Empirical Management of Infection on Critical Care Units at AUH and RLUH

LIVERPOOL CLINICAL LABORATORIES

Empirical Management of Infection on Critical Care

Units at AUH and RLUH

Patricia Crossey (Critical Care Pharmacist, RLUH), Alison Hall (ITU Consultant, RLUH), Jenifer Mason (Microbiology Consultant LCL), Robert Parker (ITU Consultant, AUH) and Clare Sales (Critical Care Pharmacist, AUH)

2017

These Guidelines refer to common ITU presentations and relate to empirical management only. For indications not covered refer to the Trust Antibiotic Formulary (Royal and Aintree).

Enquiries to: [email protected] or [email protected]

Contents General Principles ...... 2

Abdominal Infection ...... 3

Non Healthcare associated Intra-abdominal Infection...... 3

Healthcare associated intra-abdominal infection ...... 4

Variceal bleeds and acute liver failure ...... 4

Central Nervous System ...... 5

Meningitis/Encephalitis ...... 5

ENT or Dental Infection ...... 6

Epiglottitis ...... 6

Dental Abscess or other oral infection ...... 6

Respiratory Tract Infection ...... 7

Community acquired pneumonia ...... 7

Hospital Acquired Pneumonia or Ventilator Associated Pneumonia ...... 7

Aspiration Pneumonia ...... 8

Infective Exacerbation of Chronic Lung Disease (COPD, bronchiectasis) ...... 8

Suspected influenza with concurrent pneumonia...... 8

Sepsis of Unknown Origin...... 9

Sepsis of Unknown Origin – Non Neutropenic ...... 9

Neutropenic Sepsis ...... 9

Skin and Soft Tissue Infection ...... 10

Necrotising soft tissue infection of any anatomical site ...... 10

Cellulitis ...... 10

Trauma Prophylaxis ...... 11

Prophylaxis in head and neck trauma ...... 11

Prophylaxis for Compound Fractures ...... 11

Selective Decontamination of the Digestive Tract ...... Error! Bookmark not defined.

Urosepsis ...... 13

Urosepsis/pyelonephritis ...... 13

Appendix ...... 14

Infection Control Precautions ...... 14

Weekly Screening ...... 15

Notifiable Diseases...... 17

Tetanus Prone Wounds ...... 18

Processing Urgent Specimens Out of Hours (Mon-Fri 1630-0900 and Sat-Sun) ...... 19

Gentamicin and Teicoplanin Dosing ...... 21

Gentamicin ...... 21

Teicoplanin ...... 21

Contact Details ...... 21

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 1

General Principles 1. Antibiotic treatment should NEVER be delayed in an emergency. However, wherever possible, microbiological specimens should always be obtained before antibiotic therapy is commenced 2. Prior to antibiotic therapy patients should ALWAYS have TWO sets of blood cultures taken i.e. x2 aerobic and x2 anaerobic bottles. If there are lines present culture from the line AND a peripheral site. Send other specimens as appropriate (respiratory, drain fluid, wound swabs etc.) 3. Always check previous Microbiology results, with particular attention to resistant organisms (see below for common resistance patterns). Note the empirical antibiotic choice may not cover resistant organisms – please discuss with Microbiology if unsure 4. Antibiotics are not a substitute for source control (i.e. surgical drainage of an abscess) 5. Antibiotics should be administered within 1 hour in patients with signs of severe sepsis or septic shock 6. Allergy status must be checked BEFORE prescribing and administering any antibiotic and documented on the patient’s drug chart, including where possible the nature of the allergy 7. An antibiotic history should be taken and recorded in the critical care notes 8. All antibiotic prescriptions should have an indication, start date and review or stop date. 9. These guidelines are for empirical management only. Antibiotics should be focussed at the earliest opportunity on the Microbiology ward round with culture results 10. Do not dose adjust antibiotics in acute kidney injury (including Gentamicin) in the first 24 hours. Following this, and in chronic renal failure seek advice from Pharmacy

Not effective May be effective Effective Methicillin resistant Penicillin, flucloxacillin, Clarithromycin or Teicoplanin, linezolid, Staphylococcus co-amoxiclav, tazocin, clindamycin, daptomycin aureus (MRSA) cephalosporins (except doxycycline, ceftaroline) trimethoprim meropenem Vancomycin or Amoxicillin, Linezolid, tigecycline, glycopeptide resistant teicoplanin, tazocin, daptomycin Enterococci (VRE or cephalosporins, GRE) meropenem, aminoglycosides, fluoroquinolones Extended spectrum Tazocin, co-amoxiclav, Aminoglycosides, Meropenem, beta-lactamase cephalosporins, fluoroquinolones, ertapenem producing Aztreonam tigecycline, temocillin Enterobacteriaceae AND/OR de-repressed AmpCs (ESBL/AmpC) Carbapenemase Tazocin, co-amoxiclav, Fluoroquinolones, Always discuss producing cephalosporins, aminoglycosides, management of Enterobacteriaceae meropenem (in temocillin, high-dose suspected CPE (CPE) isolation) meropenem (in infection with an combination), infection specialist chloramphenicol, tigecycline, colistin

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 2

Abdominal Infection Infection involving ANY intra-abdominal organ (with the exception of Non Healthcare kidney) without any of the following: associated Intra- 1. Infection arising >48 hours after admission abdominal 2. Presence of invasive surgical device at time of presentation (e.g. Infection biliary stent) 3. History of infection or colonisation with multi-drug resistant organism (MRSA, VRE, ESBL, CPE) 4. History of surgery, hospitalisation or dialysis within 12 months of presentation

Investigations  Blood cultures  Intra-operative specimens where appropriate Recommended Amoxicillin 1g QDS IV, Metronidazole 500mg TDS IV & regular Gentamicin IV1 For oesophageal perforation also include Fluconazole 400mg IV Alternative Teicoplanin IV1, regular Gentamicin IV1 & Metronidazole 500mg TDS IV (penicillin allergy) For oesophageal perforation also include Fluconazole 400mg IV Other notes Duration: In most cases 5-7 days will suffice following complete source control. Post- surgery:  No bacterial contamination of operative field or peritoneum: Consider stopping antibiotics (discuss with Microbiology)  Bacterial contamination of operative field or peritoneum: 5-7 days from definitive operative procedure

Antifungals: With the exception of oesophageal perforation, prophylactic antifungals are not recommended in non-neutropenic ITU patients. Pre- emptive antifungals or targeted therapy to be discussed with Microbiology on individual patient basis

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 3

Healthcare Infection involving ANY intra-abdominal organ (with the exception of associated intra- kidney) with at least one of the following: abdominal 1. Infection arising >48 hours after admission infection 2. Presence of invasive device at time of presentation (e.g. biliary stent) 3. History of infection or colonisation with multi-drug resistant organism (MRSA, VRE, ESBL, CPE) 4. History of surgery, hospitalisation or dialysis within 12 months of presentation

For C. difficile treatments refer to Trust C. difficile policy.

Empirical Antibiotics are NOT required in:  Acute-Severe Pancreatitis: Antibiotics are not recommended in the acute phase. In chronic pancreatitis discuss management of all patients with Microbiology.  Bowel ischaemia with no evidence of perforation/peritoneal contamination  Acute gastroenteritis: Antibiotics may be indicated for invasive Salmonella, Shigella or Campylobacter infection – if invasive infection suspected (recent travel, immunocompromised host) discuss with Microbiology Investigations  Blood cultures  Intra-operative specimens where appropriate Recommended Tigecycline 100mg STAT then 50mg BD IV & regular Gentamicin IV1 For oesophageal perforation also include Fluconazole 400mg OD IV Alternative Tigecycline 100mg stat, 50mg BD IV & regular Gentamicin IV1 (penicillin allergy) For oesophageal perforation also include Fluconazole 400mg OD IV Other notes Duration: In most cases 5-7 days will suffice following complete source control. Post-surgery:  No bacterial contamination of operative field or peritoneum: Consider stopping antibiotics (discuss with Microbiology)  Bacterial contamination of operative field or peritoneum: 5-7 days from definitive operative procedure

Tigecycline: Tigecycline is not safe to use in indications other than intra- abdominal infection. If concurrent infection (such as pneumonia) discuss with Microbiology

Variceal bleeds and acute liver failure Investigations Recommended Tazocin 4.5g TDS BD IV

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 4

Alternative Ciprofloxacin 400mg BD IV (penicillin allergy) Other notes Further advice can be sought from Hepatology or Birmingham Transplant Unit

If signs of sepsis: Include regular Gentamicin1

Central Nervous System Meningitis/Encephalitis This is a Notifiable Disease – see appendix Additional infection prevention precautions are required for suspected meningitis – see appendix Investigations  Blood cultures  EDTA blood for meningococcal and pneumococcal PCR  CSF: For MC&S and viral PCR +/- meningococcal and pneumococcal PCR, protein and glucose  Urine pneumococcal antigen  HIV test Recommended Ceftriaxone 2g BD IV AND Acyclovir 10mg/kg IV TDS IV & Dexamethasone IV or PO* If aged over 60 or immunosuppressed: Add Amoxicillin 2g IV every 4 hours

Alternative (penicillin Chloramphenicol 25mg/kg QDS IV + Acyclovir 10mg/kg TDS IV & IV allergy) Dexamethasone IV or PO*

If aged over 60 of immunosuppressed: Add Co- trimoxazole 30mg/kg IV every 6 hours Other notes If recent history of travel please discuss with Microbiology

*Give IV dexamethasone 10mg QDS IV or PO for 4 days preferably prior to or at the same time as the first dose of antibiotics (if administration delayed dexamethasone may be given up to 12 hours after first dose of antibiotic). Note: Dexamethasone vials contain either 3.3mg or 3.8mg of Dexamethasone depending on the supplier. Suggest using either 9.9mg (3x3.3mg vials) or 9.5mg (2.5x3.8mg vials).

Contact Occupation Health and/or Microbiology regarding prophylaxis for staff members exposed to N. meningitidis

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 5

ENT or Dental Infection Epiglottitis Investigations  Throat swab for MC&S  Blood cultures Recommended Ceftriaxone 2g OD IV

Alternative (penicillin Teicoplanin1 + Ciprofloxacin 400mg BD IV allergy) Other notes

Dental Abscess or If necrotising intra-oral or neck infection suspected contact other oral infection Microbiology Investigations  Blood cultures  Intra-operative samples Recommended Amoxicillin 1g QDS IV + Metronidazole 500mg TDS IV

Alternative (penicillin Clarithromycin 500mg BD IV & Metronidazole 500mg TDS IV allergy) Other notes If necrotising intra-oral or neck infection suspected contact Microbiology

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 6

Respiratory Tract Infection Community Onset <48 hours of admission acquired pneumonia Suggested  Blood cultures x 2 Investigations  Respiratory specimen: BAL>T/asp>sputum  Urinary Legionella and pneumococcal antigen  HIV test  Within flu season (approx. October – March) throat swab for viral PCR

Acute and convalescent sera for atypical pathogens is no longer recommended Recommended Benzyl-penicillin 2.4g QDS IV & Clarithromycin 500mg BD PO/IV Alternative (penicillin Teicoplanin IV1 & Clarithromycin 500mg BD PO/IV allergy) Other notes If signs of severe sepsis or septic shock, or the diagnosis of pneumonia is unclear: STAT Gentamicin1

A negative Legionella urinary antigen result does not exclude atypical infection. Continue clarithromycin pending discussion on Microbiology.

Assess response to empirical therapy with a Microbiologist at 48-72 hours. If no response or deterioration consideration should be given to changing antibiotics.

Gram negative, in particular anti-Pseudomonal cover should be included in patients with structural lung disease (bronchiectasis, CF, long term ventilator). If no prior exposure use ciprofloxacin as an alternative to clarithromycin.

Hospital Acquired Pneumonia acquired >48 hours of admission to hospital or ventilated Pneumonia or patients Ventilator Associated Pneumonia Investigations  Blood cultures  Respiratory specimen: BAL>T/asp>sputum Recommended Benzyl-penicillin 2.4g QDS IV & Flucloxacillin 2g QDS IV & Ciprofloxacin 500mg BD PO or 400mg BD IV

If signs of severe sepsis or septic shock: STAT Gentamicin IV1 If MRSA colonised: Teicoplanin1 IV & Ciprofloxacin 500mg BD PO or 400mg BD IV1

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 7

If colonised with CPE: discuss with Microbiology Alternative (penicillin Teicoplanin IV1 & Ciprofloxacin 500mg BD PO or 400mg BD IV allergy) If signs of severe sepsis or septic shock: STAT Gentamicin1 If colonised with a CPE: discuss with Microbiology Other notes Aspiration History compatible with aspiration AND signs or symptoms of pneumonia Pneumonia AND minimum of 48 hours post aspiration event.

Aspiration of gastric contents or pneumonitis alone is not an indication for antibiotics Investigations  Blood cultures  Respiratory samples Recommended Temocillin 2g BD IV & Amoxicillin 1g QDS IV & Metronidazole 500mg TDS IV

Alternative (penicillin Ciprofloxacin 400mg BD IV, Clarithromycin 500mg BD IV & Metronidazole allergy) 500mg TDS IV Other notes

Infective Check previous respiratory samples – patients with chronic lung disease Exacerbation of become colonised with resistant Pseudomonas species. Chronic Lung Disease (COPD, bronchiectasis) Investigations  Blood cultures  Respiratory samples Recommended Benzyl-penicillin 2.4g QDS IV & Ciprofloxacin 500mg BD PO or 400mg BD IV

Alternative (penicillin Teicoplanin1 & Ciprofloxacin 500mg BD PO or 400mg BD IV allergy) Other notes In the case of recent Ciprofloxacin exposure (within the preceding 4-6 weeks): Discuss alternative agent with Microbiology

If signs of severe sepsis or septic shock: STAT Gentamicin1

Suspected Influenza – like illness with clinical features of pneumonia influenza with Additional infection prevention precautions are required for suspected concurrent influenza – see appendix pneumonia Investigations  Blood cultures  Respiratory samples  Throat swab and viral PCR Recommended Benzyl-penicillin 2.4g QDS IV & Clarithromycin 500mg BD PO/IV & Flucloxacillin 2g QDS IV & Oseltamivir 75mg BD PO Alternative (penicillin Teicoplanin IV & Clarithromycin 500mg BD PO/IV & Oseltamivir 75mg BD allergy) PO

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 8

Other notes If signs of severe sepsis or septic shock: STAT Gentamicin1

Sepsis of Unknown Origin Sepsis of Unknown Sepsis with no identifiable source. Review with Microbiology at 48 Origin – Non hours is mandatory. Neutropenic Investigations  Blood cultures (including line cultures if appropriate)  Any other appropriate investigations: Wounds, CSU, CSF, respiratory Recommended Tazocin 4.5g TDS & STAT Gentamicin IV1 Alternative (penicillin Teicoplanin IV1 & Gentamicin IV1 & Metronidazole 500mg TDS IV allergy) Other notes Review at 48 hours with Microbiology is mandatory

Neutropenic Sepsis Investigations  Blood cultures (including line cultures if appropriate)  Any other appropriate investigations: Wounds, CSU, CSF, respiratory Recommended Tazocin 4.5g TDS IV & STAT Gentamicin IV1

If pulmonary focus: Add Clarithromycin 500mg BD PO/IV 1 If MRSA positive or indwelling line: Add Teicoplanin IV If colonised with ESBL or AmpC: Give Meropenem 2g TDS IV If colonised with CPE: Discuss with Microbiology Alternative (penicillin Meropenem 2g TDS IV allergy) – see notes below If pulmonary focus: Add Clarithromycin 500mg BD PO/IV If MRSA positive or indwelling line: Add Teicoplanin IV1 If colonised with ESBL or AmpC: Give Meropenem 2g TDS IV If colonised with CPE: Discuss with Microbiology Severe penicillin allergy i.e. anaphylaxis: Discuss risk/benefit ratio Other notes It is estimated that <1% of patients with penicillin allergy react to carbapenems. In severe penicillin allergy (i.e. anaphylaxis) discuss risks and benefits of carbapenem with Microbiology

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 9

Skin and Soft Tissue Infection Necrotising soft All cases must be referred to Surgical team and discussed with tissue infection of Microbiology urgently any anatomical site This is a Notifiable Disease - see appendix Additional infection prevention precautions are required for suspected invasive Group A streptococcal infections – see appendix Investigations  Blood cultures  Intra-operative specimens (Urgent Gram stain required)  Wound swabs Recommended Meropenem 2g IV TDS & Clindamycin 1.2g QDS IV 8 hours +/- IVIG (discuss with Microbiology)

Alternative (penicillin Meropenem 2g IV TDS & Clindamycin 1.2g QDS IV 8 hours +/- IVIG allergy) 2g/kg (IVIG administration MUST be discussed with Microbiology)

Other notes Surgical debridement is imperative. Refer all patients to the Surgical Team urgently

For details regarding IVIG administration refer to IVIG Policy

Cellulitis Localised cellulitis with no features of necrotising infection Investigations  Blood cultures x2  Skin/wound swab Recommended Flucloxacillin 2g QDS IV

Alternative (penicillin Teicoplanin IV1 & Clindamycin 300 QDS allergy) If high risk of C. difficile: Use Linezolid 600mg BD IV/PO instead of above

Other notes

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 10

Trauma Prophylaxis Prophylaxis in head Prophylaxis is indicated for compound mandibular fractures, soft tissue and neck trauma pre-septal trauma, penetrating orbital injury and pharyngeal- oesophageal injury.

Please refer to “Antimicrobial Guidelines for Head and Neck Surgery” for further information

All wounds should have a tetanus risk assessment – see appendix Investigations Recommended Compound Mandibular Fractures: Chlorhexidine gluconate 0.5% mouthwash BD & Amoxicillin 1g TDS IV & Metronidazole 500mg TDS IV until operation. Soft Tissue pre-septal trauma: IV Flucloxacillin 2g QDS & topical Chloramphenicol 1% ointment TDS Penetrating Orbital Injury: Tazocin 4.5g TDS IV Pharyngeal-oesophageal Injury: Tazocin 4.5g TDS IV (& Teicoplanin IV1 if colonised with MRSA)

Alternative (penicillin Compound Mandibular Fractures: Chlorhexidine gluconate 0.5% allergy) mouthwash BD & Clarithromycin 500mg BD IV & Metronidazole 400mg TDS IV until operation Soft Tissue pre-septal trauma: IV Clarithromycin 500mg BD IV & topical Chloramphenicol 1% ointment TDS Penetrating Orbital Injury: Teicoplanin IV1 & Ciprofloxacin 750mg BD IV & Metronidazole 500mg TDS IV Pharyngeal-oesophageal Injury: Teicoplanin IV1 & Ciprofloxacin 750mg BD IV & Metronidazole 500mg TDS IV

Other notes

Prophylaxis for All wounds should have a tetanus risk assessment – see appendix Compound Fractures Investigations Recommended Co-amoxiclav 1.2g IV (alone) TDS, OR Cefuroxime 1.5g IV every 8 hours plus Metronidazole 500mg IV every 8 hours MRSA colonised: Add Teicoplanin 800mg IV 12 hourly for 3 doses DURATION: 48 hours or 24 hours post closure of wound

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 11

Alternative (penicillin Clindamycin 600mg IV QDS. allergy) Gunshot Injury or very extensive or contaminated wound: Add Ciprofloxacin 400mg IV TDS (or PO 750mg BD) MRSA colonised: Add Teicoplanin 800mg IV BD for 3 doses DURATION: 48 hours or 24 hours post closure of wound Other notes For tetanus guidance see appendix

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 12

Urosepsis Urosepsis/pyelonephritis Sepsis with features in the history or examination that clearly indicate a renal source. If source of infection is unclear treat as sepsis or unknown origin Investigations  Blood cultures  MSU or CSU Recommended Ciprofloxacin 400mg IV BD + STAT Gentamicin IV1 Alternative (penicillin Ciprofloxacin 400mg IV BD + STAT Gentamicin IV1 allergy) Other notes Dipstick has poor positive and negative predictive value and should not be used in isolation to diagnose UTI.

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 13

Appendix

Infection Control Precautions Standard precautions should be used for all patients (hand-washing, personal protective equipment for procedures etc.). Additional precautions required in specific scenarios are outlined below. There are times when side room availability is limited – in this situation a risk assessment should be conducted according to local policy. Additional support available if required from IP&C Teams and Microbiology.

Isolation Isolation Area PPE Required MRSA Yes Isolation room Plastic apron and gloves VRE/GRE Yes (priority if Priority for patients with Plastic apron and gloves diarrhoea diarrhoea and uncontrolled present) leakage of body fluids ESBL or AmpC Yes (priority if Priority for patients with Plastic aprons and gloves diarrhoea diarrhoea and uncontrolled present) leakage of body fluids Clostridium Yes Isolation room Plastic aprons and gloves difficile infection + GDH positive CPE Yes Isolation room Surgical gown and gloves Influenza Yes Isolation room Surgical gown and surgical mask

For aerosol generating procedures use FFP3 mask Suspected or Yes – for Isolation room Plastic aprons and gloves proven invasive minimum 48 Group A hours after For aerosol generating streptococcus commencing procedures including appropriate intubation use FFP3 mask antibiotic(s) Suspected Yes – review at Isolation room Plastic apron and gloves bacterial 48 hours with meningitis Microbiology For aerosol generating results procedures including intubation use FFP3 mask Neutropenic Yes Isolation room Plastic apron and gloves Inter-Hospital Yes Isolation room Plastic apron and gloves Transfer pending screen results

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 14

Weekly Screening Patients on ITU should have a multidrug resistant organism (MDRO) screen (rectal & groin AND nose & throat) for ESBL, AmpC, MRSA, VRE and CPE colonisation on admission and weekly thereafter.

Transfers It is essential that MDRO colonisation status from referring Trust is ascertained prior to transfer. Refer to local policy regarding isolation. In patients transferred from Aintree ITU, Royal ITU or HDU, Liverpool Heart and Chest ITU or Walton Centre Horsley ITU consideration may be given to early removal from side room - discuss with Microbiology or IP&C Team.

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 15

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 16

Notifiable Diseases Treating clinicians have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team (HPT) of suspected cases of certain infectious diseases. Notifiable organisms will be reported by the laboratory.

To inform Cheshire and Merseyside Health Protection Team:

 Mon-Fri 0900-1700: 0344 225 0562 (option 1)  Mon-Fri 1700-0900 or Sat-Sun: Contact the on-call Public Health Doctor via Switch Board at the Royal (0151 706 2000)

The list below gives common notifiable diseases and is not exhaustive. Please see Health Protection England website for complete list.

Notifiable Disease Definition/Comment Likely to be Urgent? Acute encephalitis No Acute meningitis Viral and bacterial Yes, if bacterial meningitis suspected Acute hepatitis Yes Anthrax Suspect in heroin user with severe sepsis, Yes necrotising skin infection or meningitis (especially haemorrhagic meningitis).

Typical skin lesion = Painless ulcer with marked oedema and black eschar Enteric fever (S. typhoid or Fever, constipation, rose spots and recent travel Yes paratyphoid) Food poisoning No – unless associated with a cluster or outbreak Haemolytic uraemic syndrome Triad of acute renal failure, microangiopathic Yes haemolytic anaemia, and non-immune thrombocytopenia following bloody diarrhoea Infectious bloody diarrhoea With or without features of HUS Yes Necrotising fasciitis (likely to be Scarlett Fever or suspected invasive infection Scarlet Fever – no invasive Group A Streptococcus (i.e. bacteraemia, necrotising fasciitis or septic Invasive Group A i.e. in PWID) arthritis) Streptococcal infection – Yes Legionnaires Disease Pneumonia (usually with extra-pulmonary signs Yes such as headache, abdominal pain, renal failure) AND history of exposure (i.e. cooler units, water, air conditioning, travel history) Meningococcal septicaemia Without meningitis for example sepsis with Yes purpuric rash SARS Yes Tetanus Rigidity, muscle spasm and autonomic Only if associated with dysfunction with history of tetanus prone injecting drug use wound or injecting drug use. Tuberculosis Clinical picture in keeping with TB and AFB on No – unless suspected sputum smear cluster, multidrug resistance or healthcare worker

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 17

Tetanus Prone Wounds A tetanus prone wound is any wound or burn that requires a surgical intervention or when treatment is delayed for more than 6 hrs, or wounds with any of the following characteristics:

o significant degree of devitalized tissue, o puncture-type injury (particularly in contact with soil or manure), o wounds containing foreign bodies, compound fractures, o wounds or burns in patients who have systemic sepsis.

High risk wounds are those contaminated with material likely to contact tetanus spores i.e. soil, manure etc.

If the wound or burn fulfils the above criteria and is considered to be high risk then tetanus immunoglobulin should be given for immediate protection irrespective of the tetanus immunization history. For further guidance see table below.

Dose: For prevention: 250IU by intramuscular injection, or 500IU if more than 24 hours have elapsed since injury or there is a risk of heavy contamination or following burns.

Clean Wound Tetanus Prone Wound

Vaccine Vaccine Immunoglobulin

Fully immunised, i.e. None required None required Only if high risk has received a total five doses of vaccine at appropriate intervals OR Protetanus Point of Care test demonstrates immunity Primary A reinforcing dose of A reinforcing dose of Yes: one dose of human immunisation vaccine and further vaccine and further tetanus complete, boosters doses as required to doses as required to immunoglobulin in incomplete but up complete the complete the different site to date recommended recommended schedule schedule (to ensure (to ensure future future immunity) immunity) Not immunised or An immediate dose An immediate dose of Yes: one dose of human immunisation status of vaccine followed, vaccine followed, if tetanus not known or if records confirm records confirm that is immunoglobulin in uncertain that is needed, by needed, by completion different site completion of a full of a full 5 dose course 5-day dose course to to ensure future ensure future immunity immunity

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 18

Processing Urgent Specimens Out of Hours (Mon-Fri 1630-0900 and Sat-Sun) The following specimens will be processed urgently out of hours: CSF, joint aspirates, ascitic fluid, and tissue specimens in suspected necrotising fasciitis. Other specimens may be processed upon request.

For urgent specimens taken out-of hours:

1) Inform the On-call Microbiology Biomedical Scientist at Royal Liverpool University Hospital via Switch board (0151 706 2000) 2) Specimen transport to Laboratory: a. For Royal ITU or HDU: Pod specimen to pod no. 710 b. For Aintree ITU: Take the specimen to Specimen Reception at Aintree (Ground floor of the main corridor, opposite A&E). The BMS will arrange transport to Liverpool Clinical Laboratories 3) The on-call BMS or Microbiologist will ring ITU with the result once processed

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 19

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 20

Gentamicin and Teicoplanin Dosing

Gentamicin  In normal renal function OR acute kidney injury: 5mg/kg STAT max 450mg.  In chronic renal failure: Discuss with Microbiology regarding alternative agents  For regular Gentamicin administration: o Royal: Take level at 8 hours post dose and refer to the Gentamicin dosing calculator +/- seek advice from ITU Pharmacist regarding further dosing. o Aintree: Take a level at 1 hour and 7 hours post dose (if not able to do these take 2 levels approximately 6 hours apart) and refer to the Gentamicin dosing calculator +/- seek advice from ITU Pharmacist regarding further dosing. Further information regarding Gentamicin dosing available on the Trust Intranet.

Teicoplanin

Loading regime

Days 1 – 2 12mg/kg BD (rounded to the nearest 200mg vial)

Days 3 – 4 12mg/kg OD (rounded to the nearest 200mg vial)

Take pre-dose (trough) level on day 4 Day 5 onwards Adjust dose according to renal function (see table 2) and review with levels

Maintenance dose (based on renal function) eGFR > 60ml/min Continue 12mg/kg OD eGFR 30-60ml/min 6mg/kg OD eGFR< 30ml/min 4mg/kg OD or 12mg/kg three times a week

Haemodialysis 12mg/kg three times a week after dialysis

Hemofiltration Load as per normal renal function

Contact Details

Microbiology (from RLUH) Ext. 4410 Microbiology (from AUH) Ext. 4900 Pharmacy at RLUH Ext. 2085 Pharmacy at AUH Ext. 3864

1 For Teicoplanin and Gentamicin Dosing refer to Appendix. Maximum dose of Gentamicin is 450mg/24 hours. Page 21