Guidelines for the empiric use of antimicrobials in adults

Transcription

Guidelines for the
empiric use of
antimicrobials
in adults
HSE South East Hospitals:
Waterford Regional Hospital
South Tipperary General Hospital
Kilcreene Orthopaedic Hospital
St. Luke’s General Hospital, Kilkenny
Wexford General Hospital
June 2013
Review Date: June 2014
Acknowledgement: Gentamicin and Vancomycin Algorithims page
23 & 25 adapted from original algorithims kindly provided by
Beaumont/Connolly Hospital Antimicrobial Stewardship Committee
in 2011.
Issued in June 2006
Revised Annually
Revision No 7
Review Date June 2014
HSE SE Antimicrobial Stewardship Group
Disclaimer:
Whilst every effort has been made to ensure the accuracy of the information and material contained
in this document, errors or omissions may occur in the content. We acknowledge that new evidence
may emerge that may overtake some of these recommendations. The document will be reviewed
and revised as and when appropriate. Prescribers should ensure that the correct drug and dose is
prescribed, as is appropriate for each individual patient. References that should be used in conjunction
with these guidelines include the British National Formulary (BNF) and the drug data sheets (available
on www.medicines.ie). Clinical guidelines are guidelines only and the interpretation and application
of the guidelines remains the responsibility of the individual clinician.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals June 2013
Index no ASG 001 Date of Approval June 2013 Revision Date June 2014 Revision no 7
Table of Contents
General Guidance
Restricted and Reserve Antimicrobials
MRSA
Septicaemia/Systemic Sepsis,
Sepsis in Pregnancy, Neutropenic Sepsis
Urinary Tract Infection
Respiratory Tract Infection
Endocarditis & Intra-abdominal Infections
Gastro-intestinal Infection
Start Smart Then Focus Care Bundle
Genital Tract Infection
Bone and Joint Infections
Skin and Soft tissue Infections
Central Nervous System
ENT infections
Appendix 1: Start Smart, Then Focus
Care Bundle
Appendix 2: Gentamicin
Appendix 3: Glycopeptides:
Vancomycin, Teicoplanin
Appendix 4: Treatment of Clostridium difficile Infection
Appendix 5: Switch from IV to PO
Appendix 6: Contingency Plan in Eventuality of Shortage of Intravenous
Co-amoxiclav
Appendix 7: Relative Costs of Antimicrobials References
Page No.
2-3
4
5
6-7
8
9 - 14
14
15
16 - 17
18
19
19
20
20
21
22 - 23
24 - 25
26 - 27
28 - 29
30
31
32
1
2
Where possible indicate intended duration of therapy at point of initial prescribing. Review IV antimicrobial
therapy daily.
Document indication for therapy and intended duration in medical record. Note these guidelines are intended
for empiric therapy. Rationalise when microbiology results become available. It is the responsibility of the
person/team ordering laboratory tests to follow up on the results to guide appropriate clinical
management of the patient.
Piperacillin-tazobactam and co-amoxiclav provide good anaerobic cover. Concurrent metronidazole is
NOT required unless there is gross faecal contamination – e.g. faecal peritonitis. Treatment of aspiration
pneumonia does NOT require addition of metronidazole to either of these antibiotics.
Some antibiotics e.g. ciprofloxacin, levofloxacin, fusidic acid and metronidazole have excellent
oral bioavailability and the oral route should be used where possible. IV formulations of these should only
be used if the patient is not absorbing or unable to have oral medications.
2. 3. 4. 5. Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals June 2013
NB: The prescriber should always check prescribing information such as cautions,
contraindications, interactions and side effects when considering antimicrobial therapy. Ensure
information on antimicrobial prescribing, including risks and side effects associated with
antimicrobial treatment, is available to patients or their legal guardians.¹
1. GENERAL GUIDANCE
3
For oral switch guidelines see pg 28. Oral switch is usually to PO formulation of same antibiotic where
available, except IV penicillin to PO amoxicillin as oral absorption of penicillin is very poor.
Penicillin allergy: obtain & document proper history. If IgE mediated allergic reaction (e.g.
anaphylaxis, angioneurotic oedema, immediate urticaria) avoid all beta-lactams. If rash only, a cephalosporin
may be considered. Erythromycin is often NOT a good substitute.
Flucloxacillin and other betalactams such as co-amoxiclav, piperacillin-tazobactam, cephalosporins and
meropenem do not cover MRSA.
Risk of Clostridium difficile associated with all antibiotic use. Particular risk with all fluroquinolones (e.g.
levofloxacin and ciprofloxacin), clindamycin and cephalosporins.
7. 8. 9. 10. Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals June 2013
Oral switch – consider when patient is afebrile and infection parameters are settling for 48 hours and normal
oral absorption. Generally NOT appropriate in meningitis, endocarditis, febrile neutropenia or acute
osteomyelitis/septic arthritis.
6. Guidelines for the empiric use of antimicrobials in adults HSE SE Hospitals June 2013
Restricted/Reserve Antimicrobials:
A Cochrane review has found that reserving access to selected antimicrobials is the most effective
10
component of any Antimicrobial Stewardship Programme.
Below is the list of Restricted and Reserve antimicrobials for the SE Acute Hospitals.
These antimicrobials should only be prescribed when this is in line with the recommendations of this
guideline or following discussion with the Clinical Microbiologist.
Indication for therapy and any discussions/advice from the Clinical Microbiologist should be
documented accurately in patient’s medical record.
Restrictions are in place which limit access to these Antimicrobials. Please refer to South East Acute
Hospitals Guidelines for use of Reserve and Restricted Antimicrobials for details.
Restricted Antimicrobials
*Reserve Antimicrobials
IV Piperacillin/Tazobactam IV Cefotaxime IV Ceftriaxone IV Ceftazidime
IV Ciprofloxacin IV Erythromycin
IV/PO Levofloxacin IV Ofloxacin
IV Chloramphenicol IV Colistin
IV/PO Clindamycin IV Daptomycin
IV Teicoplanin IV Tigecycline
IV Vancomycin
PO Fidaxomicin
IV/PO Linezolid
IV Ceftaroline
IV Meropenem
IV/PO Fosfomycin
Antifungals
Liposomal Amphotericin B
Anidulafungin Caspofungin
Voriconazole
Posaconazole
* Reserve antimicrobials should only be prescribed when recommended by a
Consultant and following discussion with the Clinical Microbiologist.
4
MRSA
(Meticillin Resistant Staphylococcus aureus)
Infection with MRSA should be suspected if:
•
Patient has previously been colonized with MRSA.
(Please check patients notes or check laboratory
enquiry for ‘SIF code’)
•
Recent hospitalization (within 12 months)
•
Transfer from another hospital or long term care
facility.
•
Other situation where increased clinical suspicion of
MRSA (Please refer to most recent edition of: Policy
on Control and Prevention of Meticillin Resistant
Staphylococcus aureus (MRSA) in Acute Hospitals in
the HSE/SE for additional information)
If MRSA infection is suspected, consider
including a glycopeptide (Vancomycin or
Teicoplanin, see page 24) in the empiric treatment regimen.
MRSA eradication: Please refer to most recent edition
of: Policy on Control and Prevention of Meticillin Resistant
Staphylococcus aureus (MRSA) in Acute Hospitals in the
HSE/SE.
5
6
Septicaemia/
Systemic Sepsis
Antibiotic
Comments
Observation Chart. 12
Adapted from: HSE Adult Patient
Check previous laboratory results
Ensure blood cultures taken. See individual
infection treatment guidelines for appropriate
therapy. Refer to NEWS Score of the adult
patient observation chart and Sepsis Six.
Consider if patient at risk for infection
due to MRSA , if so, add vancomycin.
Consider other multiresistant organisms
eg ESBL, VRE, CRE.
Watch for hypotension
Assess patient re possible focus Initial empirical therapy if no obvious
of infection –e.g. urinary tract, source: Piperacillin-tazobactam 4.5g
skin/soft tissue, abdominal, IV TDS. Consider adding gentamicin if
chest, neurological., community haemodynamically unstable / severe infection.
Consider need for additional gram positive
or hospital acquired, travel
cover e.g vancomycin(or teicoplanin if patient
history, recent antibiotic
therapy, presence of prosthetic is already on gentamicin)
devices, intravascular catheters,
Penicillin allergy: Gentamicin, metronidazole
etc.
plus teicoplanin
Condition
7
Initial empirical therapy:
Piperacillin-tazobactam 4.5g IV
TDS. Consider adding gentamicin if
haemodynamically unstable / severe infection.
Consider need for additional gram positive
cover e.g vancomycin (or teicoplanin if patient
is already on gentamicin)
Add clindamycin if invasive group A Strep
Infection suspected.
Sepsis in Pregnancy Refer to Septicaemia/
Systemic Sepsis on p6.
Clinical features suggestive
of sepsis in pregnant women:
Fever/Rigors, Diarrhoea/
Vomiting, Rash, Abdominal/
Pelvic Pain and Tenderness,
Offensive Vaginal Discharge,
Cough, Urinary Symtoms.11
Comments
Refer to NEWS/MEOWS Score and Sepsis
Six. Relevant imaging studies should be
performed promtly.
Inform Consultant Obstetrician
Refer to Critical Care Team and seek
expert advice from microbiologist
when serious sepsis is suspected.
Refer to RCOG Guideline: Bacterial Infection
in Pregnancy for further detailed guidance.11
At least 2 sets of blood cultures
recommended from each lumen of CVC
and peripheral OR peripheral X 2 if no CVC
is present.
Culture of urine, stool, CSF, skin and
respiratory specimens should be guided by
clinical signs / symptoms but should not
be performed routinely.
Persistent fever after 4 days of
antibiotic therapy: consider adding
empiric antifungal agent.
Consider need for viral testing &/or antiviral
therapy if clinical indication
Severe Neutropenia =
Neutrophil Count < 0.5 Fever = Temperature > 380C
Antibiotic
Initial Empiric therapy: Piperacillintazobactam 4.5g QDS IV. Add gentamicin if
complications (e.g. hypotension, pneumonia or
antimicrobial resistance suspected or critically ill).
Consider adding vancomycin or teicoplanin
for specific clinical indications e.g. suspected
CVC-related infection or complications as above.
Penicillin allergy (Not Severe reaction
anaphylaxis): Ceftazidime 2g TDS IV
plus vancomycin or teicoplanin.
Severe reaction/anaphylaxis to
penicillin: Ciprofloxacin plus gentamicin plus
teicoplanin
Neutropenic sepsis9 Neutropenia = Neutrophil
Count < 1.0
Condition
8
Urinary Tract
Infections³
For patients with catheter associated UTIs,
antibiotics are unlikely to resolve the UTI
unless the catheter is removed. If systemic
sepsis suspected treat as per Pyelonephritis.
Piperacillin-tazobactam 4.5g TDS for 1014 days or gentamicin (see page 18 for dosing
regimen).
Ciprofloxacin 500-750mg BD PO for
2-6 weeks.
Pyelonephritis
Prostatitis
Comments
Relapse common. Follow up advised. Check
antimicrobial sensitivity where possible.
Send blood cultures and MSU. Rationalise
therapy as soon as possible. Check culture
and antimicrobial sensitivity results.
Patients with recurrent UTIs may have
resistant organisms. Use 7-10 days
treatment in males.
Nitrofurantoin is not appropriate if creatinine
clearance is < 50 ml/min, use co-amoxiclav
(If not allergic to penicillin (discuss if needed))
In pregnancy nitrofurantoin may also be used
but it should be avoided at term.
Hospital acquired or
recurrent UTI or
complicated UTI
Catheter associated
UTI
Antibiotic
First line: Nitrofurantoin MR 100mg BD PO for
5 days
Second line:Co-Amoxiclav 625mg TDS PO for 3 days
(In penicillin allergy discuss with Microbiologist)
Refer to recent culture results.
If septicaemic: as for pyelonephritis
Condition
Lower urinary tract
infection (uncomplicated)
9
Antibiotic
Comments
CURB-65 score should be used with caution
in younger patients as it may underestimate
severity in these patients.
Community Acquired Pneumonia:
Assess severity using CURB-65 score as per
BTS guidelines:
Confusion (new onset)
Urea >7mmol/L
RR≥30/min
BP - hypotensive: SBP <90mmHg or DBP
≤60mmHg
Age ≥ 65 years
Respiratory Tract Community Acquired
Infections
Pneumonia
Condition
These guidelines are not aimed at:
(a) Patients with known predisposing conditions such as cancer or immunosuppression admitted
with pneumonia to specialist units such as oncology, haematology, palliative care, infectious
disease units or AIDS units
(b) Adults with non pneumonic LRTI, including illnesses labelled as acute bronchitis, acute
exacerbations of COPD or “chest infections”
Based on “British Thoracic Society guidelines for the management of
4
community acquired pneumonia in adults: Update 2009.”
COMMUNITY ACQUIRED PNEUMONIA
10
Community
Acquired
Pneumonia
Levofloxacin 500mg PO/IV OD (12
hourly if severe) Discuss with Microbiologist.
Legionellosis
IV route to be used if oral absorption
unreliable. Early oral switch where possible.
Microbiology: Send blood cultures,
sputum, urine for pneumococcal antigen.
7 days appropriate antibiotic therapy is
recommended.
Co-amoxiclav 1.2g tds IV plus clarithromycin
Microbiology: Send blood cultures, sputum
500mg bd IV.
(requesting legionella culture), urine for
(If legionella strongly suspected consider adding pneumococcal antigen and legionella antigen,
levofloxacin)
CRP.
Penicillin allergy (NOT IgE mediated reaction
Consider switch to PO antibiotics as soon as
/anaphylaxis): cefuroxime 750mg-1.5g tds
clinical improvement occurs and patient is
IV plus clarithromycin 500mg bd IV.
apyrexial for 24 hours.
Severe IgE mediated reaction/anaphylaxis
7-10 days appropriate antibiotics is
to penicillin: levofloxacin 500mg PO/IV OD
proposed. This may need to be extended to
(12 hourly if severe).
14-21 days according to clinical judgement.
High severity
(CURB65 = 3-5)
15 - 40% mortality
Amoxicillin 500mg-1.0g tds PO plus
clarithromycin 500mg bd PO.
(IV if PO administration not possible.)
Penicillin allergy: PO doxycycline
Comments
No microbiological tests required.
7 days appropriate antibiotic therapy is
recommended.
Moderate Severity
(CURB65 = 2)
9% mortality
Antibiotic
Amoxicillin 500mg tds PO. (IV if PO
administration not possible.)
Penicillin allergy: clarithromycin 500mg BD
or doxycycline 200mg OD PO loading dose
then 100mg OD PO.
Low severity
(CURB65 = 0-1)
<3% mortality
Condition
11
Intravenous co-amoxiclav
and macrolide
Oral amoxicillin
and macrolide
Oral amoxicillin
CURB-65 score should be used with caution in younger patients as it may underestimate severity in these patients
Inpatient
management
Inpatient
management
Outpatient
management
High risk
3-5 points
Intermediate risk
2 points
Low risk
0 or 1 point
CURB65 score
New onset mental confusion
Urea>7 mmol/L
Respiratory rate ≥ 30/min
Systolic blood pressure <90mmHg and/or
diastolic blood pressure ≤60mmHg
Age ≥65 years
BTS-recommended therapy for Community Acquired Pneumonia
(Taken from J Antimicrob Chemother 2012; 65: page 612) 4
12
Respiratory
Tract
Infections
Antibiotic
Piperacillin-tazobactam 4.5g TDS IV
If risk factors for MDR pathogens see page 13.
Penicillin allergy: if NOT IgE
mediated/anaphylaxis and if pneumonia is not severe
consider cefuroxime 1.5g TDS IV.
Severe IgE mediated reaction/anaphylaxis to
penicillin: Levofloxacin 500mg PO/IV OD (12
hourly if severe).
Comments
If patient is considered to be high risk
for MRSA, consider adding Vancomycin
For confirmed legionellosis see page 12.
Consider legionella risk. In at risk patients
send urine for legionella antigen and add
clarithromycin empirically. Send sputum for
Legionella culture, if possible
Send sputum for culture if possible
If patient is considered to be high risk
for MRSA, consider adding Teicoplanin
More than 4 days since
admission :
Within 4 days of admission Co-amoxiclav 625mg TDS PO or 1.2g TDS IV
& no recent antibiotics:
for 8 days.
Penicillin allergy (NOT IgE mediated reaction
/anaphylaxis): Cefuroxime 750 mg -1.5g TDS IV.
Severe IgE mediated reaction/anaphylaxis to penicillin:
Levofloxacin 500mg PO / IV OD. (12 hourly if severe).
Hospital acquired
pneumonia 6
Health care
Patients from nursing home/chronic care
associated pneumonia5 nursing facility/recent hospitalisation refer to
algorithm page 13.
Condition
≥2 Risks for MDR
Treat for MDR Pathogens
See HAP p.10
0 Risks for MDR
Treat as severe CAP
See CAP p.8
≥1 Risk for MDR
Treat for MDR Pathogens
See HAP p.10
Yes (CURB65 score 3 or >)
Patients with HCAP should be identified and then divided on the basis of severity of illness to guide initial therapy. Patients in each group are then further divided based on whether
they have risk factors for drug-resistant (MDR) pathogens that include: recent antibiotic therapy in the past 6 months, recent hospitalization in the past 3 months, the presence of immune
suppression, and poor functional status as defined by activities of daily living. CAP, community-acquired pneumonia; HAP, hospital-acquired pneumonia.
*Adapted from Brito V, et al. Current Opinion in Infectious Diseases 2009, 22:316-325
0-1 Risks for MDR
Treat for common
CAP Pathogens
See CAP p.8
No (CURB65 score mild or moderate)
Severe pneumonia (Based on CURB65 score)
Presence of risk factors for multi-drug resistant (MDR) pathogens
(antibiotics in past 6 months, hospitalization in past 3 months, poor functional status, immune suppression)
AND
Assess severity of illness (Use CURB65 score)
HCAP present: Patient from nursing home/chronic care facility, recent hospitalization
Algorithm for healthcare-associated pneumonia (HCAP) therapy*
13
14
Co-amoxiclav 1.2g TDS IV for 7-10
days.
First line: Co-amoxiclav 1.2g TDS IV
Second line: Piperacillin-tazobactam 4.5g TDS
IV. Consider addition of gentamicin
First line: Piperacillin-tazobactam 4.5g TDS
IV. Consider addition of gentamicin
Second line: Meropenem 1g TDS IV
Examples: Peritonitis,
Diverticulitis, Biliary tract
infections
Pancreatitis
Severe acute
necrotising Pancreatitis
Intra-abdominal
infections
Comments
Discuss with Microbiology team as soon as
possible
Severe hypersensitivity
reaction/anaphylaxis to penicillins:
metronidazole + gentamicin
Penicillin allergy (NOT IgE mediated
reaction /anaphylaxis):
Cefuroxime 750mg- 1.5g TDS and
metronidazole 500mg TDS IV+/- gentamicin.
Send 3 sets of blood cultures.
Consider antibiotic therapy if 2 or more
present:
Increased breathlessness
Increased sputum volume
Sputum purulence
If consolidation on CXR treat as CAP.
Seek advice from Microbiology.
Endocarditis
Antibiotic
Antibiotics may not be required
See “Comments”
Co-amoxiclav oral or IV depending on
severity for 5-7 days. Review need
for IV therapy on a daily basis.
Penicillin allergy : Clarithromycin 500mg BD
daily PO for 5-7 days
Condition
Respiratory Tract Acute exacerbation of
Infections
COPD
(no consolidation on CXR)
15
Antibiotic
Refer to Appendix 4 at back of booklet.
Consider antibiotics ONLY if
immunosuppressed or signs of
systemic sepsis.
Discuss with microbiology team.
Antibiotic Treatment most often not necessary.
Comments
Refer to C-Diff algorithm at back of this
booklet and on wards.
Refer to HSE SE Clostridium difficile
guidelines in the Infection Control Manual
available on all wards.8
Discontinue other antibiotics if
possible.
Discuss with microbiology team if not
responding to therapy.
Ensure appropriate isolation with standard
and contact precautions are instituted. Send
stool specimen to laboratory. Note all
patients with unexplained diarrhoea
should be isolated.
Clostridium difficile
Associated Disease
(CDAD)
Gastro-intestinal Acute gastroenteritis
Infections
Condition
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18
Infection
Genital Tract
Antibiotic
Comments
Switch to oral/outpatient regime
when satisfactory response for ≥ 24
hours.
Total duration of therapy: 14 days
Condition
Antibiotic
Comments
Consider treating partner.
In pregnancy, a macrolide (azithromycin
or erythromycin) may be used instead of
doxycycline.
Note: Fluoroquinolones (eg ciprofloxacin
Severe 1gE mediated reaction/ anaphylaxis
or ofloxacin) not recommended due to
to penicillin: Clindamycin 900 mg IV TDS +
increasing resistance. Ref: MMWR 59 (RRgentamicin (refer pg 23) + doxycycline PO
12)2010 & www.cdc.gov/std/treatment
100 mg BD
Inpatient Rx: Ceftriaxone 1g once daily IV +
doxycycline 100mg BD PO + metronidazole PO
400mg TDS
Pelvic Inflammatory
Outpatient Rx: Ceftriaxone 250mg IM or IV as
Disease (PID), Salpingitis, single dose, then doxycycline PO 100 mg BD +
Tubo-ovarian abscess
metronidazole PO 400mg TDS
Condition
19
Osteomyelitis / Septic
arthritis
Condition
Antibiotic
Flucloxacillin 2g QDS IV plus sodium
fusidate 500mg tabs TDS PO (or fusidic
acid susp. 750mg TDS PO)
reaction/anaphylaxis): Cefuroxime 1.5g TDS
IV plus fusidic acid as above.
to penicillin: Vancomycin plus fusidic acid as
above.
Benzylpenicillin (penicillin G) 1.2g-2.4g
QDS IV plus flucloxacillin 1-2g QDS IV
reaction/anaphylaxis): Cefuroxime 750mg1.5g TDS
to penicillin: Clindamycin 1.2g QDS IV.
Comments
Modify treatment according to Microbiology
results and clinical response.
Penicillin allergy: Doxycycline 100mg BD PO.
If severe discuss with microbiology team.
Refer to surgical team urgently.
Piperacillin-tazobactam 4.5g IV 6 to 8
hourly plus clindamycin 600mg-1.2g
QDS +/- gentamicin.
Co-amoxiclav 625mg TDS (or 1.2g
TDS IV if severe) for 5 days
NOTE: severe cellulitis should not be
treated with a macrolide
(erythromycin/clarithromycin).
If MRSA suspected use vancomycin.
If Group A Strep Infection confirmed,
consider de-escalation to IV benzylpenicillin
plus clindamycin, following discussion with
Microbiologist.
Switch to flucloxacillin 500mg-1g QDS PO
when clinical improvement achieved. Treat for
10 days minimum.
Discuss possible oral switch options with the
clinical microbiology team.
MRSA known or high risk: vancomycin.
Adjust treatment when cultures available.
Treat for 4 to 6 weeks. Monitor CRP.
Human and animal bites
Necrotising soft tissue
infections/Necrotising
fascitis
Suspected Severe/Invasive Treat as Necrotising fascitis, see below
Group A Strep Infection
Skin and soft tissue Cellulitis, erysipelas
Infections
Bone and Joint
Infections
20
Penicillin allergy: Consider clindamycin +
ciprofloxacin for 7-10 days.
Penicillin allergy: Clarithromycin 500mg
BD PO for 10 days
Send throat swab
Penicillin allergy: Clarithromycin 500mg BD
PO for 5-7 days
Ceftriaxone 2g BD IV for 7-10 days
Acute epiglottitis
Tonsillitis/pharyngitis Phenoxymethylpenicillin (penicillin V)
666mg QDS PO for 10 days
Severe: Benzylpenicillin (penicillin G) 1.2g
QDS IV
Sinusitis, otitis media Co-amoxiclav 1.2 g IV / 625mg TDS
PO for 5-7 days
Adjust dose in renal impairment.
Request HSV PCR on CSF.
Acyclovir 10 mg / kg IV every 8 hours
(use ideal body weight in obese patients)
Comments
Seek Microbiology advice.
Consider Dexamethasone phosphate
for bacterial meningitis.(10mg IV 6
hourly for 2 to 4 days. Must commence
before or at same time as antibiotic).
Send Blood cultures, throat swab,
EDTA blood for PCR +/- CSF. Isolate
patient. Notify Public Health.
Encephalitis
Antibiotic
Ceftriaxone 2g BD IV If Listeria risk add
amoxicillin 2g 4 hrly IV. If Strep pneumoniae
(pneumococcus) or severe infection suspected add
vancomycin until sensitivities confirmed.
Treat for 14 days if pneumococcus. Treat for 7 days
if meningococcus. Severe IgE mediated reaction/
anaphylaxis to penicillin: chloramphenicol 1g IV
QDS. If immunocompromised add vancomycin and
co-trimoxazole.
Meningitis
Condition
Appendix 1: Start Smart, Then Focus Care Bundle.
ENT Infections
Central Nervous
System
21
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Appendix 1: Start Smart, Then Focus Care Bundle.
22
Dose Adjustment
Levels
Comments
Endocarditis: 1mg/kg IV 12 hourly.
Serum levels:
pre-dose level <1μg/ml
1 hour post dose level of 3-5μg/ml
(not always necessary).
Normal renal function: twice-weekly
serum monitoring may be sufficient.
Abnormal renal function: dosage should
be adjusted according to creatinine
clearance and daily serum assay
results.
Take pre-dose level before the 3rd
dose.
NB Antibiotic assays are done at 12:00 Noon and 4.00 pm Monday to Friday and
12:00 Noon on Saturdays and Sundays. Samples must reach the laboratory in
Waterford Regional Hospital one hour before these above times.
Suitable for normal renal function,
creatinine clearance >80ml/min. Dose
reduction if <80ml/min, seek advice.
Pre-dose levels are required to monitor for
toxicity
Clotted sample 16-18h after the first dose of
gentamicin should be < 1μg/ml.
If >1μg/ml: Check timing of level, review
dosing schedule, check renal function,
NB: Gentamicin doses in excess of consider alternative therapy and seek advice
if necessary.
400mg IV / day are rarely
See page 23 for dosing algorithm.
required.
Dose should never exceed 500mg If continuing gentamicin and renal function is stable,
repeat level twice weekly. Daily levels may be
IV/Day.
required if renal function is unstable.
See page 23 for dosing algorithim.
Note: 1-hour post dose levels are not
necessary except in endocarditis – please
discuss on an individual basis (see comments).
***Clearly state dose, time of dose and time of blood
sample collection on the request form. ***
Infuse in 100ml of glucose 5% or sodium chloride 0.9% over 30-60 minutes.
Appendix 2: Once daily Aminoglycoside protocol:
Gentamicin 5mg/kg IV daily
12:00 Noon on Saturdays and Sundays. Samples must reach the laboratory in
Waterford Regional Hospital one hour before these above times.
Adult Single Daily Dosing Algorithm for Gentamicin
(Exclusions: Endocarditis & renal impairment. Caution required in CF patients,
pregnant women & patients with severe burns.)
Is Creatinine Clearance (CrCl) >80ml/min?
CrCl = (140-Age) x Weight(kg) (Use ODW if BMI>30)* x 1.23 (males) or 1.04 (females)
Serun Creatinine(µmol/L)
**If anuric (<500mls/day), treat as CrCl<10ml/min
Yes
No
Give first dose of IV
Gentamicin 5mg/kg*
(based on Actual Body Weight or ODW if obese*).
Record actual time of dose (Ideally 4-6pm)
Dose should not exceed 500mg/day
CrCl(ml/min)Dose
50-804mg/kg
30-503mg/kg*
10-302mg/kg*
<101-2mg/kg*
redose
when level
<1µg/ml
Take blood for serum gentamicin level
16-18 hours after FIRST dose.
Record actual time of sampling.
(4pm dosing = 8-10am level,
6pm dosing = 10am-12noon level)
Yes
Is trough level <1µg/ml
Continue current regimen.
Repeat trough levels and serum
creatinine concentration twice
weekly (if renal function is poor/
deteriorating and/or previous trough
levels are high, then levels need to be
checked more frequently e.g. daily)
*Weight used should be actual body weight (ABW) or
for obese patients (BMI>30), an obese dosing weight
(ODW) must be calculated.
ODW = IBW + 0.4 (ABW - IBW)
Dose should never exceed 500mg.
BMI= Weight (kg)/Height (m)²
IBW (males) Kg= 50 + (0.9 x no. of cm over 152cm)
IBW (females) Kg= 45.5 + (0.9 x no. of cm over 152cm)
1 foot = 30.5com, 1 inch = 2.54cm
No
Check time dose was given and
sample taken. Was level taken at
16-18 hours after dose?
No
Yes
Is trough level
>1(µg/ml) but
<2(µg/ml) and
treatment still
Indicated?
No
Seek advice
from Pharmacy
or Clinical
Microbiology
Yes
Reduce once daily
dose by 1mg/kg*
23
24
Levels
6 mg/kg 12 hourly for 3 doses and May be required in certain circumstances eg.
thereafter once daily. Higher doses,
endocarditis.
10- 12mg/kg, in similar dosing schedule Discuss with Microbiology team.
is indicated in serious infections e.g.
MRSA infections and endocarditis. Such
patients should be discussed with the
In severe/complicated infections a
higher dose +/- loading dose to
achieve pre-dose levels of 1520 μg/ml may be required (see
comments).
Teicoplanin dosage schedule
Levels
Collect predose level before 4th dose of
vancomycin. Give the dose. Any adjustments
necessary can be made to the 5th dose onwards.
Predose level should be between 1015μg/ml. (In severe/complicated
infection 15-20 μg/ml). If continuing
vancomycin and renal function is stable, repeat
level twice weekly. Daily levels may be required
if renal function is unstable. Note that 1- hour
post dose levels are not necessary.
Clearly state dose, time of dose and time of blood
sample collection on the request form.
At weekends routine assays are carried out at
midday on Saturdays and Sundays.
Refer to dosing algorithm page 25.
Vancomycin Dosage Schedule Comments
Renal impairment:
If teicoplanin is to be used, the full dose
is given for the first 4 days. Thereafter
extended dosing intervals are required.
Must be administered slowly IV at a
maximum rate of 10mg/min to avoid
reaction such as red man syndrome. In
severe/complicated infections a
loading dose of 25-30mg/kg can be
used to facilitate rapid attainment
of target trough serum vancomycin
concentration.
Complicated Infections:
1. Bacteraemia
2. Endocarditis
3. Osteomyelitis
4. Meningitis
5. Hospital Acquired Infections caused by
Staph aureus
Comments
Appendix 3: Glycopeptides: Vancomycin & Teicoplanin
Dosing Algorithm for Vancomycin
Is Creatinine Clearance >60ml/min?
CrCl = (140-Age) x Weight (ODW if BMI>30)* (kg) x 1.23 (male) or 1.04 (female)
Serum Creatinine (µmol/L)
If patient is anuric (output <500mls/day), treat as per CrCl < 20ml/min
Yes
Is the patient seriously ill (signs of severe sepsis)?
Yes
No
Give loading dose 25-30mg/kg
(Actual body weight)
Give loading dose 15mg/kg
(Actual body weight)
No
Prescribe maintenance dose 15mg/kg
BD. (Use Actual body weight)
(Preferably at 10am, and 10pm to
facilitate levels.)
CrCl
Dose
Check 1st level
(ml/min)
40-60
15mg/kg od
Before 3rd dose**
20-40
15mg/kg
Before 2nd dose**
every 36-48 hrs.
<20
15mg/kg
Before 2nd dose.
every 72-96 hrs. Hold dose until
level available
Once daily doses should preferably be given at
10am to facilitate checking of levels
1st level before 4th dose. (Level needs
to be PRE-dose)**
Has patient serious infection such as
endocarditis, osteomyelitis, bloodstream
infecion, meningitis or hospital acquired
pneumonia caused by S. aureus?
No
Yes
Target level is 10-15µg/ml.
Is level 10-15µg/ml?
Target level is 15-20µg/ml.
Is level 15-20µg/ml?
Pre-dose level result
Level Dose
Recheck pre-dose
alterationlevel
5-10 Increase
After adjusted dose
each dose given and before
by 250mg following morning dose**
10-15 Maintain
Twice weekly
dosing
providing renal
regimen
function is stable**
15-20 Reduce
After adjusted dose
each dose given and before
by 250mg following morning dose**
>20
Omit next
After adjusted dose
dose and given and
decrease
before following
each dose morning dose**
by 500mg
*Weight used should be actual body weight (ABW) or
for obese patients (BMI>30), an obese dosing weight
(ODW) must be calculated.
ODW = IBW + 0.4 (ABW - IBW)
BMI=Weight (kg)/Height (m)²
IBW (males) Kg= 50 + (0.9 x no. of cm over 152cm)
IBW (females) Kg= 45.5 + (0.9 x no. of cm over 152cm)
1 foot = 30.5com, 1 inch = 2.54cm
**Unless renal
function is
deteriorating or
specifically
advised DOSES
SHOULD NOT
BE HELD WHILST
AWAITING
LEVELS
Seek advice
from Pharmacy
or Clinical
Microbiology if
in doubt
Pre-dose level result
LevelDose
alteration
5-10 Increase
each dose
by 500mg
10-15 Increase
each dose
by 250mg
15-20 Maintain
dosing
regimen
20-25 Reduce
each dose
by 250mg
>25
Omit next
dose and decrease
each dose
by 500mg
Recheck
pre-dose level
After adjusted
dose given and
before following
morning dose**
After adjusted
dose given and
before following
morning dose**
Twice weekly
providing renal
function is stable**
After adjusted
dose given and
before following
morning dose**
After adjusted
dose given and
before following
morning dose**
25
Appendix 4: Treatment of
Clostridium difficile Infection
Figure R2: CDI disease severity stratification and general and specific treatment measures
for initial episode of CDI and first recurrence.(29)
INITIAL EPISODE OF CDI OR FIRST RECURRENCE
General Measures:
•
Adequate replacement of fluid and electrolytes
•
Immediately discontinue unnecessary antimicrobial therapy
•
Avoid antimotility medications
•
Review other risk factors for CDI
•
Review proton pump inhibitor use
•
Appropriate infection prevention and control to include patient isolation with Contact Precautions and
appropriate hand washing.
Mild to Moderate CDI:
•
No features of severe CDI
• Oral or nasogastric metronidazole
400 mg TDS for 10 to 14 days.
(Grade A)
• Inability to take oral medication:
intravenous (IV) metronidazole
500mg TDS for 10 to 14 days.
(Grade D)
• Metronidazole intolerance or
contraindication: oral vancomycin
125mg QDS for 10 to 14 days.
(Grade A)
• * Oral fidaxomicin 200mg BD for 10
days may be an alternative to
metronidazole(GradeC/D) or
vancomycin(Grade A) in patients
aged 16 yrs and older but only
following discussion with a clinical
microbiologistor specialist ID
consultant.
• Monitor closely for
deterioration/progressionto severe
CDI
Severe CDI:
(Suggested by any of the following)
• Clinical: fever, rigors, abdominal pain
• Laboratory: Leucocytosisof ≥15,000
cells/µL , or rise in serum creatinine of
≥50% above baseline or serum
creatinine >133 µmol/L).
• Endoscopicfindings: pseudo
membranous colitis
• Early surgical opinion
• Oral vancomycin125 mg, QDS
for 10 to 14 days. (Grade A)
• *Oral fidaxomicin 200mg BD
for 10 days may be an
alternative to vancomycin
(Grade A) in patients aged 16
yrs and older but only
following discussion with a
clinical microbiologistor
specialist infectious diseases
consultant.
Severe, complicated CDI:
Severe disease with:
•
Hypotension
•
Shock
•
Rising serum lactic acid levels
•
Ileus
•
Mega colon
• Early surgical opinion
• Vancomycin 500 mg, oral or
nasogastric QDS and
metronidazole 500mg, IV TDS
(Grade D)
• Consider Intracolonic vancomycin
500 mg, four to six times daily if
ileus present or suspected
(Grade D)
Please refer to BNF for children or local paediatric formulary for doses of metronidazole and
vancomycinfor paediatric patients.
*Fidaxomicin has not been tested in pregnant or breastfeedingwomen or in patients with a history of
inflammatory bowel disease.
32 2013 13
Adapted From Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland Update of 2008 Guidance HPSC
Updated CDI
guidelinesFebruary 2013
26
:
evels
cin
f
7. How do you manage second and subsequent recurrences and what do you do if a patient keeps getting recurrences? • Management of second and subsequent recurrences of CDI is summarised in Figure R3. • Consider supervised trial of anti‐motility agents alone if post‐infective irritable bowel syndrome is suspected after more than 20 days of anti‐C. difficile treatment (only if patient has a normal white cell count and no abdominal symptoms or signs of severe CDI). (Grade D) Figure R3: Management of Multiple Recurrences of CDI First episode of recurrent CDI
Severity assessment, general measures and specific anti‐CDI therapy as outlined in Figure R2 Second and subsequent episodes of recurrent CDI • Review all anti‐microbial therapy and other medications. Ensure adequate fluid and electrolytes and review nutritional status. (Grade D) • Contact clinical microbiologist or specialist infectious diseases consultant expert for advice • Consider the following options after expert advice as above: • Oral Vancomycin tapering/pulse therapy (Grade D): o 125mg 6 hourly for 7 days o 125 mg 12 hourly for 7 days o 125 mg daily for 7 days o 125 mg every other day for 7 days o 125 mg every 3 days for 7 days or • Oral Fidaxomicin 200mg BD for 10 days (Grade D) or • Oral Vancomycin 125mg QDS for 10 days followed by a chaser of oral rifaximin 400mg TDS for 20 days (Grade B) or • Intravenous immunoglobulin therapy 150‐400mg/kg per day for 1 to 3 doses (Grade D) or • Faecal microbiota transplantation (Grade A) 34 Updated CDI guidelines February 2013 Adapted From Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland Update of 2008 Guidance HPSC 2013
27
28
ORAL
Amoxicillin 500mg 8 hr
Co-amoxiclav 625mg 8 hr
Clindamycin 300mg 6 hr
Clindamycin 450mg 6 hr
Flucloxacillin 500mg -1g 6 hr 30 minutes before food
Clarithromycin 500mg 12 hr
Metronidazole 400mg 8 hr
Ciprofloxacin 500 - 750 mg 12 hr
Levofloxacin 500mg - 24hr/12hr
Co-amoxiclav 625mg 8 hr In Penicillin Allergy discuss with Microbiologist
IV
Benzylpenicillin 1.2 -2.4g 4-6 hr Amoxicillin 1g 6 hr
Co-amoxiclav 1.2g 8 hr Clindamycin 600mg 6 hr Clindamycin 1.2g 6 hr Flucloxacillin 1 - 2 g 6 hr Clarithromycin 500mg 12 hr Metronidazole 500mg 8 hr
Ciprofloxacin 400mg 12 hr
Levofloxacin 500mg - 24hr/12hr
Cefuroxime 750mg - 1.5 g TDS 8 hr
“Note: Oral Antimicrobials are significantly less costly than intravenous“
Examples of choices of switch from IV to oral route
Appendix 5: IV to PO Switch
Co-amoxiclav 625mg 8 hr In Penicillin Allergy discuss with Microbiologist
Cefuroxime 750mg - 1.5 g TDS 8 hr
ANTIMICROBIALS WITH GOOD
ORAL BIOAVAILABILITY
*Sanford Guide 2010
** Martindale 33rd edition
***Sanford Guide 2010 and Martindale 33rd edition
Antimicrobial Ciprofloxacin Clindamycin Fusidic Acid Fluconazole Levofloxacin Linezolid Metronidazole Oral Bioavailability
70-80%***
90%*
91%(tablets)*
90%*
98%*
100%*
99%**
29
Appendix 6: Contingency Plan in
Eventuality of Shortage of Intravenous
Co-amoxiclav
General Recommendations
Consider using PO co-amoxiclav where co-amoxiclav is recommended
for the indication and where PO route is clinically appropriate – refer to PO
switch guidelines and Point 6 under General Guidance in Guidelines for
Empiric Use of Antimicrobials in Adults.
Do not substitute IV piperacillin-tazobactam / IV ceftriaxone / cefotaxime
/ IV quinolones for IV co-amoxiclav where possible
Refer to recommended alternatives for each indication where IV coamoxiclav features in the empiric and prophylaxis guidelines
30
Practice the “Start Smart- Then Focus” protocol for antimicrobial
prescribing and the Surgical Prophylaxis Protocol diligently
Specific Recommendations
Recommended substitutes for IV co-amoxiclav by indication in HSE SE
Guidelines for the empiric use of antimicrobials in the eventuality of
unavailability of IV co-amoxiclav:
• High Severity CAP - IV cefuroxime 750mg - 1.5g TDS (plus PO
clarithromycin)
• Hospital Acquired Pneumonia within 4 days admission - IV
cefuroxime 750mg -1.5g TDS
• Acute Exacerbation COPD – Assess if PO co-amoxiclav or PO
clarithromycin sufficient, if intravenous substitute needed - IV cefuroxime
750mg -1.5g TDS
• Peritonitis, Diverticulitis Biliary Infections – IV cefuroxime 750mg 1.5g TDS plus metronidazole
• Pancreatitis (non-severe– first line) - IV piperacillin-tazobactam cefuroxime
750mg -1.5g TDS plus metronidazole (IV severe / second line)
• Human and animal bites – Use PO co-amoxiclav where possible – if IV
clinically indicated - IV cefuroxime 750mg -1.5g TDS plus metronidazole
• Sinusitis, Otitis Media – Use PO co-amoxiclav where possible – if IV
clinically indicated - IV cefuroxime 750mg -1.5g TDS +/- metronidazole
Appendix 7: Relative Costs of
Antimicrobials*
COST OF ONE WEEK’S SUPPLY OF ANTIMICROBIALS
BASED ON NORMAL ADULT DOSE
(antifungals in bold italics)
€0-€10
Flucloxacillin PO, Metronidazole PO, Ciprofloxacin PO,
Amoxicillin PO, Co-amoxiclav PO, Clarithromycin PO, Fosfomycin PO
€10-€40 Levofloxin PO, Amoxicillin IV, Metronidazole IV
Co-amoxiclav IV, Cefuroxime IV, Clindamycin PO,
Fusidic acid PO, Ciprofloxacin IV, Vancomycin IV, Fluconazole PO
€40-€60 Piperacillin-Tazobactam IV,
€150-€300 Clarithromycin IV, Levofloxacin IV, Rifampicin IV,
Meropenem IV, Ceftriaxone IV, Fluconazole IV
€300-€500 Acyclovir IV, Clindamycin IV,
€500-€1000 Linezolid PO & IV, Ceftaroline IV,
€1000-€3000 Teicoplanin IV, Tigecycline IV, Fidaxomicin PO
>€3000 Anidulafungin IV, Voriconazole IV,
Amphotericin IV, Caspofungin IV
*Correct at time of publication.
31
REFERENCES:
1. Guidelines for Antimicrobial Stewardship in Hospitals in Ireland. SARI Hospital
Antimicrobial Stewardship Working Group. December 2009.
2. Policy on Control and Prevention of Meticillin Resistant Staphylococcus aureus (MRSA) in
Acute Hospitals in the HSE/SE. November 2009.
3. Gupta K et al International Clinical Practice Guideline for the treatment of acute
uncomplicated cystitis and pylenephritis in women. 2010 update by IDSA and ESCMID.
CID 2011; 52: 103-120.
HS
St
M
M
4. Lim WS, Baudouin SV, George RC et al. BTS Guidelines for the management of
community acquired pneumonia in adults: update 2009. Thorax 2009; 64 Suppl 3: iii155.
5. Brito V et al. Healthcare - associated pneumonia is a heterogenous disease, and all
patients do not need the same broad-spectrum antibiotic therapy as complex nosocomial
pneumonia. Current Opinion in Infectious Diseases 2009; 22: 316-325.
6. Masterton. RG et al. Guidelines for the management of hospital acquired pneumonia in
the UK. JAC 2008; 62: 5-34.
7. James D. Chalmers, Mudher Al-Khairalla, Philip M. Short, Tom C. Fardon and John
H. Winter. Proposed changes to management of lower respiratory tract infections in
response to the Clostridium difficile epidemic. J Antimicrob Chemother 2010; 65: 608618.
8. Policy on Prevention and Control of Clostridium difficile – associated disease In Acute
Hospitals HSE/South East. January 2010.
Dr
Dr
M
Ph
9. Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients
with Cancer, 2010 update by the IDSA. CID 2011; 52(4): e56-e93.
W
10. Davey et al. Interventions to improve antibiotic prescribing practices for hospital
inpatients (review). The Cochrane Library Oct 2008.
SL
11. Royal College of Obstretricians Green top guideline no 64A Bacterial Sepsis in Pregnancy.
12. HSE Adult Patient Observation Chart.
13. Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland
Update of 2008 Guidance HPSC 2013
32
Dr
W
ST
HSE South East Acute Hospital Network Antimicrobial
Stewardship Group Members
Microbiology Department WRH:
Microbiology SpRs
Ext. 2490/8053
Bleep #821 278
Dr. M. Hickey Ext.
Dr. M. Doyle Ext. 2621/2097
Dr. B. Carey Ext.
Ms. C. Troy, Surveillance Scientist
Ext. 2488/2489
}
Pharmacy Departments.:
WRH Antimicrobial Pharmacist Ext. 2530/2453
WGH Antimicrobial Pharmacist Ext. 3261
SLKK/Kilcreene Antimicrobial Pharmacist Ext. 5372/5328
STGH Antimicrobial Pharmacist Ext. 7119
33
34

Guidelines for the empiric use of antimicrobials in adults

Transcription

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