Adult Antibiotic Policy: List of Contents

LIST OF CONTENTS
GENERAL NOTES 14-3

ALERT ANTIBIOTICS:
Guidelines for optimising use of key antimicrobials 14-4
Ciprofloxacin
Ceftazidime
Piperacillin + Tazobactam
Ceftriaxone
Meropenem
Linezolid
Vancomycin
ADULT ANTIBIOTIC POLICY Teicoplanin
Levofloxacin
Voriconazole
Valganciclovir
Ertapenem
Caspofungin
AMPHOTERICIN INTRAVENOUS PREPARATIONS 14-8
Indications for AmBisome therapy 14-9
BACTERIAL, FUNGAL AND VIRAL INFECTIONS 14-11
Respiratory tract 14-11
For use in Ear, nose and throat 14-12
Urinary tract 14-12
NHS TAYSIDE HOSPITALS Genital tract 14-12
Gastrointestinal 14-13
Central nervous system 14-14
Septicaemia & endocarditis 14-15
Skin and tissue and bone 14-16
Eye 14-18
MRSA infections 14-19
ANTIBIOTIC PROPHYLAXIS 14-20
In general surgery, amputation surgery, patients with CSF leak 14-20
In gastrointestinal endoscopy, variceal bleeding, SBP in ascites 14-21
In meningococcal infection 14-22
In Haemophilus influenzae type B infection 14-23
Prevention of infective endocarditis 14-24
In dental procedure under general anaesthetic 14-24
In dental procedure under local or no anaesthesia 14-24
ANTIBIOTIC DRUG DOSAGES 14-25
IMMUNISATIONS includes prevention of infection in splenectomised patients 14-29
CURRENT ANTIBIOTIC POLICIES 14-31
Sepsis protocol 14-33
Gentamicin once a day 14-34
Guidelines on vancomycin intravenous therapy 14-36
Treatment of recurrent Clostridium difficile diarrhoea 14-37
Revised June 2005 Haematology Sepsis Protocol 14-39
Haematology Fungal Policy 14-40
By the Antibiotic prophylaxis in Major Gynaecological Surgery 14-46
ASD Anti-infectives Sub-committee Pelvic Inflammatory Disease 14-48
Review June 2006 Tayside Critical Care pathway for the management of community-acquired pneumonia 14-50
Early management of suspected bacterial meningitis and meningococcal septicaemia in adults 14-51
MRSA Treatment Protocol 14-52
Updated June 2005 14-1 Uncontrolled when printed Updated June 2005 14-2 Uncontrolled when printed
ALERT ANTIBIOTICS
GUIDELINES FOR OPTIMISING USE OF
GENERAL NOTES KEY ANTIMICROBIALS
Hospitals everywhere face a problem of crisis proportions as a result of an unprecedented increase in the rate and
This policy is designed to advise the non-specialist on the most appropriate drug for the initial treatment of spread of antimicrobial drug resistance currently reported. This has arisen against a background of increased
common infections. It does not include advice on other aspects of management. Recommended adult drug prescribing coupled with escalating costs of antibiotic therapy which can account for up to one-quarter of the
dosages (but not always lengths of treatment) have been included in this section but often this will depend upon hospital’s drug bill, a proportion which still appears to be on the increase. Approximately one-third of hospital
clinical judgement of the individual case. in-patients receive antibiotics at some time during their stay: about 70% for treatment of infection and 30% for
Where possible antibiotics should be administered by the oral route unless the drug of choice is not available in prophylaxis. However, as many as half of all antibiotic courses may in fact be superfluous.
oral dosage form or the oral route is otherwise compromised. While the latter may be the case in the treatment
NHS Tayside
of acute infections, it is frequently possible to switch to suitable oral therapy soon after the regular
Pharmacy drug utilisation reports confirm the escalating cost of antibiotic prescribing within NHS Tayside.
review of the individual case is strongly encouraged. For criteria for IV to oral switch, see Sepsis Protocol
Coincidentally, various audits have highlighted inefficiencies in antibiotic use including poor documentation,
(p14-33).
irrational surgical prophylaxis, inappropriate aminoglycoside prescribing and unnecessary delay in switching from
NB If there is no response to initial treatment or if the infection recurs, specialist advice must be sought. intravenous to oral therapy. Improvements in these areas alone are likely to translate into better quality of care and
This policy does not cover the treatment of infections in neonates and children. ultimately lead to an overall reduction in cost.
Guidelines and Policies in the U.K.
A survey by the British Society for Antimicrobial Therapy of over 400 UK hospitals found that over 60% have
antibiotic guidelines in place and 75% operate an Antibiotic Formulary, though there is wide variation in scope and
methods of implementation. One way of dealing with overuse of expensive injectables, successfully employed in
some hospitals, is through introduction of an automatic stop order on prescriptions for these drugs or to permit
prescription only with the approval of the Consultant in charge of the case or on the authority of the Microbiologist or
ID physician. Of the hospitals surveyed, about one quarter operated an automatic stop order while nearly three
quarters had a restricted list requiring sanction by a senior/specialist member of staff.
Aims of Guidelines
In a pivotal US consensus statement outlining “Strategies to Prevent and Control the Emergence and Spread of
Antimicrobial-Resistant Micro-organisms in Hospitals” one major strategic goal was to “define guidelines for use
of key antibiotics”, injectables (“Alert” antibiotics) targeted in these guidelines are ciprofloxacin, ceftazidime,
cefotaxime, ceftriaxone, vancomycin (or teicoplanin), imipenem, levofloxacin, meropenem, moxifloxacin,
Tazocin, linezolid (oral/IV), voriconazole, caspofungin, valganciclovir, ertapenem and newer preparations of
amphotericin.
Collectively, these are among the drugs most frequently prescribed irrationally which is largely responsible for the
current escalation of antibiotic costs. They also account for a significant proportion of serious antibiotic toxicity
including Clostridium difficile diarrhoea and CNS toxicity/seizures as well as the emergence of major antimicrobial
resistance. Safer, cheaper and equally effective alternatives are often available which allow such agents to be kept
in reserve for occasions when there are clear cut microbiological indications. It is critical, therefore, that Alert
antibiotics be prescribed only on the recommendation of senior medical staff or after discussion with the on-call
Microbiologist or ID physician.
Alert antibiotics and their agreed indications appear in the following text
• Alert antibiotics and their indications have been agreed by the Hospital Anti-infectives Sub-committee on behalf
of NHS Tayside Drug and Therapeutics Committee.
• They will be identified on the medicine chart during daily ward rounds by the Clinical Pharmacist.
• If prescribed outwith the Guidelines, the attending clinician will be alerted and advised to discuss continued use
with the on-call ID physician or microbiologist.
• The role of the pharmacist, microbiologist and ID physician is purely advisory.
• The use of Alert antibiotics will be subject to regular audit and information feedback
Standards for Antibiotic Prescribing
These have now been produced by the Scottish Infection Standards and Strategy Group (SISS). They are available
on the Royal College of Physicians Edinburgh website under SISS at
http://www.rcpe.ac.uk/education/clinical_standards/siss/standards.html
Updated June 2005 14-3 Uncontrolled when printed Updated June 2005 Uncontrolled when printed
14-4
MEROPENEM
ALERT ANTIBIOTICS AND THEIR INDICATIONS The carbapenem of choice. Unlike imipenem it has not been associated with CNS toxicity. Also, it is administered by
convenient IV bolus injection.
CIPROFLOXACIN, INTRAVENOUS Meropenem is regarded as very much a third line agent and is reserved for:
Oral ciprofloxacin is well absorbed and this is therefore the preferred route of administration. Intravenous therapy • serious infections due to multiple resistant strains (e.g. extended spectrum beta-lactamase producers)
is only indicated in the following situations: • empiric use in the seriously ill patient in either ITU or Haematology
• When the patient is unable to swallow or the oral route is otherwise compromised • the treatment of infective exacerbations in CF
• In serious sepsis (e.g. nosocomial pneumonia in ITU) when the recommended dose is 400mg 8-hurly. • severe acute narcotising pancreatitis
• outside these clinical settings it should only be used after consultation with a Microbiologist or ID physician.
Indications for ciprofloxacin in the Antibiotic Policy, either alone or in combination, are as follows:
• second line therapy in exacerbation of chronic bronchitis Note that the Acute Services Division Anti-infectives Sub-committee recommends use at a more frequent dosing
• pyelonephritis interval than that listed in the BNF. They believe that optimum plasma concentrations are more reliably maintained
• acute inflammatory infective diarrhoeas with 6-hourly dosing.
• serious infected diabetic ulcers ERTAPENEM
• infected burn wounds with coliforms or Pseudomonas infection present • Ertapenem can only be prescribed on recommendation of an ID Specialist or microbiologist.
• treatment of documented or presumed gram-ve bacilli resistant to penicillins or cephalosporins or when the • Only indicated for outpatient or home IV therapy.
patient is allergic (history of anaphylactic reaction or rash) to these agents LINEZOLID (IV AND ORAL FORMS)
• selected haematology patients requiring prophylaxis Linezolid should only be prescribed after consulting an ID specialist or microbiologist and a mandatory order
• severe acute pelvic inflammatory disease (see protocol in this section) form completed.
Note: quinolones are the only oral agents with activity against Pseudomonas aeruginosa. • Restricted indications including infections due to proven glycopeptide-insensitive Staphylococcus aureus or
vancomycin-resistant enterococcus (currently uncommon).
CEFTAZIDIME • To enable IV/oral switch from IV vancomycin (used for MRSA or MRSE) to oral linezolid (when patient discharge
Limited use only. Main indication is documented or suspected Pseudomonas aeruginosa infection. Other is possible and continuation treatment using combination rifampicin/trimethoprim is inappropriate).
indications currently listed in the Antibiotic Policy are as follows: • May be an option in surgical site infections (e.g. large bowel surgery, vascular surgery, etc).
• second line agent in neutropenic patients with septicaemia or pneumonia • Poor IV access and a glycopeptide is indicated.
• empiric therapy of CAPD associated peritonitis (not children), 1g IV stat then 125mg/litre in each bag • Use in out-patient home parenteral antibiotic therapy for skin and soft tissue infections as an alternative to IV
• empiric therapy of post operative, post traumatic or shunt associated meningitis teicoplanin.
• empiric therapy of infective exacerbation of cystic fibrosis • Rare cases of (proven) hypersensitivity/allergy to the glycopeptides.
VANCOMYCIN
PIPERACILLIN + TAZOBACTAM (Tazocin®) Vancomycin is the drug of choice for in-patient treatment of the following infections.
Currently listed in the antibiotic Policy for the following: • Serious (e.g. bacteraemia, osteomyelitis) coagulase negative staphylococcal and MRSA infections and penicillin
• pneumonia or septicaemia in neutropenic patients (+ gentamicin) resistant enterococcal infections.
• as a single agent (or in combination with gentamicin) for treatment of sepsis which has not responded to first- • Empiric therapy in febrile neutropenic patients not responding to first line therapy
line treatment or if it is not appropriate for gentamicin to be added to first-line therapy • CAPD associated peritonitis
• Prosthetic valve endocarditis
CEFTRIAXONE Monitoring
IV Ceftriaxone has replaced cefotaxime as the drug of choice in all patients. It is currently listed in the Antibiotic Revised guidelines on the monitoring of vancomycin (trough levels only) have been issued (see vancomycin protocol).
Policy for the following:
• epiglottitis TEICOPLANIN
Teicoplanin is a suitable alternative to vancomycin only for:
• brain abscess
• patients receiving out-patient/home parenteral therapy with glycopeptides
• bacterial meningitis
• inability to tolerate vancomycin
• pyelonephritis in children
• oncology/haematology patients
• empiric therapy of septicaemia in children
• rare cases of vancomycin resistant and teicoplanin sensitive strains
• in ascites for treatment of sub-acute bacterial peritonitis
Monitoring
• skin and soft tissue infections managed via out-patients or the home IV antibiotic programme
Teicoplanin level monitoring is available in special cases after discussion with the microbiologists/ID physicians.
• acute septic monoarthritis if penicillin allergic
• spontaneous bacterial peritonitis
LEVOFLOXACIN (IV ONLY) ANTIVIRAL TREATMENTS FOR HEPATITIS B and C
• Severe community acquired or hospital acquired pneumonia in penicillin allergic patients These are only to be prescribed by a hospital specialist. The following are approved for use:
• Strictly 2nd line in accordance with BTS guidelines (ie plus benzylpenicillin) for severe pneumonia in hospitalised
patients Hepatitis B
• Severe community acquired pneumonia associated with travel abroad • Adefovir
• Lamivudine
MOXIFLOXACIN (ORAL ONLY) • Pegylated interferon
• Step down from IV levofloxacin in severe CAP / Hospital Acquired Pneumonia in penicillin allergic patients
Hepatitis C
VORICONAZOLE • Pegylated interferon
• Voriconazole can only be prescribed on recommendation of an ID Specialist or microbiologist • Ribavirin
• For treatment of fluconazole resistant serious invasive candida infections
• Haematology patients with possible intracerebral invasive fungal infection
• Invasive fungal infections in haematology patients where oral step down is appropriate
CASPOFUNGIN
• For treatment of fluconazole resistant invasive candidiasis as an alternative to amphotericin on recommendation
of an ID Specialist or microbiologist
• Empirical treatment of sepsis in haematology patients after 96 hours of treatment with antibacterial therapy and
continuing fever. If prescribed prior to 96 hours it must be discussed with ID specialist or microbiologist
VALGANCICLOVIR
• Valganciclovir can only be prescribed on recommendation of an ID Specialist or microbiologist
• Oral prodrug of ganciclovir licensed for treatment of CMV retinitis in HIV patients and CMV in solid organ
transplant patients
ANTIVIRAL TREATMENTS FOR HIV INFECTION

These are only to be prescribed by HIV specialists in hospital. The following are approved for use:
Non-nucleoside reverse transcriptase inhibitors
• Nevirapine
• Efavirenz
Nucleotide reverse transcriptase inhibitor
• Tenofovir
Nucleoside reverse transcriptase inhibitors
• Zidovudine • Didanosine
• Lamivudine • Combivir® (zidovudine/lamivudine)
• Abacavir • Kirexa® (abacavir/lamivudine)
• Stavudine
Protease inhibitors
• Kaletra® (lopinavir/ritonavir) • Fosamprenavir
• Indinavir • Saquinavir
• Nelfinavir • Atazanavir
Fusion inhibitor
• Enfuvirtide
AMPHOTERICIN INTRAVENOUS PREPARATIONS INDICATIONS FOR AMBISOME THERAPY
Although not included in the Adult or Paediatric Antibiotic Policies, amphotericin remains a first line treatment in severe 1. Where conventional amphotericin has failed
systemic and deep invasive fungal infections, despite concerns over toxicity. It is available in various forms.
• Proven severe systemic or deep mycoses unresponsive within 48 hours to initial therapy with conventional
amphotericin. Note that empiric use of amphotericin in febrile neutropenic patients despite initial antibacterial
Conventional amphotericin (Fungizone IV) therapy may also be warranted.
Usual dose range: 1.0-1.5mg/kg administered once daily by 6 hour IV infusion in glucose 5% (pH>4.2) – special buffer
added if required. The dry powder vial is first reconstituted with 10ml water for injections then diluted to final 2. Where there is concern over the toxicity of conventional amphotericin
concentration 0.1mg/ml in glucose solution. • Existing renal impairment (e.g. creatinine clearance <30ml/min:) OR creatinine clearance decreased to
<30ml/min on conventional amphotericin therapy OR serum creatinine increased by 100% on conventional
Recent evidence indicates that conventional amphotericin (which is a fraction of the cost of the newer liposomal form ie amphotericin therapy OR myeloma patients OR concurrent essential nephrotoxic drugs are being administered.
£4 versus £114) is safer and as effective when administered over 24 hours continuous intravenous infusion. Used in Clearance can be estimated from serum creatinine as follows:
this way it is less nephrotoxic and much less likely to cause acute hypersensitivity reactions (fevers, chills, etc.) 24 hour Creatinine clearance = (140-Age) x Body weight (kg) x 1.23 (Males)
continuous IV infusion of conventional amphotericin is currently unlicensed. Ref: BMJ 2001;322:1-6 (ml/minute) Serum creatinine (micromol/litre)
Dosage is limited by potentially severe nephrotoxicity, associated with reduced renal perfusion, reduced GFR,
• There is no evidence that newer forms of amphotericin are less likely to be associated with other signs of
presence of casts in urine, hypokalaemia, hypomagnesaemia, renal tubular acidosis and nephrocalcinosis.
toxicity including abnormal LFTs (elevated alkaline phosphatase and bilirubin), arrhythmias and convulsions.
Note that a salt loading regimen may reduce the incidence of nephrotoxicity induced by conventional amphotericin.
Local injection site reactions, fever, chills, rigors, headaches, nausea/vomiting and muscle and joint pain are,
This is achieved by administering 1 litre sodium chloride 0.9% IV over 1-2 hours (according to age and clinical status)
however, relatively common with conventional amphotericin.
prior to each dose of amphotericin. Monitor serum K+ and provide potassium supplements as required.
3. Recurring infection in which conventional amphotericin previously failed or clinically relevant nephrotoxicity
Newer preparations of amphotericin resulted or other severe reaction to conventional amphotericin.
New physico-chemical forms of amphotericin have been developed which more selectively target sterol binding sites in • Prescribe only at request of Consultant in charge of the case and following discussions with ID specialist and/or
the fungal cell membrane and bind less to renal tissues. While these are undoubtedly safer and better tolerated in the Consultant Microbiologist. If in doubt about potential nephrotoxicity, seek advice from Renal Physician about the
relatively high dosages used, there is little evidence that they are consistently more effective than conventional need for newer forms of amphotericin.
amphotericin. Further, their pharmacokinetic characteristics differ considerably and any influence this might have on
clinical efficacy is, as yet, unclear.
Newer amphotericin preparations are, on the other hand, very expensive. Treatment for a 70kg adult costs between
£225 and £450/day depending upon which preparation is used compared to only £8/day with conventional IV therapy.
Not surprisingly, therefore, their selective use is warranted.
The new preparation of amphotericin in current use is:

Amphotericin Liposomal (AmBisome) –
Amphotericin/phospholipid microsphere carrier system
Usual dose range: up to 3.0mg/kg administered once daily; 30-60 min: IV infusion in glucose 5%. Higher doses may
be required in proven fungal infections. Seek advice from Microbiology. Preferably reconstitution by the Centralised IV
Additive (CIVA) Pharmacy service. Maximum final concentration 2mg/ml.
14-9
Updated June 2005 Updated June 2005 14-10 Uncontrolled when printed
Uncontrolled when printed
BACTERIAL, FUNGAL AND VIRAL INFECTIONS
Clinical conditions Pathogen(s) Antibiotic(s) Comments
Respiratory Tract Infections
Exacerbation of chronic Haemophilus influenzae 1st line - Amoxicillin Ignore antibiotic therapy administered in the community. Use macrolide
bronchitis Strep. Pneumoniae 2nd line - Co-amoxiclav if allergic to penicillins. Ciprofloxacin is 2nd line therapy to macrolide.
Moraxella catarrhalis Discontinue oral theophylline if ciprofloxacin or macrolide is used.
Mild-moderate community Strep. pneumoniae Amoxicillin + Combination of amoxicillin + clarithromycin is preferred if IV therapy is
acquired pneumonia* Haemophilus influenzae erythromycin (clarithromycin is considered necessary.
Mycoplasma pneumoniae an alternative if GI upset with See Pneumonia pathway page 14-50
Legionella pneumophila erythromycin)
Staph. aureus
Influenza virus
Severe community acquired As above, but include cover for IV co-amoxiclav (or Levofloxacin IV if penicillin allergic. Change to moxifloxacin when oral
pneumonia* coliforms IV cefuroxime) + IV route available.
clarithromycin Add flucloxacillin if post-influenza pneumonia suspected.
See Pneumonia pathway page 14-50. Seek specialist advice if not
responding
Pneumonia caused by Mycoplasma pneumoniae Erythromycin Add levofloxacin if Legionella suspected. Doxycycline can be used for
14-11
atypical organisms Legionella pneumophila Mycoplasma pneumoniae.

Chlamydia pneumoniae
Coxiella burnettii
Aspiration pneumonia Oral anaerobes Co-amoxiclav
Streptococci
Neutropenia-associated Coliforms IV piperacillin/ Seek specialist advice if no response.
pneumonia Staphylococci tazobactam (Tazocin)
Pseudomonas + IV gentamicin
Post-operative pneumonia Strep. pneumoniae Amoxicillin
- short stay in hospital,
no recent antibiotics
Post-operative pneumonia Strep. pneumoniae Co-amoxiclav Add IV gentamicin if severe sepsis.
- long stay in hospital, Haemophilus influenzae
recent antibiotics or hospital Coliforms
acquired pneumonia Staphylococci
*Ref: British Thoracic Society Guidelines Management of Adult Community Acquired Pneumonia. Thorax 2001:56;suppl.IV.
Ear, Nose & Throat Infections

Tonsillitis Virus (75%) Nil Treat for 10 days to prevent sequelae. A 5 day course of erythromycin
Strep.pyogenes Penicillin V is recommended if allergic to penicillins. Avoid amoxicillin or ampicillin.
Epiglottitis Haemophilus influenzae High dose IV ceftriaxone Maintain adequate airway,
Acute otitis media Strep. pneumoniae Amoxicillin

Haemophilus influenzae
Acute sinusitis Strep. pneumoniae Penicillin V
Chronic sinusitis As for acute sinusitis plus Co-amoxiclav

anaerobes
Staph, aureus
Oral thrush
(a) immunocompromised (a) Candida albicans (a) Fluconazole Change to itraconazole if intolerant of fluconazole or fluconazole is
(b) other patients (b) Candida albicans (b) Topical nystatin otherwise contraindicated.
14-12
Urinary Tract Infections

Uncomplicated cystitis E.coli Trimethoprim or Treat for 3 days only. Consider specialist referral for recurrent infection.
Staph. Saprophyticus nitrofurantoin
Pyelonephritis E.coli, but also Ciprofloxacin po (or Subsequent treatment in line with culture. Treat for 7 days.
Proteus spp IV co-amoxiclav +/- IV
Klebsiella spp gentamicin
Asymptomatic bacteriuria E.coli Cefalexin Treat only pregnant patients. Do not treat catheterised patients.
(pregnant patients) Coliforms (nitrofurantoin is 2nd line)
Genital Tract Infections

Vaginal thrush Candida albicans Clotrimazole pessary or if
systemic treatment if planned,
use oral fluconazole
Bacterial vaginosis* Gardnerella vaginalis Metronidazole Clindamycin 2% cream also available
Updated June 2005 Uncontrolled when printed

Trichomoniasis* Trichomonas vaginalis Metronidazole Refer patient and partner to GUM Clinic.
Pelvic inflammatory Anaerobes See protocol in this section Refer to GUM Clinic if STD suspected
disease/pelvic sepsis* Chlamydia trachomatis
Gonococcus
Others
Urethritis Neisseria gonorrhoeae Refer to GUM Clinic.
Chlamydia trachomatis
*Acute prostatitis Neisseria gonorrhoeae Ofloxacin Treat for 4 weeks. Refer to GUM Clinic if STD suspected.
*Epididymo-orchitis Neisseria gonorrhoeae Ofloxacin Treat for 2 weeks. Refer to GUM Clinic if STD suspected.
Chlamydia trachomatis
Coliforms
Herpes genitalis Herpes simplex Refer to GUM Clinic.
14-13
*Ref MSSVD Guidelines 2001 (www.mssvd.org.uk)
Gastrointestinal infections
Acute inflammatory Campylobacter *Ciprofloxacin should be considered in the presence of blood/mucus in
diarrhoea* Shigella spp stool, abdominal pain, fever, tenesmus or risk factors for
Salmonella spp hypochlorhydria. Consider also Clostridium difficile (antibiotic-
associated) colitis.
E.coli 0157 Role of antibiotics unclear Seek specialist advice.
Acute non-inflammatory Toxigenic E.coli No treatment
diarrhoea Rotavirus
SRSVs
Diarrhoea in travellers As for other diarrhoeas Consider metronidazole Consider referral, stool sample required.
returning from abroad plus Giardia/Amoebae
Antibiotic-associated Clostridium difficile Oral metronidazole Treatment of recurrent infection, see C. diiff protocol. Stool sample
diarrhoea required.
Peptic ulcer Helicobacter pylori See GI guidance in Prescribing Guide for choice of regimen.
Peritonitis or diverticulitis Coliforms IV cefuroxime + metronidazole Add IV gentamicin if perforation suspected.

Bacteroides spp
Anaerobic cocci
CAPD-associated peritonitis Staph. epidermidis Vancomycin + ceftazidime Intraperitoneal administration.
Staph. aureus
Coliforms
Pseudomonas
Cholecystitis/acute cholangitis Coliforms Co-amoxiclav Add gentamicin if severe sepsis.
Anaerobes
Enterococci
Liver abscess Coliforms Co-amoxiclav + metronidazole Consider amoebic abscess.
Anaerobes
Enterococci
Staph. aureus
Spontaneous bacterial Staph. aureus IV ceftriaxone
peritonitis Coliforms
14-14
Necrotising pancreatitis Seek specialist advice

Central nervous system
infections
Meningitis in children and See Paediatric & Neonatal Seek specialist advice.
neonates Antibiotic Policy
Meningitis in adults Strep. pneumoniae High dose IV ceftriaxone Seek specialist advice. Add high dose amoxicillin (2g qds) if Listeria
Neisseria meningitides suspected. Consider role of steroids (see meningitis protocol p14-41
(Haemophilus influenzae) Ref: Journal of Infection 2003; Vol 46(2)
Meningitis, post-trauma or Haemophilus influenzae IV ceftazidime + IV flucloxacillin Seek specialist advice.
post-operative Strep. pneumoniae (high dose)
Coliforms
Pseudomonas
Staph. epidermidis
Staph. aureus
Meningitis, shunt-associated Staph. epidermidis IV ceftazidime + IV vancomycin Seek specialist advice. May require intraventricular vancomycin. Shunt
Staph. aureus may require to be removed.
Gram-negative organisms

Viral encephalitis Herpes simplex (most High dose IV aciclovir Seek specialist advice
commonly identified virus)
Brain abscess Streptococci High dose IV ceftriaxone + Add IV flucloxacillin if Staph. aureus suspected
Bacteroides spp metronidazole
Septicaemia & Endocarditis
Note: refer to Sepsis Protocol (p14-33) If source is suspected. Refer to Haematology Sepsis Protocol for haematology patients
Septicaemia in non-neutropenic E.coli Co-amoxiclav + Add metronidazole if intra-abdominal sepsis is established.
patient Strep. pneumoniae IV gentamicin
Staph. aureus
Others
Septicaemia in neutropenic Coliforms IV piperacillin/tazobactam Seek specialist advice. Teicoplanin IV should be added when suspect
patient Pseudomonas (Tazocin®) + IV gentamicin line sepsis or failure of resolution of fever 48 hours after
14-15
Staphylococci commencement of antibiotics.

Viridans streptococci
Septicaemia in patients with Staph. epidermidis High dose flucloxacillin Consider removing the catheter. Consider also changing to IV
intravascular catheter in situ Staph. aureus vancomycin if no improvement or if MRSA/MRSE is isolated in blood
culture or patient is known to be MRSA positive.
Suspected endocarditis*
(a) Acute presentation IV flucloxacillin 8-12g daily in 4 – 6 divided doses + IV gentamicin Gentamicin levels; trough <1mg/L, peak 3-5mg/L.
1mg/kg body weight 8 hourly, modified according to levels / renal Review therapy as soon as organism is identified and seek advice
function. from Microbiologist or Infectious Diseases specialist.
(b) Indolent presentation IV benzylpenicillin 7.2g daily in 6 divided doses + IV gentamicin (as Gentamicin levels; trough <1mg/L, peak 3-5mg/L.
acute presentation above) OR IV amoxicillin 2g 6 hourly + IV Review therapy as soon as organism is identified and seek advice
gentamicin (as acute presentation above) from Microbiologist or Infectious Diseases specialist.
(c) Penicillin allergy IV vancomycin 1g 12 hourly, modified according to levels/renal Gentamicin levels; trough <1mg/L, peak 3-5mg/L.
Intra-cardiac prosthesis function + oral rifampicin 300-600mg 12 hourly + IV gentamicin (as Vancomycin pre-dose level 10–15mg/L
Suspected MRSA acute presentation above) Review therapy as soon as organism is identified and seek advice
from Microbiologist or Infectious Diseases specialist.
*Reference: BSAC Guidelines, Journal of Antimicrobial Chemotherapy (Nov) 2004; 54: 971-81
Skin & soft tissue and bone infections

Impetigo Staph. aureus Flucloxacillin Topical fusidic acid for seven days is usually adequate. Oral
Strep. pyogenes flucloxacillin or clindamycin should be given for seven days if infection is
widespread (dose dependant on age).
Soft tissue infection
(a) Cellulitis Strep. pyogenes High dose oral Clindamycin is a suitable alternative. Consider referral to ID specialist
Staph. aureus flucloxacillin (4g/day) for outpatient parenteral therapy.
(b) Diabetic foot ulcers Usually mixed with: Do not prescribe antibiotics unless clinical signs of infection.
Staph. aureus
Minor superficial infections Streptococci Co-amoxiclav or flucloxacillin +
Anaerobes metronidazole
Spreading and/or deep Clindamycin and Ciprofloxacin Usually for a minimum of 3 weeks treatment If MRSA isolated consider
infection referral for OHPAT.
Post-operative wound Staph. aureus IV cefuroxime + metronidazole Drain pus if present. Add IV gentamicin if severe infection. Change to
infection – abdominal or Streptococci co-amoxiclav when the oral route is available.
female genital tract surgery Coliforms
Anaerobes
14-16
Post-operative wound Mixed aerobic and anaerobic Co-amoxiclav Drain pus if present.
infection – head & neck flora
surgery
Post-operative wound Staph. aureus Flucloxacillin Drain pus if present.

infection – surgery at other
sites
Fungal infections – Trichophyton Topical clotrimazole or For skin infections. If no response, seek specialist advice.
(dermatophytic) Epidermophyton miconazole
Microsporum Oral terbinafine For laboratory proven nail or scalp infections in adults.
Not recommended for children.

Clinical conditions Pathogens(s) Antibiotic(s) Comments
Viral infections Varicella zoster Either oral famciclovir or Only within 72 hours of rash onset. Aciclovir IV for shingles in
- Shingles valaciclovir. Alternatively, immunocompromised patients. For ophthalmic shingles, valaciclovir
IV aciclovir may be given can be commenced up to one week after onset of rash.
for first 48 hours followed
by oral valaciclovir
- Chickenpox Varicella zoster Aciclovir (oral) For chickenpox presenting within 24 hours of rash onset. Seek
specialist advice in the case of high risk groups (e.g. pregnancy,
smokers, chronic skin diseases, on systemic steroids, etc).
Bites Streptococci Co-amoxiclav If penicillin allergic use ciprofloxacin + clindamycin

Staph. aureus
Anaerobes
Pasteurella multocida
Burn wound infection
14-17
(a) burn wound with cellulitis (i) Staph. aureus (i) Flucloxacillin Take swab before treatment is commenced. Seek specialist advice if
Strep. pyogenes no improvement.
(ii) Coliforms (ii) Ciprofloxacin
Pseudomonas spp
(b) burn wound with Seek specialist advice.
septicaemia
Acute septic arthritis Staph. aureus High dose IV flucloxacillin Consider Neisseria spp and in young adults consider Chlamydia spp
also
Acute osteomyelitis Staph. aureus High dose IV flucloxacillin Consider clindamycin as an alternative. Also, consider referral to ID
specialist for outpatient parenteral therapy.
Chronic osteomyelitis Staph. aureus Clindamycin or flucloxacillin If coliforms suspected – consider adding ciprofloxacin. Also consider
Occasionally coliforms referral to ID specialist for outpatient parenteral therapy.
Prosthetic joint infections Seek specialist advice.
Eye infections
Conjunctivitis (adults) Strep. pneumoniae Usually self-limiting or else use
Staph. aureus topical chloramphenicol
Viral
Keratitis Strep. pneumoniae Specific therapy essential Obtain ophthalmic consultation

Staph. aureus,
Pseudomonas spp
14-18
Herpes simplex,
Herpes zoster
Endophthalmitis Many bacteria, viruses and Specific therapy essential Obtain urgent ophthalmic consultation.
fungi. If post-trauma or
surgery:
Staph. aureus
Pseudomonas spp
Peri-orbital cellulitis Streptococcus spp High dose flucloxacillin Medical emergency. Seek urgent specialist advice.
Staph. aureus + IV high dose ceftriaxone

MRSA
Eradication – On advice from Infection Control only

• Topical nasal mupirocin three times a day for 5 days.
• Chlorhexidine mouthwash 3 times a day for 5 days
• Chlorhexidine/Triclosan body wash for all washing purposes for 2 weeks.
• Cannot be relied upon to eradicate, may be useful in selected situations, ie reducing load pre-op.
• Unlikely to be useful in presence of an open wound.
• Contact Infection Control for further advice.
Treatment of Infection
• See MRSA Treament Protocol on page 14-52
14-19
ANTIBIOTIC PROPHYLAXIS
IN GENERAL SURGERY (Ref: SIGN Publication 45, July 2000)
NB. Prophylaxis should be given at induction by the IV route. Additional doses may be required during prolonged procedures to maintain adequate blood
antibiotic concentrations.
For further details, consult individual unit policies and guidelines.
Note: The use of antibiotic sprays or the application of antibiotic solutions to surgical wounds is not recommended.
(a) Abdominal surgery
(i) Biliary surgery (Open)
(ii) Gastric/small bowel Co-amoxiclav 1.2g slow IV bolus injection with further dose only if prolonged surgery beyond > 4 hours.
(iii) Emergency appendicectomy If penicillin hypersensitivity: gentamicin 4mg/kg IV bolus + metronidazole 1g ivi.
(iv) Colorectal surgery
Note: Laparoscopic cholecystectomy: Not recommended.
(b) Vascular surgery As for Abdominal surgery. If patients are known MRSA +ve consider gentamicin 4mg/kg prophylaxis.
(c) Abdominal or vaginal hysterectomy See Guidelines for Antibiotic Prophylaxis in Major Gynaecological Surgery.
14-20
(d) Orthopaedic surgery Cefuroxime 1.5g slow IV bolus then further 750mg dose after 4 hours if surgery prolonged beyond 4
(e.g. total hip replacement) hours. If patients are known MRSA +ve consider gentamicin 4mg/kg prophylaxis.
(e) Breast surgery Single slow IV bolus of co-amoxiclav 1.2g or clarithromycin 250mg ivi.
(f) Head and neck surgery (especially Flucloxacillin 1g by slow IV bolus injection + metronidazole 1g suppository.
following deep X-ray therapy)
(g) Endoscopic urological surgery Gentamicin 4mg/kg by IV bolus injection.
PREVENTION OF GAS GANGRENE IN AMPUTATION SURGERY

Usually requires 3 days pre-operative treatment with metronidazole
PATIENTS WITH CSF LEAK

Head trauma and compound skull fractures (with or without CSF leak) Cefuroxime 1.5g IV injection.

ANTIBIOTIC PROPHYLAXIS IN GASTROINTESTINAL ENDOSCOPY
Adapted from BSG guidelines 2001
All procedures: high risk patients Amoxicillin IV 1g + gentamicin IV 120mg

(prosthetic heart valve, prior to procedure then amoxicillin PO
previous endocarditis, 500mg 6 hours after
surgically constructed
systemic-pulmonary
shunt or conduit synthetic If penicillin allergic vancomycin IV 1g over
vascular graft less than 100 minutes + gentamicin IV 120mg prior to
1 year old) procedure.
ERCP: patients with bile stasis, Ciprofloxacin PO 750mg 60-90 minutes prior
pancreatic pseudocyst, to procedure or gentamicin IV 120mg just
prior or active cholangitis prior to procedure.
For neutropenic patients add Metronidazole IV 500mg to regime used.

14-21
PEG tube insertion all patients Co-amoxiclav IV 1.2g or if penicillin allergic

ceftriaxone IV 1g 30 minutes prior to procedure.
ANTIBIOTIC PROPHYLAXIS IN VARICEAL BLEEDING

Adapted from BSG guidelines 2000
Ciprofloxacin PO 500mg bd for 7 days
ANTIBIOTIC PROPHYLAXIS FOR SBP IN PATIENTS WITH ASCITES
Norfloxacin 400mg once daily during hospital admission only.
ANTIFUNGAL PROPHYLAXIS IN HAEMATOLOGY PATIENTS

See Haematology Antifungal Policy
MENINGOCOCCAL INFECTION PROPHYLAXIS

NB. The decision to initiate contact tracing in respect of meningococcal infection will be made by the Specialist Public Health Service of Tayside NHS Board in
conjunction with relevant clinicians. Responsibility for contract tracing, and organising the administration of chemoprophylaxis also lies with the Board’s Specialist
Public Health Service. Chemoprophylaxis will usually be prescribed either by hospital ward or primary care medical staff.
Ensure that the index case receives a course of oral rifampicin prior to discharge unless treated with ceftriaxone.
Establish a list of close contacts:

• Household contacts including those sharing an overnight stay with index case in 7 days prior to illness onset.
• Intimate lip kissing in 7 days prior to illness onset (social lip kissing is now not regarded as significant contact).
• Health care workers giving mouth to mouth resuscitation to index case unless treatment has already eradicated carriage in index case.
Give chemoprophylaxis as outlined below including pregnant contacts. Caution in breastfeeding, children <3 months and anyone with severe hepatic impairment.
The CPHM can advise.
Adults and those over 12 years Rifampicin 600mg orally, twice daily for 2 days
1-12 years Rifampicin 10mg/kg* orally, twice daily for 2 days
14-22
<1 year Rifampicin 5mg/kg* orally, twice daily for 2 days

*Round up to nearest convenient dose unit (capsules and mixture available)
NB. Patients taking rifampicin must be advised that body secretions (urine, saliva, sweat) may be discoloured yellow/orange. Soft contact lenses should not be
worn for up to 24 hours following the 2 day course since they may be irreversibly stained.
NB. For women taking the oral contraceptive, additional precautions (e.g. barrier method) should be taken for the current month and for all of the next month’s
supply of the pill. Ciprofloxacin is also known to clear the organism from the throat. The adult dose is 500mg orally stat. Ciprofloxacin is not currently licensed for
this indication in adults or children. Avoid in pregnancy.
Ref: Public Health Laboratory Service Meningococcus Forum. Guidelines for Public Health Management of Meningococcal Disease in the UK. Communicable
Disease and Public Health 2002; 5: 187-207.

INVASIVE HAEMOPHILUS INFLUENZAE TYPE B INFECTION (Hib)
NB. The decision to initiate contact tracing in respect of Hib infection will be made by the Specialist Public Health Service of Tayside NHS Board in conjunction
with relevant clinicians. Responsibility for contact tracing, and organising the administration of chemoprophylaxis also lies with the Board’s Specialist Public
Health Service. Chemoprophylaxis will usually be prescribed either by hospital ward or primary care medical staff.
Hib causes meningitis, septicaemia, epiglottitis and a range of other invasive diseases, mainly in pre-school children. Rarely, older children or even adults can be
affected.
The following groups are recommended to receive chemoprophylaxis:

• All household contacts irrespective of age and Hib immunisation history, where there is a case of Hib disease in either a child or an adult in a household
where there are one or more children under the age of 4 years who are unvaccinated or incompletely vaccinated. Chemoprophylaxis for household contact
is not indicated if all contacts under the age of 4 years have been fully vaccinated against Hib disease.
• All pre-school or school class or group contacts (including teachers) if there has been a case of invasive Hib infection in a child over the previous 120
days which can be related to the present index case.
• All index cases before discharge from hospital.
14-23
Chemoprophylaxis regimen
Rifampicin is the drug of choice prescribed for four days as shown in Table. Table: Age-related dosage for rifampicin
chemoprophylaxis
Age range Once daily dose
Adults 600mg
Children 3 months+ 20mg/kg
This regimen is different from that for meningococcal infection.
Children <3months of age should not receive rifampicin. Carriage rates are very low in this age group and the dose of rifampicin needed to eliminate carriage
may be toxic. Contacts should be advised of the side-effects and contraindications of rifampicin therapy. These are set out in the meningococcal guidelines above.
PREVENTION OF INFECTIVE ENDOCARDITIS FOR DENTAL PATIENTS REQUIRING A GENERAL ANAESTHETIC
Ref: Working Party of the British Society for Antimicrobial Chemotherapy (see BNF for further information)
NB. Consult BNF for children’s doses or check with the clinical pharmacist
Patients with valvular heart disease excluding artificial valves (a) Amoxicillin 1g IV/IM at induction then amoxicillin 500mg orally 6 hours later.
or (b) Amoxicillin 3g orally 4 hours before induction then amoxicillin 3g orally as soon as
possible after the procedure.
Special risk patients with artificial valves or those who have (c) Amoxicillin 1g IV/IM + gentamicin 120mg IV/IM at induction then amoxicillin 500g
Previously had endocarditis orally 6 hours later.
but
If penicillin allergic or have received more than a single dose (d) Vancomycin 1g ivi over at least 100 minutes then gentamicin 120mg IV at induction
of a penicillin in the preceding month or 15 minutes before the procedure.
14-24
or (e) Teicoplanin 400mg IV + gentamicin 120mg IV at induction or 15 minutes before the

procedure
or (f) Clindamycin 300mg IV (over at least 10 minutes) at induction or 15 minutes before

the procedure then oral/IV clindamycin 150mg 6 hours later.
PREVENTION OF INFECTIVE ENDOCARDITIS FOR DENTAL PATIENTS REQUIRING LOCAL OR NO ANAESTHESIA
Patients at no special risk (including those with a prosthetic valve) (a) Amoxicillin 3g orally 1 hour before the procedure.
or
If penicillin allergic or have received more than a single dose (b) Clindamycin 600mg orally 1 hour before the procedure.
of a penicillin in the preceding month
or
For those who have previously had endocarditis c) Amoxicillin 1g IV/IM + gentamicin 120mg IV/IM immediately before the procedure
then amoxicillin 500mg orally 6 hours later or other regimen as under General
Anaesthesia above.

ANTIBIOTIC DRUG DOSAGES
The following adult dose is recommended for each of the antibiotics in the preceding text (unless already Chloramphenicol
specified). Eye drops (0.5%) in conjunctivitis – 1-2 drops 2-hourly reduced to 3-4 times a day once initial control of infection is
• Drug dosages may require to be modified in the event of renal/hepatic impairment resulting in achieved. Chloramphenicol 1% eye ointment can be applied alone 3-4 times daily at this stage or administered at
altered rug clearance. night in combination with eye drops. Continue to treat for 2 days once resolution of infection occurs.
• If in doubt – contact the Medicines Information Service (Ninewells Hospital, Extension 32351) or
discuss with the Clinical Pharmacist attached to your ward or unit.
• Where available, oral antibiotic therapy is preferred, unless stated in the text or if the oral route is
Ciprofloxacin
Respiratory tract infection - 500mg 12-hourly. For proven pseudomonas
compromised.
infections, 750mg 12-hourly
• If intravenous therapy is initially considered essential, the opportunity for early IV to oral switch
Gastroenteritis - 500mg po 12-hourly for 3 days
should be taken (review every 24 hours at least) once resolution of severe acute infection is
Traveller’s diarrhoea - 500mg po stat dose
apparent.
Intravenous therapy - 400mg 12-hourly (early switch to oral route advised)
Aciclovir Clarithromycin
Varicella/Shingles - 800mg po 5 times per day
Intravenous therapy - 500mg 12-hourly
Standard IV dose - 5mg/kg 8-hourly
NB. Erythromycin preferred for oral administration
High dose IV - 10mg/kg 8-hourly
Amoxicillin Clindamycin
300-450mg po 8-hourly
500mg – 1g po 8-hourly
Severe infection - Sepsis Protocol gives 600mg IV 6-hourly
High dose IV therapy for meningitis
Vaginal cream - 5g administered via applicator for 7 nights
in adults if Listeria suspected - 2g 6-hourly
Benzylpenicillin Clotrimazole
Vaginal thrush - insert 500mg pessary as a single dose at night
(Oral absorption is poor – administered by injection only)
Standard IV/IM dose - 1.2g (2 MU) 6-hourly
High dose IV (in endocarditis) - 1.2g (2 MU) 4-hourly Co-amoxiclav
Oral route - to provide 500mg amoxicillin + 125mg
clavulanate 8-hourly
Ceftazidime Intravenous - 1.2g (amoxicillin 1g + clavulanate 200mg)
2g IV 8-hourly
8-hourly in severe infections or if the oral route is compromised
Maintenance therapy of CAPD - 125mg per litre in each bag
associated peritonitis A stat 1g IV dose is also administered
Doxycycline
200mg po stat then 100mg po once daily
Ceftriaxone
Standard dose - 1g IV once daily
Severe infections/high dose - 2g IV once daily Erythromycin
Meningitis dose - 2g 12-hourly 500mg po 6-hourly or 1g 12-hourly
Cefuroxime Famciclovir
(Oral absorption of cefuroxime axetil is poor and erratic – do not use, no longer stocked by pharmacy) Shingles - 750mg once daily for 7 days
1.5g IV 8-hourly
Cefalexin
500mg po 8-hourly
14-26
14-25
Updated June 2005 Uncontrolled when printed Updated June 2005 Uncontrolled when printed
Nystatin
Flucloxacillin Topical drops 100,000 units (1ml) 6-hourly (Lozenges 100,000 units may be sucked 6-hourly as an alternative)
Standard dose - 500mg po 6-hourly Topical drops 500,000 units (5ml) 6-hourly if extensive oropharyngeal thrush
High dose - 1g po 6-hourly
Note: if oral route unavailable, the standard dose can be administered by IV/IM injection. The IV route is
only required if high dose parenteral therapy is indicated.
Ofloxacin
400mg po once daily or 100mg po 12-hourly
Fluconazole Pelvic Inflammatory Disease – see protocol
Oral thrush (immunocompromised) - 50-100mg once daily for 15 days
Vaginal thrush - 150mg as a single dose
Phenoxymethylpenicillin
(Penicillin V)
Gentamicin 1g po 12-hourly
Gram negative sepsis - 7mg/kg once daily (see protocol)
Where once a day therapy is not appropriate:
2.5mg/kg 12-hourly or 1.5mg/kg 8-hourly
Piperacillin + Tazobactam (Tazocin®)
Note that higher doses are required in cystic fibrosis. 4g IV 8-hourly (calculated as piperacillin but contains also 500mg tazobactam)
Note that a lower dose (1mg/kg 8 hourly) is required in suspected endocarditis when gentamicin is given in
conjunction with high dose flucloxacillin / benzylpenicillin see p14-15. Rifampicin
Dose is subsequently adjusted according to blood level results – seek advice from the clinical pharmacist In MRSA: 300mg 12-hourly (always in combination)
or Medicines Information Service.
Teicoplanin
Itraconazole Dose is based on 6mg/kg given 12-hourly for the first 3 doses then once daily thereafter
Alternative to fluconazole - 100-200mg once daily for 15 days in oral thrush Administered by IV bolus injection or ivi in 100ml glucose 5%
(immunocompromised)
Terbinafine
Levofloxacin (IV only) 250mg once daily for 6 weeks to 3 months in nail infections (see main formulary)
Severe community acquired pneumonia - 500mg twice daily NB. Send sample for mycological confirmation of infection before commencing therapy
In penicillin allergic patients (see protocol)
Trimethoprim
Metronidazole Acute cystitis - 200mg po 12-hourly
Standard oral dose - 400mg 8-hourly Prophylaxis of UTI - 100mg po at night
Rectal dose - 1g 8-hourly MRSA - 200mg po 12 hourly
Intravenous dose - 500mg 8-hourly
Bacterial vaginosis - 400mg po 12-hourly for 5 days Valaciclovir
Trichomoniasis - 400mg po 12-hourly for 5 days 1g po 8-hourly
Pelvic Inflammatory Disease - see protocol
Vancomycin
Moxifloxacin (oral only) Dosage guidelines see, vancomycin protocol (p14-37)
Step down from IV levofloxacin in severe CAP /
HAP in penicillin allergic patients - 400mg once daily (see CAP protocol)
Nitrofurantoin
Acute cystitis - 50mg po 6-hourly
Prophylaxis of UTI - 100mg po at night
14-27 Uncontrolled when printed 14-28 Uncontrolled when printed

Updated June 2005 Updated June 2005
IMMUNISATIONS Pneumococcal vaccine is recommended for the following conditions:
Persons aged over 65 years
Chronic renal disease or nephritic syndrome
The immunisation schedule for Tayside is as follows:
Chronic respiratory disease including asthma requiring frequent treatment with an inhaled or systemic corticosteroid
Coeliac disease
Children Immunodeficiency or immunosuppression due to disease or treatment, including HIV infection
Vaccine Age Chronic heart or liver disease including cirrhosis
Primary course (3 doses) Diabetes mellitus
Diphtheria/tetanus/acellular pertussis/inactivated polio/ Homozygous sickle cell disease
HiB vaccine (DTaP/IPV/Hib) – Pediacel® Asplenia or severe dysfunction of the spleen (see above for additional vaccines)
+ MenC vaccine Presence of cochlear implant or CSF shunt
1st dose 2 months Child under 5 years with a history of invasive pneumococcal disease
2nd dose 3 months
3rd dose 4 months The polysaccharide vaccine is recommended for at risk groups aged 2 or over. For children aged under 2 years
Measles, mumps, rubella (MMR) 12-15 months conjugated pneumococcal vaccine is recommended. See BNF for details.
Pre-school booster:
Diphtheria (low dose)/tetanus/acellular pertussis/ Note: other immunisations may be required (e.g. Hep B Vacc, Influenza Vacc, etc) for individuals at high risk – seek
inactivated polio (dTaP/IPV) – Repevax® advice from Public Health Medicine at Kings Cross Hospital.
or
Diphtheria/tetanus/acellular pertussis/ Note: For travel immunisations, seek advice from GP in first instance.
inactivated polio (DTaP/IPV) – Infanrix-IPV® 4-5 years
Measles, mumps, rubella (MMR) booster 4-5 years Further information see ‘Immunisation Against Infectious Disease’, HMSO 1996. Advice from, Specialist Public
Health Service. Telephone 01382 596997 direct.
Older children/school leavers/pre-employment/further education
BCG See next page BCG
Diphtheria (low dose)/tetanus/inactivated polio (Td/IPV) 15-18 years In July 2005 the SEHD introduced an improved targeted programme directed towards those most at risk that will
(Revaxis®) replace the current universal (schools) BCG programme.
Those now recommended to receive BCG are:
Adults
Women seronegative for rubella Rubella vaccine (using MMR, single dose) • All infants living in UK areas where the incidence of TB is 40/100,000 or greater (no NHS Board areas in
Previously unimmunised individuals Diphtheria (low dose)/ tetanus/inactivated polio Scotland fall into that high risk category)
vaccine (Td/IPV, Revaxis®) 3 doses at intervals of 4 weeks. • Infants whose parents or grandparents were born in a country with a TB prevalence of 40/100,000 or higher
Booster dose 10 years after primary course and again 10
• Previously unvaccinated new immigrants from high prevalence countries for TB.
years later maintains satisfactory level of protection
Prevention of infection in splenectomised patients All patients should receive: • Children who would otherwise have been offered BCG through the schools’ programme will now be screened
Polysaccharide pneumococcal vaccine, boosters may be for TB risk factors, and tested and vaccinated if appropriate
needed every 5-10 years depending on antibody levels. The contact, occupational and travel related recommendations remain unchanged.
Influenza vaccine, annually.
Life-long prophylactic antibiotics: The Mantoux test will replace the Heaf test as the standard method of tuberculin skin testing. Training in use of the
Penicillin V 250-500mg twice daily or Erythromycin 250- Mantoux method should be arranged locally. SEHD will ensure that supplementary training materials will be supplied
500mg once daily. in due course.
Department of Health Leaflet and card (available from The full SEHD advice can be viewed at the following link: http://www.show.scot.nhs.uk/sehd/cmo/CMO(2005)05.pdf
Pharmacy). UK production of tuberculin PPD has now ceased and the SEHD has obtained alternative supplies of tuberculin PPD
Patients not previously immunised should receive: for Mantoux testing manufactured by Statens Serum Institute (SSI) in Denmark. This is available as an unlicensed
Haemophilus influenzae Type B vaccine, Meningococcal medicine in the UK. There are important differences between Tuberculin Mantoux PPD from SSI and Tuberculin
Group C conjugate vaccine. Mantoux PPD formerly provided in the UK. Users must carefully read the label and package insert. Full details of the
No boosters required differences and the SSI SPC with instructions for testing can be viewed at the following link:
Vaccines should be given a minimum of 2 weeks prior to http://www.show.scot.nhs.uk/sehd/cmo/CMO(2005)6.pdf
elective splenectomy or as soon as possible after recovery
from the operation and before discharge from hospital.
14-29 Uncontrolled when printed Updated June 2005 14-30 Uncontrolled when printed
Updated June 2005
CURRENT TAYSIDE ACUTE SERVICES DIVISION
ANTIBIOTIC POLICIES
14-31 14-32
Updated June 2005 Uncontrolled when printed Updated June 2005 Uncontrolled when printed
SEPSIS MANAGEMENT PROTOCOL: EMPIRIC ANTIBIOTIC THERAPY
INDICATIONS FOR IV USE Definition of Sepsis:
Clinical Symptoms of Infection (fever, sweats, chills or rigors, malaise, etc
Dosing
1. Serious or severe sepsis*
2. Febrile with neutropenia or immunosuppression Temperature >38°C <36°C Antibiotic Oral IV
3. Specific infections Tachycardia >90 bpm Amoxicillin 500mg t.d.s 500 mg t.d.s.
- endocarditis, abscess, meningitis septic Tachypnoea RR > 20/min Co-amoxiclav 375mg or 625mg t.d.s. 1.2g t.d.s
arthritis or osteomyelitis WCC <4 or >12 Erythromycin 500mg q.d.s
4. Oral route is compromised +Serious/Severe: Sepsis associated with organ dysfunction, Clarithromycin 500mg b.d. 500mg bd
- nil by mouth or <50mls fluids orally hypoperfusion (oliguria, acute alteration of mental state) or hypotension Flucloxacillin 1g q.d.s. 1-2g q.d.s
- reduced absorption Clindamycin 300-450mg t.d.s 600mg q.d.s
- mechanical swallowing disorder Ciprofloxacin 500-750mg b.d. See advice (or
- unconscious Culture appropriate area: eg. Blood Cultures (8-10ml of blood into (750mg bd only if see allergy
- no oral formulation available each of the culture bottles) urine, sputum, CSF, wound or venous Pseudomonas suspected) section)
access site Metronidazole 400mg t.d.s 500mg t.d.s
Cefuroxime - 0.75-1.50g t.d.s.
Ceftriaxone - 1.2g o.d.
Community Acquired Hospital Acquired Gentamicin - 7mg/kg o.d.**
If patient is on intravenous (Infection present or suspected (Infection 48 hours after ** except endocarditis/ascites/pregnancy (see aminoglycoside protocol)
antibiotics can you change them to on admission) admission)
oral therapy?
COPD Pneumonia UTI Skin & soft Intra- Hepatobiliary CNS PUO PUO CNS Intra- Skin & soft UTI Pneumonia ***** COPD
Exacerbation tissue/bone/joint abdominal Abdominal tissue/bone/joint exacerbation
ORAL ORAL ORAL ORAL ORAL ORAL ORAL ORAL ORAL

ORAL ORAL ORAL ORAL ORAL
Co-amoxiclav Not Not Flucloxacillin Co-amoxiclav Co-amoxiclav Ciproflox.

Amoxicillin Amoxicillin + Co-amoxiclav Flucloxacillin* Not Co-amoxiclav Not Co-amoxiclav
erythromycin** appropriate appropriate appropriate appropriate + Ciprofloxacin
IV IV IV IV IV IV IV
IV IV IV IV IV IV IV IV
Co-amoxiclav *** Cefuroxime Seek advice Co-amoxiclav Co-amoxiclav Not

Amox. Amoxicillin Co-amoxiclav Fluclox.* Cefuroxime + Co-amoxiclav *** Co-amoxiclav +/-gentamicin Ceftriaxone +metronidazole +/-gentamicin +/-gentamicin appropriate
+clarithromycin**** metronidazole +/-gentamicin Ceftriaxone +/-gentamicin (seek advice) +/-gentamicin
* If Penicillin allergy in soft tissue infections use clindamycin Please write indication for antibiotic in case records
** If gastrointestinal disturbance with erythromycin consider clarithromycin
*** Aciclovir IV may be indicated empirically
**** If severe – IV cefuroxime or IV co-amoxiclav+ IV clarithromycin If renal failure or dysfunction seek advice
See Pneumonia Protocol for further guidance Modify treatment according
***** If Legionella is a possibility add ciprofloxacin to laboratory sensitivity
See Gentamicin Protocol for dosing + monitoring
Penicillin Allergy
If patient gives a history of rash or
anaphylaxis or there is reasonable doubt: Complicated or unusual pathogen infection For further antibiotic sepsis advice contact June 2005
for gram +ve cocci cover: Review June 2006
Clindamycin IV
For gram –ve bacilli cover:
Ciprofloxacin
On Call ID Physician – NWH Switchboard Duty Microbiologist – NWH Switchboard Duty Clinical Pharmacist
Seek specialist advice in serious infection
14-33
Adult Antibiotic Policy for use in Tayside University Hospitals
GENTAMICIN ONCE A DAY

A gentamicin once a day dosing regimen operates in most Wards and Units.
An initial dose of gentamicin 7mg/kg in 100ml glucose 5% or sodium chloride 0.9% minibag is administered over one
hour iv infusion.
This dose is repeated at 24 hour intervals unless the patient has renal impairment as determined from their serum
creatinine and a population estimate of its relationship to creatinine clearance. Patients with significant renal impairment
may then receive 36 hour, 48 hour, etc. dosing depending upon their estimated GFR.
Gentamicin therapy is monitored thereafter using a simple nomogram which relates observed concentration to the time
post dose within a given concentration range. Note the following exclusions to 7mg/kg once daily dosing, pending further
investigation:
Endocarditis Pregnancy Children
Ascites Major burns Cystic fibrosis
GENTAMICIN: ONCE DAILY DOSING

Prescribing gentamicin as a single daily dose instead of in divided doses will ensure that effective peak serum
concentrations are achieved in all patients. In addition, once daily dosing may be less toxic, more economic and is easier
to monitor.
ONCE DAILY DOSING SCHEDULE:

Initial dose
7mg/kg body weight gentamicin administered by intravenous infusion over 1 hour in 100ml glucose 5% or sodium
chloride 0.9% minibag.
Subsequent doses
Repeat at intervals of 24 hours unless the patient has impaired renal function as determined from the equation:
Creatinine clearance = (140 - Age) x Bodyweight (kg)
(ml/minute) Serum creatinine (micromol/litre)
Multiply above value x 1.23 if male patient.
The maintenance dose is then adjusted according to the following schedule:

Estimated creatinine clearance Dosing interval
(ml/minute) (hours)
> 60 24
40 - 59 36
20 - 39 48
< 20 Consult pharmacist
Serum concentration monitoring

Take a single blood sample at any time between 6 and 14 hours after the start of the intravenous infusion and determine
the appropriate point on the Hartford Nomogram.
NB. It is essential that the time between commencing the infusion and taking the blood sample is accurately recorded
and documented on the request form.
Exclusions to this dosage schedule

Endocarditis, pregnancy, children, patients with ascites, major burns and cystic fibrosis.
14-34
MONITORING GENTAMICIN LEVELS:
THE HARTFORD NOMOGRAM
1. Obtain a single serum level at any time after the first dose but
between 6-14 hours after the start of the infusion. It is very
important that the exact time is documented. Evaluate on the
nomogram.
14
2. If the level falls in the area designated Q24h, Q36h or Q48h the
interval should be every 24, 36, 48 hours respectively. If the point
is on the line, choose the longer interval.
3. If the level is off the nomogram at the given time, stop the
13
scheduled therapy and obtain serial levels to determine the
appropriate time of the next dose (<2mg/litre)
4. Where appropriate, monitor blood level twice weekly.
Time between start of infusion and sample draw (hours)

12
11
10
Q48h
Q36h
Q24h
9
8
7
6
14
13
12
11
10
9
8
7
6
5
4
3
2
Concentration (mg/litre)
14-35
GUIDELINE FOR INITIATING IV VANCOMYCIN IN ADULT PATIENTS
Before starting IV Vancomycin Indications:

• Consider indication • Serious MRSA or coagulase negative staphylococcal infections
• Remember oral therapy may be • Infections due to other resistant gram positive organisms
appropriate (NB not oral vancomycin) • Prosthetic valve endocarditis
• Other infections – only after consultation with ID Physician or
Microbiologist
Note:
Contact pharmacist before starting In the case of mild MRSA infection as opposed to colonisation
Vancomycin recommended 1st line treatment is trimethoprim + rifampicin orally
Does your patient have

• Renal impairment
• Burns YES
• Ascites Seek advice from pharmacist
• Receive dialysis
• Pregnant
If Cr <60 µmol/L use 60 in calculation

Estimate Creatinine Clearance (ml/min) (a)
(140-age(years)) x weight (Kg) 1.23 (males) If obese – calculate ideal body weight
Creatinine (µmol/L) X 1.04 (females) Male 50Kg + 0.9Kg for every cm > 150cm
Female 45.5Kg + 0.9Kg for every cm > 150cm
Determine STARTING dose from table (b) below
Cr Cl (ml/min) <60Kg >60Kg

20-29 1g every 48hrs 1g every 48 hrs If CrCl <20ml/min
30-49 750mg od 750mg od
50-59 1g od 1g od
60-69 500mg bd 1g od Give 1g then sample after 24 hours and
70-79 750mg bd 750mg bd seek advice from Pharmacist
80-100 or more 750mg bd 1g bd
CONTACT DETAILS:
If starting vancomycin outwith hours and unsure • Pharmacy:
about starting dose then give 1g and contact M-F 8.45am-5pm Ward Pharmacist
pharmacist next day Sat 9-1.30pm Dispensary
Monitoring Other times – On call via switchboard
Always state exact time of sample in relation to dose on request form. • Microbiology – Lab
Always monitor renal function. M-F 8-5 ext 32559
M-F 5-9 bleep 4390
M-F Other times On call MLSO
Sat/Sun/PH 8-12 ext 32559
Other times On call MLSO
Trough Levels Peak Levels Consultant – Bleep 4039
For bd dose – pre 4th dose Not routinely required On call via switchboard
For od dose – pre 3rd dose or 4th dose If endocarditis, burns, ascites, • ID Physician:
Please discuss with pregnancy, significant oedema then On call via switchboard
pharmacist or microbiologist sample 2 hrs after end of infusion
range 5-15mg/L (10-15mg/L endocarditis) Range 20-30 mg/L
Seek advice if outwith range and about Seek advice if outwith range
further monitoring. Specialist Units – as per
Microbiology advice. Antibiotic Subcommittee June 2005
Review June 2006
References: (a) Cockroft & Gault; Nephron 1976; 16: 31-41
(b) Dr A Thomson, Clinical Pharmacokinetics Unit, Glasgow Adapted Protocol 14-36
TREATMENT OF RECURRENT
CLOSTRIDIUM DIFFICILE DIARRHOEA
15-25% of patients treated for C. difficile have recurrence of diarrhoea following withdrawal of specific antibiotic
therapy. Treating recurrence can be particularly problematic. Over use of oral vancomycin is associated with
resistance problems, with this in mind the following guidance is issued:
Confirm diagnosis of C. difficile at each stage.
First episode Metronidazole 400mg 8-hourly for 14 days

If patient has not responded to treatment after 14 days seek advice.
First recurrence Metronidazole 400mg 8-hourly for 14 days

If patient has not responded to treatment after 14 days seek advice.
Second recurrence Metronidazole tapering regime

400mg 8-hourly for 7 days
400mg 12-hourly for 7 days
400mg od for 7 days
400mg every second day for 4 doses
400mg every third day for 3 doses
then stop
If patient has not responded after full course seek advice.
Third recurrence Vancomycin 125mg 6-hourly for 7 days
Further recurrence Seek advice from Microbiology or ID
Consider adding in Brewer’s Yeast (Saccharomyces cerevisiae) 3 tablets three times a day at second or third
recurrence.
Please seek advice from Microbiology of Infectious Diseases before prescribing vancomycin at an earlier stage than
indicated above.
14-38
Updated June 2005 14-37 Uncontrolled when printed
Haematology Sepsis Protocol
9
Pyrexia and neutropenia ≤ 0.5x10 /L
July 2005 Penicillin or β lactam (ceftazidime,
Review July 2006 ®
Tazocin , meropenem) allergy
Take cultures (Blood and other clinically indicated samples) See box below (rash or anaphylaxis).
Recommend ciprofloxacin 400mg
bd IV and gentamicin (as below)
NO
YES, if any Is Teicoplanin needed?
• Colonised or previous infection

with MRSA
• Obvious catheter related infection All patients should have a full infection screen
• Systolic BP <90 mmHg with each new episode
• Blood cultures (Hickman line and peripheral
1st Line
venous)
1st Line • Tazocin 4.5 g qds +
• Throat and nasal swabs
• Tazocin 4.5 g qds + • Gentamicin** 7mg/kg lean body
• MSU
• Gentamicin** 7mg/kg lean body weight od (EXCEPT MYELOMA
• Stool culture (if diarrhoea also request C.
weight od (EXCEPT PATIENTS - 5mg/kg lean body
difficile toxin)
MYELOMA PATIENTS - weight* od)
• Swab skin lesions and Hickman line exit site
5mg/kg lean body weight* od)+
• Sputum culture
• Teicoplanin 6mg/kg 12 hrly x 3 -
• Chest x-ray
loading dose then 6mg/kg od
• Viral studies (immunofluorescence and culture
when clinically indicated)
Is the source respiratory infection? Is the source respiratory infection?
Add clarithromycin 500mg bd IV Add clarithromycin 500mg bd IV
(or oral if appropriate) (or oral if appropriate)
Consider bronchoscopy Consider bronchoscopy
Reassess after 48 - 72 hours
Afebrile within first 2-3 days of treatment

Persisting fever during first 3days of treatment
No aetiology identified Seek specialist advice Repeat cultures

Aetiology identified
2nd Line
Add teicoplanin if not already
Adjust to most Low Risk High Risk started and consider change to
appropriate treatment Neutropenia <7days Neutropenia >7days Meropenem 1g tds
Clinically well 9
Absolute neutrophil <0.1x10 /L
Unstable clinical signs
Mucositis
Change to oral If persistent fever
ciprofloxacin after 96 hours and
750mg bd for no focus of infection
Continue with same
5 days antibiotics
1st Line
Discharge Discontinue antibiotics • Caspofungin
to complete when afebrile for 5 days
antibiotics Observe carefully
as outpatient Reintroduce prophylaxis
2nd Line
Consider using liposomal Amphotericin
* (Ambisome) or voriconazole if:
Lean body weight Males: 50 kg + 0.9 kg for each cm above 150 cm • Caspofungin not tolerated
Females: 45 kg + 0.9 kg for each cm above 150 cm • No response to caspofungin or evidence
/suspicion of a fungal infection against which
caspofungin is not active ie Cryptococcus,
** Fusarium, Mucor
See once daily gentamicin dosing protocol • Suspected invasive fungal infection of central
– note MONITOR LEVELS nervous system
Discuss case with Microbiology or ID
If continuing fever and prolonged neutropenia Reassess patient

consider adding G-CSF (Discuss with consultant)
Updated June 2005 14-39 Uncontrolled when printed

Prophylaxis
HAEMATOLOGY ANTIFUNGAL POLICY
The choice of antifungal prophylaxis in haematology is risk dependent (4). Itraconazole, fluconazole and
voriconazole are the main agents used. Low-dose amphotericin is used in ALL induction.
Introduction
Itraconazole is active against a wide range of yeasts and moulds. It has been shown to significantly reduce
Patients undergoing chemotherapy for haematological malignancy are at high risk of invasive fungal infection Aspergillus infections in neutropenic patients when compared to fluconazole (5). Its use is recommended in
(IFI). Duration and severity of neutropenia are the main risk factors. Treatment of IFI is difficult because of the patients at high risk of IFI;
lack of diagnostic tests, the toxicity of some antifungal agents and also their significant cost. This policy has
been developed to ensure the appropriate treatment and prophylaxis of fungal infections in haematology • Autologous BMT
patients across NHS Tayside. Further details on these agents, such as doses and interactions, are in the • ALL
Appendix. • AML
• Lymphoma (high-dose chemotherapy)
Treatment • Myeloma (high-dose chemotherapy)
Empirical IFI treatment Patients who are intolerant of itraconazole can be prescribed fluconazole or voriconazole (currently unlicensed
Empirical antifungal therapy is indicated in neutropenic patients with pyrexia unresponsive to broad spectrum indication).
antibiotics for more than 96 hours and with no focus of infection identified. These patients are at high risk of Fluconazole is active against most yeasts and reduces invasive infection with Candida albicans in neutropenic
mould infection (most commonly Aspergillus) in the lungs. A recent multicentre randomised controlled trial in patients. It is used for low-risk patients ie. patients not in the above categories who are having inpatient
these patients showed caspofungin to be as effective as liposomal amphotericin B, with fewer side effects (1). chemotherapy.
Voriconazole is not licensed for empirical use in neutropenic fever.
Patients who have had previous treatment for IFI (i.e. for 2 weeks or more, not just empirical use until resolution
First-line treatment of neutropenic fever) may not have completely cleared the infection at the start of their next course of
Caspofungin IV chemotherapy. They are at high risk of reactivation and should be prescribed oral voriconazole for secondary
prophylaxis.
Second-line treatment
Liposomal Amphotericin B (Ambisome) IV
References
1. Walsh TJ, Teppler H, Donowitz GR, Maertens JA, Baden LR, Dmoszynska A, Cornely OA, Bourque MR,
Proven/Probable/Possible IFI Lupinacci RJ, Sable CA, dePauw BE. Caspofungin versus liposomal amphotericin B for empirical antifungal
These are definitions used by the European Organisation for Research in the Treatment of Cancer (EORTC)(2). therapy in patients with persistent fever and neutropenia. N Engl J Med. 2004 Sep 30;351(14):1391-402.
In summary, ‘Proven’ IFI is where there is a histological evidence or a fungus cultured from a normally sterile 2. Ascioglu S, Rex JH, de Pauw B, Bennett JE, Bille J, Crokaert F, Denning DW et al. Defining opportunistic
site. In practice the use of ‘Probable’ IFI is not very helpful because without the use of any Aspergillus antigen invasive fungal infections in immunocompromised patients with cancer and hematopoietic stem cell
test (e.g. serum galactomannan) the microbiological criterion will rarely be fulfilled. ‘Possible’ IFI is defined as a transplants: an international consensus. Clin Infect Dis. 2002 Jan 1;34(1):7-14
susceptible patient with some clinical evidence of IFI e.g. signs on CT chest. In the trial already mentioned (1), 3. Herbrecht R, Denning DW, Patterson TF et al. Voriconazole versus amphotericin B for primary therapy of
caspofungin was superior to liposomal amphotericin B in the treatment of baseline fungal infections and invasive aspergillosis. N Engl J Med. 2002 Aug 8;347(6):408-15.
mortality at 7 days. Voriconazole has also been shown to be superior (improved survival and clinical response) 4. Prentice HG, Kibbler CC, Prentice AG. Towards a targeted, risk-based, antifungal strategy in neutropenic
to amphotericin B in the treatment of invasive aspergillosis, with fewer side-effects (3). It is the treatment of patients. Br J Haematol. 2000 Aug;110(2):273-84.
choice for intracerebral IFI because it has very good central nervous system penetration. 5. Morgenstern GR, Prentice AG, Prentice HG, Ropner JE, Schey SA, Warnock
DW. A randomized controlled trial of itraconazole versus fluconazole for the prevention of fungal infections in
First-line treatment patients with haematological malignancies. U.K. Multicentre Antifungal Prophylaxis Study Group. Br J
Caspofungin IV Haematol. 1999 Jun;105(4):901-11.
or Voriconazole IV if evidence of intracerebral IFI
Second-line treatment Dr William Olver
Voriconazole IV or Liposomal Amphotericin B (Ambisome) IV Consultant Medical Microbiologist
Caspofungin is not active against some fungi, particularly Cryptococcus, Fusarium and Mucor. If there is
evidence / suspicion of one of these infections, caspofungin should not be used. Please discuss the case with Mr Mark Parsons
Microbiology or Infectious Diseases. Principal Clinical Pharmacist
Surgery and Oncology
Follow-on oral treatment
Duration of treatment is variable in these infections, but in general at least 2 weeks is required. Oral May 2005
voriconazole can be used if patients are well enough to be treated as outpatients because its oral bioavailability
is very high (96%).
Haematology Antifungal Policy Appendix [Liposomal Amphotericin (Ambisome®) contd]
Caution/Contraindication/Side Effects.
CASPOFUNGIN (CANCIDAS®) 50mg and 70mg vials Consult the BNF and Data Sheet – www.emc.medicines.org.uk
Available from CIVAS service Mon-Fri Can cause severe allergic reaction, monitor U&Es & LFT’s - hypokalaemia and hypomagnesaemia are common.
Dose Drug Interactions
For the purposes of this protocol the doses are; 70mg loading dose on day 1, then 50mg daily thereafter. If Azole antifungals
patient >80kg, use 70mg daily dose. Caution with other renally toxic drugs
Reconstitution (if not available from CIVAS) Caution with antiarrythmics where there are concurrent electrolyte disturbances.
Reconstitute each vial with 10.5ml water for injections and add to 250ml bag of sodium chloride 0.9%. This Corticosteriods can complicate further electrolyte disturbances
should be used immediately. CASPOFUNGIN IS INCOMPATIBLE WITH GLUCOSE – do not use solutions of Consult pharmacist for more information.
glucose to prime or flush the line.
Infusion Rate VORICONAZOLE (VFEND) INFUSION 200MG AND TABLETS 50MG+200MG
Give infusion over 60mins Note: Due to the high oral bioavailability (96%), the IV route should only be used if the oral route is unavailable.
Dosage adjustments Dose
Renal Impairment - For elderly patients (>65 years) or patients with any degree of renal impairment no IV route
dosage adjustments required Loading dose 6mg/kg every 12 hours for 2 doses
Hepatic Impairment - Mild - no dosage adjustments Maintenance dose 4mg/kg twice a day (can be reduced to 3mg/kg if not tolerated)
Moderate - initial loading dose 70mg, daily dose of 35mg thereafter Oral route
Severe - no data available >40kg: loading dose 400mg every 12 hours for 2 doses.
Use under 18 years of age not recommended Maintenance dose 200mg twice daily (300mg twice daily if response inadequate)
<40kg: loading dose 200mg every 12 hours for 2 doses
Cautions/Contraindications/Side effects Maintenance dose 100mg twice daily (150mg twice daily if response inadequate)
Consult the BNF and Summary of Product Characteristics – www.emc.medicines.org.uk
Reconstitution
Fever, injection site reactions, headache, tachycardia, altered LFTs and U+Es -consult product literature for full Reconstitute vial with 19ml water for injection. Add to normal saline 0.9% or glucose 5% to give final
list concentration of 0.5-5mg/ml (see table)
Interactions i.e. 70kg patient at 6mg/kg loading dose (420mg). Give in 100ml NaCl 0.9% over 2 hrs then 4mg/kg maintenance
Ciclosporin increases levels of caspofungin - monitor LFTs dose (280mg). Give in 100ml NaCl 0.9% over 1.5hrs
Tacrolimus levels can be reduced Required Volumes of 10 mg/ml VFEND Concentrate
Efavirenz, nevirapine, rifampicin, dexamethasone, phenytoin and carbamazepine may result in reduced
caspofungin levels. When co-administering with enzyme inducers as listed above, a daily dose of 70mg should Body Weight Volume of VFEND Concentrate (10 mg/ml) required for:
be used. (kg) 3 mg/kg dose 4 mg/kg dose 6 mg/kg dose
30 9.0 ml (1) 12 ml (1) 18 ml(1)
LIPOSOMAL AMPHOTERICIN (AMBISOME) 35 10.5 ml (1) 14 ml (1) 21 ml (2)
Available from CIVAS service Mon-Fri 40 12.0 ml (1) 16 ml (1) 24 ml (2)
Dose 45 13.5 ml (1) 18 ml (1) 27 ml (2)
For the purposes of this protocol the recommended dose is 3mg/kg (consider rounding to the nearest 50mg). 50 15.0 ml (1) 20 ml (1) 30 ml (2)
Reconstitution 55 16.5 ml (1) 22 ml (2) 33 ml (2)
Reconstitute a 50mg vial with 12ml of WATER FOR INJECTION ONLY. This will provide a solution of 4mg/ml. 60 18.0 ml (1) 24 ml (2) 36 ml (2)
Infusion concentrations should be between 0.2 to 2mg/ml in glucose (dextrose) 5%. In practice for doses 65 19.5 ml (1) 26 ml (2) 39 ml (2)
between 50mg and 400mg dilute into a 250ml glucose (dextrose) 5%. 70 21.0 ml (2) 28 ml (2) 42 ml (3)
AMBISOME IS INCOMPATIBLE WITH NaCl 0.9% (Normal Saline)- do not use solution of Sodium Chloride to
75 22.5 ml (2) 30 ml (2) 45 ml (3)
prime or flush the lines.
80 24.0 ml (2) 32 ml (2) 48 ml (3)
Infusion Rate 85 25.5 ml (2) 34 ml (2) 51 ml (3)
30 – 60 minutes.
90 27.0 ml (2) 36 ml (2) 54 ml (3)
Dosage Adjustments 95 28.5 ml (2) 38 ml (2) 57 ml (3)
Renal Impairment - no dosage adjustment recommended
Liver Impairment - can cause raised alkaline phosphatase and bilirubin. In patients with pre-existing 100 30.0 ml (2) 40 ml (2) 60 ml (3)
liver failure or changes in liver function test consult the pharmacist.
Infusion Rate
Maximum rate of 3mg/kg/hour over 1-2 hours
FLUCONAZOLE CAPSULES (DIFLUCAN)
Dosage Adjustments
Dose
Elderly (>65yrs) - No adjustments
Prophylaxis – 50mg daily or 100mg if poor absorption anticipated.
Renal Impairment - Moderate to severe -switch to oral therapy if possible to avoid accumulation of
excipients. If use IV, monitor serum creatinine. Dosage Adjustments
Hepatic Impairment- No dosage adjustments for acute hepatic injury (↑ALT, AST) Renal Impairment - In mild to moderate renal failure 50mg can be used as a maximum dose daily. In
Mild to moderate hepatic impairment - standard loading dose, half maintenance dose severe renal failure consult the pharmacist -rarely changes in electrolytes have been
seen with fluconazole therapy - of uncertain clinical significance
Cautions/Contraindications/Side Effects
Liver Impairment - In patients with pre-existing liver failure consult the pharmacist. Fluconazole can
Consult the BNF and Summary of Product Characteristics – www.emc.medicines.org.uk/
cause hepatotoxicity -if a causal relationship cannot be excluded fluconazole should
• Most side effects transient. Include rash, fever, vomiting, diarrhoea and headache Visual disturbances most be stopped and advice sought regarding alternative therapy.
common which are mild and reversible with majority spontaneously resolving within 60 minutes Caution/Contraindication/Side Effects.
• Monitor LFTs Consult the BNF and Summary of Product Characteristics – www.emc.medicines.org.uk/
• Contraindicated with Terfenadine, Rifampicin, Carbamazepine, Phenobarbital and Anti-retrovirals. Consult Patients with sensitivities to fluconazole or other azoles. Regularly monitor LFTs.
product literature for full list
Drug Interactions
Interactions Warfarin effects increased.
Omeprazole - halve dose of omeprazole Phenytoin levels increased.
Warfarin - monitor INR closely (enhanced anticoagulant effect) Ciclosporin & tacrolimus increased
Phenytoin - increase IV maintenance dose of voriconazole to 5mg/kg. Increase oral voriconazole maintenance Markedly increased levels of midazolam.
dose to 400mg bd (>40kg) and 200mg bd (<40kg) Monitor phenytoin levels and for phenytoin toxicity; avoid use Reduces effects of amphotericin
together if possible.
Ciclosporin - doses of ciclosporin should be halved and monitor levels of ciclosporin. When voriconazole is
discontinued, ciclosporin levels must be carefully monitored and the dose increased as necessary.
ITRACONAZOLE LIQUID 10mg/ml (SPORANOX®)

Only the Liquid preparation should be used.
Dose
Prophylaxis – 5mg/kg twice daily.
Dosage Adjustments
Renal Impairment - Avoid in severe renal impairment due to propylene glycol in solution.
Liver Impairment - Metabolised in the liver. Caution in patients with pre-existing liver failure -consult the
pharmacist. Itraconazole can cause hepatotoxicity -consult the pharmacist and review
SPC. If a causal relationship is suspected stop itraconazole.
Caution/Contraindication/Side Effects.
Consult the BNF and Summary of Product Characteristics – www.emc.medicines.org.uk/
Patients with sensitivities to itraconazole or other Azoles. Regularly monitor LFTs. CAN RARELY CAUSE
CONGESTIVE HEART FAILURE.
Drug Interactions
Calcium Channel Blockers – increased risk of CCF
Clarithromycin increases plasma level of itraconazole.
Warfarin effects enhanced
Phenytoin decreases itraconazole levels
Care with antipsychotics
Markedly increased and prolonged sedation with midazolam.
Digoxin levels increased.
Ciclosporin levels increase
Atorvastatin, simvastatin and lovastatin – stop these drugs as increased risk of myopathy
PPIs and histamine H2 antagonists reduce absorption
Vincristine metabolism inhibited increased risk of neurotoxicity
Busulphan metabolism inhibited increased risk of toxicity.
Methylprednisolone metabolism inhibited
Reduces effects of amphotericin
GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS Preparation for women likely to be undergoing bowel surgery
IN No history of penicillin allergy
Co-amoxiclav (Augmentin) 1.2g IV at the time of induction of anaesthesia.
MAJOR GYNAECOLOGICAL SURGERY
Suspected/known penicillin allergy
Background Gentamicin 4 mg/kg IV + metronidazole 1 g IV at the time of induction of anaesthesia.
The overall aim of antibiotic prophylaxis during gynaecological surgery is to prevent postoperative infection of the
surgical site and reduce postoperative infectious morbidity and mortality, and thereby reduce duration and the Discussion
cost of postoperative health care. (1) Studies did not indicate more benefit from single versus multiple doses of prophylactic antibiotics. (6)
Studies showed that antibiotic prophylaxis decrease the risk of infectious complications esp. after major
Agent needs to be administered at the correct dose, and time that ensures adequate concentrations at the procedure e.g. hysterectomy, and they concluded that monotherapy is the method of choice in perioperative
incision site during the period of potential contamination. prophylaxis. (7).
The agent needs to be active against the pathogens most likely to contaminate the wound and the pelvis. The ACOG guidelines support the use of first, second or third generation cephalosporin. Most of the literature
The agent needs to be safe, administered for the shortest effective period to minimize adverse effects and cost of considered first generation Cephalosporin e.g. Cefazolin is equivalent to 2nd and 3rd generation cephalosporin, but
treatment as well as development of bacterial resistance (2). there is lack of data comparing first and second generation cephalosporin, the optimal choice for prophylaxis has
The organisms responsible for gynaecological infections fall into 2 broad categories: not been determined but second generation cephalosporin have shown efficacy.(8)
1- sexually transmissible organisms
2- endogenous vaginal flora. References
1. Giuliani B, Piriti, E, Mecacci F. Antimicrobial prophylaxis in obstetric and gynaecological surgery. J
The vagina flora consists of many aerobic and anaerobic organisms in a ratio between 1:2 and 1:5. It is Chemother 1999; 11: 577-580.
dominated by peroxide producing lactobacilli, and is non-pathogenic under normal conditions. 2. S.Guaschino, D. De Santo, F. De Seta. New perspectives in antibiotic prophylaxis for obstetric and
In Bacterial Vaginosis (BV) destabilization of the vaginal ecosystem occurs with massive increase in the ratio of gynaecological surgery. J Hosp Infect. 2002; 50: 513-516.
anaerobes to aerobes 100-1000:1 and is associated with increase risk of infections. 3. Anonymous. ACOG educational bulletin. Antibiotics and gynaecologic infections. American College of
Obstetricians and Gynaecologists. Number 237, June 1997. Int J Gynaecol Obstet 1997; 58:333-340.
There is universal agreement as to the need for antibiotic prophylaxis prior to any hysterectomy (3, 4, 5,), the
4. Sign Guidelines Network. Antibiotic Prophylaxis in Surgery. 2000
American College of Obstetricians and Gynaecologists recommended the use of a single dose of penicillin,
5. Royal College of Obstetricians and Gynaecologists. The management of menorrhagia in Secondary Care.
cephalosporin, or clindamycin (if beta-lactam allergy). (3)
1999.
6. Costa RJ, Krauss-Silva L.Systemic review and meta-analysis of antibiotic prophylaxis abdominal
Major gynaecological operations at high risk of postoperative infections hysterectomy .Cad Saude Publica. 2004; 20 Suppl 2: S175-89.
1- Vaginal, abdominal, or laparoscopic hysterectomy. 7. Latkowski kJ, Blok R, Blok K., Grybos M.Antibiotic prophylaxis after abdominal hysterectomy –comparitive
2- Laparotomy (including colposuspensions, oophorectomy, hysterectomy). analysis of two treatment patterns. Ginekol Pol.2003; 74(3): 215-9.
3- Pelvic floor repairs (including TVT). 8. American Society of Health- System Pharmacists. ASHP therapeutic guidelines on antimicrobial prophylaxis
in surgery. Am J Health Syst Pharm 1999; 173: 1839-1888.
Principles
• Prophylaxis should be given intravenously.
• Within 30 minutes of induction of anaesthesia. Vanessa Kay
• A single dose is sufficient, a second dose is administered if the procedure lasts more than 3 hours or if Reham.S.Soliman
there is excessive blood loss (more than 1500 ml) (2).
• Patients with confirmed BV are given topical clindamycin for 7 days leading up to the surgery, in addition to June 2005
the usual prophylactic regimen, because prophylaxis proved to be less effective in patients with BV. Review June 2006
• It should be written up preoperatively in the once only section of the drug kardex.
• This should be written up by the admitting SHO.
• Antibiotic should be given by the anaesthetist in operating theatre at induction of anaesthesia.
Regimen
No history of penicillin allergy
Co-amoxiclav (Augmentin) 1.2g IV at the time of induction of anaesthesia.
Doubtful / unconfirmed history of penicillin allergy
Cefuroxime 1.5g IV + Metronidazole 1g IV at the time of induction of anaesthesia
History of anaphylaxis, severe urticaria, severe rash immediately after penicillin
Clindamycin 600mg IV + Gentamicin 120mg IV at the time of induction of anaesthesia.
Updated June 2005 Uncontrolled when printed Updated June 2005 14-47 Uncontrolled when printed
14-46
ANTIBIOTIC PROTOCOL FOR THE MANAGEMENT OF ACUTE PELVIC
INFLAMMATORY DISEASE*
OUTPATIENT TREATMENT
• Oral ofloxacin 400mg twice a day plus
oral metronidazole 400mg twice a day for 14 days (as per Tayside Area Prescribing Guide)
INPATIENT TREATMENT
In more severe cases inpatient antibiotic treatment should be based on IV therapy, which should be continued
until 24 hours after clinical improvement and followed by oral therapy.
• Intravenous ciprofloxacin 400mg twice a day plus intravenous metronidazole 500mg three times a day plus
intravenous Augmentin 1.2g three times a day
followed by:
• oral ofloxacin 400mg twice a day plus

oral metronidazole 400mg twice a day plus
oral Augmentin 375mg three times a day
TO COMPLETE 14 DAYS IN TOTAL
Dr M A R Thomson August 2004

Review June 2006
* As adapted from the RCOG Guideline No.32, “Management of Acute PID” May 2003 and approved by the
ASD Anti-infectives Subcommittee.
Updated June 2005 14-48 Uncontrolled when printed Updated June 2005 Uncontrolled when printed
14-49
THE TAYSIDE CRITICAL CARE PATHWAY FOR THE MANAGEMENT OF COMMUNITY-ACQUIRED PNEUMONIA
Medicine & Cardiovascular Clinical Group Pathway
PATIENT ADMITTED with SUSPECTED or PROVEN COMMUNITY-ACQUIRED PNEUMONIA
ALL PATIENTS SHOULD BE ASSESSED IMMEDIATELY FOR:

• SEVERITY - Use severity box below to guide management. Record clearly in notes
• ANTIBIOTICS – GIVE IMMEDIATELY. Take blood culture first, but DO NOT AWAIT the results
of a CXR. See appropriate antibiotic box below.
ADVICE • OXYGEN – Aim to keep Sa/PaO2 well above 92%/8.0kPa. Do ABG if SaO₂ <92%. In non-COPD ADVICE
ONLY ONLY
patients, 60-100% FiO2 is safe. COPD: 28% and adjust according to ABG
Respiratory Respiratory
(9-5pm) or
• IV FLUIDS – Aim to keep BP >90/60 with good urine output (>30mls/hour) (9-5pm) or
Medical Team on- Medical Team on-
call (5pm-9am) via THE FOLLOWING SHOULD BE PERFORMED ON ALL PATIENTS: call (5pm-9am) via
switchboard FBC, U&E, LFT, CRP, BLOOD CULTURE, SPUTUM CULTURE, BASELINE SEROLOGY, CXR, ECG and switchboard
nursing observations 4-hourly (including RR and oximetry) until stable
ASSESS SEVERITY OF PATIENT’S PNEUMONIA

CORE Adverse Prognostic Features
• CONFUSION, NEW (MSQ ≤8/10)
• UREA >7mmol/l (if available)
• RESPIRATORY RATE ≥ 30/minute
• BP <90mmHg (systolic) or ≤60mmHg (diastolic)
PRE-EXISTING Adverse Prognostic Features
• Age ≥ 50 years
• Co-existing chronic illness
ADDITIONAL Adverse Prognostic Features
• Pulse oximetry <92% or PaO2 <8.0kPa on any FiO2 (if available)
• Bilateral or multi-lobar changes on CXR (if available)
NO ADVERSE ALL OTHER PATIENTS: TWO OR MORE

PROGNOSTIC FEATURES USE CLINILCAL JUDGEMEMT CORE FEATURES
CONSIDER HOME NON-SEVERE, BUT NEEDS SEVERE

THERAPY IF: HOSPITAL MANAGEMENT
• Oral route available NO
• Satisfactory social situation
• Consider the Early Supportive Discharge
Service (9am-5pm) OR a Community ANTIBIOTICS: NON-SEVERE ANTIBIOTICS: SEVERE
Hospital bed • IF ORAL ROUTE AVAILABLE: • ALL SHOULD INITIALLY RECEIVE:
Amoxicillin 1g x3/day PLUS ERYTHROMYCIN IV CO-AMOXICLAV 1.2g x3/day PLUS IV
500mg x4/day CLARITHROMYCIN 500mg x2/day
• IF IV REQUIRED: (PENICILLIN ALLERGY: IV
YES Levofloxacin 500mg x2/day stepping down
HOME THERAPY AMOXICILLIN 1g x3/day PLUS
• 1st CHOICE: AMOXICILLIN 500mg CLARITHROMYCIN 500mg x2/day to oral Moxifloxacin 400mg once daily)
x3/day PO for 7 days (PENICILLIN ALLERGY: Erythromycin OR • ALL SHOULD HAVE: Paired serology
• ALTERNATIVE: ERYTHROMYCIN Clarithromycin monotherapy) & urinary legionella antigen tests
500mg x4/day PO OR • Treat for 7 days (IV/oral) • Treat for at least 10 days (IV/oral)
CLARITHROMYCIN 500mg x2/day PO
for 7 days PENICILLIN ALLERGY = RASH and/or ANAPHYLAXIS
• Oral fluids, antipyretics, analgesia
• Smoking advice
• CAP INFORMATION LEAFLET
ASSESS & RECORD PROGRESS EVERY 12 HOURS UNTIL STABLE
• IF NOT IMPROVING: RE-ASSESS SEVERITY, ANTIBIOTICS, OXYGENATION and IV
FLUIDS. Repeat CXR (empyema), FBC & CRP. Discuss with Respiratory Team
FOLLOW-UP • REFER TO ICU (Consultant/Senior SpR only) IF: Persistent hypoxia (PaO <8.0kPa) despite high
• CXR at 6/52 if risk of lung cancer (e.g. FiO2 Progressive hypercapnia, pH <7.26, shock or depressed GCS (<8)
smokers and/or age >50y)
• Consider further investigation for
persistent symptoms/signs
• HOSPITAL to ORGANISE CONSIDER IV to ORAL SWITCH IF:
FOLLOW-UP ARRANGEMENTS - Oral/GI route available - Temperature <38°C for 24h - SaO2/PaO2 ≥92%/8.0kPa (air)
• Influenza/pneumococcal vaccination for - Pulse <100/minute - RR < 30/minute - BP ≥90/60 mmHg
those at risk CONSIDER DISCHARGE 24-HOURS AFTER SWITCH TO ORAL THERAPY
• Smoking advice GIVE ALL PATIENTS A CAP INFORMATION LEAFLET
14-50
Updated June 2005
Second Edition
Early Management of Suspected Bacterial Meningitis and

Meningococcal Septicaemia in Immunocompetent Adults*
Additional Information
Early Recognition a
Warning Signs (see refs)
■ Petechial/purpuric non-blanching rash or signs of meningitis
Courtesy: Dr A Riordan
The following warn of impending/worsening
■ A rash may be absent or atypical at presentation shock, respiratory failure or raised
■ Neck stiffness may be absent in up to 30% of cases of meningitis intracranial pressure and require
urgent senior review and intervention
■ Prior antibiotics may mask the severity of the illness typical meningococcal rash (see algorithm):
• Rapidly progressive rash
• Poor peripheral perfusion, CRT > 4 secs,
Assess Severity & Immediate Interventiona Priority oliguria and systolic BP < 90 (hypotension
Investigations: often a late sign)
■ Airway • RR < 8 or > 30
■ FBC; U+Es; Blood
■ Breathing - Respiratory Rate & O2 Saturation sugar, LFTs; CRP • Pulse rate < 40 or > 140
■ Circulation - Pulse; Capillary Refill Time (hypotension late); ■ Clotting profile • Acidosis pH < 7.3 or BE worse than - 5
Urine output ■ Blood gases • WBC < 4
■ Mental status (deterioration may be a sign of shock or meningitis) • Marked depressed conscious level
Microbiology: (GCS < 12) or a fluctuating conscious
■ Neurology – Focal neurological signs; Persistent seizures;
■ Blood culture level (fall in GCS > 2)
Papilloedema
■ Throat swab • Focal neurology
Secure Airway ■ Clotted blood • Persistent seizures
High Flow O2 ■ EDTA blood • Bradycardia and hypertension
Large bore IV Cannula ± fluid resuscitation for PCR • Papilloedema
b
CT scan and meningitis (see refs)
This investigation should only be used when
Predominantly Predominantly Meningitis b,c,d appropriate:
Meningococcal ■ Assess patient carefully before performing LP • A normal CT scan does not exclude raised
intracranial pressure
Septicaemia ■ Call critical care team if any features of • If there are no clinical contraindications to
raised intracranial pressure, shock or LP, a CT scan is not necessary beforehand
■ Do not attempt LP respiratory failure • Subsequently a CT scan may be useful in
■ IV 2g Cefotaxime or Ceftriaxone ■ If uncertain ask for senior review identifying dural defects predisposing to
■ Call critical care team for review meningitis
■ Monitor and stabilise circulation
c
Appropriate antibiotics
for bacterial meningitis
Signs of Shock a No Raised ICP Signs of (see refs)
No Shock Raised ICP a,b Review with microbiology:
YES NO No Respiratory Failure a,b • Ampicillin IV 2g qds should be added for
individuals >55 years to cover Listeria
• Vancomycin ± rifampicin if pneumococcal
penicillin resistance suspected
Priorities Lumbar Priorities • Amend antibiotics on the basis of
■ Secure airway + High puncture a,b ■ Secure airway + High flow O2 microbiology results
flow O2 ■ Defer lumbar puncture d
■ IV 2g Cefotaxime/ Corticosteroids in adult
■ Volume resuscitation Ceftriaxone ■ IV 2g Cefotaxime/Ceftriaxone meningitis (see refs)
■ Senior review immediately ■ Consider corticosteroidsd • Dexamethasone 0.15mg/kg qds for 4 days
after LP ■ Careful volume resuscitation started with or just before the first dose of
■ Management in ■ Consider ■ 30o head elevation antibiotics, particularly where
critical care unit corticosteroidsd pneumococcal meningitis is suspected
■ Management in critical
■ if LP will be delayed care unit • Do not give unless you are confident you
Poor Good for more than 30 are using the correct antimicrobials
response response ■ Low threshold for elective
minutes give IV Intubation + Ventilation • Stop the dexamethasone if a non-bacterial
antibiotics first (cerebral protection) cause is identified
Further References:
1. Begg N, Cartwright KA, Cohen J, Kaczmarski EB, Innes JA, Leen CL, et al. Consensus statement on
diagnosis, investigation, treatment and prevention of acute bacterial meningitis in immunocompetent adults.
interventions 2.
British Infection Society Working Party. J Infect 1999;39:1-15.
de Gans J, van de Beek D. Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002;
347:1549-1556.
■ Pre-emptive Intubation
Careful Monitoring
3. Durand ML, Calderwood SB, Weber DJ, Miller SI, Southwick FS, Caviness VS, Jr., Swartz MN.
a Acute bacterial meningitis in adults. A review of 493 episodes. N Engl J Med 1993;328:21-28.
+ Ventilation 4.
5.
Heyderman RS, Klein NJ. Emergency management of meningitis. J R Soc Med 2000;93:225-229.
Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture
■ Volume support 6.
in adults with suspected meningitis. N Engl J Med 2001;345:1727-1733.
Kneen R, Solomon T, Appleton R. The role of lumbar puncture in suspected CNS infection-a disappearing
■ Inotropic/ Vasopressor
Support
Repeated Review 7.
8.
skill? Arch Dis Child 2002;87:181-183.
PHLS Meningococcus Forum. Guidelines for public health management of meningococcal disease in the UK.
Comm Dis Public Health 2002; 5:187-204.
Pollard AJ, Britto J, Nadel S, DeMunter C, Habibi P, Levin M. Emergency management of meningococcal
disease. Arch Dis Child 1999;80:290-296.
■ Consider activated 9. Riordan FA, Thomson AP, Sills JA, Hart CA. Who spots the spots? Diagnosis and treatment of early
meningococcal disease in children. BMJ 1996;313:1255-1256.
protein C12 Public Health/Infection Control
10. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M. Early goal-
directed therapy in the treatement of severe sepsis and septic shock. N Engl J Med 2001;345:1368-1377.
11. Sigurdardottir B, Bjornsson OM, Jonsdottir KE, Erlendsdottir H, Gudmundsson S. Acute bacterial meningitis
■ Good glycaemic control13 in adults. A 20-year overview. Archives of Internal Medicine 1997;157:425-430.
■ Notify CCDC† 12. National Institute for Clinical Excellence. Drotrecogin alfa (activated) for severe sepsis. London: National
■ In refractory circulatory ■ If probable or confirmed meningococcal disease, contact
Institute for Clinical Excellence; 2004. http://www.nice.org.uk/pdf/word/TA084guidance.doc (accessed 6
Dec 2004)
failure, physiological CCDC† urgently regarding prophylaxis to contacts
13. van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P,
Lauwers P, Bouillon R. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345:1359-
replacement corticosteroid ■ Notify microbiology 14.
1367.
Annane D, Bellissant E, Bollaert PE, Briegel J, Keh D, Kupfer Y. Corticosteroids for severe sepsis and septic
therapy may be beneficial14 ■ Isolate patient for first 24 hours
shock: a systematic review and meta-analysis. BMJ 2004; 329:480-489.
www.britishinfectionsociety.org www.meningitis.org
* Community acquired meningitis in the immunocompetent host.
14-51 For further copies contact
Journal of Infection February 2003; Vol 46(2) In the immunocompromised seek additional expert advice Meningitis Research Foundation 01454 281811
© British Infection Society †CPHM in Scotland Registered Charity No 1091105
pub 12/04
MRSA TREATMENT PROTOCOL MRSA isolated from specimen
(Based on recommendations of the BSAC Guidelines 2005 www.bsac.org.uk) Colonisation: MRSA is present in or on a body site but
no clinical signs or symptoms of illness or infection are
Seek Infection Control Team advice Colonisation Colonisation or Infection ?

i present.
Infection: Isolation of an organism accompanied by
Duration of therapy: clinical signs of illness or sepsis, eg fever, inflammation,
Bacteraemia – minimum of 10-14 days INFECTED SITE ↑WCC, etc.
Non-bacteraemia 5-7 days and then review
NO BACTERAEMIA Check history of antibiotic NO BACTERAEMIA

hypersensitivity (rash or anaphylaxis)
Surgical
Skin or Soft Tissue Respiratory UTI BJI*** Other
Infection (including wound Check antibiotic Prophylaxis
infection), infected ulcer susceptibility if available for implant
Follow Seek ID Seek surgery
COPD HAP* VAP** advice advice ID/Micro
Oral IV bronchiectasis Blood culture +ve in BOX 1 advice
therapy therapy BACTERAEMIA through
If related to switchboard
intravascular
IV Vancomycin + po rifampicin line urgently If history of MRSA colonisation or infection
BOX 1 ? Suitable for see IV Vancomycin prescribing consider without documented eradication consider
po doxycycline Ambulatory Home IV protocol on p14-36 of TAPG removing line glycopeptide prophylaxis +/- antibiotic active
or therapy
If IV Vancomycin
against another potential pathogen. Also see
po trimethoprim + guidance on MRSA decontamination regimen
contraindicated
rifampicin in Antibiotic Policy
or inappropriate
Contact
ID Service LINEZOLID - RESTRICTED ANTIBIOTIC IF NOT SURE ABOUT ANY ASPECT OF
(Seek ID/Micro approval) THIS PROTOCOL PLEASE SEEK ADVICE
FOR SWITCHING FROM IV TO ORAL For further guidance see Linezolid prescribing guidance FROM DUTY MICROBIOLOGIST, ID
SEEK PHARMACY, on p14-6 of TAPG PHYSICIAN OR PHARMACIST
MICRO OR ID ADVICE
*HAP = Hospital Acquired Pneumonia Antibiotic Subcommittee

**VAP = Ventilator Associated Pneumonia Complete Linezolid
***BJI = Bone & Joint Infection Mandatory Order Form August 05 Review August 07
14-52

Adult Antibiotic Policy: List of Contents

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GENERAL NOTES 14-3

ANTIVIRAL TREATMENTS FOR HIV INFECTION

The new preparation of amphotericin in current use is:

atypical organisms Legionella pneumophila Mycoplasma pneumoniae.

Clinical conditions Pathogen(s) Antibiotic(s) Comments

Ear, Nose & Throat Infections

Acute otitis media Strep. pneumoniae Amoxicillin

Chronic sinusitis As for acute sinusitis plus Co-amoxiclav

Urinary Tract Infections

Genital Tract Infections

Updated June 2005 Uncontrolled when printed

*Ref MSSVD Guidelines 2001 (www.mssvd.org.uk)

Clinical conditions Pathogen(s) Antibiotic(s) Comments

Peritonitis or diverticulitis Coliforms IV cefuroxime + metronidazole Add IV gentamicin if perforation suspected.

Necrotising pancreatitis Seek specialist advice

Updated June 2005 Uncontrolled when printed

Staphylococci commencement of antibiotics.

Clinical conditions Pathogen(s) Antibiotic(s) Comments

Skin & soft tissue and bone infections

Post-operative wound Staph. aureus Flucloxacillin Drain pus if present.

Updated June 2005 Uncontrolled when printed

Bites Streptococci Co-amoxiclav If penicillin allergic use ciprofloxacin + clindamycin

Prosthetic joint infections Seek specialist advice.

Clinical conditions Pathogen(s) Antibiotic(s) Comments

Keratitis Strep. pneumoniae Specific therapy essential Obtain ophthalmic consultation

Updated June 2005 Uncontrolled when printed

Eradication – On advice from Infection Control only

(g) Endoscopic urological surgery Gentamicin 4mg/kg by IV bolus injection.

PREVENTION OF GAS GANGRENE IN AMPUTATION SURGERY

PATIENTS WITH CSF LEAK

Updated June 2005 Uncontrolled when printed

All procedures: high risk patients Amoxicillin IV 1g + gentamicin IV 120mg

For neutropenic patients add Metronidazole IV 500mg to regime used.

PEG tube insertion all patients Co-amoxiclav IV 1.2g or if penicillin allergic

ANTIBIOTIC PROPHYLAXIS IN VARICEAL BLEEDING

Ciprofloxacin PO 500mg bd for 7 days

ANTIBIOTIC PROPHYLAXIS FOR SBP IN PATIENTS WITH ASCITES

Norfloxacin 400mg once daily during hospital admission only.

ANTIFUNGAL PROPHYLAXIS IN HAEMATOLOGY PATIENTS

MENINGOCOCCAL INFECTION PROPHYLAXIS

Establish a list of close contacts:

<1 year Rifampicin 5mg/kg* orally, twice daily for 2 days

Updated June 2005 Uncontrolled when printed

The following groups are recommended to receive chemoprophylaxis:

PREVENTION OF INFECTIVE ENDOCARDITIS FOR DENTAL PATIENTS REQUIRING A GENERAL ANAESTHETIC

or (e) Teicoplanin 400mg IV + gentamicin 120mg IV at induction or 15 minutes before the

or (f) Clindamycin 300mg IV (over at least 10 minutes) at induction or 15 minutes before

PREVENTION OF INFECTIVE ENDOCARDITIS FOR DENTAL PATIENTS REQUIRING LOCAL OR NO ANAESTHESIA

Updated June 2005 Uncontrolled when printed

14-27 Uncontrolled when printed 14-28 Uncontrolled when printed

ORAL ORAL ORAL ORAL ORAL ORAL ORAL ORAL ORAL

Co-amoxiclav Not Not Flucloxacillin Co-amoxiclav Co-amoxiclav Ciproflox.

Co-amoxiclav *** Cefuroxime Seek advice Co-amoxiclav Co-amoxiclav Not

GENTAMICIN ONCE A DAY

GENTAMICIN: ONCE DAILY DOSING

ONCE DAILY DOSING SCHEDULE:

The maintenance dose is then adjusted according to the following schedule:

Serum concentration monitoring

Exclusions to this dosage schedule

Time between start of infusion and sample draw (hours)

Before starting IV Vancomycin Indications:

Does your patient have