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INDICATIONS FOR IV ROUTE (see IVOST guidelines) SIMPLIFY, SWITCH, STOP and STATE Duration!
Guidance for initial hospital therapy in adults. Specialist units may have separate policies.
STOP AND THINK BEFORE YOU GIVE ANTIBIOTIC THERAPY! Antibiotics are overused particulary in the elderly, patients with urinary catheters or suspected UTIs and in patients with viral or non-infective exacerbations of COPD. Always
obtain cultures and consider delay in therapy unless there is a clear anatomical site of infection with high probability of bacterial aetiology, if sepsis syndrome is present or if there is clinical deterioration. Record indication and SIRS score in case notes.
1. IV antibiotic therapy (including gentamicin where indicated) should be administered within 1 hour of recognition of sepsis or severe infection in the clinical area where the diagnosis SIMPLIFY Use narrow spectrum agents whenever possible. has been made. SWITCH In the absence of +ve microbiology and specific situations (see indications for IV route) 2. Sepsis or severe sepsis or deteriorating clinical condition switch to oral therapy when signs of sepsis are resolving and oral route is not compromised. 3. Febrile with neutropenia/ immunosuppression STOP Observe indicated duration of therapy and stop if alternative non-infectious diagnosis is 4. Specific indications: endocarditis, deep abscess, bronchiestasis, meningitis, CNS infection, bone/joint infection, S.aureus bacteraemia, CF, made. intra-abdominal / biliary sepsis infection. RECORD INDICATION, SEPSIS CRITERIA AND DURATION FOR ANTIBIOTIC IN NOTES 5. Skin and soft tissue infection: IV therapy if sepsis or 2 of heat, erythema, induration/ swelling (usually IV for 48-96 hours) CRP- does not reflect the severity of infection and may remain elevated when the infection is resolving. 6. Oral route compromised: nil by mouth, reduced GI absorption, mechanical It cannot be used, in isolation, to assess the severity of infection and hence the need for IV therapy. swallowing disorder, unconscious, no oral formulation, vomiting
DEFINITION OF SEPSIS (Systemic Inflammatory Response Syndrome (SIRS)) - PLEASE RECORD IN CASE NOTES
Clinical symptoms of infection (sweats, chills, malaise, rigors etc) PLUS 2 or more of the following: Temp <36 or >38, HR >90bpm, RR >20/min and WCC <4 or >12 x109/L Severe sepsis: Sepsis + Organ dysfunction/ hypoperfusion eg. oliguria or urine <40ml/hr, confusion, lactic acidosis or hypotension (eg. systolic BP <90mmHg or reduction of 40mmHg from baseline) NB. Signs of sepsis may be masked in immunosuppression, the elderly and in the presence of anti-inflammatory drugs or beta-blockers. Culture Blood Collect 2 or more (8-10mls each bottle) and appropriate area ie. Urine, sputum, CSF, wound or venous access site
Clostridium difficile infection is associated with prescribing of; Cephalosporins, Co-amoxiclav, Clindamycin, Quinolones (Ciprofloxacin, Levofloxacin, Moxifloxacin, Ofloxacin) and Piperacillin + Tazobactam. These agents must be restricted to reduce selection pressure Gastric acid suppression may predispose the patient to Clostridium difficile. Stop gastric acid suppressive therapy if possible.
Gastro-intestinal Gastroenteritis
CNS infection
Cranberry products can prevent recurrent infections in women. Consider a trial of cranberry then. Trimethoprim 100mg 24hrly or Nitrofurantion 50mg 24hrly Give at night Inform G.P. if prophylaxis commenced as inpatient. Long term nitrofurantion prophylaxis may be associated with pulmonary toxicity.
IV therapy to be administered URGENTLY on arrival at hospital and after blood cultures. CT scan before LP if age >60, seizures, reduced GCS, CNS signs or immunosuppression. Seek ID / microbiology advice.
Which patient?
Chemotherapy within 3 weeks, high dose steroids (prednisolone>15mg/day for >2 weeks), other immunosuppressive agents (e.g. anti-TNF, cyclophosphamide), neutrophil <0.5 or < 1.0 and falling AND temp > 38C or < 36C on 2 occasions 30mins apart. primary immunodeficiency, NB. For patients with HIV infection please discuss with the ID Brownlee Centre.
Review all anatomical systems Hospital vs community-acquired infection? E.coli, Staph aureus and Pneumococcus are commonest community blood culture isolates Consider MRSA infection healthcare associated sepsis, recent hospital discharge, postoperative wound or line-related sepsis or sepsis in previous or current MRSA carrier. Consider severe Streptococcal sepsis e.g. pharyngitis, erythroderma, hypotension.
Bacterial Meningitis
Always refer to senior staff IV Ceftriaxone 2g 12hrly + IV Dexamethasone* 10mg 6hrly (for 4 days) If age 50 years, immunosuppressed, pregnant or if listeria meningitis suspected add in IV Amoxicillin 2g 4hrly to above If penicillin resistant, pneumococcus suspected add IV Vancomycin** If true penicillin allergy IV Choramphenicol 1g 6hrly +Dexamethasone* then seek ID / microbiology advice. Duration 7 days (meningococcal), 14 days (pneumococcal), 21 days (listeria). Possible viral encephalitis
Aciclovir 10mg/kg 8hrly (see prescribing guidance for dosage alteration in renal impairment) Discuss management with ID. May require repeat LP or neuro-imaging to establish diagnosis. If HSV/VSV confirmed continue therapy for 14-21 days IV (no oral switch)
Sepsis syndrome
* Clarithromycin is known to have serious drug interactions and may prolong the QTc interval. Avoid in patients with other risk factors for QTc prolongation.See BNF (appendix 1) or contact pharmacy for details
No definable site of infection Patients on high dose steroids or severely immunocompromised may not have an increased temperature but present with low blood pressure, hypothermia and or rigors.
Source unknown
IV Benzylpenicillin 1.2g- 2.4g 6hrly + IV Flucloxacillin 2g 6hrly + IV Gentamicin** if true penicillin allergy
IV Vancomycin** + IV Gentamicin** if streptococcal infection suspected ADD IV Clindamycin 600mg 6hrly (up to 1200g 6hrly) + seek ID/ microbiol-
Severe CAP
CURB 65 score: 3 or CAP PLUS sepsis syndrome: IV or oral *Clarithromycin 500mg 12hrly and either IV Amoxicillin 1g 8hrly or IV Co-amoxiclav 1.2g 8hrly (if previous treatment in the community) or if true penicillin allergy IV *Clarithromycin 500mg 12hrly + IV Vancomycin
Total duration 7-10 days (IV/oral) or up to 14 days if atypical suspected or bacteraemia
Duration 7 days
ADD IV Vancomycin** or if true penicillin allergy IV Vancomycin** + IV Gentamicin** + IV Ciprofloxacin 400mg 12hrly If haematology/oncology patient discuss with appropriate specialist and seek ID / microbiology advice. If stem cell / solid organ transplant or acute leukaemia and associated shock give IV Meropenm + IV Amikacin (see Neutropenic Sepsis in Cancer patients poster for details) Immunocompromised patients with fever and no neutropenia Manage as per infection management guidelines based on anatomical source
Upper UTI in non pregnant women and men (without sepsis) Trimethoprim 200mg 12hrly if resistant organisims suspected
ogy advice
Gentamicin must not be continued beyond 3 or 4 days. Discuss alternative with mircobiology / ID.
Aspiration pneumonia
t Rifampicin is known to have serious drug interactions. see BNF (appendix1) or contact pharmacy for details.
IV Metronidazole 500mg 8hrly and either IV Amoxicillin 1g 8hrly or IV *Clarithromycin 500mg 12hrly Duration 7 days (IV/oral)
**Gentamicin/ Vancomycin**
Avoid Gentamicin in patients with decompesated liver disease, contact microbiology or ID for advice 7. If Creatinine not available give gentamicin as follows, Actual weight Gentamicin Dose < 40Kg 5mg / kg, 40-49kg 240mg, 50-59kg 280mg, 60-69kg 320mg, 70-79kg 360mg, 80kg 400mg. 8. If CKD5 give 2.5mg/kg (maximum 180mg) 9. For gentamicin take a sample 6 -14 hrs after the start of the first infusion and review frequency once creatinine and concentration are known.
IV Gentamicin**
monotherapy
Catheter-related UTI
CURB 65 score: 3 or sepsis syndrome IV Co-amoxiclav 1.2g 8hrly + IV Gentamicin** if MRSA suspected add IV Vancomycin** or if true penicillin allergy IV Vancomycin** + IV Gentamicin**
Total duration 7 -10 days (IV/oral) or up to 14 days if atypical suspected or bacteraemia
Remove / replace catheter and culture urine. Give single dose of IV Gentamicin** Further antibiotic treatment may not be required. However: - If sepsis or deterioration treat as for pyelonephritis. Total duration 7 days (IV/oral)
1. To access dose calculator click on clinical info on staff intranet page and go to antimicrobial guidelines. 2. Check creatinine / renal function daily. 3. Record accurate times of dose administration and concentration measurement. 4. Contact pharmacy if advice required. 5. Do not use Gentamicin beyond 3 or 4 days unless on advice of mircobiology or ID. 6. Ototoxicity is associated with prolonged use of gentamicin. If the patient reports tinnitus, dizziness, poor balance, hearing loss, seeing objects oscillating, stop Gentamicin and contact Micro / ID.
RATIONALISE ANTIBIOTIC THERAPY when microbiology results become available or clinical condition changes. Review IV therapy daily and remember IV-ORAL SWITCH NB. Recomended doses are based on normal renal / liver function, see BNF for dose adjustments in renal / liver impairment.
FURTHER ADVICE Can be obtained from the Duty Microbiologist or Clinical Pharmacist or the ID Unit (Brownlee Centre), Gartnavel General Hospital, or your local Respiratory Unit (for pneumonia) or Therapeutics handbook. Infection Control advice may be given by the duty microbiologist.
Greater Glasgow & Cyde Antimicrobial Utilisation Committee, ADTC. August 2012 expires Aug 2014. Review updates on .www.ggcformulary.scot.nhs.uk/Guidelines MIS 165760/a.