IMPACT Fifth Edition (version 5.0) Reducing bacterial resistance with IMPACT – Interhospital Multi-disciplinary Programme on Antimicrobial ChemoTherapy 1 IMPACT Fifth Edition (version 5.0) Editors: Pak Leung, HO & Tak Chiu, WU Fifth Edition 2017 Version 5.0 All rights reserved. No part of this publication may be reproduced, stored in a retrieved system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, and recording or otherwise, without the prior approval from IMPACT. We seek to improve the quality of this document. If you have comments or suggestion on this publication, please email to [email protected] NOTICE This publication contains information relating to general principles of medical care, which should not be construed as specific instructions for individual patients. It is important to realise that the content cannot always account for individual variations among patients. They should not supplant clinical judgement or clinical microbiology/infectious diseases consultation when indicated. We have attempted to verify that all information is correct at the time of publication but because of ongoing research, things may change. Readers should consider our recommendation in light of their local resistance and susceptibility patterns, availability of and variations in formulations of antimicrobial agents. Manufacturers' product information, package inserts and peer-reviewed literature should be reviewed for current information, including contraindications, dosages and precautions. This publication should be cited as: PL Ho, TC Wu, David VK Chao, Ivan FN Hung, Leo Lui, David C Lung, Tommy HC Tang, Alan KL Wu (ed). 2017. Reducing bacterial resistance with IMPACT, 5th edition, Hong Kong http://www.chp.gov.hk/files/pdf/reducing_bacterial_resistance_with_impact.pdf 2 IMPACT Fifth Edition (version 5.0) IMPACT Editorial Board Editors Dr. Pak Leung, HO Director Carol Yu Centre for Infection The University of Hong Kong Dr. Tak Chiu, WU Consultant Division of Infectious Diseases Department of Medicine Queen Elizabeth Hospital Associate Editors (in alphabetical order) Dr. David Vai Kiong, CHAO Vice-President (Education and Examinations) Hong Kong College of Family Physicians Prof. Ivan Fan Ngai, HUNG Clinical Professor Department of Medicine The University of Hong Kong Dr. Leo, LUI Associate Consultant Infection Control Branch Centre for Health Protection Department of Health Dr. David Christopher, LUNG Associate Consultant Department of Clinical Pathology Tuen Mun Hospital Dr. Tommy Hing Cheung, TANG Associate Consultant Division of Infectious Diseases Department of Medicine Queen Elizabeth Hospital Dr. Alan Ka Lun, WU Consultant Division of Microbiology Department of Clinical Pathology Pamela Youde Nethersole Eastern Hospital 3 IMPACT Fifth Edition (version 5.0) Members (in alphabetical order) Dr. Kin Sang, CHAN Consultant Department of Medicine Haven of Hope Hospital Dr. Johnny Wai Man, CHAN Chief of Service Department of Medicine Queen Elizabeth Hospital Dr. Wai Ming, CHAN Chief of Service Adult Intensive Care Unit Queen Mary Hospital Dr. Eric Yuk Tat, CHAN Head and Consultant Immunologist Division of Clinical Immunology Department of Pathology Queen Mary Hospital Dr. Kwok Chiu, CHANG Senior Medical and Health Officer Tuberculosis and Chest Service Centre for Health Protection Department of Health Dr. Vincent Chi Chung, CHENG Consultant Microbiologist Queen Mary Hospital and Infection Control Officer Hong Kong West Cluster Dr. James Chung Man, HO Specialist in Respiratory Medicine Clinical Associate Professor Department of Medicine The University of Hong Kong Professor Margaret, IP Professor Department of Microbiology Chinese University of Hong Kong Dr. Wai Man, LAI Chief of Service Department of Microbiology Prince of Wales Hospital Dr. Edman Tin Keung, LAM Senior Medical and Health Officer Infection Control Branch Centre for Health Protection Department of Health Ms. Anna, LEE Chief Pharmacist Hospital Authority 4 IMPACT Fifth Edition (version 5.0) Dr. Chi Chiu, LEUNG Representative Hong Kong Medical Association Dr. Albert Chau Hung, LIT Chief of Service Accident and Emergency Department Princess Margaret Hospital and North Lantau Hospital Dr. Janice Yee Chi, LO Head Public Health Laboratory Services Branch Centre for Health Protection Department of Health Dr. Wei Kwang, LUK Senior Medical Officer Department of Clinical Pathology Tseung Kwan O Hospital Dr. Chi Wai, MAN Representative Coordinating Committee in Surgery Chief of Service Department of Surgery Tuen Mun Hospital and Pok Oi Hospital Dr. Ka Ho, NG Representative Coordinating Committee in Orthopaedics and Traumatology Consultant Department of Orthopaedics and Traumatology Queen Mary Hospital Dr. Tak Lun, QUE Consultant Microbiologist Department of Clinical Pathology Tuen Mun Hospital Dr. Wing Kin, TO Consultant Microbiologist Department of Pathology Princess Margaret Hospital Dr. Dominic Ngai Chong, TSANG Consultant Microbiologist Queen Elizabeth Hospital and Chief Infection Control Officer Hospital Authority Dr. Andrew Tin Yau, WONG Head Infection Control Branch Centre for Health Protection Department of Health 5 IMPACT Fifth Edition (version 5.0) Ms. Linda, WOO Assistant Director (Drug) Drug Office Department of Health Dr. Adrian Young Yuen, WU Specialist in Immunology and Allergy Dr. Wing Wa, YAN Chairman Coordinating Committee in Intensive Care Chief of Service Intensive Care Unit Pamela Youde Nethersole Eastern Hospital Professor Kwok Yung, YUEN Chair of Infectious Diseases Department of Microbiology The University of Hong Kong Dr. Raymond Wai Hung, YUNG Representative, Hong Kong Private Hospitals Association Specialist in Clinical Microbiology and Infection Honorary Consultant, Hong Kong Sanatorium & Hospital Secretary Dr. Ka Man, AU Senior Medical and Health Officer Infection Control Branch Centre for Health Protection Department of Health 6 IMPACT Fifth Edition (version 5.0) Contents List of tables 10 List of figures 13 Foreword 14 Preface 17 Part I Antibiotic resistance - Local scenario 19 1.1 Background: the problem of antimicrobial 20 resistance (AMR) in Hong Kong (HK) 1.2 Methicillin-resistant Staphylococcus 25 aureus (MRSA) 1.3 Vancomycin-resistant enterococci (VRE) 28 1.4 ESBL-producing Enterobacteriaceae 30 1.5 Carbapenem-resistant Enterobacteriaceae 32 (CRE) 1.6 Carbapenem-resistant Acinetobacter 36 baumannii (CRAB) 1.7 Macrolide Resistant Mycoplasma 37 pneumoniae (MRMP) Part II Antimicrobial stewardship programme 41 2.1 Antimicrobial stewardship programme (ASP) 42 2.2 Tips on safe use of antibiotics in outpatient 44 setting Part III Guidelines for selected antimicrobial use 47 3.1 Vancomycin 48 3.2 Linezolid 51 3.3 Daptomycin 52 3.4 Tigecycline 53 7 IMPACT Fifth Edition (version 5.0) 3.5 Colistin/colomycin 54 3.6 Fosfomycin trometamol 55 3.7 Carbapenems 56 3.8 Once daily aminoglycosides 58 3.9 Ceftaroline 59 3.10 Antifungal agents 60 Part IV Recommendation for the empirical 68 therapy of common infections 4.1 Guidelines for empirical therapy 70 Musculoskeletal infections 70t Skin and soft tissue infections 73t Central nervous system infections 76t Intra-abdominal and gastrointestinal system 77t infections (community-acquired) Cardiovascular infections 80t Gynaecological infections 81t Head and neck infections 81t Urinary tract infections 82t Respiratory tract infections 83t 4.2 Guidelines on the use and choice of 89 antibiotics in severe acute pancreatitis (SAP) 4.3 Management of community-acquired 92 pneumonia (CAP) Part V Guidelines for known-pathogen therapy 98 Acinetobacter baumannii 99t Clostridium difficile 99t Enterobacter cloacae complex 100t E. coli (ESBL-neg) 101t Haemophilus influenzae 101t Klebsiella pneumoniae (ESBL-neg) 102t E . coli/K. pneumoniae ( ESBL-pos) 102t Pseudomonas aeruginosa 103t Methicillin-sensitive S. aureus 103t Methicillin-resistant S. aureus 104t M ycoplasma pneumoniae 104t Stenotrophomonas maltophilia 105t 8 IMPACT Fifth Edition (version 5.0) Streptococcus pneumoniae (for infection 105t outside the central nervous system) Streptococcus pneumoniae (for central 106t nervous system infection) Part VI Guidelines for surgical prophylaxis 107 PaPart VII Cost and recommended dosage of 117 commonly-used antimicrobial agents Part VIII Other issues 128 8.1 Management of penicillin allergy 129 8.2 Tips on laboratory diagnostic tests 137 8.3 Tuberculosis (TB) 141 Abbreviations 144 References 146 Index 186 9 IMPACT Fifth Edition (version 5.0) Lis t of tables Table 1.1 Top eight organisms isolated from different 21 clinical specimens in 2016. Data from a regional hospital in HK Table 1.2 Intrinsic and associated resistance to 22 antimicrobial agents among five nosocomial pathogens Table 1.3 Resistance of common bacterial isolates from 23 all specimens in four regional hospitals (Kowloon, Hong Kong Island and the New Territories) in 2015 Table 1.4 Estimates of microorganisms significantly 24 associated with AMR, HK, 2013–2016 Table 1.5 Interpretation of vancomycin susceptibility 26 for staphylococci Table 1.6 Characteristics of vancomycin-resistant 29 E. faecium CC17 Table 1.7 Characteristics of ESBL and AmpC 32 ß-lactamases Table 1.8 Different classes of carbapenemase 35 Table 2.1 Methods to implement ASP in hospital 43 setting Table 2.2 Core elements of outpatient ASP 46 Table 3.1 Dosage table for vancomycin using 50 creatinine clearance Table 3.2 Mechanisms of antifungal action 60 Table 3.3 General patterns of antifungal susceptibility 61 Table 3.4 Comparison of selected pharmacokinetic 62 parameters