Alternative Antibiotic Options for Potential Shortage of IV Co-trimoxazole - no shortage of oral co-trimoxazole

Indication for IV Cotrimoxaxole Alternative if no IV Co-trimoxazole available Guidance Follow IVOST guidance and step down to oral co-trimoxazole if possible. Complicated UTI/Pyelonephritis/Urosepsis Hospital Antibiotic Adult UTI in patients with pencillin allergy If IV required – use gentamicin alone (if MRSA risk add Vancomycin). Monitor patient (co-prescribed with IV gentamicin) closely (especially RF) and if deterioration or no improvement seek advice.

Vancomycin/Gentamicin/Metronidazole (Replace gentamicin with aztreonam if patient not suitable for gentamicin and has Severe HAP penicillin allergy but without history of anaphylaxis or angioedema, otherwise replace Hospital Acquired Pneumonia in penicillin allergy and no renal impairment with ciprofloxacin: refer to Fluoroquinolones Warnings document)

Step down to oral co-trimoxazole + metronidazole Use oral co-trimoxazole if oral route available. Antibiotic treatment and Antibiotic prophylaxis for variceal bleeding in prophylaxis of spontaneous patients with liver cirrhosis Use IV piperacillin/tazobactam if no oral route but step down to oral co-trimoxazole as bacterial peritonitis soon as oral route is available.

Opportunistic Infections Treatment of Pneumocystis Pneumonia (PCP) Follow guidance for alternative options

Aspiration pneumonia or early post-op As per severe option for penicillin allergy: ICU Infection Management pneumonia (non-severe) in penicillin allergy IV vancomycin/gentamicin/metronidazole Guidance **Co-trimoxazole can be used for non-severe Follow alternative guidance on ICU policy or discuss with Microbiology intra-abdominal infections, HAP, UTI**

Stenotrophomonas maltophilia infection - severe Check sensitivities and seek Microbiology advice if required Adult CF Antibiotic guidance symptoms or no oral route available

Alternative Antibiotic Options for Potential Shortage of IV Co-trimoxazole - no shortage of oral co-trimoxazole

Prophylaxis Guidance Indication for IV Cotrimoxaxole Alternative if no IV Co-trimoxazole available

Open fracture – anaerobic cover required – use clindamycin + aztreonam

Arthroplasty, Open Fracture, Open surgery for Antibiotic prophylaxis in All other indications – vancomycin + aztreonam or teicoplanin + aztreonam Closed Fracture, Hip Fracture, Spinal Surgery with orthopaedic surgery Implant in penicillin allergy Use aztreonam if pencillin allergy without history of anaphylaxis or angioedema, other wise use ciprofloxacin. Use aztreonam or temocillin Antibiotic prophylaxis in For some procedures where eGFR 15-30ml/min Use aztreonam if pencillin allergy without history of anaphylaxis or angioedema, other radiological procedures PLUS severe penicillin allergy wise use ciprofloxacin.

Dosing for Surgical Prophylaxis:

Teicoplanin: Approved by AMG: June 2014  <65kg 400mg 65kg 800mg Updated: Feb 2019  No need for redosing if long procedure. Give half original dose if >1.5l blood loss in first hour of operation Review: Feb 2022 Aztreonam:  2g (even in renal impairment as per dosing for treatment of infections)  If being used for penicillin allergy but not renal impairment redose 2g if procedure >4 hours or >1.5l blood loss  In orthopaedics, where 24 hours of prophylaxis is given, 2g doses should be repeated at 8 hours and 16 hours post induction  If being used for penicillin allergy and renal impairment redose 1g if procedure >4 hours or >1.5l blood loss Clindamycin:  600mg infusion over 20mins  Redose 600mg if procedure >4 hours and repeat again if >8 hours  If >1500ml blood loss give additional 300mg after fluid replacement Temocillin:  2g (even in renal impairment as per dosing for treatment of infections)