1603 - 11th July 2013 - Attachement 1 - Adult Antibiotic Policy

Antibiotic Guidelines
Treatment and Prophylaxis for

Adults
Document Type:
Guideline
Version:
Three
Date of Issue:
October 2012
Review Date:
October 2013
Lead Director:
Consultant Microbiologists
Post Responsible for Update:
Consultant Microbiologists / Antibiotic

Pharmacist
Approving Committee:
Antimicrobial Stewardship Committee
Approved by them in the

minutes of:
5th October 2012
Distribution to:
All Trust staff via the Trust Intranet
Contents:
Heading
Heading (Insert Title)
Number
2.1
2.2
Page
Number
Contents / Risk rating
Introduction / Purpose
10
Aims of the guidance
10
Important Points
10
Prescribing an antimicrobial?
11
Considerations
12
Penicillin allergy
13
Conversion from Intravenous to Oral Antibiotics (Antibiotic

Switch)
Antibiotic Stop Policy
14
Extended duration of antibiotic treatment
15
Contact Numbers
15
Restricted Antimicrobials
16
Notification of infectious diseases
17
Bone and Joint Infections
20
Acute hematogenous osteomyelitis (Not associated with

bone/joint problems)
Contiguous osteomyelitis (associated with fracture or post
surgical bone reconstruction)
Contiguous osteomyelitis secondary to vascular
insufficiency and diabetic foot infection
Chronic osteomyelitis
20
Prosthetic joint infections
23
Septic arthritis (native joint)
24
Septic bursitis (Olecranon bursitis, prepatellar bursitis)
25
Central Nervous System Infections
26
Acute Bacterial Meningitis (empirical treatment)
26
Pathogen Specific Therapy
27
14
21
22
22
27
Neisseria Meningitides
Streptococcus Pneumoniae
27
27
Haemophilus Influenzae
Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Page 2 of 120
27
Listeria Monocytogenes
Viral Meningitis
28
Encephalitis
28
Brain abscess / subdural empyema
28
2.3
Ear, Nose and Throat Infections
29
2.3.1
Ear
29
29
Otitis externa
Acute localised (Furuncle)
29
29
Acute, diffuse (swimmers ear)
Fungal otitis externa
29
30
Perichondritis
Invasive malignant otitis externa
30
30
Acute otitis media

31
2.3.2
Acute mastoiditis
Nose
32
32
Acute rhinosinusitis
33
2.3.3
Orbital cellulitis
Throat
34
34
Acute sore throat
Peritonsillitis / Peritonsillar abscess or quinsy
34
35
Epiglottitis / Supraglottitis
36
2.4
Salivary gland infection

Gastrointestinal Infections
37
Gastro-enteritis
37
Empirical Treatment
37
Treatment Algorithm for C. Difficile Infection (CDI)
38
Pathogen SpecificTherapy
39

Page 3 of 120
39
Campylobacter
Salmonella
39
39
Shigella
E coli 0157:H7
39
39
Vibro cholerae 01 or 0139
Giardia Lamblia, Giardiasis
39
39
2.5
2.6
2.6.1
2.6.2
2.7
Entamoeba histolytica, amebiasis
Genital Tract Infections
41
Bacterial vaginosis
41
Vaginal candidiasis
41
Trichomoniasis
41
Chlamydia trachomatis
42
Neisseria gonorrhoea
42
Pelvic inflammatory disease
42
Gynaecological and Pregnancy Related Infections
43
Obstetrics
Lower Urinary Tract Infection (cystitis /
asymptomatic bacteriuria) in pregnancy
43
43
Pyelonephritis in pregnancy
43
Chorioamnionitis
44
Post partum endometritis
44
Post abortion infection
45
Episiotomy infection
Prevention of early onset neonatal group B
streptococcal (GBS) disease
46
Preterm prelabour rupture of membranes
47
Sepsis of unknown origin
47
46
Gynaecology
48
Mastitis
48
Surgical site infection after gynaecologic surgery
48
50
Infective Endocarditis
51
Empirical Treatment
51

Page 4 of 120
2.8
2.8.1
Intra-Abdominal Infections
53
Diverticulitis
53
Secondary peritonitis
53
Primary (spontaneous) bacterial peritonitis
54
Acute pancreatitis
55
Liver and biliary system
56
Acute Chloecystitis
56
Acute Cholangitis
57
Pyogenic liver abscess
57
Amoebic liver abscess
58
2.9
MRSA
59
2.10
Respiratory Tract Infections
60
Community acquired pneumonia (empirical)
60
62
Hospital Acquired, Postoperative or Ventilator Associated

Pneumonia
Acute Infective Exacerbation of Chronic Obstructive
Pulmonary Disease and Chronic Bronchitis
63
Acute Bronchitis
63
Upper Respiratory Tract Infections
63
Aspiration pneumonia
Infective Exacerbation of Bronchiectasis (not Cystic
Fibrosis)
Exacerbation of Bronchiectasis in Cystic Fibrosis
63
Lung Abscess
65
Pleural Empyema
67
Pathogen specific therapy
68
64
65
68
Pneumococcal
Staphylococcal
68
69
Legionella
Confirmed Q fever, psittacosis
69
69
Mycoplasma, Chlamydia
69
2.11
PCP
Sepsis, Severe Sepsis and Septic Shock

Page 5 of 120
71
2.12
Neutropenic sepsis
71
Skin and Soft Tissue Infections
73
73
Cellulitis
74
Erysipelas
Furuncle or carbuncle
74
75
Impetigo
Infected chronic ulcers or pressure sores (non

diabetic)
Diabetic Foot Infection
Gangrenous cellulitis (Necrotising fasciitis or gas

gangrene)
75
76
78
78
Burn wound infections

79
2.13
Post-Operative wound infection

Urinary Tract Infections (UTI)
81
81
Lower UTI uncomplicated (no urinary catheter)
Systemic UTIs
81
82
Pyelonephritis
Complicated UTI (functional or structural urinary

tract abnormalities)
UTI with urinary catheter
Acute Prostatitis
Chronic Bacterial Prostatitis
Bacterial epdidymitis / Bacterial orchitis
82
83
83
84
84
2.14
Surgical Prophylaxis
85
Antibacterial Prophylaxis in Ear, Nose and Throat Surgery

Ear, nose and throat Benign
85
Head and neck Facial
85

Page 6 of 120
85
Head and neck surgery
85
Antibacterial Prophylaxis for Gastrointestinal, Biliary,

Vascular and General Surgery
Upper gastrointestinal surgery
87
Lower gastrointestinal surgery
87
Hepatobiliary surgery
87
Diagnostic endoscopic procedures
88
Abdomen
88
Breast surgery
88
Vascular surgery
88
Antibacterial Prophylaxis for Obstetric and

Gynaecological Surgery
Obstetrics
89
87
89
89
Caesarean section
Third and fourth degree perineal tears
89
89
Manual removal of placenta
Assisted Delivery
89
89
Surgical termination of pregnancy

Gynaecology
90
90
Hysterectomy
Laparotomy
Radical pelvic surgery for gynaecological cancer
90
90
90
Vaginal repair
90
Vaginal sling procedures

Antibacterial Prophylaxis for Orthopaedic Surgery
91
Clean non-implant surgery
91
Arthroplasty
91
Surgery for closed fractures
91
Hip fracture
91
Spinal surgery
91
Lower limb amputation
91

Page 7 of 120
2.15
Open fractures
91
Antibacterial Prophylaxis for Urological Surgery
93
Transurethral resection of a bladder tumour
93
Open or transurethral resection of the prostate
93
Transrectal prostate biopsy
93
Cystoscopy uncomplicated
93
Cystoscopy complicated
93
Urethral dilatation / optical urethrotomy
93
Shock-wave lithotripsy
93
Nephrectomy
93
Percutaneous nephrolithotomy
93
Cystectomy
94
Radical prostatectomy
94
Prophylaxis Other
95
Prevention of infection after bites from humans and other

mammals
95
96
Human Bite
Dog Bite
96
96
Cat Bite
Antibacterial prophylaxis for open fractures of the fingers
2.16
96
97
Prophylaxis against Infective Endocartitis (IE) in adults

and children undergoing interventional procedures
Prevention of infection in patients with an absent or
dysfunctional spleen
Antibiotic Assays
102
Gentamicin Once Daily Dosing
102
99
106
Infusion Chart
Gentamicin Multiple Daily Dosing
107
Vancomycin
108
Antibiotic Therapeutic Drug Ranges
109
Definitions
110
Associated Documents
110
Duties
110
Consultation and Communication with Stakeholders
111
Implementation
111

Page 8 of 120
Education and training
111
Monitoring and review
111
10
References / Bibliography
111
11
Appendices
111
Risk Rating
Who will be affected by this
Procedure?
Have any existing risk
assessments related to this
procedure been appropriately
updated
Is a new risk assessment
required by this procedure?
Does this procedure require
Health and Safety training?
Does this procedure require
specialist equipment?
Name:
Jennifer Willis
Trust Employees / Patients

Yes
Details: Still current
No
Yes- Date completed
No
Details if Yes
No
Details if Yes
Date: 1st October 2012
A
Potential Severity
(1-5)
B
Likelihood of Occurrence
(1-5)
C
Risk Rating
(A x B = C)
Raw Risk Rating
16
Final Risk rating

Page 9 of 120
1
Introduction / Purpose
It is the policy of the Trust that no one will be discriminated against on grounds of
age, disability, gender reassignment, marriage and civil partnership, pregnancy
and maternity, race, religion or belief, sex or sexual orientation. The Trust will
provide interpretation services or documentation in other mediums as requested
and necessary to ensure natural justice and equality of access.
Aim of the Guidelines
The purpose of these guidelines is to provide guidelines for empirical antimicrobial
therapy. The guidelines are not intended to cover all clinical circumstances. Further
advice can be obtained from the consultant microbiologists (see contact details
below).
Important Points
To minimise infections caused by MRSA and C. difficile, avoid cephalosporins
and quinolones as much as possible. Whenever possible use beta- lactam /
beta- lactamase inhibitor combinations e.g. Co-amoxiclav (community-acquired
infections) or Piperacillin / Tazobactam (hospital-acquired infections).
Antimicrobials should only be prescribed if there is a clear indication and

the potential benefit outweighs the risk. Inappropriate prescribing promotes
the emergence and spread of resistant organisms, causes unnecessary side
effects and complications such as Clostridium difficile colitis which may be fatal,
and is costly.
Recommendations that follow are for empirical antimicrobial therapy in

adults with normal renal and hepatic function, unless stated otherwise.
Treatment should be modified according to laboratory results. A change

from empirical (often broad spectrum, expensive and likely to encourage
resistance), to definitive, specific therapy (often narrow spectrum, cheaper and
less likely to produce resistance) can be made when culture and sensitivity
results are available.
ALWAYS document indication and duration of the treatment on the drug

chart when prescribing.

Page 10 of 120
Prescribing an Antimicrobial?
In accordance with the Trust Antibiotic Guidelines and to improve
prescribing practice,
Please add to ALL antimicrobial prescriptions:
REGULAR PRESCRIPTION
YEAR
PHARMACY USE ONLY

Date
2011
MONTH
SPECIFY TIME IF
REQUIRED
May
10
10
Drug
CLARITHROMYCIN
08.00
Morning
Dose
500mg
Duration
5 day course
Route
Start date
PO
1/10/10
Signature A Doctor
Midday
Evening
Bedtime
Bleep No: (Doctor) 1234
Pharm
20.00
Print name & profession

A Doctor
Special Instructions:
Community acquired pneumonia
An Indication
Duration or Review Date
YEAR
PHARMACY USE ONLY

Date
2011
MONTH
SPECIFY TIME IF
REQUIRED
May
Drug
CO-AMOXICLAV
Dose
1.2g
Duration
Review 48
hours
Pharm
Route
Start date
IV
1/10/10
Signature A Doctor
Morning
06.00
Midday
14.00
Bedtime
R/V
Evening
22.00

A Doctor
Special Instructions:
Community acquired pneumonia

Review dates should generally be endorsed for IVs.

Aim for the lunchtime doses for review where possible.
Avoid weekends/holidays unless senior review planned.
Nurses should continue to give antimicrobials whilst awaiting review.

Page 11 of 120
CONSIDERATIONS
Does the patient have a bacterial infection?
The most common error of antimicrobial therapy is unnecessary use.
Unexplained pyrexia should not be treated with antimicrobials unless the

patient is septic or otherwise suspected of a life threatening infection. Preemptive antimicrobials in such cases usually lead to further difficulties in
establishing a correct diagnosis.
If the condition is mild and bacterial infection not obvious, treatment can be
delayed until the results of investigations are available.
If the condition is serious and treatable infection is likely, empirical antimicrobial

therapy should start immediately, the choice being based on the likely infecting
organism(s), the current local antimicrobial resistance rates and severity of the
disease. This has been reflected in the production of these guidelines.
Antibiotics should not be prescribed for a raised CRP unless other infection
markers are also present.
Have relevant specimens been collected?

Obtain all necessary bacteriological specimens before antimicrobial therapy is
started.
Blood cultures should be taken in all cases of serious infection including before
starting intravenous antibiotics.
Antimicrobial therapy however, should never be delayed in an emergency.
Is parenteral (IV) treatment necessary?

Use oral route whenever possible, e.g. metronidazole, rifampicin, fluconazole and
ciprofloxacin are well absorbed from the gut (good bioavailability).
Antibiotics should be prescribed intravenously for severe infection, e.g.

septicaemia, pyelonephritis, endocarditis, meningitis, osteomyelitis, neutropenic
fever.
Most other conditions only require intravenous antimicrobials if particularly

severe and then only one or two doses (at most 48 hr) is usually sufficient.
Is the patient allergic to any antibiotics?

Document all drug allergies clearly with the nature of the patients reaction on the
drug chart.

Page 12 of 120
PENICILLIN ALLERGY
Allergic reactions to penicillins occur in 1-10% of exposed individuals;
anaphylactic reactions occur in fewer than 0.05% of treated patients.
All patients reporting allergy to penicillin should be questioned to determine the
likelihood of true allergy and assessed as to whether their symptoms are
consistent with a type 1 allergic reaction.
Type 1 immediate hypersensitivity to penicillin
i.e. anaphylaxis, urticaria, laryngeal oedema, bronchospasm, hypotension, or rash
immediately after penicillin administration:
Avoid all penicillins
Avoid other -lactams (cephalosporins, carbapenems)
If a cephalosporin is essential in these patients because a suitable alternative
antibacterial is not available, then cefuroxime, cefotaxime, ceftazidime, ceftriaxone,
or cefixime can be used with caution; cefaclor, cefadroxil, cefalexin, and cefradine
should be avoided.
NOT type 1 penicillin allergy
i.e. minor rash (i.e. non-confluent, non-pruritic rash restricted to a small area of the
body) or a rash that occurs more than 72 hours after penicillin administration.
Penicillins use with caution and under supervision only for serious infections
Other -lactams (cephalosporins, carbapenems) can be used safely
Type 1 immediate
hypersensitivity to
penicillin
NOT Type 1 penicillin

allergy
Penicillins
Amoxicillin
Co-amoxiclav/Augmentin
Flucloxacillin
Pivmecillinam
Penicillin G (benzylpenicillin)
Piperacillin & tazobactam
(Tazocin)
Avoid
May be used with

caution and under
supervision for
serious infections.
Cephalosporins
Cefradine
Cefalexin
Cefaclor
Avoid
-lactam antibiotics kept by

MCHFT
Cefotaxime
Ceftriaxone
Cefuroxime
Ceftazidime
Carbapenems
Meropenem
Imipenem (Primaxin)
Ertapenem
Monobactams
Aztreonam
Considered safe
Use with caution ONLY if
essential and under
supervision
Use with caution ONLY if
essential and under
supervision
Considered safe
Weak cross-reactivity with

other -lactams
Considered safe
Considered safe

Page 13 of 120
CONVERSION FROM INTRAVENOUS TO ORAL ANTIBIOTICS (ANTIBIOTIC

SWITCH)
In the majority of cases, one or two doses (at most 48 hours) of intravenous
antibiotics are sufficient.
Prescriptions for intravenous antibiotics must be reviewed after 48 hours and

changed to oral administration according to microbiology results. If these are
not available change to oral administration of the same drug or an acceptable
oral alternative as per antibiotic guidelines.
Exceptionally, in some cases it is usual to administer the whole course of

antibiotics by the IV route for reasons of severity and / or poor penetration to
the site of infection e.g. endocarditis, meningitis, and cerebral abscess.
The oral switch should ideally be prescribed at the same time as the IV
treatment and the administration section blocked out to indicate when the
switch should occur.
Criteria for changing to oral antibiotics:

- temperature <38 C for >24hours
- signs of clinical improvement
- no clinical indication for continuation of IV therapy, e.g. endocarditis,
meningitis, osteomyelitis
- oral fluids tolerated
- no ongoing or potential GI tract absorption problems
- oral formulation or suitable oral alternative is available
ANTIBIOTIC STOP POLICY

This guidance aims to prevent unintended long duration of antimicrobial

therapy.
Five days duration of antibiotic treatment is usually sufficient. Please refer to

antibiotic guidelines for specific recommendations for duration of treatment of
specific infections.
The duration/review date box must always be completed and made clear if
it is a stop or review date by deleting as appropriate.

Page 14 of 120
Extended duration of antibiotic treatment is acceptable for patients that are

being investigated or treated for the following conditions where it is known that
antibiotics will be required for a prolonged duration such as:
Cavitating pneumonia
Empyema
Exacerbation of cystic fibrosis/ bronchiectasis
Endocarditis
Inadequately drained abscesses
Infected implants/prosthetics
Intracranial abscesses
Meningitis
Mediastinitis
Liver abscess
Osteomyelitis / Septic arthritis
Prostatitis
Prolonged prophylaxis where there is proven benefit e.g.
splenectomy, PCP.
Staphylococcus aureus bacteraemia
Severe or necrotising soft tissue infections
Severe infections during chemotherapy-related neutropenia
Tuberculosis
The indication for all antibiotic therapy must be clearly documented on the drug
chart (in the special instructions box) and in the medical notes.
Antibiotic prescriptions should be reviewed daily.

Page 15 of 120
RESTRICTED ANTIMICROBIALS
The following antibiotics should
recommended in the antibiotic policy.
not
be
prescribed
unless
specifically
Other than these specific indications, they can only be prescribed after consultation
with the Consultant Microbiologist.
Pharmacy will be unable to supply restricted antimicrobials unless these conditions
have been met.
All cephalosporins e.g. cefuroxime, cefotaxime, ceftazidime, ceftriaxone,

cefixime, cefaclor, cefadroxil, cefalexin and cefradine unless recommended for
specific conditions in this policy (e.g. cefradine for UTI)
All quinolones e.g. ciprofloxacin, levofloxacin unless recommended for specific

conditions in this policy
Amikacin
Chloramphenicol (systemic)
Linezolid
IV Vancomycin (except renal dialysis unit)
Tigecycline
Daptomycin

Page 16 of 120
Notification of Infectious Diseases

Health Protection Legislation (England) Guidance 2010
All notifications must be sent to the offices of the Proper Officers appointed by local
authorities for that purpose. In Cheshire & Merseyside the Proper Officers for this
purpose are the Consultants in Communicable Disease Control (CCDC) based at
Cheshire & Merseyside Health Protection Unit (CMHPU).
All notifications should be made using the forms contained in Health Protection
Legislation (England) Guidance 2010 and faxed to Cheshire & Merseyside
confidential fax number 0151 708 8417.
A copy of the notification form is included on this site to print off
Please do not return completed notification forms by email.
In addition, for urgent notification of matters of serious public health significance,

the Proper Officers may be notified by telephone on a 24-hour basis.
o During office hours they can be contacted on 0844 225 1295.
o Outside office hours the Proper Officer can be reached via the public health
on-call rota on 0151 706 3134 or 0151 706 2000 (via the Royal Liverpool
University Hospital switchboard) or 01244 365 000 (via the Countess of
Chester Hospital switchboard); the same rota is held at both hospitals.
The criteria for notification by registered medical practitioners (RMPs) attending

patients are as below:
Cases of notifiable infectious diseases (as listed in Table1)

Cases of other infections not included in Table 1 if they present, or could present,
significant harm to human health (e.g. emerging or new infections)
Cases of contamination, such as with chemicals or radiation, that may present or
could present significant harm to human health
Cases of patients who die with, but not necessarily because of, a notifiable disease
or other infectious disease or contamination that presents, or could present, or that
presented or could have presented significant harm to human health.
Notification of infections not included in Table 1 and contamination are expected to be

exceptional occurrences. Factors the RMP may wish to consider in deciding whether to
notify a case of infection that is not included in Table 1 or a case of contamination include:
The risk of transmission or spread to others and
The potential to cause significant harm to human health
RMPs should not wait for laboratory confirmation of the suspected infection or
contamination before notification. They must notify cases if they have reasonable clinical
suspicion that their patient is suffering from a notifiable disease or other relevant infection
or contamination.
Notifiable diseases, with explanatory notes and guidance on the need for urgent
notification
NB: This table is only for guidance and each case should be considered
individually.

Page 17 of 120
Table 1
Notifiable diseases
Acute encephalitis
Acute meningitis
Acute poliomyelitis
Acute infectious hepatitis
Definition / comment
Viral and bacterial.
Close contacts of acute

hepatitis A and hepatitis B
cases need rapid
prophylaxis. Urgent
notification will facilitate
prompt laboratory testing.
Hepatitis C cases known to
be acute need to be
followed up rapidly as this
may signify recent
transmission from a source
that could be controlled.
Anthrax
Botulism
Brucellosis
Cholera
Diphtheria
Enteric fever (typhoid or
paratyphoid fever)
Food poisoning
Haemolytic uraemic
syndrome (HUS)
Infectious bloody diarrhoea
Clinical diagnosis of a case

before microbiological
confirmation (e.g. case with
fever, constipation, rose
spots and travel history)
would be an appropriate
trigger for initial public
health measures, such as
exclusion of cases and
contacts in high risk groups
(e.g. food handlers).
Any disease of infectious or
toxic nature caused by, or
thought to be caused by
consumption of food or
water (definition of the
Advisory Committee on the
Microbiological Safety of
Food).
Likely to be urgent?
No
Yes, if suspected bacterial
infection.
Yes
Yes
Yes
Yes
No unless thought to be UKacquired
Yes
Yes
Yes
Clusters and outbreaks, yes.

For specific organisms see
Table 2.
Yes
See also HUS in Schedule
1 and VTEC in Schedule 2.

Page 18 of 120
Yes
Notifiable diseases
Invasive group A
streptococcal disease and
scarlet fever
Definition / comment
Legionnaires Disease
Leprosy
Malaria
Yes,
No
No, unless thought to be UKacquired
Yes
Yes
Measles
Meningococcal septicaemia
Mumps
Plague
Rabies
Rubella
Likely to be urgent?
Yes, if IGAS. No, if scarlet
fever
Post-exposure
immunization (MMR or
HNIG) does not provide
protection for contacts.
A person bitten by a
suspected rabid animal
should be reported and
managed urgently, but if a
patient is diagnosed with
symptoms of rabies, they
will not pose a risk to
human health.
Post-exposure
immunisation (MMR or
HNIG) does not provide
protection for contacts.
SARS
Smallpox
Tetanus
Tuberculosis
Typhus
Viral haemorrhagic fever
(VHF)
Whooping cough
Yellow fever

Page 19 of 120
No
Yes
Yes
No
Yes
Yes
No, unless associated with
injecting drug use
No, unless healthcare worker
or suspected cluster or multi
drug resistance
No
Yes
Yes, if diagnosed during acute
phase
No, unless thought to be UKacquired
General Document Principles
BONE AND JOINT INFECTIONS

Infection
Acute hematogenous osteomyelitis (not associated with

bone/joint prosthesis)
Vertebral osteomyelitis, spondylodiskitis, +/- epidural abscess, other sites
High risk:
- immunocompromised
- diabetics
- IV drug users
- catheter-related bloodstream infection
- elderly
Specimen
Microbiological diagnosis is essential

Obtain samples before starting antimicrobials if possible
Blood culture
Bone biopsy - at least 3 deep samples obtained during surgery
Disk biopsy - multiple specimens in sterile container and in blood culture
bottles
Needle aspirate under radiological guidance
Request TB cultures if at risk of TB
Likely Organisms
Staphylococcus aureus (including MRSA) most common

Other organisms depending on age and risk factors (coagulase negative
staphylococci, gram negative bacilli, fungi)
Treatment (empirical)
Type of patient
First line
Alternative (penicillin allergy)
Not high risk
Flucloxacillin 2 g IV by infusion 6
hrly
Teicoplanin 600 mg IV 12 hrly for 3

doses then 24 hrly thereafter
High risk
hrly
plus
Aztreonam 2 g IV 8 hrly

plus
Severe infection
Add sodium fusidate tablets 500 mg orally 8 hrly to above regimens
Tagged for MRSA
Teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter
Definitive therapy
Once bacterial sensitivities are known contact consultant microbiologist

to adjust antimicrobials if necessary and determine duration of treatment
Duration
Usually 6 weeks, preferably intravenously.

Treatment should not be stopped until symptoms (e.g. fever) and signs
(e.g. joint effusion) resolve, and the WBC and CRP return to normal.

Page 20 of 120
Infection
Contiguous osteomyelitis
Associated with fracture or post surgical bone reconstruction
Specimen
Likely Organisms
Treatment
Empirical
Microbiological diagnosis is essential

Obtain samples before starting antimicrobials
Bone biopsy, at least 3 deep samples obtained during
surgery/debridement
Blood culture if systemic infection
Staphylococci, gram negative bacilli, other
Surgical debridement
Often necessary to remove hardware
Antimicrobial therapy must be pathogen-directed
First line
Teicoplanin 600 mg IV 12 hrly for
3 doses then 24 hrly thereafter
plus
Piperacillin/tazobactam
(Tazocin ) 4.5 g IV 8 hrly

plus
Definitive
Adjust after culture results available
Duration
Prolonged course required, 6 weeks

Intravenous initially and to cover the period of any surgical
intervention and for at least 2 weeks after.
May switch to oral after that time if good clinical response to IV
therapy, CRP falling and good information on organism and its
sensitivities.
Treatment should not be stopped until symptoms (e.g. fever) and
signs (e.g. joint effusion) resolve, and the WBC and CRP return to
normal.
Contact consultant microbiologist

Page 21 of 120
Infection
Contiguous osteomyelitis secondary to vascular

insufficiency and diabetic foot infection
See Diabetic Foot Infection page 79
Infection
Chronic osteomyelitis
Long-standing infection evolving over months, relapses in the same
area, low grade inflammation, presence of necrotic bone and fistulous
tracks
Specimen
Biopsy of bone - at least 3 deep samples obtained during surgery

before starting antimicrobials
Needle aspirate under radiological guidance before starting
antimicrobials
Culture of sinus tract drainage NOT predictive of bone culture
Request TB cultures if at risk of TB
Blood culture if acute exacerbation with systemic infection
Likely Organisms
Staphylococcus aureus (including MRSA)

Streptococcus spp
Enterobacteriaceae
Pseudomonas spp
Anaerobes
Treatment
Empirical treatment: not recommended, need cultures

If acute exacerbation of chronic osteomyelitis, check previous
microbiology results if available and treat as acute hematogenous
osteomyelitis
Surgical debridement
Duration
Prolonged course required, usually > 6 weeks

Intravenous initially and to cover the period of any surgical
intervention and for at least 2 weeks after
May switch to oral after that time if good clinical response to IV
therapy, CRP falling and good information on organism and its
sensitivities
normal.

Page 22 of 120
Infection
Prosthetic joint infections
Specimen
Aspiration of joint fluid (should be carried out by an orthopaedic

surgeon in an operating theatre) before commencing antibiotics
At least 3 intraoperative periprosthetic tissue specimens (swab
cultures have a low sensitivity and should be avoided)
If revision surgery is planned, perioperative prophylaxis should not be
administered until after tissue specimens have been collected for culture
Blood culture if septic
Likely Organisms
Coagulase negative staphylococci, Staphylococcus aureus, Streptococci

Gram negative bacilli, Enterococcus, Anaerobes
Treatment
Remove infected prosthesis if possible

Early post-operative and acute late hematogenous infections can be
treated with adequate debridement and appropriate systemic antibiotics
(provided short duration of symptoms, for < 2 weeks)
In other cases, surgical drainage with retention of prosthesis followed by
antimicrobial therapy often results in treatment failure
Empirical treatment
First line
(start antibiotics after

cultures have been
obtained if possible)

plus
Piperacillin/tazobactam (Tazocin )
4.5 g IV 8 hrly

plus
Definitive treatment
Antimicrobial therapy
must be pathogendirected
Once bacterial
sensitivities are
known adjust
antimicrobials
Meticillin Sensitive S aureus (MSSA)

Flucloxacillin 2 g IV by infusion 6 hrly
plus
Rifampicin 600 mg orally 12 hrly
MRSA or
Coagulase negative staphylococci or
MSSA and penicillin allergy
Continue IV teicoplanin 600mg 24hrly (check teicoplanin trough level
after 5 days of treatment)
plus
For other organisms discuss with consultant microbiologist
Duration
Usually 6 weeks or longer

Intravenous - continue to cover the period of any surgical intervention
and for at least 2 weeks after
Switch to oral after that time if good clinical response to IV therapy, CRP
falling and good information on organism and its sensitivities
Treatment should not be stopped until symptoms (e.g. fever) and signs
(e.g. joint effusion) resolve, and the WBC and CRP return to normal.

Page 23 of 120
Infection
Septic arthritis (native joint)
Specimen
Aspirate joint (avoid introducing needle through skin affected by

cellulitis) - synovial fluid for microscopy and culture
Blood cultures 1 - 3 sets
Samples should be sent for culture from skin/wound swab if in
relation to trauma
Likely Organisms
Staphylococcus aureus (including MRSA), Streptococci

Gram negative bacilli, N. gonorrhoea
Treatment
Joint lavage or open incision and drainage is essential

Initial choice of antibiotics should be based on gram stain of joint
fluid and type of patient
If at risk for sexually transmitted disease consider N. gonorrhoea
Type of patient
First line
Immunocompetent
patient with no risk
factors for atypical
organisms
or
Gram stain: gram
positive cocci
hrly
Teicoplanin 600 mg IV 12 hrly

for 3 doses then 24 hrly
thereafter
High risk of Gram

negative organisms
(e.g. elderly,
immunocompromised,
IV drug users)
and
Gram stain negative
hrly
plus
(Tazocin ) 4.5 g IV 8 hrly to

above regimen

thereafter
plus
Once daily gentamicin IV (see
Prescribing Regimen)
Gram stain: gram

negative rods
Aztreonam IV 2 g 8 hrly
Tagged for MRSA

If high risk of Gram negative organisms, additional antibiotics as
above
Duration
3-4 weeks
Intravenous - continue for at least 2 weeks
Switch to oral after that time if good clinical response to IV therapy,
CRP falling and good information on organism and its sensitivities
normal.

Page 24 of 120
Infection
Septic bursitis
Olecranon bursitis, prepatellar bursitis
Specimen
Bursa aspirate
Staphylococcus aureus >80%
Likely Organisms
Treatment
Aspiration of bursa
Select antibiotics on basis of gram stain of aspirate
Adjust therapy according to culture results and sensitivities
First line
hrly

thereafter
Doxycycline orally 200 mg daily
may be given for mild cases
Flucloxacillin orally 500 mg 6 hrly

may be given for mild cases
Duration
2-3 weeks total

Switch to oral if good clinical response to IV therapy, CRP falling
and good information on organism and its sensitivities
References
1. Prosthetic-Joint Infections. Werner Zimmerli, Andrej Trampuz, Peter E Ochsner. The New
England Journal of Medicine. 2004;351:1645-55
2. Osteomyelitis Lew DP, Waldvogel FA, Lancet 2004;364:369-79
3. Medical treatment of diabetic foot infections. Lipsky A. Clinical Infectious Diseases 2004; 39
(S2): S104-114
4. Septic arthritis. Goldenberg DL. Lancet 1998;351:197-202
5. The Sanford guide to antimicrobial therapy, 2010
6. Guidelines for the management of hot swollen joint in adults, BER&BHPR, BOA, RCGP, BSAC,
Rheumatology 2006;45:1039-41

Page 25 of 120
CENTRAL NERVOUS SYSTEM INFECTIONS

Infection
Acute Bacterial meningitis (empirical treatment)
Specimen
CSF (unless contraindicated) for microscopy, culture and PCR

Blood culture
Blood EDTA tube for meningococcus and pneumococcus PCR
Throat swab for meningococcus
Likely Organisms
Neisseria meningitidis
Streptococcus pneumoniae
Listeria monocytogenes (> 50 years old or immunocompromised)
Haemophilus influenzae (children)
Treatment
Inform CCDC immediately and follow up in writing within 7 days

During office hours they can be contacted on 0844 225 1295.
Outside office hours the Proper Officer can be reached via the
public health on-call rota on 0151 706 3134 or 0151 706 2000
(via the Royal Liverpool University Hospital switchboard) or
01244 365 000 (via the Countess of Chester Hospital
switchboard); the same rota is held at both hospitals.
Chemoprophylaxis for close contacts if meningococcal infection is
likely (ciprofloxacin 500mg orally single dose)
Consider adjunctive treatment with dexamethasone (particularly if
pneumococcal meningitis suspected) starting before or with first dose of
antibacterial
First line
Ceftriaxone 2 g IV by infusion 12
hrly
If > 50 years old, pregnant or with

impaired cellular immunity:
Add amoxicillin 2 g IV by infusion 4
hrly
If Herpes simplex encephalitis suspected:
Add aciclovir 10 mg/kg IV by infusion 8 hrly
Duration
Depends on organism cultured (see below)

Page 26 of 120

For penicillin allergic patients contact consultant microbiologist.
Infection:
Neisseria meningitides
Treatment
Benzylpenicillin 2.4 g IV by infusion 4 hrly
Duration
7-10 days
Chemoprophylaxis
for index case
Ciprofloxacin 500mg orally single dose when able to take oral medication
and before discharge from hospital,UNLESS the disease has already
been treated with ceftriaxone.
Cases of confirmed serogroup C disease who have previously been
immunised with MenC conjugate (or polysaccharide) vaccines should be
offered a booster dose of MenC vaccine around the time of discharge
from hospital.
Vaccination for
index case
MenC conjugate vaccine should also be offered according to the

recommended national schedule to any unimmunised index cases under
the age of 25 years (whatever the serogroup).
Index cases who are in the risk-group for meningococcal disease (e.g.
asplenia, complement deficiency) and have not been immunised (or are
incompletely immunised for age) with the quadrivalent MenACWY
conjugate vaccine should complete the recommended immunisation
course (2 doses one month apart if aged <1 year; 1 dose after first
birthday), while those who received the quadrivalent MenACWY
conjugate vaccine more than 12 months previously should receive an
extra dose of the quadrivalent MenACWY conjugate vaccine.
Infection:
Treatment
Benzylpenicillin 2.4 g IV by infusion 4 hrly if organism sensitive to

penicillin (MIC < 0.1 mg/L)
If penicillin MIC 0.1 mg/L, contact consultant microbiologist
Duration
10 14 days
Infection:
Haemophilus influenzae
Treatment
Ceftriaxone 2 g IV by infusion 12 hrly
Duration
7-10 days
Infection:
Listeria monocytogenes
Treatment
First line
Amoxicillin 2 g IV by infusion
4 hrly
plus
Once daily gentamicin IV
(see prescribing regimen)
Co-trimoxazole 5mg/Kg (based on

trimethoprim component) IV or orally 6
hourly
Duration
Note: 480mg of co-trimoxazole consists of

400mg sulfamethoxazole and 80mg
trimethoprim
21 days
Gentamicin may be stopped sooner contact consultant microbiologist

Page 27 of 120
Infection
Viral meningitis
Specimen
CSF for microscopy, culture, viral PCR (HSV, enterovirus)

Throat swab in viral transport media for enterovirus PCR
Likely Organisms
Herpes simplex,
Enteroviruses
Treatment
Supportive treatment only
Infection
Encephalitis
Specimen
CSF (if not contraindicated) for HSV, VZV PCR, cell count and
differentiation
Likely Organisms
Herpes simplex, Varicella zoster
Treatment
Aciclovir 10 mg/kg IV by infusion 8 hrly until result of PCR known

If patient immunocompromised, recent travel abroad or recent exposure
to warm surface water, and abnormal CSF, or if initial PCR tests and
bacterial cultures negative AND still suspected of encephalitis:
Contact consultant microbiologist to discuss testing for unusual but
potentially treatable causes of meningo-encephalitis/myelitis such as
Cryptococcus, tuberculosis, neurosyphilis, neuroborreliosis, Mycoplasma,
Bartonella, amoebas, Toxoplasma, or Tropheryma whippelii.
Consider HIV test if immune deficiency suspected.
Duration
Herpes simplex:
14 - 21 days
Infection
Brain abscess / subdural empyema
Specimen
Pus from aspirate

CSF if not contraindicated
Blood culture
Likely Organisms
Streptococcus spp
Anaerobes
Staphylococcus aureus
Gram negative bacilli
Treatment
Drainage as appropriate
Ceftriaxone 2 g IV by infusion 12 hrly
plus
metronidazole 500 mg IV by infusion 8 hrly
Varicella zoster:
7 10 days
If tagged for MRSA:

Add vancomycin IV 1 g 12 hrly (if renal impairment contact pharmacy)
Adjust antibacterials once organism identified and sensitivities
known
Duration
Until abscess resolved (6 weeks minimum)

Page 28 of 120
EAR, NOSE AND THROAT INFECTIONS

Ear
Infection
Otitis externa
Types
Acute localised
(furuncle)
severe ear pain

localised swelling of ear canal
mild fever ( 38C)
lymphadenopathy (pre-auricular)
Likely Organisms
Specimen
Ear swab for culture only if treatment failure or chronic / recurrent cases
Treatment
First line
Incision and
drainage
and dressings
may be necessary
Flucloxacillin 500 mg orally 6 hrly

(may be given initially IV 1 g 6hrly
in severe cases)
Clarithromycin 500 mg orally 12 hrly

(may be given initially IV 500 mg 12
hrly by infusion in severe cases)
Duration
5 days total (including IV)
Acute, diffuse
(swimmers ear)
pain of variable severity

generalised swelling of ear canal
mild fever ( 38C)
lymphadenopathy (pre-auricular)
scanty discharge
Likely Organisms
Pseudomonas aeruginosa., Enterobacteriaceae
Specimen
Ear swab for culture only if treatment failure or chronic / recurrent cases
Alternative
First line
Treatment
Gentisone HC ear drops or
Sofradex ear drops or Otosporin

ear drops 2-3 drops to affected
ear(s) 3-4 times daily
Additionally, oral antibiotics may be
given in severe cases
Note: Nurse Practitioner protocol
Duration
Ciprofloxacin eye drops 0.3% in the

ear. 2-3 drops to affected ear(s) 3-4
times daily
Only after discussion with ENT
Consultant
10 days
Fungal otitis externa

Likely Organisms
Aspergillus sp., candida sp.
Treatment
Aural toilet
Clotrimazole solution 1% (Canesten ), 2-3 drops to affected ear(s) 2-3 times

daily, continue for 14 days after disappearance of infection
or
Daktarin cream, topical application to affected ear(s) twice daily, continue

for 10 days after disappearance of infection
or
Daktacort cream, topical application to affected ear(s) twice daily

Page 29 of 120
Infection
Perichondritis
Likely Organisms
Staphylococcus aureus, Pseudomonas aeruginosa
Treatment
Ciprofloxacin orally 500 mg 12 hrly
Duration
7 days
Infection
Invasive malignant otitis externa

Severe necrotising infection that spreads from the squamous epithelium
of the ear canal to adjacent areas
Risk groups:
- immunocompromised
- diabetics
- elderly
Specimen
Pus or tissue biopsy
Likely Organisms
Pseudomonas aeruginosa
Treatment
Include topical treatment i.e. dressings, gentamicin or ciprofloxacin

drops (as for acute diffuse otitis externa, swimmers ear)
First line
Early
Ciprofloxacin 750 mg orally 12 hrly
Advanced
4.5 g IV 8 hrly
Aztreonam 1-2 g IV 8 hrly
Consider adding once daily gentamicin IV (see prescribing regimen)

Duration
Ciprofloxacin, piperacillin/tazobactam (Tazocin ) or aztreonam 4 6

weeks
Gentamicin 3 - 5 days (discuss with consultant microbiologist)
Oral stepdown
Ciprofloxacin 750 mg orally 12 hrly if sensitivities allow
Infection
Acute otitis media

Acute onset of signs and symptoms (otalgia, otorrhoea, fever)
Otoscopic appearances include:
- bulging tympanic membrane with loss of landmarks
- changes in membrane colour (typically red or yellow)
- perforated tympanic membrane with discharge of pus
Specimen
Pus if perforated tympanic membrane

If severe, treatment failure, chronic / recurrent: needle aspirate from
middle ear effusion
Likely Organisms
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella

catarrhalis, Viruses
Treatment
Antibacterials should not be routinely prescribed, the following

indications may support their selective use:
- bilateral infection

Page 30 of 120
systemic symptoms, including fever (> 38.5C) or vomiting

local signs that suggest infection severe e.g. bulging or inflamed
tympanic membrane
infection at the only hearing ear
mixed hearing loss
cochlear implants, previous surgery
Type
First line
Uncomplicated
Amoxicillin 500 mg orally 8 hrly
Clarithromycin 500 mg orally 12

hrly
Treatment failure
(symptoms persist
past 3 days, or
reoccur within 14
days)
Co-amoxiclav
625 mg orally 8 hrly
or
1.2 g IV 8 hrly
Doxycycline 100 mg orally 12 hrly
Duration
Uncomplicated 5 days
Treatment failure 7 10 days
Infection
Acute Mastoiditis
Specimen
Ear drainage fluid or tissue if mastoiditis explored
Likely Organisms
Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus

pyogenes (group A -haemolytic streptococcus), S. aureus
Treatment
First line
Co-amoxiclav 1.2 g IV 8 hrly
Meropenem* 1 g IV 8 hrly
Oral stepdown
Co-amoxiclav
*Use with caution and under

supervision if history of
immediate hypersensitivity
reaction to penicillins (e.g.
anaphylaxis, urticaria)
If anaphylaxis to penicillin:
plus
Oral stepdown
According to sensitivities
or
Doxycycline 100 mg orally 12
hrly

Page 31 of 120
Nose
Infection
Acute rhinosinusitis
Specimen
Sinus discharge
Swab from middle meatus
If treatment failure, chronic / recurrent or nosocomial infection:
Sinus puncture aspirate
Likely Organisms
Community acquired:
Viruses
Streptococcus spp
Moraxella catarrhalis
S. aureus
Anaerobes
Treatment
Many are viral. Infection resolves without antimicrobial treatment in most

cases.
Reserve antibiotics for patients with
high fever and purulent nasal discharge or severe facial pain
Type
First line
Community
acquired
(systemically well)
Co-amoxiclav 625 mg orally 8 hrly

hrly
Or
Community
acquired
(systemically
unwell)

Oral stepdown
or
Co-amoxiclav
Clarithromycin 500 mg IV by
infusion 12 hrly
plus
prescribing regimen)
Nosocomial
(hospitalised and
intubated)
Nosocomial:
Often polymicrobial including
S.aureus
Pseudomonas aeruginosa,
gram negative bacilli,
yeasts
Oral stepdown
or
hrly
4.5 g IV 8 hrly
Oral stepdown
supervision if history of immediate
hypersensitivity reaction to
penicillins (e.g. anaphylaxis,
urticaria)
plus
plus

Page 32 of 120
Metronidazole 500 mg IV by
infusion 8 hrly
Oral stepdown
Duration
Review IV route after 24 - 48 hrs - convert to oral therapy, if tolerated.

Usually 5-10 days total (including IV treatment)
If no improvement, consider fungal sinusitis
Infection
Orbital cellulitis
Specimen
Eye swab of pus if present

Nasal swab for Gram stain and culture
Blood culture
Likely Organisms
Streptococcus spp
Gram negative rods
anaerobes
Treatment
First line
Ceftriaxone* 2 g IV by infusion
daily or cefotaxime 2g IV 8hrly
plus
infusion 8 hrly
plus
plus
infusion 8 hrly
*If anaphylaxis to penicillin use

with caution and under close
observation
Oral stepdown:
plus
Metronidazole 400 mg orally 8 hrly
(depending on culture and
sensitivities results)
Duration
Oral stepdown:
Discuss with Microbiologist
IV should be switched to oral as soon as clinical improvement

occurs and the temperature has been normal for 72 hrs, providing
there is no contra-indication to oral therapy.
21 days total (including IV treatment)

Page 33 of 120
Throat
Infection
Acute sore throat
Specimen
Throat swab if antibacterials are recommended (see below)
Likely Organisms
Respiratory and other viruses (e.g., EBV)

haemolytic streptococcus (group A, C and G)
Treatment
Antibacterials should not be routinely prescribed, the following

indications may support their selective use:
- features of marked systemic upset secondary to acute sore throat
- unilateral peritonsillitis
- history of rheumatic fever
- at increased risk from acute infection e.g. immunocompromised
Duration
First line
Phenoxymethylpenicillin 500 mg
orally 6 hrly

hrly
If unable to swallow:
Benzylpenicillin 1.2 g IV 6 hrly
If unable to swallow:
infusion 12 hrly
Review IV route after 24 - 48 hrs - convert to oral therapy, if tolerated, as

prolonged IV therapy has been shown to have no clinical benefit.
haemolytic streptococcus group A:
10 days total (including IV treatment) if penicillin is used.
5 days total (including IV treatment) if clarithromycin is used
Other / no organism identified: 5 days total (including IV treatment)
Infection
Peritonsillitis / Peritonsillar abscess or quinsy
Specimen
Aspirate from abscess
Likely Organisms
haemolytic streptococcus group A

Anaerobes
Treatment
Needle aspiration or incision and drainage

First line
infusion 12 hrly
add
infusion 8 hrly if not settling
after 24 hours treatment and/or
abscess drainage
Oral step down:
Phenoxymethylpenicillin 500 mg
orally 6 hrly
Duration
add
infusion 8 hrly if not settling
after 24 hours treatment and/or
abscess drainage
Oral step down:
hrly
IV should be converted to oral as soon as clinical improvement occurs

and the temperature has been normal for 24 hrs, providing there is no

Page 34 of 120
contra-indication to oral therapy

haemolytic streptococcus group A:
10 days total (including IV treatment) if penicillin is used.
7 days total (including IV treatment) if clarithromycin is used.
Other / no organism identified: 7 days total (including IV treatment)
Infection
Epiglottitis / Supraglottitis
Specimen
After establishment of an airway:

Blood culture
Likely Organisms
Haemophilus influenzae, streptococci, Staphylococcus aureus,

Streptococcus pneumoniae, other organisms
Treatment
Maintenance of an adequate airway should be the primary concern

Ceftriaxone 2 g IV by infusion daily
If anaphylaxis to penicillin use with caution and under close
observation
If ceftriaxone cannot be given:
Oral stepdown
If penicillin allergic (not anaphylaxis)
Cefaclor 500 mg orally 8 hrly
If Haemophilus influenzae type b confirmed, contact consultant
microbiologist to determine who should receive prophylaxis
Duration

contra-indication to oral therapy and a suitable agent is available
7 - 10 days total (including IV treatment)

Page 35 of 120
Infection
Salivary gland infection
Specimen
Aspirate of duct orifice

or
If aspirate not possible, swab papilla of parotid
Blood culture
Likely Organisms
Staphylococcus aureus, Streptococcus spp, oral flora
Treatment
First line
Alternative (penicillin allergy or

tagged for MRSA)
Flucloxacillin 2g IV 6hrly
Plus
Metronidazole 400mg orally 8hrly
Or metronidazole IV 500mg 8hrly if
no oral intake

Plus
Metronidazole 400mg orally 8hrly
Or metronidazole IV 500mg 8hrly if
no oral intake
Duration

contra-indication to oral therapy
10 14 days total (including IV treatment)
References
1.
2.
3.
4.
The Sanford guide to antimicrobial therapy 2010

Clinical practice guideline: otitis externa. Otolaryngol Head Neck Surg 2006;134:S4-23.
Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007;137:S1-31.
IDSA Clinical practice guideline of acute bacterial rhinosinusitis in adults and children. CID
2012; 54 (12).
5.
European position paper on rhinosinusitis and nasal polyps 2012.
http://www.rhinologyjournal.com/supplement_23.pdf
6.
Antibiotics for sore throat. Cochrane database systematic review 2006.
th
7.
Principles and Practice of Infectious Diseases. Mandell, Douglas and Bennetts. 6 edition
2006

Page 36 of 120
GASTROINTESTINAL INFECTIONS
Gastro-enteritis
Most cases do not require treatment with antibiotics. Antibiotics may be

indicated in the immunosuppressed, extremes of age, travellers diarrhoea,
prolonged course of diarrhoeal illness and severe /complicated cases.
All cases thought to be due to infectious diarrhoea need to be in a side room

and infection control nurses should be informed. Please take enteric
precautions.
Cases of food poisoning, typhoid fever, paratyphoid fever, dysentery and

cholera should be notified to Consultant for Communicable Disease Control
(CCDC) at Cheshire and Merseyside H.P.U. and followed up in writing using
the form available on this site.
During office hours they can be contacted on 0844 225 1295.

Outside office hours the Proper Officer can be reached via the public health
on-call rota on 0151 706 3134 or 0151 706 2000 (via the Royal Liverpool
University Hospital switchboard) or 01244 365 000 (via the Countess of
Chester Hospital switchboard); the same rota is held at both hospitals.
Empirical treatment
Treatment
Mild diarrhoea
( 3 unformed stools per day,
minimal symptomatology)
Moderate diarrhoea
( 4 unformed stools per day,
and/or systemic symptoms)
Severe diarrhoea
6 unformed stools per day
and/or dysenteric symptoms
(pyrexia, blood, tenesmus),
and/or high risk patient
(immunosuppression,
advanced age)
Comments
Oral rehydration
Oral rehydration
plus
Antimotility agents
Obtain stool for

culture,
Clostridium difficile testing,
parasites if travel history
Consider antibiotic treatment
Ciprofloxacin PO 500 mg 12
hrly for 5 days

Page 37 of 120
Do not use antimotility agents if

dysenteric symptoms
or
if suspected
C. difficile infection,
E. coli 0157:H7 infection,
Haemolytic Uraemic Syndrome (HUS)
Afebrile bloody diarrhoea should raise

suspicion of E. coli 0157:H7 infection
avoid antibiotics as there is an
increasing risk of precipitating
haemolytic uraemic syndrome.
Treatment algorithm for C. difficile Infection (CDI)

N.B. Treatment is not necessary for asymptomatic carriers
Diarrhoea AND one of following:
Positive CDT test or CDT test pending AND clinical suspicion of CDI
Isolate patient
Stop non-C diff antibiotics if possible
Stop PPIs if not necessary
Maintain hydration
Daily assessment
1st episode of CDI
Complications / Life threatening CDI
Oral vancomycin (DO NOT use

vancomycin IV for treatment of CDI)
250 mg qds for 10-14 days
If at any time during course of CDI
complications occur see box on
the right
Symptoms not improving

(after at least 7 days of treatment)
Add Metronidazole 400 mg PO tds
Ileus
Toxic megacolon
Hypotension
Severe colitis on CT
*Vancomycin 500 mg PO/NG qds

AND
Metronidazole 500mg IV tds
PLUS
Urgent Surgery, Gastro, Micro consultation
*Depending on degree of ileus consider
intracolonic vancomycin (500mg in 100-500ml
saline 4-12hrly) given as retention enema: 18
gauge Foley catheter with 30ml balloon inserted
per rectum, balloon inflated, vancomycin instilled,
catheter clamped for 60 minutes, deflate and
remove
Symptoms not improving (after further 7 days of treatment)
Continue vancomycin and metronidazole

Normal immunoglobulin 400 mg/kg single iv dose followed by
second dose after 3 weeks (if still inpatient) only available via
Consultant Microbiologist during normal working hours
Symptoms persist (after further 7 days of treatment)
Consider sigmoidoscopy
Consider loperamide and stopping vancomycin/metronidazole (ONLY if patient stable, WBC, CRP
normal, no abdominal pain or distension AND only after discussion with Consultant gastro/micro)
Consider rifaximin 400mg PO bd (If diarrhoea reduced to type 5 stool 1-2/day only available via
Consultant Microbiologist during normal working hours)
If at any time during course of CDI patient doesnt open bowel for 4 days, obtain AXR and if
constipation confirmed stop vancomycin+/- metronidazole (once 10-14 day course has been
completed)
Colestyramine may also be used (NOT together with vancomycin and only on the advice of
Consultant Gastroenterologist)
Recurrent CDI (2nd or subsequent episodes)

st
Antibiotic
Guidelines:
Repeat treatment
as for
1 episodeTreatment and Prophylaxis for Adults
Page
38 of 120
Once diarrhoea
controlled
stop vancomycin +/- metronidazole and start
rifaximin 400mg PO bd for 14 days (only available via Consultant
Microbiologist during normal working hours)

Campylobacter
Treatment
For most cases antibiotic treatment is not indicated (self-limiting illness)

Erythromycin 500 mg orally 6 hrly if indicated (severe cases,
immunosuppression, continuing symptoms)
Duration
5 days
Salmonella (non-typhi)
Treatment
For most cases antibiotic treatment is not indicated (self-limiting illness)

Treat if <1 year old, >60 year old, immunocompromised, vascular grafts
or prosthesis
Duration
7 days (14 days if immunocompromised)
Shigella
Treatment
Mild: none
Severe: ciprofloxacin 500 mg orally 12 hrly
Duration
3 days
E coli 0157:H7
Treatment
NO TREATMENT with antimicrobials or antimotility agents, may enhance

toxin release and increase risk of haemolytic uraemic syndrome.
Hydration important
Monitor FBC and U+Es
Vibrio cholerae 01 or 0139

Treatment
Doxycycline 300 mg orally as a single dose
Duration
Single dose
Giardia lamblia, Giardiasis

Treatment
Duration
5 days
Entamoeba histolytica, amebiasis

Treatment
Duration
Asymptomatic cyst
passes
Diloxanide furoate 500 mg orally 8 hrly for 10 days

(metronidazole not effective vs cysts)
Invasive intestinal
amebiasis
Metronidazole 800 mg orally 8 hrly for 5 days

then
Amoebic liver
abscess
Metronidazole 800 mg orally 8 hrly for 10 days

then

Page 39 of 120
See Treatment
References
2. Practice guidelines for the management of infectious diarrhoea, IDSA 2001
3. The management of infectious gastroenteritis in adults. A consensus statement
by an expert panel convened by the British Society for the Study of Infection. J
Infection 1996;33:143-152

Page 40 of 120
GENITAL TRACT INFECTIONS

Bacterial vaginosis
Specimen
High vaginal swab
Treatment
First line
Alternative
(pregnancy)
Metronidazole 400 mg orally 12

hrly
Clindamycin 2% cream (PV) nocte
7 days
7 days
Duration
Vaginal candidiasis
Specimen
High vaginal swab
Treatment
First line
Alternative
Clotrimazole pessary 500 mg nocte
Fluconazole 150 mg orally
If concurrent vulvitis add

Clotrimazole 2% cream
Duration
Single dose
Seek specialist advice if recurrent or refractory to treatment.
Trichomoniasis
Specimen
Vaginal swab for trichomonas culture
Treatment
Duration
7 days
Pregnancy
Prescribing Notes
As above
Comments
Treat partner(s) simultaneously

Refer to GUM

Page 41 of 120
Single dose
Infection
All patients with chlamydia should be referred to GUM.
If severe or upper tract infection consult GUM prior to initiating
treatment.
Specimen
Endocervical swab or urine for chlamydia testing by NAAT (nucleic acid

amplification assay)
Treatment
First line
Alternative
Uncomplicated
genital infection

for 7 days
Azithromycin 1 g orally as a single

dose
Uncomplicated
genital infection in
pregnancy
Erythromycin 500 mg orally 6 hrly for 7 days

or
Amoxicillin 500 mg orally 8 hrly for 7 days
or
Azithromycin 1 g orally as a single dose
A test of cure is required in pregnancy
Test of cure/reinfection established by NAAT should be performed at
least 5 weeks after initiation of therapy (6 weeks after azithromycin)
Chlamydial
salpingitis

plus
hrly
for 14 days
Chlamydial
epidimo-orchitis
Doxycycline PO 100 mg 12 hrly for 10-14 days
Duration
See Treatment
Ofloxacin 400 mg orally 12 hrly

plus
hrly
for 14 days
Specimen
Endocervical, urethral, rectal, pharyngeal swab for culture
Treatment
Refer to GUM

See Gynaecological infections (page 51)
References
1. Management of genital Chlamydia trachomatis infection, SIGN national clinical
guideline 2009
2. NHS evidence at http://www.library.nhs.uk/Infections/

Page 42 of 120
GYNAECOLOGY AND PREGNANCY RELATED INFECTIONS

Obstetrics
Lower Urinary Tract Infection (cystitis / asymptomatic bacteriuria) in
pregnancy
Specimen
Likely organisms
Treatment
Midstream specimen of urine

Enterobacteria
Cefradine 500 mg orally 6 hrly or according to sensitivities
Women with asymptomatic bacteriuria confirmed by a second urine
culture should be treated and have repeat urine culture at each
antenatal visit until delivery
Duration
7 days
Given the risks of asymptomatic bacteriuria in pregnancy, a urine
culture should be performed 7 days after completion of
antibacterials as a test of cure.
Pyelonephritis in pregnancy
Specimen
Likely organisms
Treatment
Check previous
urine culture
results if available
Blood culture
Enterobacteria
First line

plus
Gentamicin IV 5mg/kg single
dose (max. 560 mg)
Cefuroxime 750 mg IV 8 hrly

plus
Gentamicin IV 5mg/kg single dose
(max. 560 mg)
Oral stepdown:
Co-amoxiclav 625 mg orally 8
hrly
If anaphylaxis to penicillin
discuss with Microbiologist
Oral stepdown:
Trimethoprim 200 mg orally 12 hrly
if sensitive and >20 weeks gestation
Always check the urine culture and sensitivities results

Duration
14 days total

Page 43 of 120
Chorioamnionitis
Specimen
Likely organisms
Treatment
Duration
Diagnosis largely based on clinical findings

Amniotic fluid can be useful if available
Blood culture
Group B streptococci
E. coli
Anaerobes
Infection is often polymicrobial
First line
Amoxicillin 2 g IV 8 hrly
Cefuroxime 1.5 g IV 8 hrly
plus
plus
Gentamicin 1.5 mg/kg IV 8 hrly
plus
infusion 8 hrly
infusion 8 hrly
If history of immediate
urticaria)
Clindamycin 600 mg IV 6 hrly
plus
Gentamicin1.5 mg/kg IV 8 hrly
One additional dose of above combination is usually sufficient
postpartum therapy
Post partum endometritis

Specimen
Blood cultures
Uterine cultures
Cervical swab for Chlamydia
Likely organisms
-haemolytic streptococci, E. coli, other gram negative aerobes,

anaerobes, Gardnerella. vaginalis, Chlamydia thachomatis
Polymicrobial infection common (mixed aerobic + anaerobic flora)
First line
Treatment
Co-amoxiclav 1.2 g IV 8
hrly
plus
Gentamicin IV 5mg/kg
single dose (max. 560 mg)

plus
Metronidazole 500 mg IV by infusion 8
hrly
plus
Gentamicin IV 5mg/kg single dose (max.
560 mg)
hypersensitivity reaction to penicillins
(e.g. anaphylaxis, urticaria)
Clindamycin 600 mg IV 6hrly
plus
Once daily gentamicin IV (see prescribing
regimen)
Duration
Continue parenteral therapy until patient afebrile for >24-48hrs, pain free
and normal WBC
Follow up oral antibiotics after discharge are NOT necessary

Page 44 of 120
Post abortion infection

Specimen
Blood cultures
Uterine cultures
Cervical swab for culture, chlamydia
Urine culture
Likely organisms
Vagina flora organisms, sexually transmitted pathogens, Clostridium

perfringens
Treatment
Uterine evacuation usually necessary
Early post abortion

infection
(simple endometritis,
low grade fever, mild
uterine tenderness
following
uncomplicated
elective abortion)
Established
infection
(Fever >38C, pelvic
peritonitis,
tachycardia)
First line
Ceftriaxone 250 mg IM stat

then
plus
hrly
Ofloxacin 400 mg PO 12 hrly

plus
Metronidazole 400 mg PO 12 hrly

plus
Gentamicin IV 5mg/kg single
dose (max. 560 mg)

plus
infusion 8 hrly
plus
Gentamicin IV 5mg/kg single dose
(max. 560 mg)
urticaria)
Clindamycin 600 mg IV 6hrly
plus
Duration
5-7 days

Page 45 of 120
Episiotomy infection
Specimen
Likely organisms
Treatment
Pus if present
Wound swab
Streptococci, staphylococci, enterobacteriaceae, anaerobes
First line
Simple episiotomy
infection
Local infection along
episiotomy incision,
no systemic
manifestations
Superficial fascia
infection
Surgical exploration
may be required

hrly

hrly
plus
infusion 12 hrly
plus
infusion 8 hrly
plus
Duration
5-7 days
Infection
Add once daily gentamicin IV if

fails to respond (see prescribing
regimen)
Prevention of early onset neonatal group B streptococcal

(GBS) disease
Indicated for vaginal deliveries or emergency Caesarean Section if:
- Previous infant with invasive GBS disease
- GBS bacteriuria in this pregnancy
Should be considered if any of the following risk factors present:
- Intrapartum fever 38C
- Prematurity < 37 weeks
- Prolonged rupture of membranes (> 18 hr) at term
- GBS carriage in this pregnancy

Treatment
Antibacterial prophylaxis
First line
Benzylpenicillin 3 g IV
then
Benzylpenicillin 1.5 g IV 4 hrly until
delivery

Start as soon as possible after onset of labour and at least 2 hours before
delivery
Continue until delivery
If intrapartum fever and chorioamnionitis is suspected broad-spectrum
antibiotic therapy including an agent active against GBS should replace
GBS-specific antibacterial prophylaxis
(see chorioamnionitis above)
Duration
See treatment

Page 46 of 120
Infection
Treatment
Duration
Preterm prelabour rupture of membranes

Erythromycin 250 mg orally 6 hrly
10 days
Sepsis of unknown origin
See also guidelines for Sepsis, severe sepsis and septic shock (Page 71)
If source identified, treat as per appropriate condition
Specimens
Treatment
Obtain appropriate cultures before starting antibiotics provided

this does not significantly delay antibiotic administration
Blood cultures at least 2 sets

at least one BC should be percutaneous,
one BC from each vascular access device
Culture other sites as clinically indicated e.g.:
urine
faeces
wound or vaginal swabs

Start antibiotics ASAP and within the first hour of recognising
severe sepsis or septic shock

Check previous microbiology results if available

Remove source if appropriate e.g. infected lines, abscess,
perforated bowel
First line
For severe sepsis/septic shock, add gentamicin 1.5 mg/kg IV

8 hrly to appropriate regimen
Meropenem* 1g IV 8 hrly
penicillins contact consultant
microbiologist
Known ESBL
positive patient
Meropenem* 1g IV 8 hrly
Known / suspected
MRSA positive
or
line infection
suspected
Add teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter

to above regimen

Adjust treatment following culture results and susceptibilities

Empirical use of gentamicin as part of combination therapy
should not continue for > 3-5 days
7-10 days total
Duration

Page 47 of 120
Gynaecology
Mastitis
Specimen
Likely organisms
Treatment
Post partum mastitis
Drain abscess if
present
Aspirate of pus or swab if aspirate not possible

Staphylococcus aureus most common
Streprococci, anaerobes, coagulase negative staphylococci
First line
Flucloxacillin 2 g IV 6 hrly
or
depending on severity
Oral step down: Flucloxacillin 500
mg orally 6 hrly
Non-puerperal
mastitis
infusion 12 hrly
or
hrly
Oral step down: Clarithromycin
or
Depending on severity
infusion 12 hrly
or
hrly
If subareolar and odoriferous

Add
hrly or IV 500 mg 8 hrly
If subareolar and odoriferous

Add
hrly or IV 500 mg 8 hrly
Oral step down: Flucloxacillin 500

mg orally 6 hrly
+/Metronidazole 400 mg orally 8
hrly
Oral step down: Clarithromycin

+/Metronidazole 400 mg orally 8
hrly
Drain abscess if
present
Known / suspected
MRSA positive

Or
Doxycycline 200mg orally 24hrly (contraindicated in breastfeeding)
depending on severity
Duration
7 days total
Surgical site infection after gynaecologic surgery

Specimen
Likely organisms

Mixed aerobic and anaerobic flora (streptococci, enterobacteriaceae,
G. vaginallis, anaerobes)
Treatment
First line
Not severe

Page 48 of 120
hrly
plus
hrly
regimen)
Severe

regimen)
Duration
infusion 12 hrly
plus
infusion 8 hrly
plus
Non-severe: 5 - 7 days total

Severe: 7 - 14 days total (including IV treatment)

Page 49 of 120

Specimen
Likely organisms
Treatment
Outpatient
(mild-moderate PID)
Inpatient
(severe disease,
tubo-ovarian abscess,
pregnancy,
lack of response or
intolerance to oral
therapy)
Cervical and urethral swab for gonorrhoea

Cervical swab for Chlamydia
High vaginal swab
Chlamydia trachomatis, Neisseria gonorrhoeae, anaerobes,
streptococci, gram negative rods, mycoplasmas
First line
Alternative
Ceftriaxone 500 mg IM stat
then
plus
hrly
For 14 days
Ceftriaxone 2 g IV 24 hrly
plus
plus
hrly
Oral step down
plus
hrly
Pregnancy
Ofloxacin 400 mg orally 12 hrly

plus
hrly
For 14 days
plus
Oral step down
plus
hrly
Ceftriaxone 2 g IV 24 hrly
plus
Erythromycin 500 mg IV 6 hrly
plus
Metronidazole 500 mg IV 8 hrly
Oral step down
Duration
Erythromycin 500 mg orally 6 hrly

plus
hrly
Switch to oral >24hours after clinical improvement
14 days total
References
1. Stubblefield PG and Grimes DA. Septic abortion. NEJM 1994;331:310-314.
2. French L, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database of
Systematic Reviews 2004.
3. Hopkins L, Smaill FM. Antibiotic regimens for management of intraamniotic infection. Cochrane
Database of Systematic Reviews 2002.
4. Prevention of early onset neonatal group B streptococcal disease RCOG 2003 Green top
guideline 36.
5. Preterm prelabour rupture of membranes RCOG 2006 Green top guideline 44.
6. Management of acute pelvic inflammatory disease RCOG 2008 Green top guideline 32.
7. UK National guideline for management of PID BASHH 2011.

Page 50 of 120
Infection
Infective endocarditis (IE)

(Empirical treatment)
Specimen
Blood cultures (ensure meticulous aseptic technique)

o 3 sets from peripheral sites with >=6 hr between them
before commencing antimicrobial therapy (in
chronic/subacute cases)
o If the diagnosis of IE is in doubt, the patient is clinically
stable and has already received antibiotics, stop
antibiotics and reculture
o If patient acutely ill (severe sepsis or septic shock), take 2
blood culture sets within 1hr before starting empirical
therapy
Serology
o In patients with culture negative IE send serum for
Coxiella burnetii (Q fever) and Bartonella testing. If
negative, discuss with Microbiologist further serological
testing.
Likely Organisms
Streptococci
Enterococci
Coagulase negative staphylococci
HACEK group
Treatment
First line
Doses require adjustment according to renal function

NVE- Indolent
presentation
If patient is clinically
stable, ideally wait blood
cultures
NVE -Acute
presentation (severe
sepsis)
Amoxycillin IV 2 g 4 hrly
plus
*Gentamicin IV 1mg/kg 12 hrly
*Vancomycin IV 1 g 12 hrly
plus
plus
If patient is critically ill and has risk factors for unusual/resistant
organisms (e.g. colonisation with ESBL-producing coliforms or
intravenous drug use) substitute meropenem 2g IV 8hrly for
gentamicin
PVE pending blood

cultures or with
negative blood
cultures
plus
plus
NVE, native valve endocarditis

PVE, prosthetic valve endocardits
* Gentamicin and vancomycin require careful monitoring, especially in renal impairment
Monitor twice weekly if renal function normal and stable, otherwise daily
Dose modification is required according to renal function
Gentamicin (multiple daily dosing for infective endocarditis)
Pre-dose (trough) level should be maintained <1 mg/L
Page 51 of 120
Post-dose (peak) level 3-5 mg/L

Vancomycin
Pre-dose level 15-20mg/L.
Duration
Prolonged IV antibiotic therapy necessary (4-6 weeks)

Depends on organism cultured and presence or absence of intracardiac prosthesis
Routine switch to oral antimicrobials is not recommended
Empirical therapy must be followed by pathogen specific therapy
once culture results available
Always discuss with Consultant Microbiologist
References
1.
Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: report of the
Working Party of the British Society for Antimicrobial Chemotherapy 2011. J Antimicrob
Chemother doi:10.1093/jac/dkr450

Page 52 of 120
INTRA-ABDOMINAL INFECTIONS
Infection
Diverticulitis
Specimen
Blood culture (if clinically toxic or immunocompromised)

Pus from abscess if drained
Likely Organisms
Enterobacteriacae
Anaerobes
Enterococci, streptococci
Treatment
First line

plus
infusion (or 400 mg orally) 8 hrly
Oral stepdown:
Or
Co-trimoxazole 960 mg orally 12
hrly plus
Metronidazole 400 mg orally 8hrly
Oral stepdown:
hrly
Duration
Review IV route after 24 - 48 hrs - convert to oral therapy, if

tolerated and available.
Usually 5 - 7 days total (including IV treatment)
If persistent or recurrent evidence of infection after 5 7 days
treatment, discuss with consultant surgeon and consider appropriate
diagnostic investigations
Infection
Secondary peritonitis
Spillage of gastrointestinal or genitourinary microorganisms into the
peritoneal cavity due to loss of integrity of mucosal barrier e.g.
ruptured appendix, perforated peptic ulcer
Specimen
Blood culture (if clinically toxic or immunocompromised)

Peritoneal aspirate/pus for gram stain and culture. Request culture for
mycobacteriae if chronic peritonitis or TB suspected
Likely Organisms
Typically polymicrobial infection - Colonic flora

Gram negative bacilli, Anaerobes, Candida spp
Mycobacterium tuberculosis (chronic peritonitis)
Treatment of
secondary bacterial
peritonitis
First line
Mild/moderate
And
Communityacquired

plus
Oral stepdown:
According to sensitivities or
hrly plus
Oral stepdown:
hrly

Page 53 of 120
Severe
Or
Hospital-acquired

Oral stepdown:
Duration

For established infection continue for total of 5 - 7 days (including IV).
Upper gastrointestinal perforations operated on within 24hrs (in the
absence of malignancy or acid-reducing therapy), traumatic or
iatrogenic bowel injuries operated on within 12hrs and acute
appendicitis without evidence of perforation, abscess, or local
peritonitis require treatment for 24hrs post-op.
Infection
Primary (spontaneous) bacterial peritonitis
Meropenem 1 g IV 8 hrly
plus
plus
Oral stepdown:
Peritoneal infection that is not related directly to other intra-abdominal

abnormalities
Specimen
Ascitic fluid >=10ml inoculated into blood culture bottles at bedside

Ascitic fluid in sterile container for cell count, differential and culture
Likely Organisms
Escherichia coli, Klebsiella pneumoniae, Anaerobes, Streptococcus

pneumoniae
Treatment
Empirical antibiotic therapy should be started in patients with an ascitic fluid neutrophil count
3.
3
of >250 cells/mm . In patients with hemorrhagic ascites with fluid RBC count >10000mm , a
subtraction of 1 neutrophil per 250 RBC should be made to adjust for the presence of blood in
ascites.
Timing
First line
Initial empiric
treatment
(oral treatment can
be initiated if patient
is clinically well, with
bowel sounds)

Oral step down
Co-amoxiclav 625mg orally 8hrly
Ertapenem IV 1 g daily
If not responding
after 48 hr
(<25% reduction in
ascitic fluid
neutrophil count)
Modify antibiotic treatment

according to sensitivity results
Modify antibiotic treatment

according to sensitivity results
If culture negative switch to

If culture negative switch to

Aztreonam 2g IV 8 hrly
plus

Page 54 of 120
If anaphylaxis to penicillin use

ciprofloxacin 750mg orally 12 hrly
or
Ciprofloxacin 400mg IV 12 hrly
(if patient is on ciprofloxacin
prophylaxis, use IV regimen
below)
Also consider secondary

peritonitis
infusion 8 hrly
plus
Also consider secondary
peritonitis
Prophylaxis
Started after
completion of
treatment course
Only in cirrhotic patients after first confirmed episode of

spontaneous bacterial peritonitis
Duration
Treatment:
Review IV route after 24 - 48
hrs - convert to oral therapy, if
improving and organism sensitive
Total 5 days
Infection
Acute pancreatitis
Specimen

Pancreatic tissue if debrided
Likely Organisms
Enteric organisms
Treatment
Avoid routine prophylactic antibacterials especially if <30%

necrosis of the pancreas on CT
Give antibiotics only if proven infection, newly developed sepsis,
failure of 2 organ systems
Prophylaxis:
Until ascites resolved
If anaphylaxis to penicillin contact consultant microbiologist
Duration
7-14 days

Page 55 of 120
LIVER AND BILIARY SYSTEM

Infection
Acute Cholecystitis
Specimen
Likely Organisms
Enterobacteriacae, Anaerobes, Enterococci, streptococci
Treatment
First line
Mild cases:

or
Moderate severity (WBC>18.0,

marked local inflammation, tender
mass RUQ):

or
plus
infusion (or 400 mg orally) 8
hrly
Severe (organ dysfunction present)

or Hospital-acquired:
4.5 g IV 8 hrly
Oral stepdown
(if no positive cultures)
Duration
Oral stepdown
Co-trimoxazole 960 mg orally
12 hrly plus
Metronidazole 400 mg orally
8hrly (if no positive cultures)
Review IV route after 24 - 48 hrs - convert to oral therapy, if tolerated

and available.
Usually 5 - 7 days total (including IV treatment)

Page 56 of 120
Infection
Acute Cholangitis
Specimen
Blood culture
Likely Organisms
Treatment
Biliary drainage by either urgent ERCP or PTC is likely to be

necessary
First line
Mild/moderate

plus
Severe (organ dysfunction

present) or Hospital-acquired:

plus
plus
Oral stepdown
hrly (if no positive cultures)
Oral stepdown
hrly plus
(if no positive cultures)
Duration

For mild cases 3 days is usually sufficient
For other cases usually 5 - 7 days total (including IV treatment)
Infection
Pyogenic liver abscess
Specimen
Blood culture
Aspirate of abscess contents for gram stain and culture
Likely Organisms
Treatment
Drainage of abscess
First line
Discuss with consultant
microbiologist
Oral stepdown
Duration
Intravenous - up to 2 weeks may be necessary

Page 57 of 120
Oral stepdown once clinical parameters improving, depending on

culture results.
Total 2 - 6 weeks (10 - 14 days may be sufficient for abscesses that
are drained)
Infection
Amoebic liver abscess
Specimen
Stool for ova, cysts and parasites

Amoebic serology
Blood culture if pyrexial
Likely Organisms
Entamoeba histolytica
Treatment

then
Diloxanide furoate 500 mg orally 8 hrly
Duration
Metronidazole 10 days
Diloxanide furoate 10 days
References
th
1. Principles and practice of Infectious Diseases. 6 ed. Mandell, Douglas and Bennett.
3. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus
document, International ascites club. J of Hepatology 2000;32:142-153
4. Guidelines on the management of ascites in cirrhosis. KP Moore, GP Aithal. Gut 2006; 55:1-12.
5. UK guidelines for the management of acute pancreatitis Gut 2005;54:1-9
6. Tokyo guidelines for the management of acute cholecystitis and cholangitis. J Heapato-biliary
Pancreat surg 2007;14
7. Diagnosis and management of complicated intra-abdominal infection in adults and children:
IDSA guidelines. Clinical Infectious diseases 2010;50:133-64

Page 58 of 120
MRSA positive in-patient at MCHFT

(MRSA isolated from admission screen, weekly screen, clinical specimen etc)
Obtain full MRSA screen if not already done
Infection with MRSA
Colonisation with MRSA
Prior to any surgical procedure
(multiplication of MRSA in the tissues

with associated host response leading
to symptoms such as pyrexia,
septicaemia, skin and soft tissue
infections, pneumonia etc)
(the presence and multiplication of MRSA at a

body site without tissue invasion or host
response i.e. no signs of infection)
(for elective, outpatient surgical cases follow

the elective MRSA screening pathway)
MRSA Suppression Treatment (5 day course)

Systemic antibiotic treatment
(with antibiotics that are active
against MRSA e.g. teicoplanin I.V.
Oral options depend on susceptibility
testing refer to microbiology results
and to relevant hospital antibiotic
treatment guidelines)
Mupirocin 2% nasal ointment (Bactroban )

topically to each nostril tds for 5 days.
Triclosan 1% skin cleanser (Skinsan )

Body: daily for 5 days
Hair: on days 2 and 4
Systemic antibiotic treatment is NOT required
MRSA Suppression Treatment

start 5 days pre-operatively and
complete on the day of operation
if treatment cannot be commenced
5 days pre-op, start at the earliest
opportunity and continue for a full 5 days
Plus
Surgical antibiotic prophylaxis
(if indicated) should include
Teicoplanin 600mg I.V. at induction
Plus
MRSA Suppression Treatment
(follow instructions on the right)
Re-screen
(See Guidelines
Antimicrobial prophylaxis for surgery
on intranet under Policies and Procedures
> Antibiotic Management)
2 days after suppression treatment and all

antibacterials (topical or systemic) have been stopped
Re-screen MRSA positive
Re-screen MRSA negative
Repeat course of suppression treatment
Obtain 2 more negative MRSA screens taken

at weekly intervals before patient is considered to
be clear of MRSA
If medical device in situ that breaches skin or mucous membranes

(central line, trachea cannula, drain etc), or a urinary catheter, carry out
nd
2 suppression treatment only after all devices have been removed
DO NOT give more than two courses during a single inpatient
episode
Page 59 of 120
If any subsequent screens are positive, follow

instructions on box on the left
RESPIRATORY TRACT INFECTIONS

Infection
Community Acquired Pneumonia (empirical)

Assessment of severity using CURB 65 as an aid to clinical
judgement
Consider core adverse prognostic features (score 1 point for
each feature present):
- New mental confusion (mental test score of 8 or new
disorientation in person, place or time
- Urea > 7 mmol/L
- Respiratory rate 30 breaths/min
- Systolic BP < 90 mmHg or diastolic BP 60 mmHg
- Age 65 years
Specimen
Number of features present
Management
0-1
Low severity
2-3
Moderate severity
Treat as severe if one of the
following additional adverse
prognostic features present:
- PaO2 < 8 kPa / SaO2 < 92%
(any FiO2)
- CXR: bilateral / multilobar
shadowing
- Co-morbidity
3 with co-morbidity, 4 or 5
High severity
Blood culture for moderate/severe infection

Sputum for culture and sensitivity prior to antibiotic treatment
If severe CAP, serology for atypical organisms:
- influenza A and B
- Coxiella burnetii
- Chlamydia psittaci
- Mycoplasma pneumoniae
- Legionella pneumophilia
If severe CAP, or in patients with a travel history / hotel stay in 2
weeks prior to admission, urine for:
- Legionella antigen
Likely Organisms
Beta haemolytic Streptococcus
Legionella spp
Mycoplasma
I.V. to oral switch

contra-indication to oral therapy and a suitable agent is available.

Page 60 of 120
Treatment
Severity
First line
Low severity
(CURB 65 = 0 or 1)

If IV needed:
Amoxicillin 500 mg IV 8 hrly

hrly
or
If IV needed:
infusion 12 hrly
Moderate severity
(CURB 65 = 2 or 3)
Amoxicillin 500 mg IV 8 hrly

plus
Clarithromycin 500 mg orally
12 hrly
(or clarithromycin 500 mg IV by
infusion 12 hrly if IV needed)

plus
Clarithromycin 500 mg orally
12 hrly
(or clarithromycin 500 mg IV by
infusion 12 hrly if IV needed)
High severity
(CURB 65 = 3 plus
comorbidity, 4 or 5)

plus
infusion 12 hrly

plus
Clarithromycin 500 mg IV 12 hrly
IV only needed if no
NG/PEG and unable
to swallow or absorb
oral drugs
Oral stepdown to amoxicillin and

clarithromycin or according to
organisms isolated.
Stepdown to oral clarithromycin

or according to organisms
isolated.
If Legionella suspected:
Add rifampicin 600 mg orally or
IV by infusion (use oral if possible
as it is well absorbed) 12 hrly
Very severe and in
HDU/ICU

plus
infusion 12 hrly
If Legionella suspected:
Add rifampicin 600 mg orally or
IV by infusion (use oral if possible
as it is well absorbed) 12 hrly
Duration
IV meropenem* 1 g 8 hrly
plus
IV clarithromycin 500 mg 12 hrly.
If no improvement in 3 days, discuss with consultant microbiologist

Not severe: 5 days total (including IV treatment)
Severe: 7-10 days total (including IV treatment)

Page 61 of 120
Infection
Hospital Acquired, Postoperative or Ventilator

Associated Pneumonia
The presence of any of the following indicates a severe illness:
- Respiratory failure (PaO2 < 8 kPa and/or PaCO2 > 6.4 kPa)
- Respiratory rate > 25 breaths/min
- Rapid radiographic progression, multilobar pneumonia, or cavitation
of lung infiltrate
- Diastolic BP < 60 mmHg
9
9
- WBC < 4 x 10 /L or > 20 x 10 /L
- Poor urine output or rising creatinine
- Metabolic acidosis
Specimen
Sputum for culture and sensitivity

Blood cultures - two sets from separate sites
Likely Organisms
Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus

influenzae, Enerobacteriaceae, Pseudomonas aeruginosa
Treatment
Severity
First line
Alternative (incl. penicillin

allergy)
Not severe

hrly
or
hrly
If not responding within 24 48
hrs, treat as severe
Severe
Piperacillin and tazobactam

If source unclear, can add stat
dose of gentamicin 5mg/kg

plus
Oral stepdown
Oral stepdown
If history of MRSA
add Teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter

(if not already included)
If ESBL positive
If ICU patient
As above. In addition:
If proven MRSA pneumonia (usually ventilator associated, infiltrates on
chest X-ray, sputum culture yields MRSA only) does not respond to
teicoplanin as expected (within 48 72 hrs), contact consultant
microbiologist to discuss switching to linezolid.
urticaria), contact consultant
microbiologist
Linezolid must only be prescribed on the advice of a consultant

microbiologist
Duration
Non severe: 5 - 7 days total (including IV treatment)

Severe: 14 days total (including IV treatment)

Page 62 of 120
Infection
Acute Infective Exacerbation of Chronic Obstructive

Pulmonary Disease and Chronic Bronchitis
Specimen
Sputum
Blood culture if pyrexial
Likely Organisms
Viruses, Haemophilus influenzae, Streptococcus pneumoniae, Moraxella

catarrhalis, Staphylococcus aureus (consider if influenza present)
Treatment
Antibiotic treatment
should be given only
if COPD
exacerbation is
associated with
increased sputum
purulence.
In the absence of
increased sputum
purulence do not use
antibiotics, unless
patient has clinical
signs of pneumonia
or CXR consolidation
First line
Alternative (severe infection)
Doxycycline 100mg orally 12 hrly

and
Duration
5 - 7 days total
Infection
Acute Bronchitis
Likely Organisms
Usually viral
Treatment
Antibacterials not recommended
Infection
Upper Respiratory Tract Infections
Likely Organisms
Usually viral
Treatment
Antibacterials not recommended
Infection
Aspiration pneumonia
Prophylactic antibiotics to patients in whom aspiration is suspected or
witnessed, or for patients with aspiration pneumonitis (acute chemical
injury following the inhalation of acidic gastric acid contents) is
NOT RECOMMENDED.
Empirical antibiotic therapy should be considered in patients with
aspiration pneumonitis that fails to resolve within 48 hours of
aspiration and/or in patients whose sputa become mucopurulent or
purulent and who exhibit other features consistent with pneumonia.
Specimen
Blood culture
Likely Organisms
Streptococcus pneumoniae, Streptococcus spp, Anaerobes,


Page 63 of 120
Treatment
Severity
First line
Not severe

plus
infusion 8 hrly
infusion 12 hrly
plus
infusion 8 hrly
Oral step down:

plus
hrly
Severe and
community
acquired

Oral stepdown
hrly

plus
infusion 8 hrly
Oral stepdown
hrly
plus
hrly
Severe and
hospital acquired
Piperacillin and tazobactam

Duration

plus
plus
infusion 8 hrly
Infection
Infective Exacerbation of Bronchiectasis (not Cystic

Fibrosis)
Specimen
Sputum
Bronchoalveolar lavage
Likely Organisms
Haemophilus influenzae, Pseudomonas aeruginosa, Streptococcus

pneumoniae, Staph aureus
Treatment
Check last sputum result If last culture report within 3 months treat
according to sensitivities. If sensitivities not known treat according to
regimen below
Severity
First line

Page 64 of 120
Not severe and no

history of
Pseudomonas
Not severe and

history of
Pseudomonas:
Severe impairment
of lung function or
acute respiratory
failure and
sensitivities not
known
4.5 g IV 8 hrly
Duration
Switch to oral (if sensitivities allow) as soon as clinical improvement

occurs
Infection
Exacerbation of Bronchiectasis in Cystic Fibrosis
Specimen
Likely Organisms
Pseudomonas aeruginosa
Treatment
Check last sputum result If last culture report within 3 months treat
according to sensitivities. If sensitivities not known treat according to
regimen below

hrly
plus
If history of Pseudomonas (most patients), give the following

antibacterials unless bacteria resistant or patient sensitive to
antibacterial:
Ceftazidime 4 g IV 8 hrly
plus
Gentamicin IV 8 hrly (same dose as last admission; if not known 10
mg/kg daily in divided doses 8 hrly)
th
Monitoring
Gentamicin or tobramycin levels before and after the 5 dose (within 48

hr of starting treatment)
Trough < 2 mg/L
Peak (1 hr post-dose) 8 - 12 mg/L
Duration
14 days
Infection
Lung Abscess
Specimen
Blood culture
Fluid from lung abscess
Likely Organisms
Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus spp,

Anaerobes
Treatment
First line

Page 65 of 120
4.5 g IV 8 hrly
If not anaphylaxis or urticaria (Type

1 allergy)
Discuss with consultant
microbiologist
Adjust antibiotic treatment according to culture results

Oral stepdown:
Dependent on sensitivities, clinical and radiological response
Duration
Dependent on clinical and radiological response, but may be 6 weeks or

more
Switch to oral antibiotics once clinical and biochemical improvement and
suitable oral agent available.

Page 66 of 120
Infection
Pleural Empyema
Features of ongoing sepsis and raised CRP in patients with pneumonia
after >=3 days may indicate progression to pleural infection
Specimen
Blood culture
Fluid from pleural cavity
Likely Organisms
Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus

pyogenes, Streptococcus milleri, Escherichia coli, Pseudomonas
aeruginosa, Klebsiella spp, Anaerobes
Treatment
Chest tube drainage is usually required
Type
First line
Community
acquired

plus
plus
infusion 8 hrly
Hospital acquired
4.5 g IV 8 hrly
Positive for ESBL
Discuss with consultant microbiologist
Tagged for MRSA
Add teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter

to above regimens if not already included
plus
plus
infusion 8 hrly
If MRSA proven (cultured in pleural fluid) or likely cause of empyema

(e.g. recent relevant specimen other than pleural fluid positive for MRSA):
Discuss use of additional antibacterial with consultant microbiologist
Duration
IV should be transferred to oral as soon as clinical and biochemical

improvement occurs and the temperature has been normal for 24 hrs,
providing there is no contra-indication to oral therapy. Use oral
antibacterial with good tissue penetration to which organism sensitive
(discuss with Consultant Microbiologist).
Continue antibacterial therapy for a prolonged period of time (at least 3
weeks), based on clinical, biochemical and radiological respone (usually
beyond when all the fluid has gone and the drain removed).

Page 67 of 120

Type of pneumonia
Pneumococcal
Likely Organisms
Treatment
First line

or
(according to severity)
infusion 12 hrly
or
hrly
If not sensitive to clarithromycin,
discuss with consultant
microbiologist
Duration
Type of pneumonia
Staphylococcal
Uncommon, but consider if ventilated or influenza suspected
Staphylococcal pneumonia may cause lung abscess or cavitating
pneumonia. In the latter case, also send 3 sputums or a BAL for AFB
Likely Organisms
Staphylococcus aureus (including MRSA)
Treatment
For assessment of severity see Community Acquired Pneumonia

(empirical)
Treat Staphylococcal pneumonia aggressively, but do not treat every
Staphylococcus aureus isolated in sputum as this commonly represents
oropharyngeal colonisation
Severity
First line
Alternative (penicillin allergy or

tagged for MRSA)
Not severe

Severe
Add rifampicin 600 mg orally (IV by infusion if unable to swallow or

absorb oral drugs) 12 hrly to above regimens and check that organism
cultured is sensitive to rifampicin
Severe necrotizing
pneumonia due to
PVL S. aureus
Linezolid 600 mg IV 12 hrly

plus
Clindamycin 1.2 g IV 6 hrly
plus
Rifampicin 600 mg IV 12 hrly
Duration
Not severe 10-14 days total (including IV treatment)

Severe 14 - 21 days total (including IV treatment)

Page 68 of 120
Type of pneumonia
Legionella
Likely Organisms
Legionella spp
Treatment

(empirical)
Duration
Not severe
Severe

hrly
infusion 12 hrly
plus
Rifampicin 600 mg orally (IV by
infusion if unable to swallow or
absorb oral drugs) 12 hrly
Oral stepdown
hrly
plus
Not severe 7 days total (including IV treatment)

Severe 10 - 21 days total (including IV treatment)
Type of pneumonia
Confirmed Q fever, psittacosis
Likely Organisms
Coxiella burnetti
Chlamydia psittaci
Treatment
Duration
14 days total
Type of pneumonia
Mycoplasma, Chlamydia
Likely Organisms
Mycoplasma pneumoniae, Chlamydia pneumoniae
Treatment

(empirical)
Not severe
Severe

hrly
infusion 12 hrly
Duration
Type of pneumonia
PCP
Occurs in patients who are immunosuppressed due to disease or
treatment
PaO2 < 8 kPa on air
Metabolically compensated respiratory acidosis
Specimen
Bronchoalveolar lavage for Pneumocystis PCR

(Induced) sputum for Pneumocystis PCR
Organism
Pneumocystis jirovecii
Treatment
Discuss urgently with consultant microbiologist or consultant

haematologist before starting treatment
Co-trimoxazole 120 mg/kg IV by infusion / orally daily in 2 4 divided
doses
If PaO2 < 8 kPa on air:

Page 69 of 120
Add prednisolone 40 mg orally each morning

Duration
Convert to oral (same dose) as soon as clinical improvement occurs

References
1. Guidelines for the Management of Community Acquired Pneumonia in Adults 2009 update
2. Management of pleural infection in adults, BTS pleural disease guideline 2010. H E Davies, R J O
Davies, C W H Davies, on behalf of the BTS Pleural Disease Group, Thorax 2010;65(Suppl
2):ii41ii53.
3. BTS guidelines for non-CF bronchiectasis Thorax 2010, vol 65 suppl 1.
4. management of COPD in adults. NICE CG 101, 2010.
5. Saving Lives: reducing infection, delivering clean and safe care Antimicrobial prescribing A
summary of best practice
http://www.dh.gov.uk/en/Publichealth/Healthprotection/Healthcareacquiredinfection/Healthcareac
quiredgeneralinformation/ThedeliveryprogrammetoreducehealthcareassociatedinfectionsHCAIincl
udingMRSA/index.htm
6. Healthcare associated infections, in particular infection caused by Clostridium difficile
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_0
63090

Page 70 of 120
SEPSIS, SEVERE SEPSIS AND SEPTIC SHOCK

Definitions
Sepsis
Presence of documented or suspected infection plus systemic inflammatory response

(SIRS) (e.g. temperature >38.3C or <36C, tachycardia, tachypnoea, leukocytosis)
Severe sepsis
Sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion (e.g. hypotension,

diminishing renal function, clotting disturbance, hypoxia, ARDS, raised lactate)
Septic shock
Severe sepsis plus hypotension (systolic BP <90 mmHg) persisting despite adequate
fluid resuscitation
Likely organisms
Wide variety of organisms, depends on source of infection

Specimens

Treatment

Source identified
Obtain appropriate cultures before starting antibiotics provided this does not
significantly delay antibiotic administration
Blood cultures at least 2 sets
at least one BC should be percutaneous,
one BC from each vascular access device
Culture other sites as clinically indicated e.g.:
urine
faeces
CSF
Start antibiotics as soon as possible and within the first hour of recognising
severe sepsis or septic shock
Check previous microbiology results if available
Treat as per appropriate guideline e.g. severe pneumonia, meningitis, intra-abdominal

infection
Remove source if appropriate e.g. infected lines, abscess, perforated bowel
First line
Source unclear
4.5 g IV 8 hrly
Severe sepsis
Septic shock or
Pseudomonas
infection suspected
Suspected
Neutropenic sepsis
(neutrophil count < 1.0
9
x 10 /L)
Do not wait for
confirmatory bloods
for any patient who
is unwell and has
had chemotherapy in
the last 28 days
Known / suspected
MRSA positive
or
line infection
suspected
If history of immediate hypersensitivity

reaction to penicillins
plus
Teicoplanin 600mg IV 12 hrly for 3 doses then
24 hrly thereafter
Add
Once daily gentamicin IV (see prescribing regimen)
4.5 g IV 8 hrly
plus
prescribing regimen) unless had
platinum based chemotherapy within
last 28 days (e.g. cisplatin,
carboplatin, oxaliplatin)
*Use with caution and under supervision if
history of immediate hypersensitivity
reaction to penicillins (e.g. anaphylaxis,
urticaria)
If history of immediate hypersensitivity reaction
to penicillins contact consultant microbiologist
Always discuss cases of neutropenic sepsis with oncologist or haematologist and

consider the need for G-CSF.
Add
Teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter (if not already
included)

Page 71 of 120
Known ESBL
positive patient
Duration
*Use with caution and under supervision if history of immediate hypersensitivity
reaction to penicillins (e.g. anaphylaxis, urticaria)
If history of immediate hypersensitivity reaction to penicillins contact consultant
microbiologist
Adjust treatment following culture results and susceptibilities
Empirical use of gentamicin as part of combination therapy should not continue
for > 3-5 days
7-10 days total
References
1. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic
shock. Crit Care Med 2008; 36: 296-327.

Page 72 of 120
SKIN AND SOFT TISSUE INFECTIONS

Infection
Cellulitis
Not severe:

systemically well with temperature 36 - 38C

cellulitis not involving the face or hand

not previously treated with adequate oral antibacterials for the same
complaint
Severe if any of the following present:

lesion spreading rapidly

systemic features e.g. temperature > 38C or < 36C, hypotension,
tachycardia

cellulitis involving the face or hand

progression despite adequate doses of appropriate oral antibiotics

significant co-morbidities e.g.asplenia, neutropenia, cirrhosis,
immunocompromised, cardiac or renal failure, or pre-existing oedema
Specimen
Swab from port of entry or aspirate of pus

Swab of cannula site and tip for culture (if source)
Likely Organisms
Staphylococcus aureus, haemolytic streptococci

Anaerobes particularly in diabetics or ischaemic limbs
Treatment
Treat underlying cause e.g. portal of entry such as tinea pedis or remove
cannula if source
Severity
First line
Not severe
Severe
Outline area
plus

If patient is unwell,
the presence of
marked systemic
toxicity or pain out
of proportion to the
local findings
should alert the
physician to the
possibility of
necrotising
fasciitis. If this
cannot be
excluded, obtain
urgent surgical
opinion
Oral step down:

According to sensitivites
or
(once apyrexial and skin lesions
improving unless blood culture has
become positive)
Oral step down:

Or
(once apyrexial and skin lesions
improving unless blood culture has
become positive)
If MRSA likely

Oral step down: Doxycycline 100mg orally 12hrly (if susceptible)
Duration
10 - 14 days total (including IV treatment)

Page 73 of 120
Infection
Erysipelas
Non-severe:
- systemically well with temperature < 38C
- not involving the face or hand
- not previously treated with adequate oral antibacterials for the same
complaint
Severe if any of the following present:
- systemic features e.g. temperature 38C, hypotension, tachycardia
- involving the face or hand
- progression despite adequate doses of appropriate oral antibiotics
significant co-morbidities e.g.asplenia, neutropenia, cirrhosis,
immunocompromised, cardiac or renal failure, or pre-existing
oedema
Specimen
Swab site/port of entry

Likely Organisms
Streptococcus pyogenes
Treatment
Treat underlying cause e.g. portal of entry such as tinea pedis
Severity
First line
Not severe
Severe
Clarithromycin 500 mg IV by infusion

12 hrly
Oral stepdown
Or
If significant co-morbidities consider

IV meropenem (not if type 1 penicillin
allergy e.g. anaphylaxis) and/or
discuss with consultant
microbiologist
Oral stepdown
Or
Duration
Not severe: 5 - 7 days total

Infection
Furuncle or carbuncle
Specimen
Likely Organisms
Treatment
Incision and drainage of pus if abscess formation

Most furuncles can be conservatively treated without antibacterials
Antibacterials only required for furuncle or carbuncle with systemic signs
of infection e.g. cellulitis or fever
Duration
First line

hrly
5 - 7 days

Page 74 of 120
Infection
Impetigo
Specimen
Wound swab
Likely organisms
Streptococcus pyogenes
Treatment
Severity
First line
Mild, very localised

lesion
Fusidic acid 2% cream topically 6 hrly
Severe
Duration
Topical: 5 days
Systemic: 7 days
Infection
Infected chronic ulcers or pressure sores (non diabetic)
Specimen
Routine wound swabs not recommended, swab if evidence of cellulitis

Likely Organisms
Staphylococcus aureus (including MRSA), Streptococcus pyogenes

Anaerobes
Treatment
Antibacterials only required if evidence of active infection e.g.

pyrexia

increasing pain

enlarging ulcer

cellulitis
Treat as cellulitis (see cellulitis page 74)
If osteomyelitis present refer to Bone and Joint Infections section (page
22)
Duration
See appropriate guideline

Page 75 of 120

hrly
Infection
Diabetic foot infection
Clinical classification of a diabetic foot infection

Clinical manifestations of infection
Infection severity
Wound lacking purulence or any manifestations of inflammation

Presence of >= 2 manifestations of inflammation (purulence, or erythema,
pain, tenderness, warmth, or induration), but any cellulitis/erythema
extends <_2cm around the ulcer, and infection is limited to the skin or
superficial subcutaneous tissues; no other local complications or
systemic illness.
Infection (as above) in a patient who is systemically well and metabolically
Stable but which has >=1 of the following characteristics: cellulitis extending
>2 cm, lymphangitic streaking, spread beneath the superficial fascia,
deep-tissue abscess, gangrene, and involvement of muscle, tendon,
joint or bone
Infection in a patient with systemic toxicity or metabolic instability
(e.g., fever, chills, tachycardia, hypotension, confusion, vomiting,
leukocytosis, acidosis, severe hyperglycemia, or azottemia)
Specimen

Likely Organisms
Uninfected
Mild
Moderate
Severe
Obtain specimens prior to starting empiric antibiotic therapy if

possible
Deep tissue cultures obtained by biopsy or curettage after wound
has been cleansed and debrided are recommended
a superficial swab after wound has been cleansed could be an
alternative
bone biopsies should be collected if possible if osteomyelitis is
present (soft tissue or sinus-tract cultures do not accurately predict
bone pathogens
Swab cultures are not useful in clinically uninfected patients
Cellulitis without open wound or recent ulcers: Staphylococcus aureus

and beta-haemolytic streptococci
Chronic ulcers, long standing infection: Polymicrobial infections including
staphylococci, streptococci, gram negative bacilli, anaerobes
Treatment
Severity
First line
mild, antibiotic
naive
Clarithromycin 500mg orally 12hrly
If MRSA likely:
doxycycline 100mg orally 12 hrly
mild with prior
antibiotic therapy
Or co-amoxiclav 625 mg orally 8

hrly
If MRSA likely:
or
Co-trimoxazole 960mg orally 12
hrly
(check previous sensitivities)

Page 76 of 120

hrly
or
Moderate
severe
Co-amoxiclav IV 1.2g 8hrly
Clarithromycin 500mg IV 12hrly

Plus
Gentamicin once daily (see
protocol)
If MRSA likely:
Add teicoplanin 600 mg IV 12 hrly
for 3 doses then 24hrly
If MRSA likely:
Gentamicin once daily (see
protocol)
plus
teicoplanin 600 mg IV 12 hrly for 3
doses then 24hrly thereafter
Oral stepdown
Or
co-amoxiclav 625 mg orally 8 hrly
Oral stepdown
Or
hrly
Tazocin 4.5g IV 8hrly
plus
infusion 8 hrly
plus
Oral stepdown (when patient is

systemically well)
Oral stepdown (when patient is

systemically well)
If MRSA likely:
Add teicoplanin 600 mg IV 12 hrly for 3 doses then 24hrly thereafter if not
already included
Osteomyelitis in
DFI
Consider osteomyelitis in any infected, deep, or large ulcer, especially

one that is chronic or overlies bony prominence
If X-ray is not diagnostic, use MRI or WBC scanning if MRI is
contraindicated
Treat according to severity as above
Tissue/bone cultures should be obtained whenever possible
Duration
Mild
7-10 days
Moderate
10-14 days
Severe
14 days
Osteomyelitis in
DFI
Prolonged, >4 weeks

Intravenous initially (except co-trimoxazole) and to cover the period of
any surgical intervention and for at least 2 weeks after

Page 77 of 120
May switch to oral after that time if good clinical response to IV therapy,
CRP falling and good information on organism and its sensitivities
If radical resection performed with no remaining infected tissue short
antibiotic course (3-5 days) post op should be sufficient
1. Diabetic foot problems NICE Clinical Guideline 119, 2012
2. 2012 Infectious Diseases Society of America, clinical practice guideline for the diagnosis and
treatment of diabetic foot infections, Clinical Infectious Diseases 2012;54(12): 1679-84.
Infection
Gangrenous cellulitis (Necrotising fasciitis or gas

gangrene)
Specimen
Aspirate or tissue biopsy for gram stain and culture

Deep tissue specimens are essential for immediate gram stain and
culture if necrotising fasciitis suspected
Blood culture
Likely Organisms
Gas gangrene: Clostridium spp

Necrotising fasciitis type 1: Mixed aerobes and anaerobes
Necrotising fasciitis type 2: -haemolytic streptococcus group A either
alone or in combination with Staphylococcus aureus
Treatment
This is a surgical emergency. Immediate surgical opinion for

exploration and debridement of necrotic tissue
First line
Meropenem 1g IV 8 hrly
plus
Clindamycin 1.2 g IV by infusion 6
hrly
If penicillin allergy is anaphylaxis,

contact consultant microbiologist
Review antibiotic treatment when culture results available. Discuss with

consultant microbiologist
Duration
Switch to oral when apyrexial for 48 hrs and infection parameters normal
At least 10 days total (including IV treatment)
Infection
Burn wound infections
Specimen
Aspirate or tissue biopsy if possible

If sepsis cannot be attributed to any other source, send biopsy or aspirate
(not swabs)
Likely Organisms
Staphylococcus aureus, Pseudomonas aeruginosa, Enterobacteriaceae

Enterococcus spp
Prophylaxis
Current data do not support use of antibacterials in the in-patient

population
Treatment
Urgent surgical intervention if bacteraemia present and other sources

eliminated
Surgical excision to the level of the fascia when wound invaded with
gram negative organisms
Choice of antibacterial is based on previous biopsy sensitivity data or
data on sensitivity in the current population of burns patients. Discuss
with consultant microbiologist
Duration
Discuss with consultant microbiologist

Page 78 of 120
Infection
Post-operative wound infection
Specimen

Likely Organisms
Staphylococci, Streptococci
Mixed aerobic and anaerobic flora in wounds on perineum or surgery on
gastrointestinal or female genital tract
Treatment
Antibacterials only required if evidence of active infection e.g.

pyrexia

purulent drainage

pain or tenderness

localised swelling

redness

heat
A higher index of suspicion should be exercised in the presence of postoperative vascular or orthopaedic implants
Clean wound, head,

neck, trunk,
extremity
According to culture results

If no culture results available or no significant growth obtained, treat as
cellulitis (see cellulitis page 74)
Wound on perineum or surgery on gastrointestinal or female genital tract or vascular graft

surgery (see below)
For severity assessment (see cellulitis page 74)
Severity
First line
Not severe

hrly
plus
regimen)
Severe

regimen)
Oral stepdown

doses then 24hrly thereafter y
plus
infusion 8 hrly
plus
Oral stepdown
If MRSA likely:
Add teicoplanin 600 mg IV 12 hrly for 3 doses then 24hrly thereafter if not
already included
Duration
Non-severe: 5 - 7 days total

References
1. Managing skin and soft tissue infections: expert panel recommendations on key decision
points. The British Society for Antimicrobial Chemotherapy 2003 Journal of Antimicrobial
Chemotherapy (2003) 52, Suppl. S1, i3i17.
2. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections
(IDSA) Clinical Infectious Diseases 2005; 41:1373406
Page 79 of 120
3. Medical treatment of diabetic foot infections. Lipsky A. Clinical Infectious Diseases 2004; 39
(S2): S104-114
4. Healthcare associated infections, in particular infection caused by Clostridium difficile
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/D
H_063090
5. Diabetic foot problems NICE Clinical Guideline 119, 2012
6. 2012 Infectious Diseases Society of America, clinical practice guideline for the diagnosis and
treatment of diabetic foot infections, Clinical Infectious Diseases 2012;54(12): 1679-84.

Page 80 of 120
URINARY TRACT INFECTIONS (UTI)

Infection
Lower UTI uncomplicated (no urinary catheter)
Specimen
Likely Organisms
Enterobacteriaceae, enterococci
Treatment
First line
Pivmecillinam 400 mg stat, then

Nitrofurantoin 100 mg orally 6 hrly

Do not use if recent isolate
resistant
Pregnancy
Women with
asymptomatic
bacteriuria confirmed
by a second urine
culture should be
treated and have
repeat urine culture
at each antenatal
visit until delivery
Given the risks of asymptomatic bacteriuria in pregnancy, a urine

culture should be performed 7 days after completion of
antibacterials as a test of cure
Duration
Uncomplicated non-pregnant females 3 days (5 days for nitrofurantoin)

Pregnancy 7 days
If anatomical or neurological abnormality is present a longer course may
be required
Infection
Systemic UTIs
Specimen
Blood culture
Likely Organisms
Treatment
Duration

Or
Cefradine 500 mg orally 6 hrly
Oral stepdown:
Adjust treatment according to sensitivities
5 7 days

Page 81 of 120
Infection
Pyelonephritis
Specimen
Blood culture
Likely Organisms
Enterobacteriaceae
Treatment
Community
acquired
Once daily gentamicin IV (see prescribing regimen)*

Oral stepdown:
(Cefradine 500 mg orally 6 hrly or trimethoprim 200 mg orally 12 hrly)
Hospital acquired

Oral stepdown:
According to sensitivities (ciprofloxacin should only be used for patients
discharged from hospital if no other oral alternative. If patient remains in
hospital, IV treatment would be preferable to an oral quinolone)
ESBL positive
Ertapenem 1g IV by infusion 24 hrly
Duration
Adjust treatment according to sensitivities

Review IV route after 48 hrs - convert to oral therapy, if available and
tolerated.
14 days total
Infection
Complicated UTI (functional or structural urinary tract

abnormalities) and all UTIs in men
Specimen

Blood culture
Likely Organisms
Depends on cause
Treatment

Or
Cefradine 500 mg orally 6 hrly
Oral stepdown:
If ESBL positive: ertapenem 1 g IV by infusion 24 hrly
Duration
7-14 days

Page 82 of 120
Infection
UTI with urinary catheter
Specimen
Blood culture
Catheter specimens of urine (if pyrexial or systemic signs of infection)
Urine samples should only be sent for laboratory culture if clinical sepsis
present, not because the appearance or smell of the urine or the urine
dipstick suggests that bacteriuria is present
Likely Organisms
Enterobacteriaceae, enterococci, Pseudomonas aeruginosa,

Treatment
According to recent urine culture if available, otherwise

Oral stepdown:
Remove catheter if possible, or change urinary catheter while on
treatment
If ESBL positive: Ertapenem 1g IV by infusion daily
Prophylaxis
Antibacterial prophylaxis for the prevention of UTI in catheterised patients

is not recommended.
Mixed growth of organisms in an asymptomatic patient does not indicate
infection and investigation and treatment is not indicated.
Duration
If catheter:
- removed 5 days
- replaced 7 days
Infection
Acute Prostatitis
Consider sexually transmitted infections
Specimen
Midstream specimen of urine for culture

Urine for chlamydia PCR
Blood culture
Likely Organisms
Treatment
First line

plus
Gentamicin IV 5mg/Kg single
dose (max. 560 mg)

Oral stepdown:
Duration
Adjust according to culture results

4 weeks total (including IV treatment)

Page 83 of 120
Oral stepdown:
Infection
Chronic Bacterial Prostatitis
Specimen
Send and process immediately

- urethral urine
- midstream specimen of urine
- prostatic secretions expressed by massage
- urine voided after massage
Likely Organisms
Treatment
Duration

Minimum 4 weeks
If recurrent 6 - 12 weeks
Infection
Bacterial epididymitis/Bacterial orchitis
Specimen
Urethral swab for culture

Midstream specimen of urine for culture
Urine for chlamydia and gonococcal PCR
Likely Organisms
< 35 yrs old:

> 35 yrs old:

Enterobacteriaceae
Pseudomonas spp
Gram positive cocci
Age
First line
<35 years old or

infection likely due
to sexually
transmitted
pathogens
Ceftriaxone 500 mg IM single dose

plus
>35 years old or

infection likely due
to enteric
organisms
4.5 g IV 8 hrly
Duration

2 weeks
Treatment
2010 United Kingdom national guideline for the management of epididymo-orchitis, Clinical
Effectiveness Group, British Association for Sexual Health and HIV. www.bashh.org/guidelines
United Kingdom National guideline for the management of prostatitis (2008) Clinical Effectiveness
Group British Association of Sexual Health and HIV, www.bashh.org/guidelines

Page 84 of 120
ANTIBACTERIAL PROPHYLAXIS IN EAR, NOSE AND THROAT SURGERY

General notes
The following recommendations apply to the administration of prophylactic antibiotics at the preoperative phase. If there is significant unexpected contamination encountered during an operation or
existing infection then prophylaxis should be followed by a treatment regime. Please refer to the
relevant treatment antibiotic guidelines on the hospital intranet.
If patient has history of MRSA in preceding 12 months see last row of table
Ear, nose and

throat benign
Ear surgery
(clean/cleancontaminated)
Routine nose, sinus
and endoscopic sinus
surgery
Tonsillectomy
Adenoidectomy
Stapedectomy /
ossiculoplasty
Likely Organisms
Antibacterial Prophylaxis
Uncommon
Not recommended
Staphylococcus
aureus
Streptococcus spp
Co-amoxiclav 1.2 g IV at induction
If penicillin allergic or MRSA positive:

1
Teicoplanin 600 mg IV at induction

Complex
septorhinoplasty
(if prosthetic material is
used)
Staphylococcus
aureus
Streptococcus spp

1
Head and neck

facial
Likely Organisms
Facial surgery - clean
Uncommon
Not recommended
Facial plastic surgery

with implant
Staphylococcus
aureus
Streptococcus spp

1
Head and neck

surgery
Clean, benign
including
parathyroidectomy,
thyroidectomy
Likely Organisms
Uncommon
Not recommended

Page 85 of 120
Clean, malignant;
neck dissection
Prophylaxis may
be considered

If penicillin allergic:

plus
Metronidazole 500 mg IV by infusion at
1
induction
plus
1
Gentamicin 3 mg/kg IV at induction
Clean-contaminated
or contaminated
surgery
History of MRSA in
preceding 12 months
Staphylococcus
aureus
Streptococcus spp
Anaerobes
Haemophilus
influenzae
Gram negative
bacilli

If penicillin allergic:

plus
Metronidazole 500 mg IV by infusion at
1
induction
plus
1
Gentamicin 3 mg/kg IV at induction
Add teicoplanin 600 mg IV to appropriate
1
regimen at induction if not already included
NOTES:
1. In the event of major intraoperative blood loss (>1500 mL), give an additional dose of prophylactic
antibacterials after fluid replacement.
If surgery > 90 minutes, give additional dose of co-amoxiclav. Metronidazole, gentamicin and
teicoplanin have longer half-lives and do not need to be repeated
References
Antibiotic prophylaxis in surgery, SIGN 2008, www.sign.ac.uk
Surgical site infection, NICE CG74, 2008

Page 86 of 120
ANTIBACTERIAL PROPHYLAXIS FOR GASTROINTESTINAL, BILIARY,

VASCULAR AND GENERAL SURGERY
General notes
If patient has history of MRSA in preceding 12 months see last row of table
Operation
Likely
organisms
First line
Alternative
(penicillin allergy)
Upper gastrointestinal surgery
Oesophageal
Gastroduodenal
Small intestine
Aerobic and
anaerobic GI
tract flora
Co-amoxiclav 1.2 g IV
1
at induction
Gentamicin 3 mg/kg
1
IV at induction
plus
Metronidazole 500
mg IV by infusion at
1
induction
Percutaneous endoscopic
gastrostomy
GI tract flora
1
at induction
Gentamicin 3 mg/kg
1
IV at induction
Aerobic and
anaerobic GI
tract flora
1
at induction
Gentamicin 3 mg/kg
1
IV at induction
plus
Metronidazole 500
1
induction
Aerobic and
anaerobic GI
tract flora
1
at induction
Gentamicin 3 mg/kg
1
IV at induction
plus
Metronidazole 500
1
induction
Lower gastrointestinal surgery
Appendicectomy
Colorectal
Hepatobiliary surgery
Pancreatic surgery
Liver surgery
Bile duct surgery
Gall bladder surgery
(open)
Endoscopic retrograde
cholangiopancreatography
(ERCP)
Gall bladder surgery

(laparoscopic)
Should be considered in high risk patients only (pancreatic

pseudocyst, immunosuppression, incomplete biliary drainage)
Gram negative
bacilli
enterococci
staphylococci
1
at induction
Uncommon
Not recommended
Gentamicin 3 mg/kg
1
IV at induction
Consider prophylaxis in high risk patients

(intraoperative cholangiogram, bile spillage,
conversion to laparotomy, acute
cholecystitis/pancreatitis, jaundice, pregnancy,
immunosuppression, insertion of prosthetic
devices
Page 87 of 120
If prophylaxis required follow recommendations

for open gall bladder surgery
Uncommon
Not recommended
Uncommon
Not recommended
Uncommon
Not recommended
Breast surgery with implant
staphylococci,
streptococci
1
at induction
Breast cancer surgery

Breast reshaping procedures
Prophylaxis should be considered (types of antibiotics as above) in

patients with risk factors (e.g. immunosuppression, diabetes
mellitus, reconstructive surgery)
Vascular surgery
staphylococci,
gram negative
bacilli,
anaerobes
History of MRSA in
preceding 12 months
Add teicoplanin 600 mg IV at induction to appropriate regimen if

not already included (except breast surgery)
Insertion of surgical and

radiological drains
Diagnostic endoscopic
procedures
Abdomen
Laparoscopic or nonlaparoscopic hernia repair

with mesh
Breast surgery
1
at induction
If penicillin allergic
or history of MRSA
in preceding 12
months:
Teicoplanin 600 mg
1
IV at induction
Teicoplanin 600 mg
1
IV at induction
plus
Gentamicin 3 mg/kg
1
IV at induction
plus
Metronidazole 500
1
induction
NOTES:
1.
In event of major intraoperative blood loss (>1500 mL), give additional dose of prophylactic
If surgery >90 minutes, give additional dose of co-amoxiclav. Metronidazole, gentamicin and
teicoplanin have longer half-lives and do not need to be repeated.
References
Surgical site infection, NICE CG74 2008

Page 88 of 120
ANTIBACTERIAL PROPHYLAXIS FOR OBSTETRIC AND GYNAECOLOGICAL

SURGERY
General notes
Obstetrics
Surgery
Caesarean
section
Third and fourth

degree perineal
tears
Likely Organisms
First line
Streptococci
S. aureus
Enterococcus
faecalis
Gardnerella
vaginalis
Bacteroides spp
Peptostreptococci
Cefuroxime 1.5 g IV
1
prior to incision
Clindamycin 600 mg IV by
1
infusion prior to incision
Gram negative
bacilli
Anaerobes
Streptococci

then
Injury to
perineum
involving anal
sphincter / rectal
mucosa
If MRSA positive in last 12 months

Add
1
Teicoplanin 600 mg IV prior to incision
1
For 5 days
If MRSA positive in last 12

months
Add
1
Follow on therapy depends on
MRSA susceptibility discuss with
Microbiologist
Gentamicin 3 mg/kg IV
plus
infusion
1
at induction
then
Clindamycin 450 mg orally 6hrly
plus
Trimethoprim 200 mg orally 12
hrly
For 5 days
If MRSA positive in last 12
months
Teicoplanin 600 mg IV
plus
plus
infusion
1
at induction
Follow on therapy depends on
MRSA susceptibility discuss
with Microbiologist
Manual removal
of placenta
Streptococcus spp
Anaerobes
Assisted
delivery
uncommon
NOT recommended
Surgical
termination of
pregnancy
Anaerobes
Metronidazole 1 g PR with pre-med

plus
Doxycycline 100 mg orally 12 hrly for 7 days, commencing on the day
of abortion, unless pre-operative screening has excluded genital tract
chlamydial infection

Page 89 of 120
Gentamicin 3 mg/kg IV at
plus
1
infusion at induction
Gynaecology
If patient has history of MRSA in preceding 12 months, see last row of table
Surgery
Hysterectomy
Laparotomy
Radical pelvic
surgery for
gynaecological
cancer
Likely Organisms
Escherichia coli
Other gram negative
bacilli
Streptococci
S. aureus
Enterococci
Gardnerella vaginalis
Bacteroides spp
Peptostreptococcus
First line
Alternative (penicillin
allergy)
Co-amoxiclav 1.2 g
1
IV at induction
plus
Metronidazole 500 mg
IV by infusion
1
at induction
Vaginal repair
Vaginal sling
procedures
History of MRSA in preceding 12 months
Add
1
teicoplanin 600 mg IV at induction to
appropriate regimen
NOTES:
1.
In event of major intraoperative blood loss (>1500 mL), give additional dose of prophylactic
If surgery > 90 minutes, give additional dose of co-amoxiclav.
Metronidazole, gentamicin and teicoplanin have longer half-lives and do not need to be repeated
References
The Care of Women Requesting Induced Abortion. Clinical Guideline No 7, RCOG 2004.
Surgical site infection, NICE CG74 2008.
The management of third and fourth degree perineal tears. Green top guideline No 29, RCOG
2007.
Caeserian Section. NICE CG132 November 2011.

Page 90 of 120
ANTIBACTERIAL PROPHYLAXIS FOR ORTHOPAEDIC SURGERY

General notes
Surgery
Likely Organisms
First line
Clean non-implant
surgery
o Arthroscopy
o Joint aspiration
Arthroplasty
Surgery for closed
fractures
Hip fracture
Spinal surgery
Lower limb amputation
Alternative (penicillin
allergy)
Uncommon
Not recommended
Staphylococcus
aureus,
coagulase negative
staphylococci,
streptococci,
enterococci,
diphtheroids,
gram negative
organisms
Staphylococcus
aureus,
streptococci,
anaerobes,
gram negative
organisms
Co-amoxiclav 1.2 g IV at
1,2
induction
Teicoplanin 600 mg IV at
1,2
induction
If history of MRSA in
preceding 12 months
1,2
induction
Co-amoxiclav 1.2 g IV at
1,2
induction
preceding 12 months
1,2
induction
plus
Metronidazole 500 mg IV
1,2
by infusion at induction
Add
1,2
induction
Open fractures
Wide spectrum, with

higher proportion of
Gram negative and
anaerobic infections
(N.B. Tetanus
prophylaxis)
Co-amoxiclav 1.2 g IV 8
hrly
plus
preceding 12 months
Teicoplanin IV 600 mg 12
hrly for 3 doses then 24
hrly thereafter
Add
Teicoplanin 600 mg IV
plus
by infusion 8 hrly
Start as soon as possible and continue for 72 hours

after injury or for 24 hours post-op
NOTES:
1. In the event of major intraoperative blood loss (>1500 mL), give an additional dose of
prophylactic antibacterials after fluid replacement.
If surgery > 90 minutes, give an additional dose of co-amoxiclav.
Teicoplanin and gentamicin have longer half-lives and do not need to be repeated.
2. Give prophylaxis earlier for operations in which a tourniquet is used.

Page 91 of 120
References
Antibiotics in trauma and orthopaedic surgery a primer of evidence-based recommendations. Injury,
Int.J.Care Injured 2006;37:s74-80.

Page 92 of 120
ANTIBACTERIAL PROPHYLAXIS FOR UROLOGICAL SURGERY

General notes
If patient has history of MRSA in preceding 12 months, see last row of table
Send MSU at pre-admission screening and where possible treat urinary tract
infections before admission
Surgery
Likely
Organisms
1
Transurethral
resection of a
bladder tumour
(TURBT)
Gram negative
bacilli
Enterococci
Gentamicin 3mg/kg IV at induction
Open or
transurethral
resection of the
prostate (TURP)
Gram negative
bacilli
Enterococci
Transrectal prostate
biopsy
Gram negative
bacilli
Enterococci
Anaerobes
Ciprofloxacin 750 mg orally 2 hours before procedure
If risk factors present i.e. bacteriuria, prostatitis,

diabetes, immunosuppression or steroids,
Continue ciprofloxacin 500 mg orally 12 hrly for 3
days post-op
Cystoscopy
uncomplicated (no
recent or current
infection, pre-op urine
culture negative, no
urinary catheter)
Uncommon
Not recommended
Cystoscopy
complicated or
patient catheterised
Urethral dilatation /
optical urethrotomy
Shock-wave
lithotripsy
2
Nephrectomy
Gram negative
bacilli
Enterococci
Percutaneous
nephrolithotomy
Gram negative
bacilli
if pre-op cultures negative give oral antibiotics for

48hrs pre-op as follows:
No known penicillin allergy: co-amoxiclav
500/125mg 8hrly
Penicillin allergic (rash): cefradine 500mg
6hrly
Penicillin anaphylaxis: ciprofloxacin 500mg
12hrly
If pre-op cultures positive, treat according to

Page 93 of 120
sensitivity results:
i.e. trimethoprim, mecillinam (pivmecillinam) or
cefradine, but avoid nitrofurantoin.
On Induction:
Gentamicin 3mg/kg IV (check pre-op urine cultures
if positive to ensure susceptibility to gentamicin. If
resistant to gentamicin, choose a different antibiotic
according to sensitivities)
Intra-operatively:
Send initial pelvic puncture urine for MC&S
Send stone fragments for MC&S
Post-Op; First 48hrs
Continue the same antibiotic which was started preop.
Give a second dose of gentamicin 5mg/kg IV the day
after the operation
Post-Op; Beyond 48 hrs
Review intra-operative pelvic urine and stone culture.
If cultures are positive treat as complicated UTI and
according to culture results. (Continue with same
antibiotic the patient is already on if organism isolated
is susceptible to it. See also Urinary tract infections
section page 80).
If cultures negative and pre-op urine was also culture
negative, stop antibiotics after 48 hours even if stone
fragments are known to have been left behind.
Cystectomy
Radical
prostatectomy
History of MRSA in
preceding 12 months
AND antibiotic
prophylaxis is
indicated
Gram negative
bacilli
Anaerobes
Co-amoxiclav 1.2g IV at
1
induction
Gentamicin 3mg/kg IV at
1
induction
plus
1
by infusion at induction
Add teicoplanin 600 mg IV to appropriate regimen at

1
induction
NOTES:
1. In the event of major intraoperative blood loss (> 1500 ml), give an additional dose of
prophylactic antibacterials after fluid replacement.
If surgery > 90 minutes, give additional dose of co-amoxiclav.
Metronidazole, gentamicin and teicoplanin have longer half-lives and do not need to be
repeated.
2. If nephrectomy is expected to be clean surgery, then no prophylaxis indicated.
References

Page 94 of 120
PROPHYLAXIS - OTHER
Prevention of infection after bites from humans and other mammals
Introduction
After initial management, give prophylactic antibacterials to:
All human bite wounds less than 72 hours old, even if there is no sign of infection.
Animal bite wounds if the wound is less than 48 hours old and the risk of infection is
high as follows:
- Animal bites to the hand, foot, and face; puncture wounds; wounds requiring
surgical debridement; crush wounds with devitalised tissue; wounds in genital
areas; wounds with associated oedema; wounds involving joints, tendons,
ligaments, or suspected fractures.
- Wounds that have undergone primary closure.
- People who are at risk of serious wound infection (e.g. those who are
diabetic, cirrhotic, asplenic, immunosuppressed, or had mastectomy).
- Asplenic and cirrhotic patients are especially susceptible to Capnocytophaga
canimorsus infection and should receive prophylaxis even after trivial animal
bites.
- People with a prosthetic valve or a prosthetic joint.
- Antibiotics are not generally needed if the wound is more than 2 days old and
there is no sign of local or systemic infection.
Seek advice from consultant microbiologist or consultant in infectious diseases if
source is known or suspected to be positive for HIV, hepatitis B or C, or rabies.
Outpatients should be warned of signs of developing infection and to attend urgently
for review should this happen.
For bites from other mammals, contact consultant microbiologist
Specimens
- tissue, aspirate or swab for bacterial cultures if clinical infection present
- blood cultures if the patient is systemically unwell
Tetanus vaccine (single antigen tetanus vaccine is no longer available, use
diptheria, tetanus and poliomyelitis vaccine, dTP vaccine) and human tetanus
immunoglobulin if indicated (see current BNF).

Page 95 of 120
Type of Bite
Likely Organisms
Human, dog or cat

Not penicillin allergic
See below

hrly
Human
Penicillin allergic
Streptococci
Staphylococcus
aureus
Haemophiilus spp
Bacteroides
Fusobacterium spp
Other anaerobes
Eikenella corrodens

hrly
plus
hrly
Dog or cat
Penicillin allergic
Pasteurella spp
Capnocytophaga
Streptococci
Staphylococci
Anaerobes

hrly
plus
hrly
Duration
5 days
5 days
5 days
References:
1.
http://www.cks.library.nhs.uk/bites_human_and_animal/view_whole_topic_rev
iew
2.
Morgan M. "Hospital management of animal and human bites" Journal Hosp
Infection 2005, 61:1-10.
3.
Practice guidelines for the diagnosis and management of skin and soft-tissue
infections, IDSA guidelines, Clinical Infectious Diseases 2005;41:1373-406.
Antibacterial prophylaxis for open fractures of the fingers

Prophylactic antibiotics may be unnecessary in wounds presented early, with thorough wound
toilet and careful soft tissue repair in patients without risk factors for developing infection (e.g.
diabetes, peripheral vascular disease, steroids, immunosuppression)
Likely Organisms
staphylococci
Antibacterial
Prophylaxis
First line
Flucloxacillin orally 500 mg 6

hrly
for 5 days
Clarithromycin orally 500 mg 12

hrly
for 5 days
References:
1.
Hand Surg Am 1990 Sep;15(5):761-4.Role of antibiotics in open fractures of
the finger. Suprock MD, Hood JM, Lubahn JD.
2.
J Hand Surg Br. 2003 Oct;28(5):388-94. The use of prophylactic flucloxacillin
in treatment of open fractures of the distal phalanx within an accident and
emergency department: a double-blind randomized placebo-controlled trial.
Stevenson J, McNaughton G, Riley J.

Page 96 of 120
PROPHYLAXIS AGAINST INFECTIVE ENDOCARDITIS (IE)

In adults and children undergoing interventional procedures
Introduction
Past practice has been to routinely offer prophylactic antibiotics to patients
undergoing interventional procedures who are considered at risk of IE. In a
significant change to this approach, the National Institute for Health and Clinical
Excellence (NICE) guideline now recommends that preventive antibiotics should
not be given to adults and children with structural cardiac defects at risk of IE who
are undergoing dental and non-dental interventional procedures.
i.e. antibiotic prophylaxis is no longer routinely recommended for defined
interventional procedures including dental procedures and procedures
involving the gastrointestinal, genitourinary and respiratory tracts.
Summary of NICE recommendations
(Reproduced from NICE CG64 - Prophylaxis against infective endocarditis:
March 2008)
1. Adults and children with structural cardiac defects at risk of developing
Infective Endocarditis
Acquired valvular heart disease with stenosis or regurgitation
Valve replacement
Structural congenital heart disease, including surgically corrected or palliated

structural conditions, but excluding isolated atrial septal defect, fully repaired
ventricular septal defect or fully repaired patent ductus arteriosus, and closure
devices that are judged to be endothelialized
Hypertrophic cardiomyopathy
Previous infective endocarditis
2. Offer patients at risk of IE clear and consistent information about

prevention:
The benefits and risks of antibiotic prophylaxis, and an explanation of why

antibiotic prophylaxis is no longer routinely recommended
The importance of maintaining good oral health
Symptoms that may indicate IE and when to seek expert advice
The risks of undergoing invasive procedures, including non-medical

procedures such as body piercing or tattooing.
3. Prophylaxis against Infective Endocarditis

Antibiotic prophylaxis against IE is not recommended:
for people undergoing dental procedures
for people undergoing non-dental procedures at the following sites:

Page 97 of 120
upper and lower gastrointestinal tract

genitourinary tract; this includes urological, gynaecological and obstetric
procedures, and childbirth
upper and lower respiratory tract; this includes ear, nose and throat
procedures and bronchoscopy.
Chlorhexidine mouthwash should not be offered as prophylaxis against
infective endocarditis to people at risk of infective endocarditis undergoing dental
procedures.
4. Managing infection
Investigate & treat promptly any episodes of infection in people at risk of IE to
reduce the risk of endocarditis developing
Offer an antibiotic:
If a person at risk of IE is receiving antimicrobial therapy because they are
undergoing a gastrointestinal or genitourinary procedure at a site where there is
a suspected infection, the person should receive an antibiotic that covers
organisms that cause IE.
If patients regarded as at risk of developing IE (see above) are undergoing such
a procedure at a site where infection is suspected or established, additional IE
prophylaxis is required with an antibiotic(s) that includes cover against organisms
associated with endocarditis that may be present e.g. enterococci, viridans
streptococci and staphylococci unless such cover is already part of the treatment
regimen. Standard peri-operative prophylaxis may need modification and exact
choice of antibiotic regimen will depend on the site of infection, nature of the
infection and microbiological results. The appropriate choice should therefore be
discussed with a Consultant Microbiologist.

Page 98 of 120
PREVENTION OF INFECTION IN PATIENTS WITH AN ABSENT OR

DYSFUNCTIONAL SPLEEN
A. IMMUNISATION
Patients should be offered the following vaccines:
Hib vaccine (irrespective of age)
influenza vaccine (yearly)
meningococcal ACWY conjugate vaccine (irrespective of age)
pneumococcal vaccine (revaccination every 5 years with 23-valent PPV
vaccine is recommended)
Vaccines should ideally be administered 2 weeks before or 2 weeks after
splenectomy
The following table has been copied from the DH Immunisation against infectious disease (Green
Book), chapter 7
Suggested schedule for immunisation with conjugate vaccines in individuals with
asplenia, splenic dysfunction, immunosuppression or complement deficiency
Age at which asplenia,
splenic dysfunction, or
immunosuppression is
acquired or when
complement deficiency
diagnosed
Vaccination schedule
Where possible, vaccination course should ideally be started at
least two weeks before surgery or commencement of
immunosuppressive treatment. If not possible, see advice in
pneumo chapter.
Month 0
Month 1
Later
First presenting under

two years
Complete according
to national routine
childhood schedule
including booster
doses of Hib/MenC
and PCV13.
A dose of
MenACWY
conjugate vaccine
should be given at
least one month
after the Hib/MenC
and PCV13 booster
doses.
After the second

birthday, one
additional dose of
Hib/MenC and a
dose of PPV should
be given.
First presenting over two

years and under five
years (previously
completed routine
childhood vaccinations
with PCV7)
Hib/MenC Booster
MenACWY
conjugate vaccine
PPV
(at least 2 months
after PCV13)

years (previously
completed routine
childhood vaccinations
with PCV13)
Hib/MenC Booster

years (unvaccinated or
previously partially
vaccinated with PCV7)
Hib/MenC vaccine
First presenting over five

years (regardless of
vaccination history)
Hib/MenC vaccine
PPV
PCV13
MenACWY
conjugate vaccine
PPV
MenACWY
conjugate vaccine
First dose of PCV13
MenACWY
conjugate vaccine

Page 99 of 120
Second dose of
PCV13 and then
PPV (at least 2
months after
PCV13)
PCV = pneumococcal conjugate vaccine, PPV = pneumococcal polysaccharide vaccine

Data on long-term antibody levels in these groups of patients are limited. Additional doses to
cover the highr risks of Hib, meningococcal and pneumococcal disease during childhood, should
be considered, depending on the childs underlying condition. Specialist advice may be required.
B. ANTIBIOTIC PROPHYLAXIS
Life long prophylactic antibiotics should be offered to patients considered at
continued high risk of pneumococcal infection including
aged less than 16 years or greater than 50 years,
inadequate serological response to pneumococcal vaccination,
history of previous invasive pneumococcal disease,
splenectomy for underlying haematological malignancy particularly
in the context of on-going immunosuppression
Patients not at high risk should be counselled regarding the risks and benefits of
lifelong antibiotics and may choose to continue or discontinue prophylaxis
After splenectomy for trauma the risk is greatest in the immediate post-operative
period, and antibiotic prophylaxis should include this period at least.
Phenoxymethylpenicillin (oral)
Oral Prophylaxis
Child under age 6 years

Child aged 6 12 years
Adult
125 mg 12 hourly
250 mg 12 hourly
500mg 12 hourly or once daily if
compliance a problem
Erythromycin only in Penicillin allergic

patients
Child under 2 years
Adult and child over 8 years
125 mg daily
250 mg daily
500 mg daily
Amoxicillin (only if Haemophilus influenzae

cover required)
Adult
125 mg 12 hourly
250 mg 12 hourly
250 500 mg daily
C) Early treatment packs should be kept at home to take immediately if

patients develop raised temperature, malaise or shivering. Suitable packs
would include:
Oral Amoxicillin
Oral Clarithromycin
D) Advice should be given about foreign travel including:
(i)
The inadvisability of visiting malaria endemic areas.
(ii)
The risks of meningitis A in endemic countries (a vaccine is available).
(iii) The risks of tick bites causing babesiosis.

(iv)
Antibiotic prophylaxis when holidaying in countries with a high risk of

penicillin resistance e.g. Spain, USA etc.

Page 100 of 120
References
1. DH Immunisation against infectious disease (Green book), chapter 7.
Available at www.dh.gov.uk
2. Davies JM et al. Review of guidelines for the prevention and treatment of
infection in patients with an absent or dysfunctional spleen:
Prepared on behalf of the British Committee for Standards in
Haematology by a Working Party of the Haemato-Oncology Task Force. BJH
2011; 155: 308-317.

Page 101 of 120
GENTAMICIN ONCE - DAILY DOSING

Please also print off the gentamicin infusion sheet and attach to the patients drug chart
This protocol should NOT be used for patients in the following categories:
paediatrics
ascites
pregnant women
endocarditis
cystic fibrosis (CF)
major burns
creatinine clearance (CrCl) < 30 ml/min see end of guideline for advice
In these situations, unless a specific protocol exists, use multiple daily dose regimens
If there are no contraindications to its use, once daily dosing with gentamicin is safer, more
convenient, and cheaper than multiple daily dose regimens
Dosing
This regimen gives a standard dose of gentamicin of 7mg/Kg calculated from ideal body weight (usual
maximum dose is 560mg).
A serum gentamicin level should be measured 6-14 hours after the first dose to determine the dosage
interval.
Step 1: Check renal function

If the patient has an eGFR < 40 ml/min, calculate their creatinine clearance (ml/min) using the
Cockroft and Gault equation:
Men = 1.23 x (140-age) x weight (Kg)
Serum creatinine (mol/L)
Women = 1.04 x (140-age) x weight (Kg)

Serum creatinine (mol/L)
If the calculated creatinine clearance is less than 30ml/min, see end of this guideline for advice.
Step 2: Calculate the dose

Find out the patient's sex, height, weight in kg
Read off the patients ideal body weight (IBW) for their sex and their height from the
appropriate chart below
Compare the patients actual body weight (ABW) with their ideal body weight (IBW)
If the patients ABW is less than their IBW (i.e. they are underweight), use their ABW to
estimate the gentamicin dose from the charts below
If the patients ABW is more than, or the same as, their IBW, use their IBW to estimate the
gentamicin dose from the charts below
If patient is > 20% above IBW, use Obese Dosing body Weight (ODW).
ODW = IBW + 0.4 (actual body weight ideal body weight)
(To convert from imperial weight measurements to metric 1 stone = 6.35kg 1 lb = 0.45kg)

Page 102 of 120
Step 3: Prescribe the dose

Prescribe the selected gentamicin dose on the Gentamicin Administration Sheet AND on the patients
drug chart (stating to please refer to the attached Gentamicin Administration Sheet).
PHARMACY USE ONLY
2011
YEAR
Date
1
June
MONTH
10
SPECIFY TIME
IF REQUIRED
Drug
Gentamicin
Morning
Please see separate Gentamicin Administration Sheet
Dose
See chart
Duration
5 days
Route
Start date
IV
01/06/11
Signature A Doctor
Bedtime
Pharm:

A Doctor
Special Instructions
Midday
Evening
UTI
ADULT MALES (>16 yrs)
ADULT FEMALES (> 16 yrs)

ABW
ABW
(use if
Height
61 or over
IBW
Gentamicin
less
(kg)
dose (mg)
than
Over 79.9
560
(1.85m or over)
510 6
73 77.6
520
(1.77 1.82m)
57 59
66.1 70.7
480
(1.7 1.75m)
55 56
61.5 63.8
440
(1.65 1.68m)
52 54
54.6 59.2
400
(1.57 1.63m)
51 or under
(1.55m or under)
Under 52.3
360
(use if
Height
IBW (kg)
Gentamicin
less
dose (mg)
than
IBW)
IBW)
(kg)
(kg)
78 82
72 - 77
66 - 71
60 - 65
55 - 59
49 - 54
6 3 (1.9m) or
79.5
560
72.6 77.2
520
68 70.3
480
61.1 65.7
440
54.2 58.8
400
49.6 51.9
360
Under 47.3
320
over
6 62
(1.82 1.88m)
510 511
(1.77 1.8m)
57 59
(1.7 1.75m)
54 56
(1.63 1.68m)
52 53
(1.57 1.6m)
51 or under
(1.55m or under)

Page 103 of 120
78 - 82
72 - 77
66 - 71
60 - 65
55 - 59
49 - 54
43 - 48
Step 4: How to give the gentamicin

Dilute the gentamicin dose in 100ml sodium chloride 0.9% and give by intravenous infusion over 60
minutes
Gentamicin dose (mg)
Number of ml gentamicin
80mg/2ml
560
14
520
13
480
12
440
11
400
10
360
320
Record on the Gentamicin Administration Sheet the exact start time of the infusion (this
information will be needed to calculate the dose interval in step 6)
Step 5: How to measure gentamicin levels

Obtain a serum gentamicin level (10 mL clotted blood) and creatinine level 6-14 hr after the
start of the first infusion. Do not sample via cannula used for infusion
Document the EXACT time and date the sample was taken and the EXACT time and
date the infusion was set up on the microbiology request form (the lab will then note these
times on the system)
Step 6: Dose interval selection

Using Figure 1, plot the level (plasma concentration mg/ml) against the time between start of
infusion and sample drawn and to select a dose interval (24 hrly, 36 hrly or 48 hrly)
If a point is on the line, choose the longer dosing interval
If result falls above upper limit for Q48h, STOP the gentamicin and obtain random gentamicin
levels until the level is <1mg/L. Reduce next dose to 5mg/Kg.
Discuss with Microbiologist or a pharmacist if in doubt.

Key
Q24h = give dose every 24 hours
Antimicrob Agents Chemother
1995;39(3):650-655

Page 104 of 120
If Creatinine Clearance is <30 ml/min, give initial dose and obtain serial levels (e.g. at 24, 36 and
48 hours) to determine the appropriate time for the next dose (when the gentamicin level is <1mg/L
the next dose may be given). Discuss with Microbiologist if in doubt.
CrCl 10-30 ml/min, initial dose 5mg/kg (usual maximum dose 560mg)
CrCl <10 ml/min, initial dose 2.5mg/kg (usual maximum dose 560mg)
Step 7: Repeated monitoring

(Please note that this is only for ONCE DAILY dosing. If prescribed more than ONCE daily,
follow multiple daily dosing and monitoring guideline)
In stable patients, repeat gentamicin levels 1-2 times per week and check creatinine level 2-3
times per week
If the clinical state, especially renal function, is unstable, repeat levels daily
If result falls in Q24h sector it is not necessary to recheck gentamicin concentration within five
days unless patients condition suggests renal function may be compromised
If dose interval >Q24h, check serum creatinine every 2-3 days (more frequently if renal function
unstable). Calculate creatinine clearance (CrCl) to check dose interval has not changed
If dose interval has to be changed, check gentamicin concentration 6-14 hr after start of next
infusion (note time of start of infusion and time of sampling) and use Figure 1 to verify correct
dose interval

Page 105 of 120
First name:
Last name:
DOB:
Hospital No.:
Once Daily Gentamicin Infusion

(In 100ml glucose 5% or sodium chloride 0.9% by IV infusion over 60 minutes)
NB: Gentamicin still needs to be prescribed on the drug chart.
Initial dose
Date
Time
Drug
Route
Gentamicin
IV
Dose
(maximum
560mg)
Drs signature
Infusion
start time
Given by
Witnessed
by
..mg
Initial level (6 - 14 hours post dose)

Date of
level
Time of
level
Time after start

of infusion (hrs)
Gentamicin level
result (mg/l)
Dosing interval chosen

(24 / 36 / 48 HOURS according
to nomogram)
Creatinine
mol/L
Every .. hours
Subsequent doses
Gentamicin IV to be given every 24 / 36 / 48 hours (please circle appropriate dosing interval)
(refer to nomogram in gentamicin once daily dosing guidelines and on quick reference guides)
If dose changes or renal function deteriorates, prescribe new dose on a separate gentamicin sheet and
cross through the old gentamicin sheet.
Date Dose
Due
Dose
No
Time Dose Due

(NB check this
corresponds
with dosing
interval above)
Dose
(maximum
560mg)
Drs signature
Given
by
Date
Time
Witnessed
by
2
3
4
5
PLEASE RECORD ALL LEVELS TAKEN BELOW
Gentamicin Levels (take twice weekly if renal function remains stable)
Date of
level
Time of
level
Time after start of infusion

(hrs)

Page 106 of 120
Level result
(mg/l)
Creatinine
mol/L
Dosing
interval
GENTAMICIN - MULTIPLE DAILY DOSING

This protocol is based on that used at the Tayside area hospitals, Scotland
Gentamicin nomogram for multiple daily dose regimens
This nomogram is NOT to be used for patients with CF or children
Nomogram for gentamicin

dosage (devised by Prof. G.
Mawer), which provides a
loading dose (L), a
maintenance dose (M), and a
suitable interval between
doses for an adult patient
whose serum creatinine
concentration (A), age (B)
and body weight (D) are
known
To use, join A to B with a line
that crosses C; then join this
intercept on C to D with a line
which crosses M and L
Monitoring multiple daily dose regimens

Measure serum gentamicin after 24 hr. A trough sample should be taken

immediately before the 3rd to 5th dose, and a peak sample 1 hr after the dose
The target peak concentration is 5-10 mg/L
The trough concentration should be maintained <2 mg/L
The relationship between maintenance dose and steady state concentration is

linear. Doubling the dose will double the peak and trough serum concentrations,
assuming renal function is stable

Page 107 of 120
VANCOMYCIN
Dosage
1)
Normal renal function

1g 12 hourly (infuse over at least 60 minutes)
2)
Renal failure
Please contact Medicines Information on Ext. 2267 or Consultant Microbiologist
for advice.
Assays

Levels should always be checked after 48 hours.

Pre dose immediately prior to infusion
Specimen should contain 5-10mls of clotted blood and should be sent with a single
form.
Subsequent assays should be repeated 2-3 times per week according to levels.
Levels
Pre dose levels should be 10-15 mg/L.
There is no need to take post dose levels.

Page 108 of 120
ANTIBIOTIC THERAPEUTIC DRUG RANGES
Gentamicin
Teicoplanin
Pre dose
Post dose
Trough
Peak
See separate guideline

For severe infections
only (e.g. MRSA,
osteomyelitis, septic
arthritis) when
treatment is likely to
continue for more than
2 weeks.
20 - 40 mg/L
Please see notes
(take immediately
th
before giving the 5 or
th
6 dose i.e. 4-5 days
after starting
treatment)
Tobramycin
Notes
< 2 mg/L
8 -12 mg/L
< 2 mg/L
6 - 10 mg/L
(multiple daily dosing

for cystic fibrosis
patients only)
Tobramycin
(multiple daily dosing
for NON cystic fibrosis
patients)
Vancomycin
10 -15 mg/L

Page 109 of 120
On the advice of
consultant
microbiologist only
Definitions
AFB:
ARDS:
AXR:
BAL:
BNF:
CDT:
CRP:
CSF:
CSU:
EBV:
ESBL:
FBC:
G-CSF:
HACEK:
HIV:
HNIG:
HPU:
HSV:
HUS:
IGAS
IM:
IV:
MMR:
MRSA:
NG:
PCP:
PCR:
PEG:
PID:
PO:
PPI:
PR:
PVL:
RUQ
TB:
U+Es:
UTI:
VTEC:
VZV:
WBC:
acid fast bacilli

acute respiratory distress syndrome
abdominal x-ray
bronchoalveolar lavage
British National Formulary
Clostridium difficile toxin
C-reactive protein
cerebrospinal fluid
catheter specimen of urine
Epstein-Barr virus
extended spectrum beta lactamase
full blood count
granulocyte colony stimulating factor
Haemophilus spp., Actinobacillus actinomycetemcomitans,
Cardiobacterium hominis, Eikenella spp., Kingella spp.
human immunodeficiency virus
human normal immunoglobulin
Health Protection Unit
herpes simplex virus
haemolytic uraemic syndrome
invasive Group A streptococcal disease
intramuscularly
intravenous
measles/mumps/rubella
meticillin resistant Staphylococcus aureus
nasogastric
Pneumocystis jirovecii (carinii) pneumonia
polymerase chain reaction
percutaneous gastrostomy
pelvic inflammatory disease
per oral
proton pump inhibitors
per rectum
Panton-Valentine leukocidin
Right Upper Quadrant
tuberculosis
urea + electrolytes
urinary tract infection
verotoxin producing E coli
varicella zoster virus
white blood cell
Associated Documents
None
Duties
The Consultant Microbiologists and Antibiotic Pharmacists are responsible for
updating this document and maintaining the Antimicrobial Management section on
the MCHFT Intranet. The document will be approved by the Antimicrobial
Stewardship Committee.

Page 110 of 120
Consultation and Communication with Stakeholders

This document has been reviewed by the Consultant Microbiologists taking into
consideration National Guidance, latest research and local resistance patterns.
Details of the relevant sections have been emailed directly to Consultants for
comments prior to document approval.
Implementation
The guidelines will replace the previous guidelines on the Antimicrobial Management
section of the intranet. A memo will be sent to all prescribers to state that the
guidelines have been updated and a reminder will be set on the trust intranet.
Pharmacists and Consultant Microbiologists will remind prescribers that the
guidelines have been updated.
Education and Training

No direct education and training on usage of the document is required as the main
format has not changed.
Monitoring and Review

The table below must be completed in the document to demonstrate effective
monitoring of all documents.
Monitoring and Audit
Standard/process/issue
required to be
monitored
Process
for
monitoring
e.g. audit
Responsible
individual
/group
Adherence to antibiotic
guidelines
Audit
ASC
Frequency
of
monitoring
Responsible
committee
Annual
ASC
9.1 Audit Proforma

The MCHFT Audit proforma must be used to demonstrate effective monitoring
and implementation of planned actions. This can be found on the intranet in
frequently used forms/clinical audit.
10
References / Bibliography
Please see individual sections within the guidelines for relevant references.
11
Appendices
All Appendices must be in numerical order 1, 2, 3 etc and positioned before the
mandatory appendices below.
A
B
C
Version Control Document

Communication / Training plan
Equality Impact and Assessment Tool

Page 111 of 120
APPENIDX A - Control Sheet

This must be completed and form part of the document appendices each time the document
is updated and approved.
VERSION CONTROL SHEET
Date
dd/mm/yy
01/10/12
Version
Three
Author
Reason for changes
Dr S Panagea / Dr M
ODonoghue / J Willis
Updated guidelines to bring in line with

current evidence, national guidelines and
local resistance patterns.
Changed format to comply with trust
format.

Page 112 of 120
APPENDIX B - Training needs analysis

Communication/Training Plan (for all new / reviewed documents)
Goal/purpose of the
communication/training plan
Target groups for the
Target numbers
Methodology how will the
communication or training be carried
out?
Communication/training delivery
Funding
Measurement of success. Learning
outcomes and/or objectives
Review effectiveness learning
outputs
Issue date of Document
Start and completion date of
Support from Learning & Development
Services
Awareness of updated guidelines

Prescribers, pharmacists, nursing staff
300
Intranet and personal communication. A memo
will also be sent out to all prescribers.
Consultant Microbiologists / Antibiotic
Pharmacist
N/A
Audit results
N/A
5th October 2012
Start 5th October 2012 until guidelines are
reviewed
N/A
For assistance in completing the Communication / Training Plan please contact the MCHT
Learning and Development Services

Page 113 of 120
APPENDIX C - Form 1
Equality Impact Screening Assessment
Please read the Guide to Equality Impact Assessment before completing this form. To be
completed and form part of the policy or other document appendices when submitted to
governance-policies@mcht.nhs.uk for consideration and approval or to be completed and form
part of the appendices for proposals/business cases to amend, introduce or discontinue
services.
POLICY/DOCUMENT/SERVICE
Yes/
No
A
Does the document, proposal or service

affect one group less or more favourably
than another on the basis of:
Race, ethnic origins (including gypsies and

travellers) or nationality
No
Sex
No
Transgender
No
Pregnancy or maternity
No
Marriage or civil partnership
No
Sexual orientation including lesbian, gay

and bisexual people
No
Religion or belief
No
Age
No
Disability - learning disabilities, physical

disability, sensory impairment and mental
health problems
No
10
Economic/social background
No
Human Rights are there any issues

which may affect human rights
Right to Life
No
Freedom from Degrading Treatment
No
Right to Privacy or Family Life
No
Other Human Rights (see guidance note)
No
Justification and Data Sources
NOTES
If you have identified a potential discriminatory impact of this document, proposal or service, please complete
form 2 or 3 as appropriate.
st
Date: 1 October 2012
Name: Jennifer Willis
Signature: J A Willis
Job Title: Antibiotic Pharmacist
Date: ..
Name: ..

Page 114 of 120
Signature:
Job Title: ..

Page 115 of 120
Form 2
Equality Impact Assessment
Please read the Guide to Equality Impact Assessment before completing this form. To be completed when
potential impact has been identified, but necessary steps to address that impact have been identified, agreed
and included in the document or proposal. If you have identified a potential discriminatory impact of the
document or proposal for which actions need to be identified or for which actions are complex in nature,
please complete form 3 instead. To form part of the policy or other document appendices when submitted to
governance-policies@mcht.nhs.uk for consideration and approval or to form part of the appendices for
proposals/business cases to amend, introduce or discontinue services. Any actions listed in this form
should be highlighted in red, with timescales for action and lead responsibility noted.
Yes/
No


Sex
Transgender
Sexual orientation including lesbian, gay and

bisexual people
Religion or belief
Age
Justification & data sources.

Include nature of impact for which
action has been agreed and
details of that action. Also record
provisions already in place to
mitigate impact.

health problems
10

Right to Life
NOTES:
Date..
Name..
Signature
Job Title.. ..
Date..
Name..

Page 116 of 120
Signature
Job Title.....

Page 117 of 120
Form 3

Please read the Guide to Equality Impact Assessment before completing this form. To be completed when
potential impact has been identified, but necessary steps to address that impact have been identified, agreed
and included in the document or proposal. If you have identified a potential discriminatory impact of the
document or proposal for which actions need to be identified or for which actions are complex in nature,
please complete form 3 instead. To form part of the policy or other document appendices when submitted to
governance-policies@mcht.nhs.uk for consideration and approval or to form part of the appendices for
proposals/business cases to amend, introduce or discontinue services. Any actions listed in this form
should be highlighted in red, with timescales for action and lead responsibility noted.
Section A
Yes/
No


Sex
Transgender

bisexual people
Religion or belief
Age

health problems
10

Right to Life
NOTES

Page 118 of 120
Justification & data sources.

action has been agreed and
details of that action. Also record
provisions already in place to
mitigate impact.

SECTION B
Issues for which action needs to be

agreed.
Yes/
No
Justification and data sources.

action needs to be agreed.
Then complete section C.


Sex
Transgender

bisexual people
Religion or belief
Age

health problems
10

Right to Life
NOTES

Page 119 of 120
SECTION C
Please expand tables below as necessary
SECTION B
NUMBER
NATURE OF IMPACT
EVIDENCE
A1-10, B1-4
SECTION B
NUMBER
STAKEHOLDER INVOLVEMENT
ACTION
A1-10, B1-4
SECTION B
NUMBER
COST
LEAD
TIMESCALE
A1-10, B1-4
Date..
Name..
Signature
Job Title....
Date..
Name..
Signature
Job Title....

Page 120 of 120
RISK ASSESSMENT
SCORE

1603 - 11th July 2013 - Attachement 1 - Adult Antibiotic Policy

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

1603 - 11th July 2013 - Attachement 1 - Adult Antibiotic Policy

Hochgeladen von

Copyright:

Verfügbare Formate

Antibiotic Guidelines

Treatment and Prophylaxis for

Post Responsible for Update:

Consultant Microbiologists / Antibiotic

Antimicrobial Stewardship Committee

Approved by them in the

5th October 2012

All Trust staff via the Trust Intranet

Heading (Insert Title)

Contents / Risk rating

Aims of the guidance

Conversion from Intravenous to Oral Antibiotics (Antibiotic

Extended duration of antibiotic treatment

Notification of infectious diseases

Bone and Joint Infections

Acute hematogenous osteomyelitis (Not associated with

Prosthetic joint infections

Septic arthritis (native joint)

Septic bursitis (Olecranon bursitis, prepatellar bursitis)

Central Nervous System Infections

Acute Bacterial Meningitis (empirical treatment)

Pathogen Specific Therapy

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Brain abscess / subdural empyema

Ear, Nose and Throat Infections

Acute localised (Furuncle)

Acute, diffuse (swimmers ear)

Fungal otitis externa

Invasive malignant otitis externa

Acute otitis media

Acute sore throat

Peritonsillitis / Peritonsillar abscess or quinsy

Salivary gland infection

Treatment Algorithm for C. Difficile Infection (CDI)

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Vibro cholerae 01 or 0139

Giardia Lamblia, Giardiasis

Entamoeba histolytica, amebiasis

Genital Tract Infections

Pelvic inflammatory disease

Gynaecological and Pregnancy Related Infections

Post partum endometritis

Post abortion infection

Preterm prelabour rupture of membranes

Sepsis of unknown origin

Surgical site infection after gynaecologic surgery

Pelvic inflammatory disease

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Primary (spontaneous) bacterial peritonitis

Liver and biliary system

Pyogenic liver abscess

Amoebic liver abscess

Respiratory Tract Infections

Community acquired pneumonia (empirical)

Hospital Acquired, Postoperative or Ventilator Associated

Upper Respiratory Tract Infections

Pathogen specific therapy

Confirmed Q fever, psittacosis

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Skin and Soft Tissue Infections

Infected chronic ulcers or pressure sores (non

Diabetic Foot Infection

Gangrenous cellulitis (Necrotising fasciitis or gas

Burn wound infections