Antibiotics in Surgery

July 2010

Contents

Page

1. Introduction...3 1.1 Principles of antimicrobial prophylaxis...3 1.2 MRSA screening of surgical patients.....3 2. Classification of surgical procedures4 3. Timing of prophylaxis..4 4. Contact details..5 5. Choice of agent6 5.1 Prevention of infection in thoracic surgery ...6 5.2 Prevention of infection in vascular surgery...7 5.3 Prevention of infection in trauma and orthopaedic surgery.8 9 5.4 Prevention of infection in gynaecological surgery...9 5.5 Prevention of infection in ear, nose, throat & endocrine surgery........10 5.6 Prevention of infection in gastrointestinal surgery 11 5.7 Prevention of infection in urological procedures ...12 6. Splenectomy: vaccination and antibiotic prophylaxis....................13 6.1 Perioperative vaccination......14 6.2 Annual vaccination..14 7. Empirical treatment guidelines for surgical infections..16 Skin and soft tissue infections..16 18 Bone and joint infections19 21
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Septicaemia.....21 Lower respiratory tract infections....22 24 Genitourinary infections....25 26 Gastrointestinal tract infections...27 28 Bites and stings..........29 8. Intravenous to oral switch of antimicrobial therapy.30 9. Therapeutic drug monitoring...30

1. Introduction
1.1 Principles of antimicrobial prophylaxis Antibiotic prophylaxis is the use of antimicrobial agents to prevent infection or to prevent the clinical manifestations, if infection is incubating. There are a number of situations where prophylactic antibiotics may be indicated e.g. various types of surgery (Section 2) or the insertion of a medical device or prosthesis. All patients with contaminated wounds (e.g., following trauma) should have their tetanus status assessed. The choice of agent will be governed by the procedure and the likely potential pathogens. These guidelines apply to patients admitted from the community for clean, clean-contaminated and contaminated surgical procedures. The guidelines do not cover transplant and neurosurgical specialities. If the patient has been in hospital or has a history of MRSA colonisation, please contact the microbiologists for advice, as the patients antibiotic prophylaxis will need adjustment. Surgical prophylaxis should be prescribed in the appropriate section of the drug Kardex. The duration of antimicrobial surgical prophylaxis should be a SINGLE dose, except in certain circumstances. An agent that may be appropriate for surgical prophylaxis may not be the optimal agent for the treatment of an established infection. Therefore, the continuation of an agent to treat established infection that was initially used for prophylaxis may represent suboptimal therapy. If concerned, contact the microbiologists for advice. If the patient is allergic to one of the recommended agents, please contact the microbiologists for advice Please refer to the paediatric BNF for advice on dosing of antimicrobials in paediatric patients. 1. 2 MRSA screening of surgical patients who to screen Patients known to be MRSA colonised and who are being re-admitted to hospital Patients admitted from another hospital or health-care facility (e.g., nursing home) Patients with non-intact skin, including wounds and ulcers Patients due to undergo elective high-risk surgery (e.g. vascular and orthopaedic implant surgery)

2. Classification of surgical procedures

Surgery may be classified as clean, clean-contaminated or contaminated (see below) No prophylaxis is usually necessary for clean surgery (unless insertion of a device or a prosthesis) One dose of antibiotics is usually adequate for clean-contaminated surgery or the insertion of a medical device/prosthesis There is no benefit in prolonging antibiotics beyond 24 hours, but there may be side-effects such as Clostridium difficile associated diarrhoea etc. For contaminated surgery, a 5 7 day treatment course may be required Clean
No breach of respiratory, alimentary or genito-urinary tracts Non-traumatic No inflammation No break in technique

Clean-Contaminated
Non-traumatic but break in technique or breach of respiratory, alimentary or genitourinary tract No significant spillage

Contaminated
Major break in technique Gross spillage from a viscus that may include purulent material Dirty traumatic wounds, faecal contamination, foreign body, de-vitalised viscus Pus encountered from any source during surgery

No Prophylaxis (usually)

Prophylaxis for 24 hours

Treatment course may be required for 5-7 days

3. Timing of prophylaxis
The aim of prophylaxis is to have maximum tissue antibiotic levels at the time of the first incision - For this reason, prophylaxis is administered AT INDUCTION (30 to 60 MINUTES BEFORE SKIN INCISION) - The duration of surgical prophylaxis should be a SINGLE dose, except in two circumstances. These are: A. Blood loss fluid replacement - Serum antibiotic concentrations are reduced by blood loss and fluid replacement, especially during the first hour of surgery when antibiotic levels are high. In the event of major intra-operative blood loss (>1.5 litres) additional doses of prophylactic antibiotic should be considered after fluid replacement. B. Prolonged surgical procedures - Many antibiotics, such as cephalosporins like cefuroxime, are short acting and therefore an additional dose should be administered during the surgery if the procedure lasts longer than 3 hours.

4. Contact details
Medical enquiries Consultant Microbiologists Dr E Smyth Prof H Humphreys Dr F Fitzpatrick Phone Ext 2017 Ext 3312 Ext 2938 Ext 2667/3320/3321 Bleep 319/443/323 Consultant-on-call via switch Ms. Sarah Foley Bleep 046 sarahfoley2@beaumont.ie E mail edmondsmyth@beaumont.ie hilaryhumphreys@beaumont.ie fidelmafitzpatrick@beaumont.ie

Registrars office

Out of hours Pharmacy enquiries Antimicrobial Senior Pharmacist

5. Choice of agent
5.1 Prevention of infection in THORACIC Surgery
PROCEDURE Breast reconstruction with implant Breast cancer surgery Breast reshaping procedures Implantable cardiac device (ICD) Screen patients for MRSA at least 5 days before surgery according to MRSA guidelines MRSA-negative REGIMEN CO-AMOXICLAV 1.2g IV Penicillin allergy TEICOPLANIN 400mg IV CEFUROXIME 1.5g IV STAT at induction Inpatient: give two further doses 8 hours apart Day case: two doses of CEFUROXIME 500mg po 8 hours apart for patient to take at home following ICD insertion TEICOPLANIN 400mg IV (Further antibiotic prophylaxis is NOT required due to extended duration of action) CO-AMOXICLAV 1.2g IV Penicillin allergy TEICOPLANIN 400mg IV 1 dose at induction Number and timing of doses** 1 dose at induction

MRSA colonised (follow MRSA eradication protocol)

Penicillin allergy

1 dose at induction

Pulmonary resection

**For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)

5. 2 Prevention of infection in VASCULAR surgery

PROCEDURE Amputation Aortic aneurysm repair Prevention of gas gangrene in high lower limb amputation or following major trauma (penetrating abdominal injuries) Vascular surgery (bypass or amputation) a) elective procedures MRSA screen patient pre operation MRSA-negative If MRSA colonised (follow MRSA eradication protocol) b) procedures that are carried out as emergencies and/or on patients who have not been screened REGIMEN Number and timing of doses**

CO-AMOXICLAV 1.2g IV Penicillin allergy CEFUROXIME 1.5g IV plus METRONIDAZOLE 500mg IV Penicillin allergy severe immediate hypersensitivity reaction *Contact Microbiology to discuss antibiotic choice*

1 dose at induction

TEICOPLANIN 400mg IV plus CEFUROXIME 1.5g IV plus METRONIDAZOLE 500mg IV Penicillin allergy severe immediate hypersensitivity reaction *Contact Microbiology to discuss antibiotic choice*

**For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)

5.3 Prevention of infection in TRAUMA and ORTHOPAEDIC Surgery

PROCEDURE Arthroscopy Minor metalwork insertion (e.g., K-wire, screws, small orthopaedic plates) Elective major procedures involving metalwork, including joint, pelvic or spinal implants Screen patients for MRSA at least 5 days before surgery according to MRSA guidelines MRSA-negative If MRSA colonised (follow MRSA eradication protocol) TEICOPLANIN 400mg IV plus GENTAMICIN 5mg/kg IV REGIMEN ANTIMICROBIAL PROPHYLAXIS IS NOT RECOMMENDED Number and timing of doses

CEFUROXIME 1.5g IV Penicillin allergy Severe immediate hypersensitivity reaction *Contact Microbiology to discuss antibiotic choice* 1 dose at induction

Major procedures involving metalwork including joint, pelvic or spinal implants carried out as emergencies and/or on patients who have not been screened

**For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)

5.3 Prevention of infection in TRAUMA and ORTHOPAEDIC Surgery

PROCEDURE Compound fracture intervention (+/- insertion of a screw / nail) Screen patients for MRSA at least 5 days before surgery according to MRSA guidelines MRSA-negative If MRSA colonised (follow MRSA eradication protocol) REGIMEN CEFUROXIME 1.5g IV plus METRONIDAZOLE 500mg IV Penicillin allergy Severe immediate hypersensitivity reaction *Contact Microbiology to discuss antibiotic choice* TEICOPLANIN 400mg IV plus GENTAMICIN 5mg/kg IV plus METRONIDAZOLE 500mg IV Number and timing of doses** Duration should be no longer than 24 hours

**For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours) N. B. In distal limb surgery antibiotics should be administered at least 15 minutes before inflation of the tourniquet, i.e., before induction of anaesthesia.

5.4 Prevention of infection in GYNAECOLOGICAL surgery

PROCEDURE Hysterectomy REGIMEN CO-AMOXICLAV 1.2g IV Penicillin allergy CEFUROXIME 1.5g IV plus METRONIDAZOLE 500mg IV Penicillin allergy severe immediate hypersensitivity reaction *Contact Microbiology to discuss antibiotic choice* Number and timing of doses** 1 dose at induction

**For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)

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5.5 Prevention of infection in EAR, NOSE, THROAT and ENDOCRINE Surgery

Most procedures do not require prophylaxis. Where the patient is debilitated, if surgery is likely to be complex or the patient has a malignancy, prophylaxis may be indicated: CEFUROXIME 1.5g IV plus METRONIDAZOLE 500mg IV as single doses Penicillin allergy GENTAMICIN 3mg/kg plus METRONIDAZOLE 500mg IV PROCEDURE Ear surgery (clean/clean-contaminated) Tonsillectomy Adenoidectomy Routine nose, sinus and endoscopic sinus surgery Thyroid, parathyroid surgery Cochlear implant REGIMEN Number and timing of doses**

ANTIMICROBIAL PROPHYLAXIS IS NOT RECOMMENDED

Complex septorhinoplasty

CO-AMOXICLAV 1.2g IV Penicillin allergy CEFUROXIME 1.5g plus METRONIDAZOLE 500mg IV Penicillin allergy severe immediate hypersensitivity reaction *Contact Microbiology to discuss antibiotic choice* OFLOXACIN 0.3% drops topically post operatively

1 dose at induction

Duration should be no longer than 24 hours Single dose

Grommet insertion

**For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)

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5.6 Prevention of infection in GASTROINTESTINAL surgery

PROCEDURE Upper GI (stomach or oesophagus) Gall bladder surgery (open) Gall bladder surgery (laparoscopic) Lower GI (colon, rectum, appendix) ERCP - antibiotic prophylaxis is NOT recommended unless high risk* patient Hernia repair - antibiotic prophylaxis is NOT recommended unless mesh insertion Splenectomy CO-AMOXICLAV 1.2g IV Penicillin allergy CEFUROXIME 1.5g plus METRONIDAZOLE 500mg IV Penicillin allergy severe immediate hypersensitivity reaction *Contact Microbiology to discuss antibiotic choice* REGIMEN Number and timing of doses**

1 dose at induction

ANTIMICROBIAL PROPHYLAXIS IS NOT RECOMMENDED unless immunosuppression (COAMOXICLAV 1.2g IV Penicillin allergy CEFUROXIME 1.5g plus METRONIDAZOLE 500mg IV) Please see pages 12 13 for advice on perioperative vaccination and post-splenectomy antibiotic prophylaxis

1 dose at induction

*Antibiotic prophylaxis should be considered for high risk patients {intraoperative cholangiogram, pancreatic pseudo-cyst, immunosupression, incomplete biliary drainage, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, pregnancy, immunosupression and insertion of prosthetic devices, T tube} **For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)

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5.7 Prevention of infection in UROLOGICAL procedures

Patients with a laboratory confirmed urinary infection should be treated with the appropriate agent based on the susceptibility results. Pre-operative urine analysis will guide the choice of agent if the urine is culture positive. If the susceptibility results are not available or unknown: PROCEDURE Regimen Number and timing of doses** CIPROFLOXACIN 400mg IV 1 dose at induction Transrectal prostrate biopsy Transurethral resection of the prostate GENTAMICIN 5mg/kg IV as a single dose plus AMOXICILLIN 1g STAT Penicillin allergy GENTAMICIN 5mg/kg IV plus TEICOPLANIN 400mg IV as single doses ANTIMICROBIAL PROPHYLAXIS IS NOT RECOMMENDED CO-AMOXICLAV 1.2g IV Penicillin allergy GENTAMICIN 5mg/kg plus METRONIDAZOLE 500mg IV GENTAMICIN 5mg/kg IV GENTAMICIN 5mg/kg IV 1 dose at induction

Transurethral resection of bladder tumours Nephrectomy

1 dose at induction

Shock wave lithotripsy Endoscopic ureteric stone fragmentation/removal

1 dose at induction 1 dose at induction

CIPROFLOXACIN 500mg PO bd for one week preoperatively 1 week Percutaneous nephrolithotomy Preoperative Antibiotic prophylaxis recommended with stone >20mm or with pelvicalyceal dilation **For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)

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6. Splenectomy: vaccination and antibiotic prophylaxis When?

Elective: Vaccines should preferably be given two weeks prior to the procedure. If this is not practical, the patient should be immunised as soon as possible after recovery from the operation and before discharge from hospital. Patients who have had immunosuppressive chemotherapy or radiotherapy should not be vaccinated for 6 months after treatment. Patients should be advised to have a pre-travel consultation to address what immunisations are recommended prior to foreign travel.

Inform the patient and relatives

Patients and their relatives must be informed that the spleen has been removed and that consequently: 1. Antibiotic prophylaxis is necessary for life 2. The patient must attend a doctor immediately if they feel unwell 3. They should be given a copy of the patient information leaflet

Documentation
Document that patient has had a splenectomy and that vaccination and advice regarding antibiotics has been instituted On the front of the patients chart

Inform the patients GP

The patients general practitioner should be notified of the splenectomy and the vaccinations given (by telephone and in discharge letter).

Antibiotic Prophylaxis for a patient following splenectomy

Prophylaxis with antibiotics is usually life-long. It is especially important in the first 2 years post splenectomy. Antibiotic Options 1st line : PHENOXYMETHYLPENICILLIN 2nd line: AMOXICILLIN 3rd line: CLARITHROMYCIN (Penicillin allergy) Dose 333 666mg twice daily 1st line treatment 500mg daily 500mg daily

Patient Counselling infective symptoms Please inform the patient that should infective symptoms such as a raised temperature, malaise, or shivering develop, the patient should seek immediate medical help.

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6.1 Perioperative Vaccination

Vaccine Pneumococcal Vaccine (Pneumovax II) Licensed Dose and Administration for adults Dose: 0.5ml IM or SC Preferably 2 weeks before splenectomy. Otherwise administer before discharge Single dose injection Dose: 0.5ml IM Preferably 2 weeks before splenectomy. Otherwise administer before discharge. Use only in unimmunised individuals. Give 2 doses of MenC vaccine 2 months apart. Dose: 0.5ml IM Preferably 2 weeks before splenectomy. Otherwise administer before discharge. Use only in previously unvaccinated individuals. Give 2 doses of Hib vaccine 2 months apart. Reimmunisation required Yes Every 5 years Live?

No

Meningococcal Group C conjugate vaccine (Meningitec)

.Yes 2 months after 1st vaccination

No

Haemophilus influenza Type B Vaccine (Hiberix)

Yes 2 months after 1st vaccination

No

6.2 Annual Vaccination

Licensed Dose and Administration for adults Influenza Vaccine Dose: 0.5ml IM or deep SC Annual Vaccination (Agrippal, Enzira, Imuvac, Fluarix) Vaccine Reimmunisation required Every Year Live? No

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Reference 1. British Committee for Standards in Haematology. Update of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. 2001. http://www.bcshguidelines.com/pdf/SPLEEN96.pdf 2. British Committee for Standards in Haematology. Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. BMJ. 1996; 312(7028): 430-34. 3. National Immunisation Advisory Committee. Immunisation Guidelines for Ireland. Royal College of Physicians, 2008 4. Immunisation against infectious diseases. The Green Book. Department of Health United Kingdom. 2006 (updated April 2010)

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7. Empiric treatment guidelines (before microbiology results available) for surgical patients with infection These guidelines are designed for use by admitting doctors for common infectious conditions encountered in adult
surgical patients admitted from the community. If the patient has had a recent hospital admission or recent antibiotics, please contact the microbiologist for advice as antibiotic therapy may have to be modified. Please refer to the above guidelines for advice on surgical prophylaxis. ILLNESS SKIN & SOFT TISSUE Cellulitis -Mild COMMENTS ANTIBIOTIC DURATION OF Tx

Investigations: Blood cultures, swab if exudates present, CRP/ESR/WBC, check for underlying DVT or diabetes Investigations: Blood cultures, swab if exudates present, CRP/ESR/WBC, check for underlying DVT or diabetes

FLUCLOXACILLIN 500mg PO qds Penicillin allergy DOXYCYLINE 100mg bd or CLINDAMYCIN 450mg PO qds Oral therapy: FLUCLOXACILLIN 500mg PO qds Intravenous therapy: FLUCLOXACILLIN 1 2g IV qds Penicillin allergy CLINDAMYCIN 450mg PO qds (or IV if required)

7 days

Cellulitis -Moderate

10 14 days

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Cellulitis -Severe

Patient may be in septic shock If suspected gas gangrene or necrotising fasciitis urgent surgical debridement necessary send pus or tissue (not swab) from surgery for culture and susceptibility testing. If out of hours, please contact On-Call Microbiologist

FLUCLOXACILLIN 2g IV qds plus CLINDAMYCIN 450mg IV qds Penicillin allergy VANCOMYCIN 15mg/kg bd in place of flucloxacillin above Contact the microbiologists if gas gangrene/necrotising fasciitis

10 14 days

Surgical site infection (wound) after clean surgery

Investigations: Blood cultures, swab if exudates present, CRP/ESR/WBC Surgical drainage may be required if severe or deep infection send pus or tissue from surgery for culture and susceptibility testing

Treat as CELLULITIS MILD, MODERATE or SEVERE as above

See Cellulitis above for advice

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Surgical site infection (wound) after contaminated surgery

Investigations: Blood cultures, swab if exudates present, CRP/ESR/WBC Surgical drainage may be required if severe or deep infection send pus or tissue from surgery for culture and susceptibility testing Commonly colonised with multiple organisms. Clinically non-infected ulcers should not be cultured

CO-AMOXICLAV 1.2g tds IV *Contact the microbiologists if concerned*

5 7 days

Leg ulcers and pressure areas

DO NOT TREAT WITH ANTIBIOTICS UNLESS CLINICAL EVIDENCE OF INFECTION Topical antiseptics and wound care usually sufficient Antibiotics only indicated if there is evidence of cellulitis or deeper infection

Superficial swabs from infected ulcers are not ideal for culturing, as both colonising and infecting organisms are recovered. Pathogens are more reliably detected in specimens obtained by curettage.

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ILLNESS BONE AND JOINT INFECTION Acute osteomyelitis

COMMENTS

ANTIBIOTIC

DURATION OF Tx

Investigations: Blood cultures, CRP/ESR/WBC. Bone biopsy do not rely on the results of superficial swabs of ulcers to identify the cause(s) of the bone infection

FLUCLOXACILLIN 2g qds IV plus SODIUM FUSIDATE 500mg tds PO Penicillin allergy CLINDAMYCIN 450mg IV qds plus SODIUM FUSIDATE 500mg tds PO

6 weeks in total: At least 2 weeks of IV therapy followed by 4 weeks PO

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Chronic osteomyelitis

Investigations: Blood cultures, CRP/ESR/WBC, bone biopsy for C&S, AFB & mycobacterial culture Bone biopsy do not rely on the results of superficial swabs of ulcers to identify the cause(s) of the bone infection. The range of potential pathogens (including mycobacterial species) is extensive. Patients (usually diabetics) with infected foot ulcers, multiple bacterial species may be implicated. It is ESSENTIAL therefore to identify the microbiological cause(s).

*Contact microbiology for advice

Long term therapy required (3 6 months)

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Acute Septic arthritis

Investigations: Blood cultures, CRP/ESR/WBC Joint aspirate (urgent gram stain)- if possible take before antibiotics Treatment requires adequate drainage of joint fluid and antibiotics If gonoccocal infection suspected - STD screen

FLUCLOXACILLIN 2g qds IV plus SODIUM FUSIDATE 500mg tds PO Penicillin allergy CLINDAMYCIN 450mg IV qds plus SODIUM FUSIDATE 500mg tds PO

6 weeks in total: At least 2 weeks of IV therapy followed by 4 weeks PO

Add CEFTRIAXONE 1g IV od or CEFOTAXIME 1g tds IV *Contact microbiology for advice on treatment options & duration*

Infected prosthetic joint

Investigations: Blood cultures, CRP/ESR/WBC Joint aspirate (gram stain and culture) If possible take before antibiotics

COMMENTS ILLNESS SEPTICAEMIA (blood stream infection) no obvious source Investigations: - WCC, send full septic screen ie. [MSU, blood cultures (2 sets), sputum, wound swab] - Check operative site? collection? surgical site/wound infection - CXR & other radiological investigations are indicated - If suspect semi permanent line/catheter sepsis take central & peripheral blood cultures, remove line send tip for C&S - Consider or rule out infective endocarditis

ANTIBIOTIC

DURATION OF Tx

*Contact microbiology for advice on treatment & duration*

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ILLNESS

COMMENTS

ANTIBIOTIC

DURATION OF Tx

LOWER RESPIRATORY TRACT INFECTIONS CURB-65 score <3 Community-acquired pneumonia (seek medical advice) CURB-65 score >3 CURB-65 Severity assessment
score for CAP Score 1 for each feature present - Confusion - Urea >7mmol/L - Respiratory rate > 30/min - Blood pressure SBP < 90mmHg +/or DBP< 60mmHg - Age > 65 years

CLARITHROMYCIN 500mg PO bd CO-AMOXICLAV 1.2g tds IV plus CLARITHROMYCIN 500mg PO bd Oral Switch: CO-AMOXICLAV 625mg tds PO plus CLARITHROMYCIN 500mg PO bd Penicillin allergy CLARITHROMYCIN 500mg bd IV plus CEFUROXIME 750mg 1.5g tds IV Penicillin allergy Severe immediate hypersensitivity reaction *Contact Microbiology to discuss treatment options*

7 days REVIEW IV at 48hours Total course length 10 days

Investigations: sputum C&S, BAL, Blood culture, CXR, FBC, U&E, ?TB, urine Legionella & pneumococcal antigen, serum for Q fever, mycoplasma & chlamydia serology

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Healthcare associated pneumonia

>5 days in hospital or from longterm care, nursing home, or recent hospital admission previous 6 weeks Community acquired aspiration pneumonia

Investigations: Sputum C&S, BAL (if intubated), blood culture, CXR, FBC Treat according to cultures Review at 48 hours

PIPERACILLIN/TAZOBACTAM 4.5g tds IV Penicillin allergy *Contact Microbiology to discuss treatment options* BENZYLPENICILLIN 1.2g qds IV plus METRONIDAZOLE 500mg IV tds Penicillin allergy CEFOTAXIME 2g tds IV plus METRONIDAZOLE 500mg tds IV PIPERACILLIN/TAZOBACTAM 4.5g tds IV Penicillin allergy *Contact Microbiology to discuss treatment options*

7 days

Investigations: Sputum C&S, BAL (if intubated), Blood culture, CXR, FBC & SALT assessment (speech & language therapy)

REVIEW IV therapy at 48hours 7 days

Healthcare associated aspiration pneumonia >5 days in hospital or from longterm care, nursing home, or recent hospital admission previous 6 weeks Empyema Investigations: Sputum C&S, Blood Culture, CXR, FBC +/- drainage (fluid C&S)

*Discuss treatment options with microbiology*

14 days

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Tonsillitis

Investigations: Throat swab, consider monospot

BENZYLPENICILLIN 1.2g qds IV Or if patient can tolerate oral therapy Oral Switch: AMOXICILLIN PO 500mg tds CO-AMOXICLAV 1.2g tds IV for 48 hours then Oral Switch: CO-AMOXICLAV 625mg tds PO

10 14 days

Quincy

Investigations: Aspiration/pus C&S, Blood Culture, throat swab

7 days post drainage

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ILLNESS GENITOURINARY INFECTIONS UTI (uncomplicated/lower)

COMMENTS

ANTIBIOTIC

DURATION OF Tx

Investigations: MSU/CSU, WBC (?pyelonephritis/obstruction) Rationalise treatment choice based on urine C&S results Investigations: blood cultures, MSU/CSU, WBC, renal U/S Review any previous urine C&S results

TRIMETHOPRIM 200mg PO bd or NITROFURANTOIN 50mg PO qds (avoid if renal function <60mL/minute)

7 days (Male) 3 days (Female)

Pyelonephritis/complicated UTI

CO-AMOXICLAV 1.2g tds IV plus # GENTAMICIN 5mg/kg IV od (use for 3 5 days only) Penicillin allergy *Contact Microbiology to discuss treatment options* DOXYCYCLINE 100mg PO bd

Total course length 14 days

Acute epididymorchitis

Investigations: Blood Culture, MSU, WBC +/- urethral swab, STI screen

14 days

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Pelvic inflammatory disease Investigations: Blood culture, MSU, STI screen

Contact tracing is recommended if STI documented *Refer to Gynaecology for advice* If patient has an IUCD or IUS in place, consider removal discuss alternative contraception.

DOXYCYCLINE 100mg PO bd plus METRONIDAZOLE 400mg PO tds (plus CEFTRIAXONE 250mg IM STAT if infection with gonorrhoea likely) If unable to tolerate oral therapy, pregnant, systemically unwell or examination suggests presence of tubo-ovarian abscess, discuss management with Microbiology.

14 days 10 days

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ILLNESS

COMMENTS

ANTIBIOTIC

DURATION OF Tx

GASTROINTESTINAL/ABDOMINAL Cholangitis Investigations: Blood cultures, WBC, CRP If patient has percutaneous drain or abscess, send sample Investigations: Blood cultures, WBC, CRP Send pus or tissue from surgery for culture & sensitivity testing Investigations: Blood cultures, WBC, CRP Send operative/radiological pus sample for culture & sensitivity testing Investigations: Blood cultures, WBC, CRP Send operative/radiological pus sample for culture & sensitivity testing Investigations: Blood cultures, WBC, CRP Send operative/radiological pus sample for culture & sensitivity testing PIPERACILLIN/ TAZOBACTAM 4.5g tds IV Penicillin allergy *Contact Microbiology to discuss treatment options* CO-AMOXICLAV 1.2g IV tds +/# GENTAMICIN 5mg/kg od Penicillin allergy CEFUROXIME 750mg 1.5g tds plus METRONIDAZOLE 500mg IV tds PIPERACILLIN/ TAZOBACTAM 4.5g tds IV +/- #GENTAMICIN 5mg/kg od *Contact Microbiology to discuss treatment options* Treat as for community acquired peritonitis above 7 days

Peritonitis Community acquired

5 10 days

Peritonitis Hospital acquired

Diverticulitis

Intra-abdominal collection

*Contact Microbiology to discuss treatment options*

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Upper gastrointestinal (GI) perforation

Investigations: Blood cultures

CO-AMOXICLAV 1.2g IV tds plus FLUCONAZOLE 400mg IV od +/# GENTAMICIN 5mg/kg od Penicillin allergy *Contact Microbiology to discuss treatment options* *Contact Microbiology to discuss treatment options* CO-AMOXICLAV 1.2g IV tds Oral Switch: CO-AMOXICLAV 625mg tds PO 7 10 days

Hospital acquired GI perforation Investigations: Blood cultures Cholecystitis Investigations: Blood cultures

Pancreatitis

Investigations: Blood cultures, aspirates, tissue First line agent Severe infection WCC >20x109/L Serum lactate 2.2 4.9mmol/L Sepsis

*Contact Microbiology to discuss treatment options*

Clostridium difficile infection ISOLATE PATIENT! Review concurrent antibiotic treatment, PPIs or laxatives & discontinue where appropriate

METRONIDAZOLE PO 400mg tds VANCOMYCIN 125mg PO qds plus METRONIDAZOLE 500mg tds IV if not tolerating oral intake plus Surgical review *Always contact Microbiologist if severe symptoms*

10 days

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ILLNESS

COMMENTS

ANTIBIOTIC

DURATION OF Tx

BITES & STINGS Adult: Animal bites First line Assess tetanus and rabies risk. Antibiotic prophylaxis may not be indicated for all cases. Antibiotic prophylaxis advised for puncture wound, bite involving hand, foot, face, joint, tendon, ligament, immunocompromised, diabetic, elderly, asplenic. Human bites Antibiotic prophylaxis advised. Risk assess for relevant blood borne viruses e.g. hepatitis B Treat only if clinically infected Penicillin allergy CLINDAMYCIN 450mg PO qds CO-AMOXICLAV 625mg PO tds 7 days

CO-AMOXICLAV 625mg PO tds Penicillin allergy CLINDAMYCIN 450mg PO qds Treat as for mild to moderate Cellulitis PAGE 2.

7 days

Insect bites or stings

7 days

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8. SWITCHING FROM INTRAVENOUS TO ORAL THERAPY

Treatment which is initially administered by the parenteral route should be 'switched' to the oral route as early as possible according to the following criteria: a) b) c) d) e) Temperature <38oC for 2 consecutive days Patient able to tolerate oral food and fluids Absence of ongoing or potential problem of absorption Exceptionally high antibiotic tissue concentrations not essential (as for patients with meningitis, etc) Oral formulation or suitable alternative is available

9. Therapeutic Drug Monitoring for intravenous VANCOMYCIN & GENTAMICIN

full on the intranet Vancomycin

please see the policies in

Pre-dose: 10 15mg/L in uncomplicated Serum level pre 4th dose, then Check pre-dose levels every 2 3 days infections. Impaired renal function check predose levels daily Pre-dose: 15 20mg/L in complicated infections such as osteomyelitis, meningitis, bacteraemia, infective endocarditis and healthcare associated pneumonia. Pre-dose: <1mg/L

Gentamicin once daily

Serum level 18 24 hours after 1st dose, then check pre-dose levels every 2 3 days Impaired renal function check predose levels daily

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