PRINCIPALS OF GOOD ANTIBIOTIC PRESCRIBING EMPIRICAL TREATMENT SEPSIS RESPIRATORY RESPIRATORY (cont’d) URINARY TRACT Community Acquired Pneumonia (CAP) . Severity of CAP criteria (CURB-65) - 1 point for each C onfusion (new onset) U rea > 7mmol/L R espiratory rate ≥ 30/minute B lood pressure (SBP < 90mmHg; DBP ≤ 60mmHg) 65 age ≥ 65 years   Mild CAP (CURB-65 score 0 - 1) 1st line: Amoxicillin 500mg PO TDS Penicillin allergy: Clarithromycin 500mg PO BD Total duration: 5-7 days Moderate CAP (CURB-65 score 2) 1st line: Amoxicillin 500mg - 1g PO TDS + Clarithromycin 500mg PO BD Total duration: 7-10 days Severe CAP (CURB -65 score ≥ 3) 1st line: Co-amoxiclav 1.2g IV TDS + Clarithromycin 500mg PO/IV BD Penicillin allergy: Teicoplanin 400mg IV BD for 3 doses then 400mg OD (depending on renal function) + Clarithromycin 500mg IV/PO BD Contact Microbiology for further advice, especially if there is any history of immunosuppression, underlying respiratory disease or excess alcohol consumption Test for legionella antigen (urine) in moderate and severe CAP Infective exacerbation of COPD 1st line: Doxycycline 100mg PO BD for 7 days If intolerant to tetracyclines , Amoxicillin can be used. Hospital acquired pneumonia (HAP) 1st line: Co-amoxiclav 1.2g IV TDS If known MRSA : Add Teicoplanin 400mg IV BD for 3 doses then 400mg OD (depending on renal function.) Penicillin allergy: Teicoplanin 400mg IV BD for 3 doses, then 400mg IV OD + Gentamicin 3-5mg/kg IV OD Contact Microbiology for further advice Review treatment at 5 days – most do not require further antibiotic Legionella Pneumonia (only if confirmed legionella) Consider in HAP: - Inpatient - Living in an institution - Recent hospital admission - Travel History 1st line: Levofloxacin 500mg IV BD NB check urinary antigen (rapid diagnostic test). Positive contact microbiology Negative consider stopping Levofloxacin Community Acquired Aspiration pneumonia (If treatment is necessary): Review diagnosis after 5 days. Many do NOT require further antibiotics. 1st line: Amoxicillin 500mg IV TDS + Metronidazole 500mg IV TDS Penicillin allergy: Clarithromycin 500mg IV BD Hospital Acquired Aspiration pneumonia 1st line: Amoxicillin 500mg IV TDS + Gentamicin 3-5mg/kg IV Penicillin allergy: Teicoplanin 400mg IV BD for 3 doses, then 400mg IV OD (depending on renal function) + Gentamicin 3-5mg/kg IV OD + Metronidazole 500mg IV TDS PRINCIPALS OF GOOD ANTIBIOTIC PRESCRIBING Uncomplicated, Lower UTI . 1st Line: Nitrofurantoin 100mg PO QDS for 3 days for women, 7 days for men If GFR <45ml/min then choose from below 1st Line: Pivmecillinam PO Body-weight 40 kg and above: Initially 400 mg for 1 dose, then 200 mg every 8 hours for 3 days for women, 7 days for men. 2nd Line: Gentamicin 3-5mg/kg IV OD ( see gentamicin guideline). Complicated UTI, Pyelonephritis & Catheter associated UTI 1st Line: Gentamicin 3-5mg/kg IV OD (max dose: 480mg) Review at 48 hours, streamline choice as per sensitivities , if necessary, seek Microbiology advice Pyelonephritis – IV to Oral switch Co-amoxiclav 625mg TDS for 14 days Penicillin Allergy : Ciprofloxacin 500mg BD for 14 days Start antibiotics within 1 hour for severe / life-threatening infections Blood Cultures must be taken – Mandatory Sepsis criteria See Sepsis Care pathway Suspicion of infection AND 2 or more of the following: • Temperature <36oC or >38oC • Respiratory rate >20 BPM • Heart rate >90 BPM • WCC <4 or >12 x 109/L Septicaemia (unknown source) Severe systemic infection before results available – review antibiotics in 48-72 hours. Refer to surviving sepsis guideline 1st line: Co-amoxiclav 1.2g IV TDS + Gentamicin 3-5mg/kg IV OD (as per gentamicin guideline) Severe Penicillin allergy (i.e. anaphylaxis): Ciprofloxacin 400mg IV BD + Teicoplanin 400mg IV BD for 3 doses then 400mg IV OD (depending on renal function) + Gentamicin 3-5mg/kg IV OD (as per gentamicin guideline). Neutropenic sepsis (Full guidance available on HUB) Febrile neutropenia is defined as •Temperature >38oC for more than 1 hour or a single reading >38.5oC and •Neutrophil count of <0.5x109/litre or count of <1x109/litre with predicted decrease to <0.5x109/litre 1st line: Piperacillin/Tazobactam (Tazocin) 4.5g IV QDS Non-severe Penicillin allergy (e.g. delayed rash): Meropenem 1g IV TDS Severe Penicillin allergy i.e. anaphylaxis: + Teicoplanin 400mg IV BD for 3 doses and then 400mg IV OD (depending on renal function) + Gentamicin 3-5mg/kg IV OD (as per gentamicin guideline) For all other groups of patients, refer to full guideline on the HUB EMPIRICAL USE OF ANTIBIOTICS POCKET GUIDELINES FOR PRESCRIBING IN ADULTS 2017/2018 START SMART: PLEASE AVOID ANTIBIOTICS IN THE ABSENCE OF CLINICAL EVIDENCE OF BACTERIAL INFECTION Take cultures before antibiotic administration Check allergy history and document nature of severity Prescribe in line with BTUH policies / guidelines Give first dose of antibiotic within 1 hour for severe / life-threatening infections Document indication for antibiotic in medical notes and on drug chart Record duration of therapy (stop / review date) on drug chart Consult microbiology when appropriate THEN FOCUS: At 48 hours review diagnosis and need for antibiotics. STOP antibiotics if no evidence of infection SWITCH from IV to oral therapy CHANGE antibiotics: de-escalate / substitute / add agents as per culture results CONTINUE and review again after a further 24 hours Document decisions in medical notes. For hospital acquired infections check culture and sensitivity results before starting antibiotics. Full guidelines are available on the intranet (the HUB) All doses are based on NORMAL RENAL FUNCTION For dosing in renal impairment check the antimicrobial doses for adult in renal impairment on the clinical HUB. Gentamicin dosing – For patients with GFR <45ml/min, please refer to the Trust Guidelines. Prescribe 3mg/kg OD for those >75 years. This is an aid for initial antibiotic prescribing. All antibiotic prescriptions should be reviewed daily and consider further discussion with Microbiology, particularly if the initial presentation is complex (e.g. immunocompromised patients outside of the neutropenic sepsis protocol, returning traveler etc.) or if there is poor clinical response. Indication and duration / review date must be written on the drug chart at time of prescribing. MENINGITIS (Contact Microbiology) Do NOT delay treatment Start treatment as soon as blood cultures have been taken 1st Line: Ceftriaxone 2g IV BD (Give IM if no venous access) for 7-14 days Severe Penicillin allergy: Chloramphenicol 1g IV QDS for 7-14 days If Listeria suspected (e.g. patient pregnant or immunosuppressed or age>55 years): Add Amoxicillin 2g IV 4 hourly If Listeria suspected and penicillin allergic speak to microbiology If gram positive cocci seen/cultured or if pneumococcal aetiology is likely (e.g. age>50yrs; sinus infection /otitis media / mastoiditis; csf leak; EtOH; immunocompromised): Add Dexamethasone 0.15mg/kg IV QDS for 4 days. Must start either before, or with the first dose of antibiotic. If GCS <15, recent seizures or suspected viral encephalitis: Add Aciclovir 10mg/kg IV TDS for 14-21 days Review treatment in light of CSF cultures and PCR results For further advice contact Consultant Microbiologist: Dr Edwards (ext 1249)/Microbiology Consultant via switchboard Antimicrobial Pharmacist: Bleep 6347 / 6005 Pharmacy Medicines Information: ext 3788 Out of hours contact switchboard for on-call Microbiology and/or Pharmacist PRESCRIBING IN PENICLLIN ALLERGY Produced by: Antimicrobial Stewardship Group Approved: May 2017 Review: May 2018 Please check nature of allergy and confirm with patient and GP • Drugs in RED are contra-indicated in penicillin allergy • Drugs in ORANGE should be prescribed with caution • Drugs in GREEN are considered safe See Penicillin allergy (PenA) table for more information Version 006 Q Pulse Number. 001/CP/0185 Adapted from UCLH antimicrobial pocket guide

DO NOT USE CAUTION SKIN & WOUND GASTROINTESTINAL CLOSTRIDIUM DIFFICILE COLITIS IV to ORAL SWITCH CRITERIA GENTAMICIN DOSING PENICILLIN ALLERGIES Cellulitis 1st Line: Mild-moderate: Flucloxacillin 1g IV QDS (if patient is >70kg 2g QDS IV) Moderate-severe: Benzylpenicillin 2.4g IV 6hourly with Clindamycin 600mg IV QDS Penicillin Allergy: Clindamycin 600mg IV QDS - Discontinue if diarrhoea develops - Discuss with microbiology If patient >65 years Switch to oral when appropriate MRSA: Teicoplanin 400mg IV BD for 3 doses then 400mg OD (depending on renal function) + Sodium fusidate 500mg PO TDS Isolate the patient Take stool sample (stool type 5-7 →must take shape of container) Stop precipitating antibiotics if possible Avoid laxatives and anti-motility agents Review use of proton pump inhibitors (PPIs) Review response to therapy daily 1st Line: Metronidazole 400mg PO TDS (if strict NBM or paralytic ileus use Metronidazole 500mg IV TDS) If poor response to 1st line after one week switch to: 2nd Line: Vancomycin 125mg PO QDS (Do not give vancomycin intravenously – it is not effective) IV reviewed daily with a view to switch to oral therapy as soon as possible, according to the following criteria: C Clinical Improvement observed: signs & symptoms of infection improving & haemodynamically stable. O Oral route not compromised (vomiting, malabsorption disorder, NBM, Swallowing difficulties, unconscious, Severe diarrhoea) N.B if fed via NG, PEG, RIG, NJ etc. consult ward Pharmacist M Markers showing a trend towards normal Apyrexial: Temp >36°C + <38°C for at least 24 hours BP stable Plus NOT more than one of: Heart rate >90bpm Respiratory Rate >20 breaths/min WCC <4 or >12 S Specific/deep seated infection (see exclusion criteria below) Exclusion Criteria Certain infections require persistent IV therapy to ensure sufficient drug levels are attained at the site of infection to optimise response: Deep abscess: Liver abscess, Cavitating pneumonia, intracranial abscess Bone & Joint infections: Septic arthritis & Osteomyelitis Emphysema Staphylococcus aureus bacteraemia Severe soft tissue infections: necrotising fasciitis, cellulitis Cystic Fibrosis/Bronchiectasis Infected implants/prosthesis Meningitis/Encephalitis Endocarditis/mediastinitis Sepsis & Neutropenic sepsis For <75 years 1st dose: 5mg/kg (max 500mg. Round up or down to nearest 20mg) Dose is calculated using a dosing weight in obese patients Dosing Weight = Ideal Body Weight + 0.4 X [actual Weight – ideal weight] Subsequent doses: Check pre-dose level before further doses are given Pre-dose levels must be taken 18-24 hours after a dose Daily U+E’s If <1mg/L give the same dose at 24 hour intervals If 1-2mg/L Reduce dose to 75% of initial dose 24 hourly (Reduce dose once only. If levels still ≥1mg/L discuss with microbiology) If >2mg/L No further doses until level is <1 (discuss with microbiology) Dose Adjustment in Renal Impairment Estimate GFR using creatinine clearance calculator Creatinine Clearance (ml/min) = [140 – age (years) x ideal body weight (kg) x F] /Serum creatinine (F = 1.04 in females and 1.23 in males) GFR (ml/min) 10-40 Dose 3mg/kg (max 240mg dose rounded to nearest 20mg) <10 Dose 2mg/kg (max 160mg dose rounded to nearest 20mg) Check Levels 18-24 hours after 1st dose. Re-dose only when levels <1mg/L Dose Adjustment in >75 years 1st Dose: 3mg/kg (max 240mg. Dose rounded to nearest 20mg) Not all penicillins sound like they contain a penicillin PENICILLINS CAN KILL IF GIVEN TO A PATIENT WITH PENICILLIN ALLERGY For any antibiotics NOT listed below please contact your ward Pharmacist or Medicines Information Biliary tract infection/ Diverticulitis / Liver abscess/ Peritonitis/ Cholecystitis/ Cholangititis/ Post-operative Gastrointestinal Sepsis/ Biliary Sepsis (including recent instrumentation e.g. ERCP) 1st Line: Co-amoxiclav 1.2g IV TDS +/- Gentamicin 3-5mg/kg IV stat Penicillin allergy: Teicoplanin 400mg IV BD for 3 doses then 400mg IV OD + Metronidazole 500mg IV TDS + Gentamicin 3-5mg/kg IV OD Duration: 7-10 days Acute Gastroenteritis Isolate the patient Avoid laxatives and anti-motility agents Correct fluid and electrolytes Mild symptoms No antibiotic therapy required Moderate to severe symptoms (i.e. dehydration, bloody stools, abdominal pain, fever) Send stool sample and await cultures If antibiotics required discuss with Microbiology CONSIDERED SAFE DO NOT USE CAUTION STOP! Contraindicated in Penicillin Allergy Amoxicillin or ampicillin Benzylpenicillin Co-Amoxiclav (Augmentin® = Amoxicillin + Clavulanic acid) Flucloxacillin Penicillins (Phenoxymethylpenicillin, Procaine, Benzathine) Piperacillin / Tazobactam (Tazocin®) Pivmecillinam Temocillin Ticarcillin + clavulanic acid (Timentin) BONE & JOINT (Contact Microbiology) PELVIC INFLAMMATORY DISEASE CAUTION! Use with caution in Penicillin Allergy Consult Microbiology before prescribing AVOID if history of severe allergy. CAUTION if non-severe allergy Cefalexin Ceftriaxone Meropenem Cefixime Cefuroxime Aztreonam Cefotaxime Ertapenem Ceftazidime Imipenem Ceftaroline fosamil . Ceftolozane + Tazobactam Approximately 10% of penicillin sensitive patients may be sensitive to a drug in this group. Discuss with Microbiology if MRSA suspected and in all cases of suspected prosthetic joint infection Osteomyelitis 1st Line: Flucloxacillin 1-2g IV QDS + Sodium Fusidate 500mg PO TDS Pen allergy: Teicoplanin 800mg IV BD for 3 doses then 800mg IV OD (depending on renal function) + Sodium Fusidate 500mg PO TDS Add Gentamicin 3-5mg/kg IV OD if systemically unwell Duration if acute 42 days Duration if chronic 90 days Septic Arthritis 1st Line: Benzylpenicillin 1.2g IV QDS + Flucloxacillin 1g IV QDS 2nd Line: Teicoplanin 800mg IV BD for 3 doses the 800mg OD (depending on renal function) + Clindamycin 600mg QDS IV (contact microbiology if patient >65 yrs) Duration: 4-6 weeks NB discontinue clindamycin if diarrhoea develops 1st Line: Ceftriaxone 2g IV stat + Doxycycline 100mg PO BD + Metronidazole 400mg PO TDS Penicillin allergy: If severe allergy then discuss with Microbiology Total duration: 14 days NB Gonococcal resistance is an increasing clinical problem. Please discuss outpatient treatment with either Microbiology or GU Medicine. Please discuss all cases of tubo-ovarian abscesses with microbiology. SAFE! Considered Safe in Penicillin Allergy Amikacin Fosfomycin Sodium Fusidate Azithromycin Gentamicin Teicoplanin Chloramphenicol Levofloxacin Tetracycline Clarithromycin Linezolid Trimethoprim Clindamycin Lymecycline Tobramycin Colistin Metronidazole Tigecycline Co-Trimoxazole Moxifloxacin vancomycin Ciprofloxacin Minocycline Daptomycin Nitrofurantoin Doxycycline Oxytetracycline Erythromycin Ofloxacin Rifampicin MRSA SUPPRESSION THERAPY Refer to MRSA screening policy on HUB for further information. Treatment for 5 days 1st line: Mupirocin (Bactroban®) nasal ointment TDS to both nostrils Octenisan® body wash OD Octenisan® shampoo hair on days 2 and 4 For alternative agents in case of adverse effects or resistance contact Infection Prevention & Control