weeks, discuss with Diarrhoea should resolve in 1-2 weeks, discuss with Microbiologist if symptoms not resolving or worsening Microbiologist if symptoms not resolving or worsening after 7 days treatment after 7 days treatment

If evidence of severe CDI developing Surgery/GI/Micro Consultation WCC >15 x 109/L, acute rising creatinine, T>38.5oC or signs/symptoms of severe colitis AND, depending on degree of ileus Change to Vancomycin 250-500mg PO/NG qds +/- Oral Vancomycin 250mg qds 14 days Metronidazole 500mg IV tds – both for 10 days PLUS CONSIDER Intracolonic vancomycin 500mg in 100-500ml saline 4-12 hourly.

Recurrent or subsequent episodes

Discuss with Microbiology but other options may include fidaxmoycin, intracolonic vancomycin or faecal transplantation Antimicrobial Policy for Adults 2017 19 Page 43

MRSA Decolonisation and follow up of patients

All MRSA positive patients should be prescribed the following decolonisation regime in an attempt to eradicate MRSA.

For first decolonisation treat all sites regardless of where positive and for any subsequent decolonisation treat the positive site only.

PROCEDURE PRODUCT DIRECTIONS DURATION Nasal Clearance Mupirocin nasal ointment 2% Apply to both nostrils 5 Days (Bactroban Nasal®) 3 times daily

Shower/bath Octenisan® solution 2% Thoroughly apply daily 5 Days directly on to wet skin covering all areas. Allow contact time of 3 minutes before rinsing.

Hair wash Octenisan® solution 2% Shampoo hair with this 5 Days product twice during the 5 day period Allow contact time of 3 minutes before rinsing.

If throat positive refer to Chlorhexidine mouthwash 10 mL Twice daily 5 Days microbiology

If wound swab positive Povidone iodine Based on wound assessment (in non pregnant) including advice from tissue viability

Octenilin wound cleanser If infected systemic antibiotics may be needed

Forty eight hours after the completion of above treatment swab from nose, groin, wound and any other previously positive site must be sent.

If 3 consecutive swabs are negative for MRSA no further action is required if he/she is discharged into the community.

Inpatients Whilst the patient is still in the hospital the following must be sent weekly to check for MRSA (including the original positive site): • nasal, groin, and any wound swabs, • CSU if catheterised, • sputum samples if productive, If found positive again repeat the decolonisation regime. If still positive after second decolonisation contact Infection Control Team for further advice.

Only take repeat swabs 48 hours after decolonisation therapy has been completed

Please refer to Infection Control Policy Page 44 Antimicrobial Policy for Adults 2017 19

ANTIMICROBIAL PROPHYLAXIS [39] Principles of Surgical Prophylaxis Antimicrobial prophylaxis should be used as an adjunct to, not a substitute for good surgical technique

Choice of antimicrobial The selected antimicrobial for prophylaxis must cover the expected pathogen for that operative site.

MRSA carriage MRSA carriage should be eradicated with intranasal mupirocin and/or octenisan prior to surgery.

History of MRSA A glycopeptide must be given, usually Teicoplanin.

History of other alert A different antimicrobial agent my be needed. Discuss prophylaxis organisms for example. with microbiology in these circumstances. ESBL, C Difficle, GRE, CPE

Timing of Antimicrobial should be administered before tourniquet is applied administration and 30–60 minutes before skin incision. Clear documentation of timing is mandatory.

Dose of antimicrobial A single therapeutic dose of antimicrobial with a long enough activity through the operation is recommended.

A longer course of 24 hours may be necessary in high risk surgery

Duration of surgery Operations lasting longer than 4 hours may require a second dose of antimicrobial with the exception of teicoplanin, gentamicin and ciprofloxacin.

Additional doses Should be considered if intraoperative blood loss more than 1500 mL.

Routes of Prophylactic antimicrobials should be administered intravenously. administration Ciprofloxacin given orally has comparable serum and tissue levels to intravenous administration.

In addition to intravenous antimicrobials, impregnated cement is recommended for cemented joint replacements.

Writing prescription In the “once only” section of the Medicine Chart. Classification of surgery

Class Type

Clean - no inflammation encountered - no entry into respiratory, alimentary or urinary tract

Clean-contaminated - entry into respiratory, alimentary or urinary tract but without significant spillage

Contaminated - acute infection (without pus) - visible contamination of the wound - compound/ open injuries less than 4 hours old

Dirty -in the presence of pus -previously perforated hollow viscus -compound/ open injuries more than 4 hours old Antimicrobial Policy for Adults 2017 19 Page 45

SURGICAL PROPHYLAXIS Head and Neck [11, 19]

Timing: administer i/v antimicrobials 30-60 minutes before incision

1st line Patients with Penicillin Patients with History allergy of MRSA Head and neck - Intracranial

Penetrating Head injury Co-amoxiclav i/v Not life threatening allergy Add Teicoplanin i/v Requires prophylaxis only in 1.2 g 8 hourly for 5 days Cefuroxime i/v 400 mg 12 hours for 3 doses • Failed suicide attempts with 1.5 g 8 hourly for 5 days then 400 mg once daily for the wound originating in the 5 days oropharynx Life threatening allergy • Orbital fractures Clindamycin i/v • Fragments of wood, clothing 600 mg 12 hourly for 5 days or soil in the wound

CSF leak No prophylaxis No prophylaxis

Spinal surgery Flucloxacillin i/v Teicoplanin i/v Teicoplanin i/v 2 g single dose 600 mg single dose 600 mg single dose plus plus plus Gentamicin i/v Gentamicin i/v Gentamicin i/v 120 mg single dose 120 mg single dose 120 mg single dose

Head and neck

Head and neck surgery No prophylaxis No prophylaxis Clean, benign

Head and neck surgery Co-amoxiclav i/v Non life threatening allergy Teicoplanin i/v Clean, malignant; 1.2 g single dose Cefuroxime i/v 600 mg single dose Neck dissection 1.5 g single dose plus plus Metronidazole i/v Metronidazole i/v 500 mg single dose 500 mg single dose plus Gentamicin i/v Life threatening allergy 120 mg single dose Clindamycin i/v 600 mg single dose plus Gentamicin i/v 120 mg single dose

Head and neck surgery Co-amoxiclav i/v Non life threatening allergy Teicoplanin i/v Contaminated/ 1.2 g 8 hourly Cefuroxime i/v 600 mg followed clean contaminated for 3 doses 1.5 g 8 hourly for 3 doses by 400 mg 12 hours later plus plus Metronidazole i/v Metronidazole i/v 500 mg 8 hourly for 3 doses 500 mg 8 hourly for 3 doses plus Life threatening allergy Gentamicin i/v Clindamycin i/v 120 mg 12 hourly for 2 doses 600 mg 12 hourly 2 doses plus Gentamicin i/v 120 mg 12 hourly for 2 doses Page 46 Antimicrobial Policy for Adults 2017 19

SURGICAL PROPHYLAXIS, Maxillofacial [11, 39]

Timing: administer i/v antimicrobials 30-60 minutes before incision

1st line Patients with Penicillin Patients with History allergy of MRSA Facial

Open reduction and internal Co-amoxiclav i/v Clindamycin i/v Teicoplanin i/v fixation of mandibular 1.2 g 8 hourly 600 mg 12 hourly 600 mg followed by 400 mg fractures for 3 doses for 2 doses 12 hours later plus plus Gentamicin i/v Metronidazole i/v 120 mg 12 hourly for 2 doses 500 mg 8 hourly four 3 doses plus Gentamicin i/v 120 mg 12 hourly for 2 doses

Intraoral bone grafting Co-amoxiclav i/v Clindamycin i/v Teicoplanin i/v procedures 1.2 g single dose 600 mg single dose 600 mg single dose plus plus Gentamicin i/v Metronidazole i/v 120 mg single dose 500 mg single dose plus Gentamicin i/v 120 mg single dose

Orthognathic surgery Co-amoxiclav i/v Clindamycin i/v Teicoplanin i/v 1.2 g 8 hourly for 3 doses 600 mg bd for 2 doses 600 mg followed by 400 mg plus 12 hours later Gentamicin i/v plus 120 mg 12 hourly for 2 doses Metronidazole i/v 500 mg 8 hourly for 3 doses plus Gentamicin i/v 120 mg 12 hourly for 2 doses

Facial surgery (clean) No prophylaxis No prophylaxis

Facial plastic surgery Co-amoxiclav i/v Clindamycin i/v Teicoplanin i/v (implant) 1.2 g single dose 600 mg single dose 600 mg single dose plus plus Gentamicin i/v Metronidazole i/v 120 mg single dose 500 mg single dose plus Gentamicin i/v 120 mg single dose Antimicrobial Policy for Adults 2017 19 Page 47

SURGICAL PROPHYLAXIS, ENT and Opthalmology [11, 39]

Timing: administer i/v antimicrobials 30-60 minutes before incision

1st line Patients with Penicillin Patients with History of allergy MRSA Ear, nose and throat

Ear surgery No prophylaxis No prophylaxis clean/ clean contaminated Routine nose, sinus and No prophylaxis No prophylaxis endoscopic sinus surgery Complex septorhinoplasty Co-amoxiclav i/v Non life threatening allergy Teicoplanin i/v Including grafts 1.2 g 8 hourly Cefuroxime i/v 600 mg followed by 400 mg for 3 doses 1.5 g 8 hourly 12 hours later for 3 doses plus plus Gentamicin i/v Metronidazole i/v 120 mg 12 hourly 2 doses 500 mg 8 hourly plus for 3 doses Metronidazole i/v 500 mg 8 hourly Life threatening allergy for 3 doses Clindamycin i/v 600 mg 12 hourly for 2 doses plus Gentamicin i/v 120 mg 12 hourly 2 doses Tonsillectomy No prophylaxis No prophylaxis Discuss with microbiologist

Adenoidectomy No prophylaxis No prophylaxis Discuss with microbiologist

Grommet insertion Single dose of topical antibiotic

Ophthalmology

Cataract surgery Cefuroxime intracameral Cefuroxime intracameral Cefuroxime intracameral 1mg in 0.2mL 1mg in 0.2mL 1mg in 0.2mL or or or Cefuroxime Cefuroxime Subconjunctival Cefuroxime Subconjunctival Subconjunctival 125 mg in 0.5mL 125 mg in 0.5mL 125 mg in 0.5mL Glaucoma or corneal grafts Chloramphenicol Chloramphenicol Chloramphenicol eye drops 0.5% eye drops 0.5% eye drops 0.5% qds for two weeks qds for two weeks qds for two weeks

Lacrimal surgery Chloramphenicol Chloramphenicol Chloramphenicol ointment 1% ointment 1% ointment 1% bd for 1 week bd for 1 week bd for 1 week

Penetrating eye injury Cefuroxime Cefuroxime Cefuroxime Subconjunctival Subconjunctival Subconjunctival 125mg in 0.5mL then 125mg in 0.5mL then 125mg in 0.5mL then systemic as advised by systemic as advised by systemic as advised by microbiologist microbiologist microbiologist Lid surgery Chloramphenicol Chloramphenicol Chloramphenicol ointment 1% bd for 1 week ointment 1% bd for 1 week ointment 1% bd for 1 week Squint surgery Maxitrol ointment Maxitrol ointment Maxitrol ointment bd for 1 week bd for 1 week bd for 1 week Page 48 Antimicrobial Policy for Adults 2017 19

SURGICAL PROPHYLAXIS, Thorax and Hepatobiliary [11, 39]

Timing: administer i/v antimicrobials 30-60 minutes before incision

1st line Patients with Penicillin Patients with History allergy of MRSA Thorax

Breast reshaping procedures Benzylpenicillin i/v Teicoplanin i/v Teicoplanin i/v 1.8 g single dose 600mg single dose 600mg single dose Breast surgery with implants plus plus plus (reconstructive or aesthetic) Gentamicin i/v Gentamicin i/v Gentamicin i/v 120 mg single dose 120 mg single dose 120 mg single dose Breast surgery for cancer Cardiac pacemaker insertion Teicoplanin i/v Teicoplanin i/v Teicoplanin i/v 600 mg single dose 600 mg single dose 600 mg single dose plus plus plus Gentamicin i/v Gentamicin i/v Gentamicin i/v 120 mg single dose 120 mg single dose 120 mg single dose

Hepatobiliary

Gall bladder surgery (open) Gentamicin i/v Gentamicin i/v Gentamicin i/v 120 mg single dose 120 mg single dose 120mg single dose and bile duct surgery plus plus plus Metronidazole i/v Metronidazole i/v Metronidazole i/v 500 mg single dose 500 mg single dose 500mg single dose If infection suspected, If infection suspected, plus continue for 3 days continue for 3 days Teicoplanin i/v then review then review 600mg single dose

If infection suspected, continue for 3 days then review

Gall bladder surgery No prophylaxis unless No prophylaxis unless Contact microbiologist (laparoscopic) high risk patients, high risk patients, then as above for open then as above for open surgery High risk patients : surgery single dose single dose intraoperative cholangiogram, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, pregnancy, immunosuppression, insertion of prosthetic devices Antimicrobial Policy for Adults 2017 19 Page 49

SURGICAL PROPHYLAXIS, Lower Gastrointestinal [8, 29]

Timing: administer i/v antimicrobials 30-60 minutes before incision

1st line Patients with Penicillin Patients with History allergy of MRSA

Lower gastrointestinal

Appendicectomy Co-amoxiclav i/v Gentamicin i/v Gentamicin i/v 1.2 g single dose 120 mg single dose 120 mg single dose plus plus Metronidazole i/v Metronidazole i/v 500 mg single dose 500 mg single dose plus Teicoplanin i/v 600 mg single dose

Colorectal surgery Gentamicin i/v Gentamicin i/v Gentamicin i/v 120 mg single dose 120 mg single dose 120 mg single dose plus plus plus Metronidazole i/v Metronidazole i/v Metronidazole i/v 500 mg single dose 500 mg single dose 500 mg single dose plus Teicoplanin i/v 600 mg single dose

Spleen

Splenectomy Elective: Immunisation

Emergency: Benzylpenicillin i/v Teicoplanin i/v Teicoplanin i/v 1.8g single dose 600mg single dose 600mg single dose plus plus plus Gentamicin i/v Gentamicin i/v Gentamicin i/v 120mg single dose 120mg single dose 120mg single dose plus plus plus Immunisation 2 weeks later Immunisation 2 weeks later Immunisation 2 weeks later

Abdomen Hernia With or without mesh: - laparoscopic No prophylaxis

- incisional At the discretion of the surgeon in case of bowel adhesion, trauma

Open laparoscopic surgery At the discretion of surgeon with mesh (eg gastric band or in high risk patients rectoplexy) Page 50 Antimicrobial Policy for Adults 2017 19

SURGICAL PROPHYLAXIS, Endoscopy and PEG Prophylaxis [23, 39, 41] Caution CIPROFLOXACIN ENCOURAGES THE EMERGENCE OF MRSA

Timing: administer i/v antimicrobials 30-60 minutes before incision

1st line Patients with Penicillin Patients with History allergy of MRSA GI Endoscopy

Any procedure From admission From admission From admission Prophylaxis is not usually needed unless the patient has cirhhosis Co-amoxiclav i/v Aztreonam i/v Ciprofloxacin i/v with acute GI bleed 1.2 g tds for 5 days 1g tds 400 mg bd for 5 days plus Plus Teicoplanin i/v Teicoplanin i/v 400 mg 12 hourly for 3 doses 400 mg 12 hourly for 3 doses than once daily for 4 days than once daily for 4 days

If Aztreonam is not available Ciprofloxacin i/v 400 mg bd for 5 days plus Teicoplanin i/v 400 mg 12 hourly for 3 doses than once daily for 4 days

PEG * <1 hour before procedure <1 hour before procedure <1 hour before procedure All patients Benzylpenicillin i/v Teicoplanin i/v Teicoplanin i/v MRSA screen all patients prior 1.8g single dose 600 mg single dose 600 mg single dose to PEG plus plus plus Gentamicin i/v Gentamicin i/v Gentamicin i/v 120mg single dose 120 mg single dose 120 mg single dose

GI dilatation/ Discuss with Haematologist Discuss with Haematologist Discuss with Haematologist Sclerotherapy/ & Microbiologist & Microbiologist & Microbiologist ERCP** in obstructed system In patients with neutrophils <0.5 x109 or advanced haematology malignancy

ERCP** Co-amoxiclav i/v If Penicillin allergy or Co- Add Teicoplanin i/v In patients with CBD stone / 1.2 g tds for 5 days amoxiclav in the last 4weeks to recommended prophylaxis obstruction / stent change or 600 mg 12 hourly for 3 doses Oral 625 mg tds for 5 days Ciprofloxacin oral then once daily for 4 days Only when decompression is 500 mg bd not achieved at ERCP: plus Doxycycline oral 200 mg stat followed by 100 mg od for 5 days

If C. difficile or any other concerns, discuss with Microbiologist

*Percutaneous endoscopic gastrostomy **Endoscopic Retrograde Cholangio-Pancreatography

Antimicrobial Policy for Adults 2017 19 Page 51

SURGICAL PROPHYLAXIS, Endoscopy [23, 39, 41] Caution CIPROFLOXACIN ENCOURAGES THE EMERGENCE OF MRSA

Timing: administer i/v antimicrobials 30-60 minutes before incision

1st line Patients with Penicillin Patients with History allergy of MRSA GI Endoscopy continued

ERCP From admission Teicoplanin i/v Teicoplanin i/v In patients with ongoing 600 mg single dose 600 mg single dose cholangitis or sepsis elsewhere Co-amoxiclav i/v plus plus 1.2 g tds for 5 - 7 days Gentamicin i/v Gentamicin i/v High dose High dose If Co-amoxiclav in the last (Appendix A) (Appendix A) 4 weeks: Piperacillin/tazobactam Discuss with Microbiologist for Discuss with Microbiologist i/v continuing antimicrobial choice for continuing antimicrobial 4.5 g tds for 5-7 days choice

ERCP Gentamicin i/v Gentamicin i/v Gentamicin i/v In patients with PSC, hilar 120 mg (on table) 120 mg (on table) 120mg single dose cholangiocarcinoma, pancreatic or or plus pseudocyst, neutrophils Ciprofloxacin oral Ciprofloxacin oral Teicoplanin i/v <0.5 x109 /L ± advanced 750 mg 750 mg 600mg single dose haematology malignancy (60 -90 minutes before) (60 -90 minutes before)

ERCP 1 hour pre-procedure 1 hour pre-procedure 1 hour pre-procedure In patients post liver transplant Amoxicillin i/v Teicoplanin i/v Teicoplanin i/v 1g single dose 600 mg single dose 600 mg single dose plus plus plus Gentamicin i/v Gentamicin i/v Gentamicin i/v 120 mg single dose 120 mg single dose 120 mg single dose Page 52 Antimicrobial Policy for Adults 2017 19 SURGICAL PROPHYLAXIS Obstetrics and Gynaecology [11, 39]

Timing: administer i/v antimicrobials 30-60 minutes before incision

1st line Patients with Penicillin Patients with History allergy of MRSA Obstetrics and Gynaecology Hysterectomy Co-amoxiclav i/v Gentamicin i/v Teicoplanin i/v - Abdominal 1.2 g single dose 120 mg single dose 600 mg single dose - Vaginal plus plus Clindamycin i/v Gentamicin i/v 600 mg single dose 120 mg single dose plus Metronidazole i/v 500 mg single dose Salpingooophorectomy No prophylaxis No prophylaxis

Caesarian section Cefuroxime i/v Non-life threatening allergy Gentamicin i/v 1.5 g single dose Cefuroxime i/v 2mg/kg single dose Assisted delivery plus 1.5 g single dose plus Metronidazole i/v plus Metronidazole i/v Manual removal of placenta 500 mg single dose Metronidazole i/v 500mg single dose 500 mg single dose plus Teicoplanin i/v Life threatening allergy 600mg single dose Gentamicin i/v 120 mg single dose plus Clindamycin i/v 600 mg single dose Perineal tear Cefuroxime i/v Non-life threatening allergy Gentamicin i/v For third/fourth degree 1.5 g single dose Cefuroxime i/v 2mg/kg single dose perineal tear involving the plus 1.5 g single dose plus anal sphincter/rectal mucosa Metronidazole i/v plus Metronidazole i/v 500 mg single dose Metronidazole i/v 500mg single dose 500 mg single dose plus Teicoplanin i/v Life threatening allergy 600mg single dose Gentamicin i/v 120 mg single dose plus Clindamycin i/v 600 mg single dose Induced abortion Metronidazole i/v Metronidazole i/v Metronidazole i/v 500 mg single dose 500 mg single dose 500 mg single dose

if genital Chlamydia can not if genital Chlamydia can not be if genital Chlamydia can not be ruled out ruled out be ruled out Doxycycline oral Doxycycline oral Doxycycline oral 100 mg bd for 7 days 100 mg bd for 7 days 100 mg bd for 7 days

Evacuation of incomplete No proplylaxis No proplylaxis No proplylaxis miscarriage

Intrauterine contraceptive No prophylaxis No prophylaxis No prophylaxis device (IUCD) insertion Antimicrobial Policy for Adults 2017 19 Page 53 SURGICAL PROPHYLAXIS, Urology [11, 39] Caution CIPROFLOXACIN ENCOURAGES THE EMERGENCE OF MRSA

Timing: administer i/v antimicrobials 30-60 minutes before incision

1st line Patients with Penicillin Patients with History allergy of MRSA Urology

Transrectal prostate biopsy Ciprofloxacin oral Ciprofloxacin oral Discuss with Microbiologist Rotherham 500 mg bd for 3 days, first 500 mg bd for 3 days, first dose 1-2 hours before biopsy dose 1-2 hours before biopsy

Barnsley see separate interim guideline see separate interim guideline see separate interim guideline

Shock wave lithotripsy No prophylaxis No prophylaxis No prophylaxis

Percutaneous Co-amoxiclav i/v Non life threatening allergy Discuss with Microbiologist nephrolithotomy 1.2g 8 hourly for 3 doses Cefuroxime i/v 750 mg 8 hourly for 3 doses plus Metronidazole i/v 500 mg 8 hourly for 3 doses

Life threatening allergy discuss with microbiologist

Endoscopic ureteric Gentamicin i/v Gentamicin i/v Gentamicin i/v stone fragmentation/ 120 mg single dose 120 mg single dose 120 mg single dose removal For patients with stones ≥20mm or with pelvicalyceal dilation

Transurethral resection of Gentamicin i/v Gentamicin i/v Gentamicin i/v prostate 120 mg single dose 120 mg single dose 120 mg single dose Transurethral resection of bladder tumours

Penile prosthesis At induction At induction Discuss with Microbiologist Gentamicin i/v Gentamicin i/v 160 mg 160 mg plus plus Metronidazole i/v Metronidazole i/v 500 mg 500 mg plus then from next day Co-amoxiclav i/v Gentamicin i/v 1.2 g 80 mg 8 hourly for 3 doses then from next day plus Gentamicin i/v Ciprofloxacin oral 80 mg 8 hourly for 3 doses 500 mg bd for 5 days plus Ciprofloxacin oral 500 mg bd for 5 days

Nesbitt’s / Lue Procedure Gentamicin i/v Gentamicin i/v Gentamicin i/v 120 mg single dose 120 mg single dose 120 mg single dose

Intravesical botox therapy Ciprofloxacin oral Ciprofloxacin oral Discuss with microbiologist via flexible cystoscopy 500mg bd for 3 days 500mg bd for 3 days First dose 1-2 hours before First dose 1-2 hours before procedure procedure Page 54 Antimicrobial Policy for Adults 2017 19

SURGICAL PROPHYLAXIS, Limb [11, 39]

Timing: administer i/v antimicrobials 30-60 minutes before incision

1st line Patients with Penicillin Patients with History allergy of MRSA Limb

Arthroplasty Flucloxacillin i/v Teicoplanin i/v Teicoplanin i/v (Joint replacement) 2 g followed by 1 g 800 mg single dose 800 mg single dose 6 hourly for 3 doses plus plus plus Gentamicin i/v Gentamicin i/v Gentamicin i/v 160 mg single dose 160 mg single dose 160 mg single dose

Open fracture Co-amoxiclav i/v Teicoplanin i/v Teicoplanin i/v 1.2 g 8hourly 800 mg single dose 800 mg single dose for 3 doses plus plus Gentamicin i/v Gentamicin i/v 160mg single dose 160mg single dose

Open surgery for closed Co-amoxiclav i/v Teicoplanin i/v Teicoplanin i/v fractures 1.2 g 8 hourly 800 mg single dose 800 mg single dose for 3 doses plus plus Gentamicin i/v Gentamicin i/v 160 mg single dose 160 mg single dose

Hip fracture Co-amoxiclav i/v Teicoplanin i/v Teicoplanin i/v 1.2 g 8 hourly 800 mg single dose 800 mg single dose for 3 doses plus plus Gentamicin i/v Gentamicin i/v 160mg single dose 160mg single dose

Orthopaedic surgery No prophylaxis No prophylaxis No prophylaxis (without implant)

Lower limb amputation Gentamicin i/v Gentamicin i/v Gentamicin i/v 160 mg single dose 160 mg single dose 160 mg single dose plus plus plus Benzyl penicillin i/v Teicoplanin i/v Teicoplanin i/v 1.8 g single dose then 400 mg 12 hourly for 3 doses 400 mg 12 hourly for 3 doses 600 mg 6 hourly for 5 days then once daily for 5 days then once daily for 5 days

Soft tissue surgery Co-amoxiclav i/v Teicoplanin i/v Teicoplanin i/v of the hand 1.2 g single dose 800 mg single dose 800 mg single dose Antibiotic prophylaxis for plus plus clean surgery is not normally Gentamicin i/v Gentamicin i/v recommended but if complicated , 160 mg single dose 160 mg single dose then it should be considered. Antibiotic prophylaxis is recommended for surgery involving insertion of a prosthetic device or implant. Antimicrobial Policy for Adults 2017 19 Page 55

MEDICAL PROPHYLAXIS

PROCEDURE ANTIMICROBIALS Meningococcal disease/ Ciprofloxacin oral 500 mg single dose Meningitis contacts (Unlicensed Indication) or [11] Rifampicin oral 600 mg bd for 2 days

PREGNANCY Ceftriaxone i/m 250 mg single dose

Haemophilus influenzae type b Rifampicin oral 600 mg od for 4 days contacts [11] Pregnancy Ceftriaxone i/m or i/v 1G OD for 2 days

Whooping cough contacts Clarithromycin oral 500 mg bd for 7 days [11] for details on those who need chemoprophylaxis please consult the most recent British National Formulary (BNF) see section: Antibacterials, use for prophylaxis.

https://www.medicinescomplete. com/mc/bnf/current/PHP78210- antibacterials-use-for-prophylaxis.htm

Post splenectomy / asplenic Penicillin V oral 250 mg bd for life patients (or sickle cell disease patients) Penicillin allergy: Erythromycin oral 500 mg bd for life [11] Immunisation Please refer to Splenectomy Guidelines (Appendix G)

Tuberculosis prophylaxis Isoniazid oral 300 mg od for 3 months (susceptible close contacts plus or those who have become Rifampicin oral 600 mg od (450 mg if less than 50kg) for 3 months tuberculin positive) (or for selected patients) [11] Isoniazid oral 300 mg od for 6 months

Discuss with consultant chest physician Page 56 Antimicrobial Policy for Adults 2017 19

PROPHYLAXIS AGAINST INFECTIVE ENDOCARDITIS [24] Introduction Antimicrobials have been offered routinely as a preventative measure to people at risk of infective endocarditis undergoing interventional procedures. However, there is little evidence to support this practice. Antimicrobial prophylaxis has not been proven to be effective and there is no clear association between episodes of infective endocarditis and interventional procedures. Any benefits of prophylaxis need to be weighed against the risks of adverse effects for the patient and of antibiotic resistance developing. As a result, this guideline recommends that antimicrobial prophylaxis is no longer offered routinely for defined interventional procedures.

Summary of recommendations Adults and children with structural cardiac conditions. Regard people with the following cardiac conditions as being at risk of developing infective endocarditis. • Acquired valvular heart disease with stenosis or regurgitation • Valve replacement • Structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus and closure devices that are judged to be endothelialised • Hypertrophic cardiomyopathy • Previous infective endocarditis

Advice Offer people at risk of infective endocarditis clear and consistent information about prevention, including: • The benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended • The importance of maintaining good oral health • Symptoms that may indicate infective endocarditis and when to seek expert advice • The risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.

When to offer prophylaxis Do not offer antibiotic prophylaxis against infective endocarditis routinely- • To people undergoing dental procedures • To people undergoing non-dental procedures at the following sites: 1. upper and lower gastrointestinal tract 2. genitourinary tract: this includes urological, gynaecological and obstetric procedures and childbirth 3. upper and lower respiratory tract, this includes ear, nose and throat procedures and bronchoscopy. • Do not offer chlorhexidine mouthwash as prophylaxis against infective endocarditis to people at risk undergoing dental procedures. • Discuss with microbiology if the patients’ clinical status is of a complex nature.

Managing infection • Investigate and treat promptly any episodes of infection in people at risk of infective endocarditis to reduce the risk of endocarditis developing. • Discuss with microbiology if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection. Antimicrobial Policy for Adults 2017 19 Page 57

REFERENCES Introduction

1 National Institute for Health and Care Excellence (2014) Drug allergy: diagnosis and management NICE Guidance (CG 183) www.nice.orguk/guidance/cg183

2 Frumin J, Gallagher JC (2009) allergic cross - sensitivity between penicillin, carbapenem and monobactam antibiotics: What are the chances? Ann Pharmacother 43(2) 304-315

3 Resistance to antibiotics and other antimicrobial agents. Report of the House of Lords Select Committee on Science and Technology. London: Stationary office, 1998. http://www.parliament.the-stationery-office.co.uk/pa/ld199798/ldselect/ldsctech/081vii/st0701.htm

4 Chief Medical Officer Winning Ways: Working together to reduce Healthcare Associated Infection in England. Department of Health, December 2003. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4064682

5 Department of Health 2005 Saving Lives: Toolkit. A delivery programme to reduce healthcare associated infection including MRSA. http://www.clean-safe-care.nhs.uk/ArticleFiles/Events/Saving-Lives-publicaiton-confed-final-version.pdf

6 Department of Health 2006 The Health Act 2006, Code of Practice for the Prevention and Control of Health Care Associated Infections, General Health Protection. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081927

7 Department of Health, 1998 Standing Medical Advisory Committee: Sub-Group on Antimicrobial resistance. The path of least resistance. http://www.publications.doh.gov.uk/pub/docs/doh/smacrep.pdf

8 Public health England 2015 Antimicrobial stewardship: Start Smart- Then Focus . Antimicrobial Stewardship toolkit for English Hospitals https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/417032/Start_Smart_Then_Focus_ FINAL.PDF

9 National Institute for Health and Care Excellence (2015) antimicrobial stewardship : systems and processes for effective antimicrobial medicine use (NG15)

10 Department of Health 2007 Saving Lives: reducing infection, delivering clean and safe care. Antimicrobial Prescribing: A summary of best practice www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=147766&Rendition=Web

For all infections

11 British National Formulary 71, March 2016. http://www.bnf.org.uk/bnf/bnf/current/index.htm

12 Health Protection Agency Management of infection guidance for primary care for consultation and local adaptation. May 2017

13 British Society of Antimicrobial Chemotherapy (BSAC) Treatment of Hospital Infections 2009 www.bsac.org.uk/pyxis

14 The Sanford Guide to Antimicrobial Therapy 2010

15 The Infectious Diseases Manual (2nd Edition) 2003 Blackwell Publishing Ltd. Page 58 Antimicrobial Policy for Adults 2017 19

Respiratory

16 The British Thoracic Society Guidelines for the management of community-acquired pneumonia in adults Thorax 2009: Update http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pneumonia/Guidelines/CAPGuideline-full.pdf

17 National Institute for Health and Care Excellence (2014) Preumonia in adults: diagnosis and management. NICE guideline (CG 191)

18 National Institute for Health and Care Excellence (2010) Chronic obstructive pulmonary disease in over 16s: diagnosis and management NICE guidelines (CG101)

19 The British Thoracic Society Bronchiectasis (non-CF) guideline group (2010) Guideline for non - CF Branchiectasis Thorax 65 (i) 1-58

20 National Institute for Health and Care Excellence (2016) Tuberculosis. NICE guideline (NG-33)

Urinary Tract infections 21 Scottish Intercollegiate Guidelines Network Management of suspected bacterial urinary tract infection in adults. Clinical guideline 88. 2012 http://www.sign.ac.uk/pdf/qrg88.pdf Sepsis

22 National Institute for Health and Care Excellence (2016) Sepsis: recognition, diagnosis and early management. NICE guideline (NG 51) Endocarditis

23 Eliott TSJ, Foweraker J, Gould FK et al. Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal Antimicrobial Chemotherapy 2012; 67: 269–289 Advance Access publication 14 November 2011 http://jac.oxfordjournals.org/content/early/2011/12/02/jac.dkr450

24 National Institute for Health and Care excellence (2008) prophylaxis against infective endocarditis: Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures NICE guideline (CG 64) http://www.nice.org.uk/CG064 Skin and Soft Tissue Infections

25 Edmonds ME, Foster VM (2014) Managing the diabetic foot (Third edition) Wiley-Blackwell

26 Holt T, Kumar S (2010) ABC of diabetes (6th Edition) Wiley-Blackwell/ BMJ books

27 National Institute for Health and Care Excellence (2015) Diabetic foot problems: prevention and management. NICE guideline (NG 19) https://www.nice.org.uk/guidance/ng19/resources/diabetic-foot-problems-prevention-and-management- pdf-1837279828933 Antimicrobial Policy for Adults 2017 19 Page 59

Obstetrics & Gynaecological infections 28 Royal College of Obstetricians and Gynaecologists (2012) Bacterial Sepsis following pregnancy: Green-top guideline (64b)

29 Clinical Effectiveness Group, British Association for Sexual Health and HIV (2011) "UK National Guideline for the Management of Pelvic Inflammatory Disease" https://www.bashhguidelines.org/media/1143/pid-2012.pdf

Sexually Transmitted Infections 30 Clinical Effectiveness Group, BASHH (British Association for Sexual Health and HIV) (2011) National Guideline on the management of Gonorrhoea http://www.bashh.org/documents/3920

31 Clinical Effectiveness Group, British Association for Sexual Health and HIV "2015 UK national guideline for the management of infection with Chlamydiatrachomatis" https://www.bashhguidelines.org/media/1045/chlamydia-2015.pdf

32 Clinical Effectiveness Group, British Association for Sexual Health and HIV (2012) National Guideline for the management of bacterial vaginosis http://www.bashh.org/documents/4413

33 Clinical Effectiveness Group, British Association for Sexual Health and HIV. (2014) United Kingdom National Guideline on the Management of Trichomonas vaginalis https://www.bashhguidelines.org/media/1042/tv_2014-ijstda.pdf

34 Clinical Effectiveness Group, British Association for Sexual Health and HIV (2014) UK National guideline for the management of anogenital herpes

35 Clinical Effectiveness Group, British Association for Sexual Health and HIV (2010) United Kingdom national guideline for the management of epididymo-orchitis https://www.bashh.org/documents/3546.pdf Haematological Infections 36 National Institute for Clinical Excellence. Neutropenic Sepsis: prevention and management of Neutropenic Sepsis September 2012 http://guidance.nice.org.uk/CG151 Gastrointestinal Infections 37 Department of Health Clostridium difficile infection: How to deal with a problem. December 2008 http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1232006607827

38 National Institute for Clinical Excellence. (2006) Dyspepsia: Managing Dyspepsia in Primary Care. http://www.nice.org.uk/guidance/index.jsp?action=byID&o=10950 Clostridium difficile Surgical Prophylaxis 39 Scottish Intercollegiate Guidelines Network. Surgical Prophylaxis Guideline 104. 2008 (updated 2014) http://www.sign.ac.uk/pdf/sign104.pdf Page 60 Antimicrobial Policy for Adults 2017 19

40 Sandoe J.A.T. et al (2015) guideline for the diagnoisis, prevention and management of implantable cardiac electronic device infection. Report of a joint working party project on behalf of British society for antimicrobial chemotherapy (BSAC, host organisation), British Heart rhythm society (BHRS), British Cardiovascular society (BCS), British Heart valve society (BHVS) and British Society for echocardiography (BSE). Journal of Antimicrobial Chemotherapy 70 (2) page 325-359

41 Allison MC, Sandoe JAT, Tighe R et al. Antibiotic prophylaxis in gastrointestinal endoscopy. GUT 2009; 58: 869-880. http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/prophylaxis_09.pdf

Medical Prophylaxis 42 DJ Suh Prophylaxis of spontaneous bacterial peritonitis: primary and secondary. Journal of Gastroenterology and Hepatology 2004; 19: 8200 – 8203 Therapeutic Drug Monitoring 43 Nicolau DP, Freeman CD, Belliveau PP et al. Experience with once-daily aminoglycoside program administered to 2184 adult patients. Antimicrobial agents and Chemotherapy 1995; 39(3): 650-655 Doses in Renal Impairment 44 The Renal Drug Handbook (4th Edition; 2014) Ed. Caroline Ashley and Aileen Dunleavy Radcliffe Publishing Ltd. Antimicrobial Policy for Adults 2017 19 Page 61

THERAPEUTIC DRUG MONITORING

Aminoglycosides (Gentamicin, Amikacin, Tobramycin)

Gentamcin is widely used for surgical prophylaxis and for the treatment endocarditis and other serious infections. Amikacin and tobramycin are used in case of resistance to gentamicin.

Aminoglycosides are excreted via the kidneys and therefore accumulation occurs in renal impairment. The side effects associated with toxic levels are hearing and balance disorders and further renal impairment. These drugs should be used with caution in the Elderly patients, during pregnancy and in patients with renal impairment. If possible an alternative should be considered.

Patients must be informed of potential side effects.

Dose calculation and monitoring serum concentration • The dose and dose interval must be based on patient’s ideal body weight and renal function. • Serum concentrations must be monitored to avoid both excessive and subtherapeutic levels. • The doses must be given at the times prescribed. • Serum concentrations must be monitored according to the regimens. • Time of dose and time of sample must be documented at all times, otherwise the results cannot be acted upon. • The treatment with aminoglycosides must be reviewed daily.

Glycopeptides (Vancomycin and Teicoplanin)

Glycopeptides are used for surgical prophylaxis and for the treatment of infections.

Intravenous Vancomycin dose calculation and monitoring serum concentration • Vancomycin dose and dose interval must be based on patient’s ideal body weight and renal function when treating infection. • Serum concentrations must be monitored to avoid both excessive and subtherapeutic levels. • The doses must be given at the times prescribed. • Serum concentrations must be monitored according to the regimens. • Time of dose and time of sample must be documented at all times, otherwise the results cannot be acted upon. • The treatment with vancomycin must be reviewed daily.

Teicoplanin serum levels require monitoring in deep seated infections to ensure adequate levels have been achieved. Page 62 Antimicrobial Policy for Adults 2017 19

APPENDIX A High Dose Gentamicin Regimen [43] Inform patient of potential side effects (hearing, balance and renal impairment)

HIGH DOSE GENTAMICIN REGIMEN Protocol Need for treatment must be reviewed daily To calculate dose and interpret levels

This regime gives a constant dose of gentamicin of 7 mg/kg calculated from ideal body weight. A serum level is measured 6 – 14 hours after the first dose to determine the dosage interval. High dose gentamicin must be prescribed on the high dose gentamicin (7mg/kg) prescription, administration and monitoring chart.

1. FIND OUT PATIENT DETAILS Calculate • Indication • Height (feet / inches) creatinine clearance* • Allergy status • Weight (kg) • Male/ Female • Serum creatinine (micromol/L) • Age • U&Es

2. CONTRAINDICATIONS FOR HIGH DOSE GENTAMICIN REGIME Do not use this regimen for: • Any patient who has - Major burns Consider • Pregnant women - Ascites - Renal transplant interactions • Children < 16 years - Limb amputation - Renal impairment • Urology surgery prophylaxis - Cystic fibrosis (creatinine clearance - Endocarditis <30 mL/minute)*

3. SELECT THE DOSE AND PRESCRIBE ON THE CHART • Read off patients Ideal Body Weight (IBW). • Compare Ideal Body Weight with Actual Body Weight (ABW) • Select gentamicin dose based on whichever weight is less, Ideal Body Weight or Actual Body Weight.

ADULT MALES (>16 years) ADULT FEMALES (>16 years)

Height Calculated IBW Gentamicin dose ABW Height Calculated IBW Gentamicin dose ABW kg mg (use if less than IBW) kg mg (use if less than IBW) kg kg

5’ 1.52m 50 360 49 to 54 5’ 1.52m 45.5 320 43 to 48 5’1” 1.55m 52.3 5’1” 1.55m 47.8

5’2” 1.57m 54.6 5’2” 1.57m 50.1 360 49 to 54 5’3” 1.6m 56.9 400 55 to 59 5’3” 1.6m 52.4 5’4” 1.62m 59.2 5’4” 1.62m 54.7

5’5” 1.65m 61.5 5’5” 1.65m 57.0 400 55 to 59 440 60 to 65 5’6” 1.67m 63.8 5’6” 1.67m 59.3 5’7” 1.7m 66.1 5’7” 1.7m 61.6 5’8” 1.72m 68.4 480 66 to 71 5’8” 1.72m 63.9 440 60 to 65 5’9” 1.75m 70.7 5’9” 1.75m 66.2 5’10” 1.78m 73.0 5’10” 1.78m 68.5 5’11” 1.8m 75.3 520 72 to 77 5’11” 1.8m 70.8 480 66 to 71 6’ 1.82m 77.6 6’1” 1.85m 79.9 6’ 1.82m 73.1 520 72 to 77 6’2” 1.88m 82.2 560 78 to 82 6’1” 1.85m 75.4 6’3” 1.9m 84.5 6’2” 1.88m 77.7 6’3” 1.9m 80.0 560 78 to 82

For heights outside this range contact pharmacy

Height in feet/inches = Height in centimetres *Creatinine clearance (mL/minute) = F x (140 – age) x Body Weight 2.54 serum creatinine IBW calculations: Male = 50 kg + (2.3 kg x number of inches over 5 feet) F: Males 1.23 Females 1.04 Female = 45.5 kg + (2.3 kg x number of inches over 5 feet) Body weight: Actual or Ideal, whichever is less Antimicrobial Policy for Adults 2017 19 Page 63

HIGH DOSE GENTAMICIN REGIMEN Protocol Need for treatment must be reviewed daily To calculate dose and interpret levels

4. Administration Dilute the required dose of gentamicin in 100 mL sodium chloride 0.9%. • Give by intravenous infusion over 1 hour. • Record on the medicine chart the EXACT start time of the infusion.

5. Monitoring Gentamicin therapy Requires monitoring of gentamicin levels and renal function

i. Documentation required on: • EXACT time & date of starting gentamicin infusion. Medicine chart & Microbiology form • EXACT time & date of taking blood sample.

ii. Blood samples Must only be taken by venepuncture from a site other than that used for administration.

iii. Monitoring serum levels • 6 to 14 hours after (ideally 7 hours) start of the FIRST infusion (if possible during 0900 - 1800 hours).

• Further monitoring as below:

Dose interval Monitoring levels 24 hours 6-14 hours after every third dose 36 hours 6-14 hours after every dose 48 hours 6-14 hours after every dose

6. Interpretation of levels

• Plot the level on the nomogram.

• Adjust the dose interval according to where the level falls (ie 24 hourly, 36 hourly or 48 hourly).

• Adjust to the longer dose interval if the level falls on a one line.

• Stop gentamicin if the level is above the 48 hour line. Continue taking levels daily until the levels fall below 2 mg/L. Discuss with Microbiologist/ Pharmacist.

• If the serum creatinine is rising significantly, measure the gentamicin level as soon as possible, within the 6-14 hour window, and reassess the dosage interval.

Reference Protocol produced by Yorkshire Antibiotic Pharmacist Group (May 2007) Antimicrobial Agents and Chemotherapy 1995; 39: 650-655 Adapted by Rotherham / Barnsley Antibiotic Policy Development Group (2007 and 2010)

CONTACT NUMBERS Rotherham Barnsley Consultant Microbiologist 4742 7712 Consultant Microbiologist 2749 Microbiology Laboratory 4242 Microbiology laboratory 2687 Ward Clinical Pharmacist Bleep Ward Clinical Pharmacist Bleep Medicines Information 4126 Medicines Information 2857 Out of hours – via the switch board Page 64 Antimicrobial Policy for Adults 2017 19

APPENDIX B Therapeutic drug monitoring – Gentamicin Conventional Dose Regimen [11] When High Dose Gentamicin Regimen contraindicated

Inform patient of potential side effects (hearing, balance and renal impairment)

Patient details • Clinical diagnosis Required to advise /revise • Height, weight, age Gentamicin dose • Serum creatinine • Gentamicin - dose, times of doses - time samples taken and serum levels Prescribing Gentamicin Endocarditis Streptococci and Other infections, when High Dose Dose Enterococci Gentamicin regimen contraindicated (symmetric dosing) 80 mg 12 hourly Loading dose 2 mg/kg for 3 doses Followed by 2 doses 1.5 mg/kg 12 hourly

Revise dose after blood levels on 3rd dose

Therapeutic levels

Pre-dose < 1 mg/L < 2 mg/L immediately before dose

Post dose 3 – 5 mg/L 5 – 10 mg/L 1 hour post dose

Administration

Intravenous bolus over 3 –5 minutes.

Important • Doses must be given at prescribed times otherwise interpretation is difficult. • Document on Drug Kardex the EXACT time the dose is given.

Monitoring Gentamicin levels

• First Pre-dose & Post dose levels on the 3rd dose. • Monitor blood levels on 3rd dose after changing the dose. • Monitor twice a week if levels stable and the renal function stable

Important • Blood samples must be taken via a venepuncture, not from any existing venous access. • Document the EXACT times the bloods are taken on Drug Kardex and Laboratory Request Forms.

Monitoring renal function Three times a week Antimicrobial Policy for Adults 2017 19 Page 65

APPENDIX C Therapeutic Drug Monitoring – Amikacin [11]

Inform patient of potential side effects (hearing, balance and renal impairment)

Patient details • Clinical diagnosis Required to advise /revise Amikacin dose • Height, weight, age • Serum creatinine • Amikacin - dose, times of doses - time samples taken and serum levels

Prescribing Amikacin First 3 dose doses 7.5 mg /kg 12 hourly for 3 doses then review after blood levels on 3rd dose Dose (symmetric dosing)

Therapeutic serum levels

Pre-dose (Trough) Less than 10 mg/L

One hour Post dose (Peak) 20 to 30 mg/L

Administration Intravenous bolus over 3 –5 minutes.

Important • Doses must be given at prescribed times otherwise interpretation is difficult. • Document on Drug Kardex the EXACT time the dose is given.

Monitoring Amikacin levels • First Pre-dose & Post dose levels on the 3rd dose. • Monitor blood levels on 3rd dose after changing the dose. • Monitor twice a week if levels stable and the renal function stable

Important • Blood samples must be taken via a venepuncture, not from any existing venous access. • Document the times the bloods are taken on Drug Kardex and Laboratory Request Forms.

Sampling times Pre-dose (trough) levels - immediately before dose.

Post dose (peak) levels - one hour after i/v bolus dose.

Monitoring renal function Three times a week Page 66 Antimicrobial Policy for Adults 2017 19

APPENDIX D Therapeutic Drug Monitoring – Tobramycin [11]

Inform patient of potential side effects (hearing, balance and renal impairment)

Patient details • Clinical diagnosis Required to advise /revise Tobramycin dose • Height, weight, age • Serum creatinine • Tobramycin - dose, times of doses - time samples taken and serum levels

Prescribing Tobramycin In normal renal function Loading dose Dose 3mg/kg (symmetric dosing) followed by 2 doses 1.5 mg/kg for 12 hourly

Revise dose based on serum levels on 3rd dose

Impaired renal function - contact Microbiologist Therapeutic serum levels

Pre-dose (Trough) Less than 2 mg/L

One hour Post dose (Peak) 6 to 10 mg/L

Administration Intravenous bolus over 3 –5 minutes.

Important • Doses must be given at prescribed times otherwise interpretation is difficult. • Document on Drug Kardex the EXACT time the dose is given.

Monitoring Tobramycin levels Monitor blood levels on 3rd dose after starting tobramycin or when changing dose.

Important • Blood samples must be taken via a venepuncture, not from any existing venous access. • Document the EXACT times the bloods are taken on Drug Kardex and Laboratory Request Forms.

Sampling times Pre-dose (trough) levels - immediately before dose.

Post dose (peak) levels - one hour after i/v bolus dose.

Monitoring renal function Three times a week Antimicrobial Policy for Adults 2017 19 Page 67

APPENDIX E Therapeutic Drug Monitoring – Teicoplanin

Patient details • Clinical diagnosis Required to advise /revise Teicoplanin dose • Height, weight, age • Serum creatinine • Teicoplanin - dose, times of doses - time sample taken and serum level

Prescribing Teicoplanin Dose depends on the indication and Renal function. See Appendix E (i) and (ii) on pages 68 and 69 Therapeutic serum levels Routine monitoring not necessary. Monitor in renal impairment and serious infections, e.g. endocarditis, osteomyelitis Pre-dose (Trough) More than 10 mg/L

20-60 mg/L for osteomyelitis, HIV patients, i/v drug users

Administration Intravenous bolus over 3 – 5 minutes - see Medusa injectable medicines guide for details

Intravenous infusion - see Medusa injectable medicines guide for details

Monitoring Blood levels before 5th or 6th dose after starting teicoplanin or 2-3 days after changing the dose.

Important • Blood samples must be taken via venepuncture, not from any existing venous access.

Sampling times Pre-dose (trough) levels - immediately before dose.

References: Spc Targocid accessed via electronic medicines compendium on 24/03/2016 BNF March 2016 : accessed via medicines complete on 24/03/2016 Renal drug handbook 4th edition 2014 Page 68 Antimicrobial Policy for Adults 2017 19

APPENDIX E (i) Teicoplanin Dosing 6mg/kg

Creatinine Clearance greater than 80mls/min

Weight less than 70kg Weight greater than 70kg Loading dose 400mg 12 hourly for 3 doses* 6mg/kg 12 hourly for 3 doses Maintenance dose 400mg od* 6mg/kg od * Consider using mg/kg dosing in patients with low body weight

Creatinine Clearance 30 to 80mls/min

Weight less than 70kg Weight greater than 70kg Loading dose - days 1 to 4 400mg 12 hourly for 3 doses then 6mg/kg 12 hourly for 3 doses then 400mg od* 6mg/kg od Maintenance dose from day 5 200mg od* 3mg/kg od * Consider using mg/kg dosing in patients with low body weight

Creatinine Clearance less than 30 mls/min

Weight less than 70kg Weight greater than 70kg Loading dose - days 1 to 4 400mg 12 hourly for 3 doses then 6mg/kg 12 hourly for 3 doses then 400mg od* 6mg/kg od Maintenance dose from day 5 133mg od* 2mg/kg * Consider using mg/kg dosing in patients with low body weight

Targeted trough level as measured by FPIA >15mg/L

Dose reduction in renal failure is based upon normal loading dose on days 1 to 4 then maintence dose of 50% for Creatinine clearance 30-80mls per minute and 33% for creatinine clearance less than 30mls/min References: Spc Targocid accessed via electronic medicines compendium on 24/03/2016 BNF March 2016 : accessed via medicines complete on 24/03/2016 Renal drug handbook 4th edition 2014 Antimicrobial Policy for Adults 2017 19 Page 69

APPENDIX E (ii) Teicoplanin Dosing 12mg/kg

Creatinine Clearance greater than 80mls/min

Dose based on actual weight Loading dose 12mg/kg 12 hourly for 3 doses Maintenance dose 12mg/kg od

Creatinine Clearance 30 to 80mls/min

Dose based on actual weight Loading dose - days 1 to 4 12mg/kg 12 hourly for 3 doses then 12mg/kg od Maintenance dose from day 5 6mg/kg od

Creatinine Clearance less than 30 mls/min

Dose based on actual weight Loading dose - days 1 to 4 12mg/kg 12 hourly for 3 doses then 12mg/kg od Maintenance dose from day 5 4mg/kg

Targeted trough level as measured by FPIA >20mg/L for bone and joint infections >30mg/L for endocarditis

APPENDIX F Therapeutic Drug Monitoring – Vancomycin

Inform patient of potential side effects (hearing, balance and renal impairment)

Patient details • Clinical diagnosis Required to advise /revise Vancomycin • Height, weight, age dose • Serum creatinine • Vancomycin - dose, times of doses - time samples taken and serum levels

Prescribing Vancomycin In normal renal function

Dose Commence with (symmetric dosing) 1g 12 hourly for 3 doses then review after the blood levels on the 3rd dose

Impaired renal function - contact Microbiologist

Therapeutic serum levels

Pre-dose (Trough) 10 - 15 mg/L (15 - 20mg/L in endocarditis)

Administration Reconstitute I g vial with 20 mL water for injection Dilute 1 g with 250 mL Infusion fluid

Infusion fluid: sodium chloride 0.9% or glucose 5%

Intravenous infusion rate 10 mg /minute

Important • Doses must be given at prescribed times otherwise interpretation is difficult. • Document on Drug Kardex the EXACT time the dose is given.

Monitoring blood levels • Immediately before giving the 3rd dose.

• Repeat level twice a week if levels and the renal function stable.

Important • Blood samples must be taken via a venepuncture, not from any existing venous access.

Sampling times Pre-dose (trough) levels - immediately before dose.

Monitoring renal function Three times a week Antimicrobial Policy for Adults 2017 19 Page 71

APPENDIX G Post-Splenectomy prevention of infection – Advice for Clinicians All clinical areas incuding Inpatients and Outpatients

INTRODUCTION

Patients that have had splenectomies, or who have conditions causing hyposplenism, are at risk of infections. The organisms are usually encapsulated bacteria, of which Streptoccus pneumoniae is the most common but includes Haemophilus influenzae and Neisseria meningitidis. Other pathogens include Escherichia coli, Pseudomonas aeruginosa, and Capnocytophagia canimorsus from dog and animal bites. They are also at risk from other infections including protozoa (malaria and babesiosis).

The incidence of overwhelming post splenectomy infection is at 0.18 – 0.42% per year. The mortality may be as high as 69%. There is a lifelong risk of infection, but it is thought to be increased in the first two years post-splenectomy. The risk of infection is increased in children with Thalassaemia major and sickle cell disease. Patients with Hodgkin’s disease, or immunosuppression are also at greater risk.

PATIENT EDUCATION

1. Information leaflet regarding infection risks and alert card 2. Medic alert bracelet 3. Regular antibiotics 4. Vaccinations 5. Attend hospital if feel unwell 6. Seek advice before travelling abroad

SPLENECTOMY ALERT

1. Complete the patient data alert inside the front cover of the patient’s notes.

2. Inform the patient’s General Practitioner that the patient has had a splenectomy and communicate any vaccinations given in the hospital. Primary care records need to be marked concerning the patient’s increased risk of infection and vaccination status.

3. Ensure the patient has been given a splenectomy leaflet and alert card (available from the Haematology Department on request).

4. Encourage the patient to obtain a medic alert disc, or carry an alert card.

5. There is a small risk of splenectomised individuals being exposed to infective biological materials in certain occupations. This needs to be considered and discussed with the employer.

6. Patients having had a splenectomy, or who are hyposplenic, who become unwell and may have developed an infection, need to be admitted to hospital for systemic antibiotics.

IMMUNISATIONS

Planned Splenectomy Immunisations should ideally be given four to six weeks (at least two weeks) prior to a planned splenectomy as long as there is no history of allergy.

Emergency Splenectomy Immediately after an emergency splenectomy, patient's ability to mount antibody response is low and therefore immunisation should be given when the patient is recovering, prior to discharge from hospital (ideally at least 2 weeks after splenectomy). Page 72 Antimicrobial Policy for Adults 2017 19

a) Pneumococcal polysaccharide vaccine (Pneumovax II). Revaccination is recommended every 5 years in individuals with no spleen or splenic dysfunction as antibody levels are likely to decline more rapidly b) Haemophilus influenzae type b vaccine conjugate and meningococcal C vaccine (combined Hib/MenC). One dose irrespective of previous immunisation status. c) First dose Meningococcal group B vaccine d) Single dose Quadrivalent meningococcal ACWY conjugate vaccine and second dose of Meningococcal group B vaccine 1 month after pneumococcal polysaccharide and combined Hib/Menc and Meningococcal group B vaccines.

Other vaccination considerations a) Influenza vaccine should be offered annually. b) Ensure vaccination and re-vaccination status is documented in notes c) Patients that have had a splenectomy in the past should be offered vaccinations but consideration of lifelong antibiotic prophylaxis should be discussed with the patient.

ANTIBIOTICS N.B. CONSULT PAEDIATRIC DOSES FOR CHILDREN

1. Patients should be advised to continue antibiotics lifelong. This is normally Penicillin V 250mg twice daily (adult dose). If the patient is allergic to Penicillin V, Erythromycin 500mg twice daily should be given.

2. If the patient is unlikely to comply with lifelong medication, it may be appropriate for them to have a course of antibiotics at home (eg Amoxicillin 3g) for “at risk” situations. This could also be given to all patients to be taken if they begin to feel unwell. Patients taking Erythromycin should be advised to increase this to therapeutic doses if they begin to feel unwell.

3. There is an increased risk of unusual infections following dog bites and in these cases the Penicillin V / Erythromycin should be increased to therapeutic doses.

4. Patients developing infection despite the above measures may need to be admitted as an emergency for intravenous antibiotics.

TRAVEL

1. Patients who have had a splenectomy, or have conditions causing hyposplenism, are at potential risk with overseas travel. Specialist advice may be obtained from infectious disease or tropical disease units.

2. Consider giving the patient a course of antibiotics to take with them on holiday. Patients visiting areas with meningitis should be offered the meningococcal ACWY polyvalent vaccine.

3. The main protozoal infections that cause problems associated with splenectomy are malaria and babeisosis. Patients travelling to regions with malaria should be advised to assiduously follow standard recommendations regarding basic preventative measures, prophylaxis and diagnosis and treatment of suspected malaria. Asplenic patients with malaria may have delayed clearance of parasites from the blood stream despite appropriate treatment. If they feel unwell on returning from holiday they should be advised to inform a health professional that they have been to a malarial area.

4. Babesiosis is a tic borne protozoal disease with similar clinical manifestations to malaria; the disease is rare and confined to a few regions around the world. Treatment for this includes a combination of Clindamycin and quinine.

References

BMJ 2005; 331: 417 - 418 British Journal of Haematology 2011 155 308-17 Journal of Travel Medicine 2003; 10(2): 117 Clinical Microbiology & Infection, 2001; 7(12): 657 Immunisation against Infectious Diseases DOH http://immunisation.dh.gov.uk/category/the-green-book accessed 2011 October 13 Antimicrobial Policy for Adults 2017 19 Page 73

APPENDIX H Antimicrobial doses in renal impairment Adapted from The Renal Drug Handbook (4th edition) [44] Key: CrCl Creatinine Clearance (based on Cockroft and Gault equation) RF Renal function CVVH Continuous venovenous haemofiltration

Doses

Antimicrobials Route Normal renal CrCl CrCL CrCl function 20-50 mL/ 10-20 mL/ <10 mL/ minute minute minute Unless Unless Unless different different range different range stated stated range stated

Aciclovir oral Herpes simplex 25 to 50 ml/ 10 to 25 ml/ 200 mg 200-400 mg minute minute 12 hourly 4 hourly As normal RF 200 mg (five times daily) 6 - 8 hourly

oral Herpes zoster As normal RF 800 mg 400 to 800mg 800 mg 8 -12 hourly 12 hourly 4 hourly (five times daily) Aciclovir i/v 5 to 10 mg/kg 25 to 50ml/ 10-25 ml/ 2.5-5 mg/kg 8 hourly minute minute 24 hourly 5 to 10 mg/kg 5 to 10 mg/kg 12 hourly 24 hourly Amikacin i/v 7.5 mg/kg bd ideal Seek advice Seek advice Seek advice Monitor serum levels body weight Max. 1.5 g /day Amoxicillin oral i/v 500 mg As normal RF As normal RF As normal RF 8 hourly Max 6 g /day Max. 6 g /day 12 g in endocarditis in endocarditis Amphotericin i/v 1 to 3 mg/kg/day As normal RF As normal RF As normal RF (Ambisome) Max 5 mg/kg Unlicensed dose Azithromycin Oral Genital Chlamydia As normal RF As normal RF As normal RF 1 g single dose 33% increase in systemic Other infections exposure- 500 mg daily manufacturer advises use with caution Aztreonam i/v 1 g 30 to 50 ml/ 10 to 30 ml/ First dose 1g 8 hourly min minute to 2g increased in severe As normal RF first dose 1g then infections to 2g 6 to to 2 g 25% of 8 hrly then 50% of appropriate appropriate normal dose normal dose

Anidulafungin i/v 200mg loading dose As normal RF As normal RF As normal RF then 100mg daily Benzylpenicillin i/v 1.2 – 2.4 g As normal RF 1.2g to 2.4g 1.2 g 6 hourly 6 hourly 6 hourly Max. 14.4 g /day Caspofungin i/v 70 mg loading As normal RF As normal RF As normal RF dose then 50 mg daily (70 mg daily if >80 kg) Cefotaxime i/v 1 to 2 g As normal RF 5 to 20 mls/ < 5 ml/minute 8 hourly minute reduce dose by Max 12g in As normal RF 50% 3 to 4 divided doses Ceftriaxone i/v 1 g once daily As normal RF As normal RF As normal RF Max 2 to 4 g daily Max 2 g daily Page 74 Antimicrobial Policy for Adults 2017 19

Antimicrobial doses in renal impairment, continued Key: CrCl Creatinine Clearance (based on Cockroft Goult equation) RF Renal function CVVH Continuous venovenous haemofiltration

Doses

Antimicrobials Route Normal renal CrCl CrCL CrCl function 20-50 mL/ 10-20 mL/ <10 mL/ minute minute minute Unless Unless Unless different different range different range stated stated range stated Cefuroxime i/v 1.5 g As normal RF 750 mg to 1.5g 750 mg to 1.5g 8 hourly 12 hourly once daily Ciprofloxacin i/v 400 mg 30 to 50ml/ 10 to 30 ml/ 200 mg 12 hourly minute minute 12 hourly As normal RF 200 mg to 400mg 12 hourly Oral 500 mg 30 to 50ml/ 10 to 30 ml/ 250 mg 12 hourly minute minute 12 hourly As normal RF 250 mg to 500mg 12 hourly Clarithromycin i/v 500 mg 30 to 50ml/ 10 to 30ml/ 250 - 500 mg oral 12 hourly minute minute 12 hourly As normal RF 250 to 500 mg 12 hourly Clindamycin i/v 600 mg to 1.2 g As normal RF As normal RF May require 6 hourly dose reduction

Oral 150 to 450 mg 6 hourly Co-amoxiclav i/v 1.2 g 30 to 50ml/ 10 to 30ml/ 1.2 g stat then 8 hourly minute minute 1.2 g As normal RF 1.2 g 12 hourly 12 hourly

Oral 625 mg As normal RF As normal RF As normal RF 8 hourly Co-trimoxazole i/v PCP: 120 mg/kg 30 to 50ml/ 15 to 30ml/ <15 ml/minute (in 2-4 divided doses) minute minute 30 mg/kg As normal RF 60 mg /kg 12 hourly 12 hourly for only if 3 days then Haemodialysis 30 mg/kg facilities are 12 hourly available Daptomycin i/v 4 to 6mk/kg once 30 to 50ml/ 10 to 30ml/ 4 to 6mg/kg daily minute minute every 48 hours As normal RF 4-6mg/kg every 48 hours Doxycycline Oral 100 to 200 mg As normal RF As normal RF As normal RF once daily Gentamicin i/v 7 mg/kg Seek advice Seek advice Seek advice Monitor levels Ideal body weight Appendix A Flucloxacillin i/v 1g to 2g As normal RF As normal RF As normal RF 6 hourly Max 4 g daily Fluconazole i/v 400 mg od 50% to 100% 50% to 100% 50% normal normal dose normal dose dose Fusidic acid /sodium Oral Depends on formulation As normal RF As normal RF As normal RF fusidate Antimicrobial Policy for Adults 2017 19 Page 75

Antimicrobial doses in renal impairment, continued

Key: CrCl Creatinine Clearance (based on Cockroft Goult equation) RF Renal function CVVH Continuous venovenous haemofiltration

Doses

Antimicrobials Route Normal renal CrCl CrCL CrCl function 20-50 mL/ 10-20 mL/ <10 mL/ minute minute minute Unless Unless Unless different different different range range stated range stated stated Meropenem i/v 1 g to 2 g 500mg to 2g 500 mg 500 mg to 1g 8 hourly 12 hourly 8 hourly 24 hourly

Metronidazole i/v 500 mg As normal RF As normal RF As normal RF 8 hourly

Nitrofurantoin oral 50 to 100 mg Avoid if Contraindicated Contraindicated 6 hourly creatinine clearance <45ml/minute

Ofloxacin oral 200 to 400 mg daily 200 to 400 mg 200 to 400 mg 100mg to increasing to once daily once daily 200 mg 400 mg once daily 12 hourly Penicillin V oral 500 mg As normal RF As normal RF As normal RF 6 hourly Piperacillin / i/v 4.5 g 40 to 50mls/ 20 to 40ml/ <20ml/minute tazobactam 8 houry minute minute 4.5 g As normal RF 4.5 g 12 hourly 8 hourly Rifampicin i/v 450mg to 1.2g daily in Seek advice Seek advice Seek advice oral 2 to 4 divided doses Teicoplanin i/v Loading dose 30 to 80mls/ 10-30mls/minute Reduce dose 400 mg 12 hourly for minute. Reduce Reduce dose after fourth day 3 doses dose after after fourth day of treatment to then fourth day of of treatment to either one third of 200 to 400 mg once treatment to either one third maintenance dose daily either half of of maintenance every 24 hours or maintenance dose every administer normal dose every 24 hours or maintenance dose 24 hours or administer every 72 hours. administer normal normal maintenance maintenance dose every 72 dose every 48 hours. hours. Temocillin i/v 1 to 2g every 12 hours 30 to 60 ml/ 10 to 30 ml/ 1g every 48 hours minute 1g every minute or 500mg daily 12 hours 1g daily

Tigecycline i/v 1st dose 100 mg As normal RF As normal RF As normal RF then 50 mg 12 hourly Tobramycin i/v 1st dose 2 mg/kg Seek advice Seek advice Seek advice Monitor serum levels then 1.5 mg/kg 12 hourly Page 76 Antimicrobial Policy for Adults 2017 19

APPENDIX I Types of Antimicrobials [11]

ANTIBACTERIALS

Betalactams

Penicillins Cephalosporins Carbapenems Monobactam Amoxicillin Cefalexin Ertapenem Aztreonam Benzylpenicillin Cefotaxime Imipenem Co-amoxiclav Ceftazadime Meropenem Flucloxacillin Ceftriaxone Penicillin V Cefuroxime Piperacillin/tazobactam Temocillin

Macrolides Tetracyclines Quinolones Sulphonamides

Azithromycin Doxycycline Ciprofloxacin Co-trimoxazole Clarithromycin Minocycline Ofloxacin Erythromycin Tigecycline Levofloxacin

Aminoglycosides Glycopeptides Others

Amikacin Teicoplanin Chloramphenicol Rifampicin Gentamicin Vancomycin Clindamycin Sodium fusidate (Fusidic acid) Tobramycin Colomycin (Colistimethate) Tedizolid Daptomycin, Trimethoprim Fosfomycin Linezolid Metronidazole Nitrofurantoin

ANTIFUNGALS Amphotericin (Ambisome®) Miconazole Anidulafungin Nystatin Caspofungin Posaconazole, Fluconazole Terbinafine Itraconazole Voriconazole

ANTIVIRALS Aciclovir Famciclovir Valaciclovir

See BNF for further details and drugs not listed Antimicrobial Policy for Adults 2017 19 Page 77

CONTACT NUMBERS

ROTHERHAM NHS FOUNDATION TRUST BARNSLEY HOSPITAL NHS FOUNDATION TRUST Telephone number 01709 820000 Telephone number 01226 730000

Consultant Medical Microbiologist 7712 Consultant Medical Microbiologist 2749

Associate Specialist 4742 Consultant Medical Microbiologist 4986

Microbiologist on Duty Bleep 280 Microbiologist on Duty Bleep 207

Clinical Scientist 4741 Chief Biomedical Scientist 3044

Microbiology Laboratory 4242 Microbiology Laboratory 2687

Ward Clinical Pharmacist DECT phone Ward Clinical Pharmacist Bleep

Medicines Information Pharmacist 4126 Medicines Information Pharmacist 2857

Pharmacist Antimicrobial Lead 8132 Pharmacist Antimicrobial Lead Bleep 688

Out of hours – contact appropriate on-call staff via Switchboard

Consultant in Communicable Disease Centre (CCDC) 0900 - 1700 Tel: 0114 3211177 1700 - 0900 via switchboard

Authors Professor W Al-Wali, Consultant Microbiologist and Director of Infection Prevention and Control Dr J Rao, Consultant Microbiologist Dr M Asensio, Associate Specialist Microbiologist Dr M Pang, Consultant Microbiologist C Hughes, Microbiology Clinical Scientist S Ahuja, Pharmacist Medicines Evaluation B Campbell, Pharmacist Antimicrobial Lead G Lawson, Pharmacist Antimicrobial Lead

In consultation with all consultants and senior prescribers of both hospitals

J Slater, Graphic Design

Issue date:January 2018 Review date: December 2020 Page 78 Antimicrobial Policy for Adults 2017 19

CONTACTING MICROBIOLOGIST

Before contacting for advice: • Assess the patient • Know the admitting diagnosis • Read the most recent medical and nursing notes • Have appropriate documents available eg Nursing and Medical Records, PAR (Patient at risk), Charts, Allergies, IV fluids, Resuscitation status and communicate using the SBAR Reporting Tool.

SBAR Reporting Tool

Situation • State your name and unit/ward • I am calling about patient’s name and age • The reason I am calling is…

Background • State the admission diagnosis/working diagnosis and date of admission • Relevant medical history including family history; underlying condition/ co morbidities • A brief summary of treatment to date; current antimicrobial therapy and duration; recent antimicrobial use (within the last month if possible) • History of MRSA/ ESBL/ CPE/ C.difficile diarrhoea • Previous microbiology results • Infective markers • Travel history

Assessment State your assessment of the patient • Allergies • Renal function • Hepatic function

Don’t forget to document the call! Antimicrobial Policy for Adults 2017 19 Page 79

Six simple tasks that save lives! WITHIN 1 HOUR: 1. Give high flow oxygen via non rebreathe mask 2. Take blood cultures 3. Give IV antibiotics 4. Start IV resuscitation. Hartmanns or equivalent 5. Check Full Blood Count (FBC) and lactate 6. Monitor hourly Urine Output. May require catheter

The Rotherham NS Foundation Trust Rotherham Hospital Barnsley Hospital Moorgate Road Gawber Road Oakwood Barnsley Rotherham S75 2EP S60 2UD

Telephone 01709 820000 Telephone 01226 730000 www.therotherhamft.nhs.uk www.barnsleyhospital.nhs.uk

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