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Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.

0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 1 of 26
Royal United Hospital Bath NHS Trust





Microbiology Department

Guideline for the Empirical Treatment of Infections in Adults
______________________________________________________________________

Appropriate prescribing of antibiotics

Decision to prescribe
The use of antibiotics carries significant risks to the patient and the decision to prescribe
an antibiotic should always be clinically justified following a risk-benefit assessment. Do
not start antibiotics in the absence of clinical evidence of bacterial infection unless the
patient is gravely ill and sepsis is part of the differential diagnosis. If the clinical picture
is not clear and the patient is stable, it may be possible to wait, monitor the patient
clinically and review with laboratory results.

If there is evidence/suspicion of sepsis, use local guidelines to initiate broad spectrum
antibiotic treatment within one hour of diagnosis (or as soon as possible) in patients with
life threatening infections. Delay in starting adequate antibiotic therapy in severe
infection is associated with increased morbidity and mortality. Individual patient and
drug-specific factors to consider in all cases include:
previous antimicrobial history
previous colonisation or infection with multi-resistant organisms
allergies and other side effects (including risk of Clostridium difficile infection)
contraindications and cautions
availability of and absorption by oral route

Appropriate specimens for microscopy, culture and sensitivity should be obtained prior
to commencing antibiotics wherever possible but do not delay starting treatment in
patients who are severely ill.

Minimising the use of broad-spectrum antibiotics
The use of broad-spectrum antibiotic agents is a major factor in inducing C. difficile
infection. In addition there is evidence to show an association between total
antimicrobial use and use of some specific classes of antibiotics with higher MRSA
prevalence. Clinicians should avoid the use of cephalosporins, quinolones, broad-
spectrum penicillins (including amoxicillin) and clindamycin unless there are clear
clinical indications for their use.
Broad-spectrum antibiotics should be restricted to the treatment of serious infections
when the pathogen is not known or when other effective agents are unavailable.

Information for Clinicians

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 2 of 26
Royal United Hospital Bath NHS Trust

Documentation
The clinical indication, duration or review date, route and dose should be clearly
documented in the patients medical notes and on the drug chart.

Reasons for any deviations from empirical treatment guidelines should be recorded in
the patients medical notes.

Allergies must be recorded in the patients medical notes and on the front of the drug
chart and anaesthetic record, along with the nature of the reaction.

Review of antibiotic treatment
Review the clinical diagnosis and the continuing need for antibiotics by 48 hours then
daily with a clear plan of action - the Antimicrobial Prescribing Decision. The five
Antimicrobial Prescribing Decision options are:
1. Stop antibiotics if there is no evidence of infection
2. Switch IV to Oral
3. Change antibiotics ideally to a narrower spectrum or broader if required
4. Continue and review again after a further 24 hours
5. Outpatient Parenteral Antibiotic Therapy (OPAT)
It is essential that the review and subsequent decision is clearly documented in the
medical notes. Treatment with antibiotics should not continue beyond 7 days (IV and
oral) unless recommended by a local guideline or microbiologist.

Department of Health Guidance recommend a Start Smart - then Focus approach for all
antibiotic prescriptions

Start smart is:
Do not start antibiotics in the absence of clinical evidence of bacterial infection
If there is evidence/suspicion of bacterial infection, use local guidelines to initiate
prompt effective antibiotic treatment
Document on drug chart and in medical notes: clinical indication, duration or review
date, route and dose
Obtain cultures first
Prescribe single dose antibiotics for surgical prophylaxis; where antibiotics have
been shown to be effective

Then focus is:
Review the clinical diagnosis and the continuing need for antibiotics by 48 hours and
make a clear plan of action - the Antimicrobial Prescribing Decision
The five Antimicrobial Prescribing Decision options are:
- Stop antimicrobials
- Switch IV to Oral
- Change,
- Continue
- Outpatient Parenteral Antibiotic Therapy (OPAT).

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 3 of 26
Royal United Hospital Bath NHS Trust

Intravenous or oral therapy
Intravenous (IV) therapy should only be used for patients with severe infections,
patients who have a focus of infection requiring high doses of antibiotics, patients who
are unable to take or absorb oral antibiotics, and when there are no alternative suitable
oral agents.

IV antibiotics should be reviewed on a daily basis and, if appropriate, the patient
switched to an oral equivalent within 24 hours of meeting switch criteria.

Oral switch criteria are:

temperature <37.5 C for 24 hours
signs and symptoms of infection are improving
inflammatory markers are decreasing
patient able to tolerate oral food and fluids
absence of on-going or potential problem of absorption
oral formulation or suitable oral alternative is available

Exceptions to this include some serious infections where exceptionally high antibiotic
tissue concentrations are essential (e.g. meningitis, infective endocarditis) or following
microbiological advice.






















Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 4 of 26
Royal United Hospital Bath NHS Trust

Using this guideline

This antibiotic policy gives initial empirical treatment only but should be used
discriminately with consideration of contra-indications, interactions and previous culture
results. Doses are based on normal hepatic and renal function in a 70kg man and
may require adjustment. Durations are given as a guide but should be evaluated
based on the condition being treated & the clinical response. Antibiotics should be
reviewed and rationalised with microbiology results and clinical progress.

Vancomycin and Gentamicin - Always check levels at appropriate intervals and
adjust dose / dosage interval accordingly. See Guidelines for the dosing and
monitoring of Gentamicin, Vancomycin and Teicoplanin for further advice. Do not
use Gentamicin for more than 7 days without discussion with a Microbiologist.
Penicillin allergy - patients with a history of anaphylaxis, urticarial rash or a rash
immediately after penicillin administration (type 1 allergy) should not receive a
penicillin, cephalosporin or other beta-lactam antibiotic. Check before prescribing if
you are unsure which class an antibiotic belongs to. Discuss alternative antibiotic
treatment with a Microbiologist if a suitable one is not given in the policy.
MRSA - If a patient has been in hospital for more than five days, has previously
been known to be colonised with MRSA, or is at risk for MRSA colonisation (e.g.
recent hospital admission or resident in a Nursing or Residential home) consider
using Vancomycin or Teicoplanin.
Extended Spectrum Beta-Lactamase (ESBL) producers, Vancomycin Resistant
Enterococci (VRE) and other multi-resistant organisms - If a patient has been
previously colonized or infected with a multi resistant organism or may have risk
factors for colonisation (e.g. recurrent urinary tract infections, admitted from a
nursing home or a long term catheter in situ) an alternative antibiotic regime may be
necessary discuss with Microbiology.
Tetanus - for further information see Immunisation Against Infectious Diseases -
The Green Book December 2006, Chapter 30: Tetanus.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAn
dGuidance/DH_079917












Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 5 of 26
Royal United Hospital Bath NHS Trust
Empirical Treatment Guidelines


Adult Empiri cal Treatment Guidelines: Sepsi s (anti biotics should be initiated within 1 hour of diagnosis)

Infection Antibiotic Treatment IV Option Comments

Community-acquired
sepsis of unknown
origin, meningitis not
suspected

Co-amoxiclav 1.2g tds &
Gentamicin 5mg/kg od
+/- Metronidazole 500mg tds if
anaerobic infection suspected


If neutropenia or suspected neutropenia,
see Neutropenic Sepsis Guideline

If ESBL producer or other multi-resistant
organism present, or if concern regarding
clinical response or renal function, discuss with
Microbiology

Discuss all cases with Microbiology within 24
hours


Penicillin allergy:
Teicoplanin 600mg 12 hourly for
first 3 doses then 600mg od &
Gentamicin 5mg/kg od
+/-Metronidazole 500mg tds if
anaerobic infection suspected
Hospital acquired
sepsis
Discuss with Microbiology
Vancomycin and Gentami cin check levels at appropriate intervals and adjust dose/dosage interval
accordingly. See Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin


Adult Empiri cal Treatment Guidelines: CNS Infections

Infection Antibiotic Treatment IV Option Comments

Suspected Bacterial
Meningitis
Ceftriaxone 4g od

Add Amoxicillin 2g
4 hourly if patient >50 years old or if
immunocompromised or pregnant

Discuss with Microbiology if recent
travel abroad or penicillin allergy
Consider adjunctive dexamethasone
(0.15 mg/kg 4 hourly for 24 days with the first
dose administered 1020 min before, or at least
concomitant with, the first dose of antimicrobial
therapy) in adults with suspected or proven
pneumococcal meningitis

Discuss all suspected cases with a
Microbiologist

Inform relevant Health Protection Unit (via
switchboard)

Send EDTA blood sample for Meningococcal
and Pneumococcal PCR

Suspected HSV
encephalopathy

Aciclovir 10mg/kg tds
Dose reduction required if
eGFR<50
Treat for 14-21 days

Inform relevant Health Protection Unit (via
switchboard)

CSF should be sent for viral PCR

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 6 of 26
Royal United Hospital Bath NHS Trust

Adult Empiri cal Treatment Guidelines: Genitourinary
Previous urine culture results should guide empirical therapy
Review with urine culture results
Urine dipsticks are often positive in elderly patients and treatment may not be indicated see UTI in the Non
Catheterised Older Adult Guidelines
Infection Antibiotic Treatment Total
Duration
Additional Comments

Uncomplicated
UTI in
women (See UT
I in the non
catheterised
Older Adult
Guidelines
Trimethoprim 200mg po bd
3 days

Nitrofurantoin is contra-indicated
in patients with eGFR <20ml/min
and may be ineffective if eGFR
20-60ml/min

Discuss with Microbiology if
there is high risk of, or previous
infection/ colonisation with a
VRE, ESBL producing isolate, or
other multi-resistant organism
If recent Trimethoprim use or known
Trimethoprim resistant isolate:
Co-amoxiclav 625mg po tds

Penicillin allergy: Nitrofurantoin 50mg po qds

UTI in
men (See UTI
in the non
catheterised
Older Adult
Guidelines
Trimethoprim 200mg po bd
7 days
If recent Trimethoprim use or known
Trimethoprim resistant isolate:
Co-amoxiclav 625mg po tds

Penicillin allergy: Nitrofurantoin 50mg po qds


Mild UTI in
pregnancy

Cefalexin 500mg po bd

7 days
Repeat MSU 7 days after
completion of antibiotics as test
of cure
IV treatment: Oral treatment:

Pyelonephritis
Co-amoxiclav
1.2g tds & single
dose of
Gentamicin
5mg/kg
Co-amoxiclav 625mg
tds


10-14
days



Discuss with Microbiology if
there is high risk of, or previous
infection/ colonisation with a
VRE, ESBL producing isolate, or
other multi-resistant organism


Review oral switch with culture
results and clinical progress
Penicillin allergy:
Ciprofloxacin
500mg po bd
& single dose of
Gentamicin
5mg/kg iv
Penicillin allergy:
Ciprofloxacin 500mg bd
(7 days treatment only
required if ciprofloxacin
used)

7 days

Urinary Catheter
Infection
(Urinary
symptoms,
fever, sepsis,
inflammatory
markers).


Amoxicillin1g tds
& Gentamicin
5mg/kg od

Oral treatment not
recommended for
empirical treatment

7 days
Discuss with Microbiology if
there is high risk of, or
previously infection/ colonisation
with a VRE, ESBL producer, or
other multi-resistant organism

Consider catheter change once
antibiotic known to be active
against isolate

Please ensure that symptoms
are clearly indicated on the
request form for CSU culture
Penicillin allergy:
Gentamicin
5mg/kg once daily
& single dose of
Vancomycin 1g
Adult Empiri cal Treatment Guidelines: Genitourinary

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 7 of 26
Royal United Hospital Bath NHS Trust
Infection Antibiotic Treatment Total
Duration
Additional Comments
Asymptomatic
bacterial
colonisation of
urinary catheter
No treatment required Urinalysis for leukocytes &
nitrites is non-specific in CSUs
Epididymo-
orchitis STI
suspected

Ceftriaxone 500mg im single dose &
Doxycycline 100mg po bd for 14 days
OR
If likely due to chlamydia or other non-
gonococcal organisms:
Doxycycline 100mg po bd or
Ofloxacin 200mg po bd
OR
If severe epididymo-orchitis or features
of bacteraemia, Ceftriaxone 1g iv od &
Gentamicin 5mg/kg iv od for 3-5 days
until fever subsides, and then review
with culture
OR
Ofloxacin 200mg po bd

14 days

Refer to GUM



Epididymo-
orchitis STI not
suspected

If systemically well
Ciprofloxacin 500mg po bd

If severe epididymo-orchitis or features
suggestive of bacteraemia, Ceftriaxone
1g iv od & Gentamicin 5mg/kg iv od for
3-5 days until fever subsides, and then
review with culture results



10 days



Bacterial
Prostatitis STI not
suspected


Ciprofloxacin 500mg po bd

28 days

If STI suspected, refer to GUM

Review with culture results
Urethritis, Epididymo-orchitis, Prostatitis:
If STI suspected refer to GUM for investigation and treatment (Ext 4558)
Out of hours take (1) urethral swab for gonorrhoea culture (2) first void urine or urethral swab for chlamydia and
gonorrhoea NAAT (3) MSU for culture, and then start antibiotics. Refer to GUM for follow up.
Change of long term indwelling urethral catheter in males
Prophylactic antibiotics are recommended in patients with a history of catheter-associated urinary tract
infection following catheter change, or if catheter change likely to be traumatic.
Be guided by culture results of pre-change CSU (please state indication for culture clearly on request form).
If empirical cover necessary, give Gentamicin 1.5mg/kg iv or im
Vancomycin and Gentami cin check levels at appropriate intervals and adjust dose/dosage interval
accordingly. See Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin





Adult Empiri cal Treatment Guidelines: Infective Endocarditis (IE)


Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 8 of 26
Royal United Hospital Bath NHS Trust
Infection Antibiotic Treatment IV
Option

Comments
Infective Endocarditis: indolent
presentation
Amoxicillin 2g iv 4 hourly &
Gentamicin 1mg/kg (ideal body
weight) iv bd

It is preferable to wait for blood
culture results before
commencing treatment

Discuss all suspected cases with a
Microbiologist within 24hours,
particularly if critically ill

Take 3 sets of blood cultures from
separate venepunctures before
commencing treatment

Send a clotted sample for baseline
atypical endocarditis serology

TARGET LEVELS in treatment of IE:
Vancomycin:
Pre-dose 10-15mg/l but higher
levels may be required (discuss
with Microbiology)

Gentamicin:
Pre-dose: <1mg/l
Post dose 3-5mg/l
Infective Endocarditis: acute
presentation (or indolent
presentation with penicillin allergy)
with no risk factors for
multi-resistant bacteria

Vancomycin iv dosed
according to local guidelines &
Gentamicin 1mg/kg (ideal body
weight) iv bd. If eGFR <45 use
Ciprofloxacin 750mg po bd/
400mg iv bd 12 hourly instead
of Gentamicin

Infective Endocarditis: prosthetic
heart valve or suspected MRSA
Vancomycin dosed according
to local guidelines &
Gentamicin 1mg/kg ideal body
weight 12 hourly & rifampicin
300-600mg 12 hourly po/iv
(use lower dose of rifampicin if
severe renal impairment)











Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 9 of 26
Royal United Hospital Bath NHS Trust

Adult Empiri cal Treatment Guidelines: Respiratory Tract
CURB-65 Guidelines to determine management of Community Acquired Pneumonia (CAP)
Infection Antibiotic
Treatment IV
Option
Antibiotic Treatment Oral
Option
Total
Duration
Additional Comments
Non-severe
exacerbations of
COPD
Treat as low severity Community Acquired
Pneumonia
5 days
Low severity
CAP

Based on
clinical
judgement and
CURB-65
Amoxicillin 1g tds Amoxicillin 500mg tds 5 days Use IV only if unable to
swallow or absorb orally
If there is a high clinical
suspicion of pneumonia
caused by atypical
pathogens (including
legionella) add
Clarithromycin 500mg bd to
Amoxicillin
Penicillin allergy or
recent Amoxicillin:
Clarithromycin
500mg po/iv bd
Penicillin allergy or recent
Amoxicillin:
Doxycycline

200mg on day 1 then 100mg
od
OR
continue Clarithromycin
500mg bd if switching from IV
Moderate
severity CAP
Amoxicillin 1g tds
& Clarithromycin
500mg po/iv bd
Amoxicillin 500mg tds
& Clarithromycin 500mg bd
7-10 days Treat with Co-amoxiclav 1.2g
iv tds instead of Amoxicillin if
recent Amoxicillin use in the
community

Send urine for legionella
antigen


Penicillin allergy:
Vancomycin dosed
according to local
guidelines &
Clarithromycin
500mg po/iv bd
Penicillin allergy: Doxycycline
200mg day 1 and then
100mg od
OR
continue Clarithromycin
500mg bd if switching from IV
High severity
CAP

Use iv
treatment
initially


Co-amoxiclav 1.2g
tds
& Clarithromycin
500mg iv bd
Follow on from iv treatment:
Co-amoxiclav 625mg tds &
Clarithromycin 500mg bd
7 - 10
days
If MRSA pneumonia
suspected add iv
Vancomycin

Send urine for legionella
antigen and pneumococcal
antigen


Penicillin allergy:
Vancomycin dosed
according to local
guidelines &
Clarithromycin
500mg iv bd (if pre-
existing chest
disease, consider
using Ciprofloxacin
in place of
Clarithromycin)
Follow on from iv treatment if
Penicillin allergy:
Doxycycline 200mg on day 1
then 100mg od

Markers of Severity
Confusion: new disorientation in person place or time or MTS of 8 or less
Urea: raised >7mmol/L
Respiratory rate raised 30/min
Blood pressure: systolic <90mmHg and/or diastolic 60mmHg
65 years old or above

0-1 3 or more
Low Severity

High Severity



2
Moderate Severity


Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 10 of 26
Royal United Hospital Bath NHS Trust
Infection Antibiotic
Treatment IV
Option
Antibiotic Treatment Oral
Option
Total
Duration
Additional Comments
Aspiration
pneumonia
(inpatient <48
hours)
Co-amoxiclav 1.2g
tds
Amoxicillin 500mg po tds 5-10 days
Note that in the first 48 hours
post aspiration, the patient
may present with chemical
pneumonitis for which
antibiotics are not indicated

If suspected lung abscess,
necrotising pneumonia or
patient very unwell , discuss
with Microbiology
Penicillin allergy:
Clarithromycin 500mg po/iv BD &
Metronidazole po/iv tds

Aspiration
pneumonia
(inpatient >48
hours)
Co-amoxiclav 1.2g
tds

Co-amoxiclav 625mg tds 5-10 days
Penicillin allergy:
Clarithromycin 500mg po/iv BD &
Metronidazole po/iv tds
Infective
exacerbation of
bronchiectasis,
CF or other
suppurative lung
condition
Discuss with
Respiratory/
Microbiology
Discuss with Respiratory/
Microbiology
According
to clinical
response
Empirical therapy depends
upon culture results. Two
agents may be required.

CAP pregnancy
or breast
feeding
Cefuroxime 1.5g
tds &
Clarithromycin
500mg po / iv bd
Amoxicillin 500mg tds &
Clarithromycin 500mg bd
5 -10
days
Send urine for legionella
antigen

Treat with Co-amoxiclav
625mg po tds instead of
Amoxicil lin if recent
Amoxicil lin use in the
community
Penicillin allergy:
Discuss with
Microbiology
Penicillin allergy:
Clarithromycin 500mg bd
Discuss with Microbiology if
concerns

HAP
(Hospital <5
days and no
previous
antibiotics)


Co-amoxiclav 1.2g
tds
Co-amoxiclav 625mg tds 7 - 10
days
Add Vancomycin iv dosed
according to local
guidelines if MRSA
suspected

Send legionella urinary
antigen and discuss with
Microbiology if any history
suggestive of legionella

If not responding to therapy,
discuss with Microbiology
Penicillin allergy:
Vancomycin iv
dosed according to
local guidelines
& Ciprofloxacin po
500mg bd (or
400mg iv bd if oral
route not
appropriate)

Penicillin allergy:
Discuss with Microbiology


HAP
(Hospital >5
days or previous
Co-amoxiclav)
Piperacillin-
tazobactam 4.5g
tds
Discuss with Microbiology 7 - 10
days
Add Vancomycin iv dosed
according to local
guidelines if MRSA
suspected or patient very
unwell

Send urine for legionella
antigen

If not responding to therapy,
discuss with Microbiology

Penicillin allergy:
Vancomycin iv
dosed according to
local guidelines
& Ciprofloxacin po
500mg bd (or
400mg iv bd if oral
route not
appropriate)
Vancomycin and Gentami cin check levels at appropriate intervals and adjust dose/dosage interval accordingly.
See Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 11 of 26
Royal United Hospital Bath NHS Trust


Adult Empiri cal Treatment Guidelines: ENT

Infection Antibiotic
Treatment IV
Option
Antibiotic
Treatment Oral
Option
Total Duration Additional Comments

Tonsillitis/ Quinsy

Benzylpenicillin
1.2g qds


Penicillin V 500mg
qds

10 days

Consider infectious
mononucleosis

Add Metronidazole 500mg iv
tds if quinsy
Penicillin allergy:
Clarithromycin
500mg bd

Penicillin allergy:
Clarithromycin
500mg po bd

Epiglottitis
Ceftriaxone 2g iv
od
Follow on from iv
treatment:
Co-amoxiclav
625mg tds
10-14 days Add Metronidazole 500mg iv
tds if abscess
Penicillin allergy:
Discuss with
Microbiology

Penicillin allergy:
Discuss with
Microbiology

Acute sinusitis
Co-amoxiclav 1.2g
tds
Co-amoxiclav
625mg tds

OR

Doxycycline 200mg
on day 1 then
100mg od
5-7 days Use iv only if unable to
swallow or absorb po
antibiotic
Penicillin allergy:
Doxycycline 200mg
po on day 1 then
100mg po od

Acute severe otitis
externa
Flucloxacillin 1g
qds

Flucloxacillin
500mg qds

According to
clinical
response

Penicillin allergy or
MRSA suspected:
Vancomycin iv
dosed according to
local guidelines

Penicillin allergy:
Doxycycline 200mg
on day 1 then
100mg od

Invasive otitis
externa
Piperacillin-
tazobactam 4.5g
tds & Gentamicin
5mg/kg iv od

Discuss with
Microbiology
According to
clinical
response
Add Teicoplanin 600mg i v
12 hourl y for first 3 doses
then 600mg iv od if MRSA
isolated or suspected
Penicillin allergy:
Discuss with
Microbiology

Vancomycin and Gentami cin check levels at appropriate intervals and adjust dose/dosage interval accordingly.
See Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin



Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 12 of 26
Royal United Hospital Bath NHS Trust








Adult Empiri cal Treatment Guidelines: Bone and Joint

Infection Antibiotic
Treatment
IV Option
Total Duration Additional
Comments

*********Always try to take appropri ate specimens for culture prior to antibiotic therapy*********

Septic arthritis
native joint
Flucloxacillin 2g iv
qds & Gentamicin
5mg/kg iv od
Consider gonorrhoea

Please discuss with Microbiology within 1 week

Treatment usually requires 2 weeks iv then 4
weeks oral antibiotics

If MRSA isolated or
suspected, discuss
with Microbiology

Rationalise therapy
based on results of
deep tissue culture
results

Penicillin allergy:
Vancomycin iv
dosed according
to local guidelines
& Ciprofloxacin
750mg po bd
Acute
osteomyelitis
Flucloxacillin 2g iv
qds & Gentamicin
5mg/kg iv od
Please discuss with Microbiology within 1 week

Chronic
osteomyelitis
Discuss individual case with Microbiology
Diabetic foot with
possible
underlying
osteomyelitis
If sepsis, Piperacillin-tazobactam 4.5g iv
tds. Add Vancomycin iv dosed according
to local guidelines if MRSA is suspected


If MRO suspected, discuss with Microbiology

If not septic, discuss with Microbiology

Liaise with Diabetic Foot Team
Penicillin allergy: Discuss with
Microbiology
Suspected
prosthetic joint
infection
Vancomycin iv dosed according to local
guidelines.

Add Piperacillin-tazobactam 4.5g iv tds if
previous or suspected infection with Gram
negative organisms or patient septic or
sinus present

Continue antibiotics until culture results are
available, then review treatment with Microbiology

Penicillin allergy: Discuss with
Microbiology
Open fracture with
and without
significant
contamination
See Antibiotic Guideline: Surgical Prophylaxis in
Adults
Vancomycin and Gentamicin check levels at appropriate intervals and adjust dose/dosage interval accordingly.
Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 13 of 26
Royal United Hospital Bath NHS Trust
Adult Empiri cal Treatment Guidelines: Skin and Soft Tissue

Infection Antibiotic Treatment IV
Option
Antibiotic Treatment
Oral Option
Total
Duration
Additional Comments
Human or
animal bite
Co-amoxiclav 1.2g tds Co-amoxiclav 625mg tds 7 days Check tetanus status and
discuss with Microbiology if
human bite or concern
regarding rabies
Penicillin allergy:
Ciprofloxacin 400mg iv bd
& Clindamycin 600mg iv
qds
Penicillin allergy:
Ciprofloxacin 500-750mg
bd & Clindamycin 300-
450mg qds
Cellulitis

Flucloxacillin 1g qds

Flucloxacillin 500mg qds 5 - 7 days

Only if severe consider adding
Clindamycin 300-450mg po
qds to Flucloxacillin /
Vancomycin
(substitute if on Doxycycline)

Penicillin allergy or MRSA
suspected: Vancomycin iv
dosed according to local
guidelines
Penicillin allergy:
Doxycycline 200mg po on
day 1 then 100mg po od
Bursitis

Flucloxacillin 1g qds Flucloxacillin 500mg qds 7 days
Penicillin allergy or MRSA
suspected: Vancomycin iv
dosed according to local
guidelines
Penicillin allergy:
Doxycycline 200mg po on
day 1 then 100mg po od
Mastitis Flucloxacillin 1g qds
OR
consider Co-amoxiclav
1.2g tds if breastfeeding,
post- operative or recent
Flucloxacillin
Flucloxacillin 500mg qds
OR
consider Co-amoxiclav
625mg tds if
breastfeeding, post -
operative or recent
Flucloxacillin
5-7days
Penicillin allergy or MRSA
suspected: Vancomycin iv
dosed according to local
guidelines
Penicillin allergy or MRSA
suspected:
Discuss with Microbiology

Moderate-
severe
cellulitis in
association
with diabetes
or post GI
surgery


Co-amoxiclav 1.2g tds

If severe consider adding
Clindamycin 300-450mg
po qds
Co-amoxiclav 625mg tds 7 -10
days
If MRSA is suspected add
Vancomycin iv dosed
according to local guideli nes

Liaise with Diabetic Foot Team
Penicillin allergy:
Clindamycin 600mg iv qds
& Ciprofloxacin 750mg po
bd (or 400mg iv bd if oral
route not appropriate)
Penicillin allergy:
Discuss with Microbiology
Necrotising
Fasciitis
Meropenem 1g tds
& Clindamycin 600mg iv
qds
& Metronidazole 500mg
tds & single dose
Gentamicin 5mg/kg
Not appropriate


According
to clinical
response
If suspected get an URGENT
surgical opinion and discuss
with a Microbiologist

If MRSA is suspected add
Vancomycin iv dosed
according to local guideli nes
Vancomycin and Gentami cin check levels at appropriate intervals and adjust dose/dosage interval accordingly.
See Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
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Adult Empiri cal Treatment Guidelines: Skin and Soft Tissue
Infection Antibiotic Treatment IV
Option
Antibiotic
Treatment Oral
Option
Total
Duration
Additional Comments
Severe pre
septal and
orbital cellulitis
Ceftriaxone 2g bd Discuss with
Microbiology
According
to clinical
response
Discuss with Microbiology,
Ophthalmology and ENT

Consider urgent imaging
Penicillin allergy or MRSA
suspected: Discuss with
Microbiology
Penicillin allergy or
MRSA suspected:
Discuss with
Microbiology
Cellulitis
surrounding
ulcer or
pressure sore
Flucloxacillin 1g qds
+/- Metronidazole 500mg
tds
Flucloxacillin 500mg
qds +/-
Metronidazole
400mg tds
OR
Co-amoxiclav 625mg
tds
According
to clinical
response
Consider possibility of a deep
seated infection and referral to
Tissue Viability
Penicillin allergy or MRSA
suspected: Vancomycin iv
dosed according to local
guidelines +/-
Metronidazole 500mg tds

Penicillin allergy or
MRSA suspected:
Doxycycline 200mg
on day 1 then 100mg
od +/- Metronidazole
400mg tds
Ulcer or
pressure sore
with no
evidence of
cellulitis
Pressure relief and topical wound care should be adequate
Vancomycin and Gentami cin check levels at appropriate intervals and adjust dose/dosage interval accordingly.
See Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin
Adult Empiri cal Treatment Guidelines: Gynaecology
Infection Antibiotic
Treatment IV
Option
Antibiotic
Treatment Oral
Option
Total
Duration
Additional Comments
PID (low risk
gonococcal)


Ceftriaxone
2g od &
Metronidazole
500mg tds &
Doxycycline
100mg po bd

Ofloxacin
400mg bd &
Metronidazole
400mg bd


14 days Pregnancy: Use Erythromycin instead of
Doxycycline

Refer to GUM

Anaerobes are of greater importance in severe
PID; Metronidazole may be discontinued in
patients with mild or moderate PID who are
unable to tolerate it.
PID (high risk
gonococcal)

Ceftriaxone 2g
od &
Metronidazole
500mg tds &
Doxycycline
100mg po bd
IM ceftriaxone
500mg single
dose then
Doxycycline
100mg po bd &
Metronidazole
400mg po bd
14 days

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Adult Empiri cal Treatment Guidelines: Intra-abdominal Infections
Infection Antibiotic Treatment IV
Option
Antibiotic
Treatment Oral
Option
Total
Duration
Additional Comments

Appendicitis,
diverticulitis
or peritonitis
Amoxicillin 1g tds &
Metronidazole 500mg tds &
Gentamicin 5mg/kg od
OR
If eGFR <45, treat with
Piperacillin-tazobactam 4.5g
tds & Metronidazole 500mg
iv tds
Co-amoxiclav 625mg
tds & Metronidazole
400mg tds


5 - 7 days Continue IV for 5-7 days if
peritoneal contamination

Review with culture results
prior to switching to oral
therapy
Penicillin allergy:
Teicoplanin 600mg 12 hourly
for 3 doses then 600mg od &
Metronidazole 500mg tds &
Gentamicin 5mg/kg od
OR
If eGFR <45, discuss with
Microbiology
Penicillin allergy:
Ciprofloxacin 500 mg
bd & Metronidazole
400mg tds


Cholecystitis
and
Cholangitis
Amoxicillin 1g tds &
Metronidazole 500mg tds &
Gentamicin 5mg/kg od
OR
If eGFR <45, treat with
Piperacillin-tazobactam 4.5g
iv tds & Metronidazole
500mg iv tds
Co-amoxiclav 625mg
tds & Metronidazole
400mg tds
7 days
Penicillin allergy:
Teicoplanin 600mg 12 hourly
for 3 doses then 600mg od &
Metronidazole 500mg tds &
Gentamicin 5mg/kg od
OR
If eGFR <45, discuss with
Microbiology
Penicillin allergy:
Ciprofloxacin 500 mg
bd & Metronidazole
400mg tds


Severe
Pancreatitis
with infected
necrosis



Piperacillin/ tazobactam 4.5g
tds& Metronidazole
500mg iv tds

Not appropriate 7 days Add Gentamicin 5mg/ kg
od if septic

Note:
Infected necrosis is rare in
the first week. Infection is
presumed when there is
extraluminal gas in the
pancreatic and/or
peripancreatic tissues or
when FNA is positive for
bacteria and / or fungi on
Gram stain and culture.
Penicillin allergy: Discuss
with Microbiology
Vancomycin and Gentami cin check levels at appropriate intervals and adjust dose/dosage interval accordingly.
See Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin

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Adult Empiri cal Treatment Guidelines: Intra-abdominal Infections
Infection Antibiotic Treatment IV
Option
Antibiotic Treatment
Oral Option
Total
Duration
Additional Comments

Spontaneous
Bacterial
Peritonitis
Piperacillin/ tazobactam
4.5g iv tds


Be guided by culture
results

5-7 days

Penicillin allergy: Discuss
with Microbiology

Variceal
haemorrhage
with cirrhosis
Piperacillin/ tazobactam
4.5g iv tds


5-7 days

Penicillin allergy:
Teicoplanin 600mg 12
hourly for 3 doses then
600mg od &
Gentamicin 5mg/kg od
OR
If eGFR <45, discuss with
Microbiology
Vancomycin and Gentamicin check levels at appropriate intervals and adjust dose/dosage interval accordingly.
Guidelines for the Dosing and Monitoring of Gentamicin, Vancomycin and Teicoplanin

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References

British National Formulary 65
th
edition. March- September 2013.

Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare
Associated Infection (ARHAI). Antimicrobial Stewardship: Start Smart Then Focus.
2011.

Scottish Intercollegiate Guidelines Network. Management of suspected bacterial urinary
tract infection in adults. Clinical Guideline 88. Updated J uly 2012.

British Society for Sexual Health and HIV. Management of epididymo-orchitis (2010)
http://www.bashh.org/documents/3546.pdf

British Society for Sexual Health and HIV. United Kingdom National guideline for the
management of prostatitis (2008)

IDSA Guidelines. Practice Guidelines for the Management of Bacterial Meningitis. Clin
Infect Dis 2004; 39:126784
http://cid.oxfordjournals.org/content/39/9/1267.full

Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: a report of
the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob
Chemother 2012; 67: 269289.
http://jac.oxfordjournals.org/content/67/2/269.full.pdf+html

British Thoracic Society. Guidelines for the Management of Community Acquired
Pneumonia in Adults. Thorax 2009, Vol 64 Supplement III
http://www.brit-thoracic.org.uk/Portals/0/Guidelines/Pneumonia/CAPGuideline-full.pdf

IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and
Adults. Clin Infect Dis. 2012 doi: 10.1093/cid/cir1043
http://cid.oxfordjournals.org/content/early/2012/03/20/cid.cir1043.full.pdf+html

Repanos C, Mukherjee P, Alwahab Y. Role of microbiological studies in management of
peritonsillar abscess J Laryngol Otol. 2009;123(8):877-9. doi:
10.1017/S0022215108004106. Epub 2008 Dec 4.
.
IDSA Guidelines. Practice Guidelines for the Diagnosis and Management of Group A
Streptococcal Pharyngitis. Clin Infect Dis 2002; 35:11325.
http://cid.oxfordjournals.org/content/35/2/113.full.pdf+html

SIGN Guideline 117. April 2010. Management of sore throat and indications for
tonsillectomy, A national clinical guideline.
http://www.sign.ac.uk/pdf/sign117.pdf


Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults Version: 1.0
Approved by: William Hubbard, Head of Medicine Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page 18 of 26
Royal United Hospital Bath NHS Trust
BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen
joint in adults. Rheumatology 2006; 45 (8): 1039-1041.
http://rheumatology.oxfordjournals.org/content/45/8/1039.full.pdf+html

British Society for Sexual Health and HIV. UK National Guideline for the Management of
Pelvic Inflammatory Disease (2011).
http://www.bashh.org/documents/3572.pdf

IDSA Guidelines. Practice Guidelines for the Diagnosis and Management of Skin and
Soft-tissue. Clin Infect Dis. 2005;41:1373-406.

UK Guidelines for the Management of Acute Pancreatitis. Gut 2005;54:iii1-iii9
doi:10.1136/gut.2004.057026
http://gut.bmj.com/content/54/suppl_3/iii1.full

AASLD Practice Guidelines. Prevention and Management of Gastroesophageal
Varices and Variceal Hemorrhage in Cirrhosis. Hepatology 2007; 46 (3).
http://www.aasld.org/practiceguidelines/documents/bookmarked%20practice%20guideli
nes/prevention%20and%20management%20of%20gastro%20varices%20and%20hem
orrhage.pdf

J alan R and Hayes PC.UK Guidelines on the management of patients with variceal
haemorrhage in cirrhotic patients.
Gut 2000;46:iii1-iii15 doi:10.1136/gut.46.suppl_3.iii1
http://gut.bmj.com/content/46/suppl_3/iii1.full

IDSA Guideline. Diagnosis and Management of Complicated Intra-abdominal Infection
in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious
Diseases Society of America. Clin Infect Dis 2010;50:133-64.

EASL clinical practice guidelines on the management of ascites, spontaneous bacterial
peritonitis, and hepatorenal syndrome in cirrhosis. Journal of Hepatology 2010; 53:397-
417.
http://www.easl.eu/assets/application/files/21e21971bf182e5_file.pdf

Classification of acute pancreatitis2012: revision of the Atlanta classification and
definitions by international consensus. Banks et al. Gut 2013;62:102111.








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Related documents

Guidelines for the dosing and monitoring of Gentamicin, Vancomycin and
Teicoplanin
Guidelines for UTI in Elderly
Neutropenic Sepsis Guideline
Antibiotic Guidelines: Paediatric and Neonatal
Control of Infection Strategy
Antibiotic prescribing Policy
Antibiotic Guideline: Surgical Prophylaxis in Adults

List of abbreviations

CAP Community Acquired Pneumonia
CF Cystic Fibrosis
CSU Catheter sample of urine
ESBL Extended Spectrum Beta-Lactamase
HAP Hospital Acquired Pneumonia
HSV Herpes Simplex Virus
IE Infective Endocarditis
MRO Multi-resistant organisms
MSU Mid- stream urine
NAAT Nucleic Acid Amplification Test
OPAT Outpatient Parenteral Antibiotic Therapy
PID Pelvic Inflammatory Disease
STI Sexually Transmitted Infection
VRE Vancomycin Resistant Enterococci

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Version: 1.0
Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013 Page: 20 of 26
Royal United Hospital Bath NHS Trust
Page 20 of 26
Appendix 1: Guidance on Penicillin Allergies

Crossover allergy possible
(up to 6.5%):

Avoid if history of immedi ate hypersensitivity to
penicillin. Use with caution if non-severe al lergy (e.g.
minor rash onl y)
Cephalosporins:
Cefalexin
(s)
Cefaclor
(s)
Cefuroxime
(s)

Cefotaxime
(s)
Ceftazidime
(s)
Cefixime
(s)

Cefradine
(s)
Ceftriaxone
(s)


Other beta-lactam antibiotics :
Aztreonam
(s)
Ertapenem
(s)
Meropenem
(s)


Non Beta-lactam antibiotics:
Amikacin

Doxycycline Oxytetracycline
Azithromycin
(s)
Erythromycin Rifampicin
Chloramphenicol

Gentamicin Sodium Fusidate


Ciprofloxacin
(s)
Levofloxacin
(s)
Teicoplanin
(s)

Clarithromycin
(s)
Linezolid

Trimethoprim
Clindamycin
(s)
Metronidazole Tobramycin
(s)

Colistin
(s)
Minocycline
(s)
Vancomycin
(s)

Co-trimoxazole
(s)
Nitrofurantoin

Penicillin Containing Antibiotics:
Amoxicillin
Augmentin (Co-amoxiclav contains amoxicillin & clavulanic acid

)
Flucloxacillin
Penicillin G (benzylpenicillin)
Penicillin V (phenoxymethyl -penicillin)
Piperacillin + tazobactam (Tazocin)
CONTRA-INDICATED
CONSIDERED SAFE

Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
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Version: 1.0
Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013
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Page 21 of 26
Appendix 2: Prescribing and monitoring once dail y Gentamicin in adults

The standard treatment dose is 5mg/kg,
The standard prophyl axis dose is 3mg/kg
No single dose of Gentamicin should normally exceed 520mg
Neutropenic sepsis dose is 6mg/kg, max dose at discretion of prescribing clinician

Figure 1 Suggested gentamicin doses of 5mg/kg according to height and weight in MALE pati ents,
taking into account a correction factor for obese patients


Figure 2 Suggested gentamicin doses of 5mg/kg according to height and weight in FEMALE
patients, taking into account a correction factor for obese pati ents






6' 5 280 320 320 360 400 400 440 440 480 480 480 480 480 480 520 520 520 520 520 520 520 520 520 520 520 520 520
6' 4 280 320 320 360 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520 520 520 520 520 520
6' 3 280 320 320 360 400 400 440 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520 520 520 520 520
6' 2 280 320 320 360 400 400 440 440 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520 520 520 520
6' 1 280 320 320 360 400 400 440 440 440 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520 520 520
6' 0 280 320 320 360 400 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520 520 520
5' 11 280 320 320 360 400 400 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520 520
5' 10 280 320 320 360 400 400 400 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520
5' 9 280 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520 520
5' 8 280 320 320 360 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520 520
5' 7 280 320 320 360 360 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520
5' 6 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520 520
5' 5 280 320 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520
5' 4 280 320 320 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520
5' 3 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520
5' 2 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520
5' 1 280 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520
5' 0 280 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520
60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 185 190
Mal e
H
e
i
g
h
t

i
n

f
e
e
t
Actual wei ght i n kg
6' 3 200 240 240 280 320 320 360 400 400 440 440 440 440 440 440 480 480 480 480 520 520 520 520 520 520
6' 2 200 240 240 280 320 320 360 400 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520 520
6' 1 200 240 240 280 320 320 360 400 400 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520 520
6' 0 200 240 240 280 320 320 360 400 400 400 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520
5' 11 200 240 240 280 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520 520
5' 10 200 240 240 280 320 320 360 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520 520
5' 9 200 240 240 280 320 320 360 360 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520
5' 8 200 240 240 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480 520
5' 7 200 240 240 280 320 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480 480
5' 6 200 240 240 280 320 320 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480
5' 5 200 240 240 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480 480
5' 4 200 240 240 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480 480
5' 3 200 240 240 280 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480
5' 2 200 240 240 280 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440 480
5' 1 200 240 240 240 240 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440 440
5' 0 200 240 240 240 240 240 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440 440
4' 11 200 240 240 240 240 240 240 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440
4' 10 200 200 200 240 240 240 240 280 280 280 280 320 320 320 320 360 360 360 360 400 400 400 400 440 440
45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165
Actual wei ght i n kg
Femal e
H
e
i
g
h
t

i
n

f
e
e
t

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Version: 1.0
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Page 22 of 26

Dosing interval and monitoring

Gentamicin is cleared predominantly via the kidneys and the dosage interval needs to
be increased in patients with impaired renal function.

Renal
Function
Suggested
eGFR
(ml/min/1.73m
2
)
Dose Time
interval
First assay
time

Do I give next dose
before assay results
available?

Normal


> 60

24 hours

Check level 24
hours post
dose


In patients <65 years
old, with good urine
output give 2
nd
dose
without waiting for result

In patients >65 years
old, wait for result
before giving 2
nd
dose


Impaired


30-60

Dependent
on levels

Check level 24
hours post
dose

Wait for result before
giving any further doses


Severe
Impairment


<30

Discuss with microbiology


Take pre dose levels up to one hour before the second dose is given
Patients >65 years old, or with abnormal renal function or poor urine output: the pre
dose gentamicin level must be 1mg/litre before any further dose is given
For patients with normal and stable renal function check pre dose level twice weekly
For patients with abnormal renal function, check the pre dose gentamicin level
before each dose
Renal function must be checked regularly. If renal function deteriorates, more frequent
monitoring may be needed, the dosing interval may need to be increased or
discontinuation of therapy may be required. Discuss alternative antibiotics with a
Microbiologist.





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Version: 1.0
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Prescribing and Monitoring of Vancomycin

Normal renal function:
Age
(years)
Vancomycin Dose

Dose Frequency

<65 1000mg 12 hourly
65-75 750mg 12 hourly
>75 500mg 12 hourly

Check levels pre dose levels at 3
rd
or 4
th
dose and give dose
Assay twice weekly if pre-dose levels <15mg/l and renal function stable

Impaired renal function:
Renal
Impairment
Suggested
eGFR
(ml/min/1.73m
2
)
Age
(years)
Vancomycin Dose

Dose
Frequency


Mild to moderate
45-60 >75 1000mg

measure
level at 24h
and await the
result before
giving the
next dose

Moderate or
Severe

<45
All ages 1000mg

Pre dose level should be <15mg/l. Consider dose reduction (e.g. to 750mg OD) if higher

Renal function must be checked regularly. If renal function deteriorates more frequent
monitoring may be needed.
Aim for pre-dose levels 5-15mg/l (aim for 10-15mg/l for serious or deep seated
infections)






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Document Control Information
Consultation Schedule
Name and Title of Individual Date
Consulted
Dr Paul Lyons, Consultant Neurologist 12/9/13
Dr Dominic Williamson, Consultant in Emergency Medicine 12/9/13
Dr Philip Kaye, Consultant in Emergency Medicine 12/9/13
Dr Chris Dyer, Consultant Geriatrician 12/9/13
Dr Arnold Fernandes, Consultant in GU Medicine 2/8/13
Dr Kate Horn, Consultant in GU Medicine 2/8/13
Dr Anu Garg, Consultant Physician 12/9/13
Dr Mark Mallet, Consultant Physician 12/9/13
Dr J ohn Linehan, Consultant Gastroenterologist 12/9/13
Dr Ben Colleypriest, Consultant Gastroenterologist 25/9/13
Dr Mark Farrant, Consultant Gastroenterologist 25/9/13
Dr J ulia Maltby, Consultant Gastroenterologist 25/9/13
Dr J onathan Quinlan, Consultant Gastroenterologist 25/9/13
Dr Rob Lowe, Consultant Cardiologist 12/9/13
Dr J acob Easaw, Consultant Cardiologist 12/9/13
Dr Vidan Masani, Consultant Respiratory Physician 12/9/13
Dr Adam Malin, Consultant Respiratory Physician 12/9/13
Dr Tony Robinson, Consultant Physician 12/9/13
Dr Marc Atkin, Consultant Physician 12/9/13
Dr Kim Gupta, Consultant Anaesthetist 12/9/13
Dr Andy Georgio, Consultant Anaesthetist 12/9/13
Mr Simon Gregg-Smith, Consultant Orthopaedic Surgeon 12/9/13
Mr Steve Pope, Consultant Orthopaedic Surgeon 12/9/13
Mr J ohn Budd, Consultant Surgeon 12/9/13
Mr Stephen Dalton, Consultant Colorectal Surgeon 12/9/13
Mr Mike Williamson, Consultant Colorectal Surgeon 12/9/13
Ms Catherine Ashworth, Clinical Director ENT 12/9/13
Mr David Walker, Consultant Gynaecologist 12/9/13
Mr J on McFarlane, Consultant Urologist 12/9/13
Mr Richard Antcliff, Consultant Ophthalmic Surgeon 12/9/13

The following people have submitted responses to the consultation process:
Name and Title of Individual Date
Responded
Miss Nicola Lawrence, Consultant Breast Surgeon 20/9/13
Mr Richard Sutton, Consultant Breast Surgeon 18/9/13
Mr Nick J ohnson, Consultant Gynaecologist 16/9/13
Mr Rick Porter, Consultant Gynaecologist 18/9/13
Mr David Walker, Consultant Gynaecologist 17/9/13
Mr Mike Williamson, Consultant Colorectal Surgeon 18/9/13

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Version: 1.0
Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013
Royal United Hospital Bath NHS Trust
Page 25 of 26
Mr J ohn Budd, Consultant Surgeon 12/9/13
Dr Philip Kaye, Consultant in Emergency Medicine 18/9/13
Miss Claire Taylor, Consultant in Emergency Medicine 17/9/13
Dr Mark Mallet, Consultant Physician 13/9/13
Dr Adam Malin, Consultant Respiratory Physician 16/9/13
Dr Rob Lowe, Consultant Cardiologist 12/9/13
Dr J acob Easaw, Consultant Cardiologist 12/9/13
Dr Vidan Masani, Consultant Respiratory Physician 12/9/13
Dr Kate Horn, Consultant in GU Medicine 2/8/13
Dr Arnold Fernandes, Consultant in GU Medicine 2/8/13
Mr Neil Bradbury, Consultant Orthopaedic Surgeon 17/9/13
Mr Steve Pope, Consultant Orthopaedic Surgeon 18/9/13
Mr Allister Trezies, Consultant Orthopaedic Surgeon 7/10/13

Name of Committee/s (if applicable) Date of
Committee




Ref.: Antibio-005_Empirical_Treatment_of_Infections_in_Adults
Approved by: William Hubbard, Head of Medicine
Version: 1.0
Approved on: 2013
Author: Teh Li Chin, Rachel Mayer, Wendy Fletcher Review date: 2016
Date of Issue: 2013
Royal United Hospital Bath NHS Trust
Page 26 of 26
Ratification Assurance Statement

Dear

Please review the following information to support the ratification of the below named
document.
Name of Guideline: Guideline for the Empirical Treatment of Infections
Name of author: Wendy Fletcher and Teh Li Chin
J ob Title: Antimicrobial Pharmacist and Consultant Microbiologist

I, the above named author, confirm that:

The Guideline presented for ratification describes best practise known to me at the time
of the development of the guideline.
I will bring to the attention of my clinical director or line manger any information which
may affect the validity of this Guideline as soon as this becomes known to me;
I have undertaken appropriate consultation on this Guideline and have considered all
responses.
I acknowledge that the policy will be kept under review, and that I may be asked to refine
the guideline. If no interim changes are required it will then be formally reviewed on its
documented review date.
Signature of Author: Date: 21/11/2013
Name of Person
Ratifying this Guideline: William Hubbard
Job Title: Head of Medicine
Signature: Date: 21/11/2013


To the person approving this Guideline:

Please ensure this page has been completed correctly, then print, sign and
post this page only to: The Policy Coordinator, J ohn Apley Building.

The whole guideline must be sent electronically to: ruh-tr.policies@nhs.net