KC: Login Screen · General Principles of Antimicrobial Prescribing Avoid unnecessary antibiotic use Antibiotics have harmful effects e.g. allergy, toxicity, superinfection (e.g

Trust Guideline for

Antimicrobial Agents in Adults

(Antibiotic Guidelines)

A guideline recommended for use

In All areas except Childrens Services and Mount Vernon Cancer Centre

By Doctors Pharmacists and Nurses involved in prescribingsupplyingadministering antimicrobials

For All non-pregnant adult patients (ie aged 16yrs and over) in East amp North Hertfordshire NHS Trust (except Mount Vernon Cancer Centre)

Key Words Antimicrobial agents antibiotics treatment infection prophylaxis gentamicin

Written by Dr Saba Qaiser (Consultant Microbiologist)

Dr Sumita Pai (Consultant Microbiologist)

Dr Vrinda Shet (Consultant Microbiologist)

Ana Patricio (Antimicrobial Pharmacist)

Approved by Therapeutics Policy Committee

Dr Adie Viljoen (Chair)

11th October 2017

Trust ratified

Jacqui Evans

4th December 2017

To be reviewed before December 2020

To be reviewed by Chair of the Trustrsquos Antimicrobial Forum

Guideline supersedes Version 16 of this Guideline

CGSG Guideline Registration No 008 Version No 17

ANTIBIOTIC GUIDELINES East amp North Herts NHS Trust

All dosage recommendations are for adults and assume normal renal and liver function

Authors Dr Qaiser et al Date of issue December 2017 Page 2 of 64 CGSG Registration No 008 Version No 17 Review before December 2020

Dissemination and Access This Guideline can only be considered valid when viewed via the East amp North Hertfordshire NHS Trust Knowledge Centre If this document is printed in hard copy or saved at another location you must check that it matches the version on the Knowledge Centre

Equality Impact Assessment This Guideline and its impact upon equality has been reviewed in line with the Trustrsquos Equality Scheme and no detriment was identified

Associated Documentation

Antimicrobial Agents in Neonates (Antibiotic Guidelines)

Neonatal Antibiotic Policy

CP 187 Antimicrobials for Renal Patients

CGSG 058 Childrenrsquos Antibiotic Guideline (Antimicrobial Agents in Children)

CP102 Trust Policy for The Prevention and Management of Clostridium difficile Infection (P 18)

Trust Policy for Gentamicin Dosing and Monitoring for Adults

CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults

Caesarean Section Guideline no 427

Review This document will be reviewed within three years of issue or sooner in light of new evidence Version Control

Version No Issue Date Reasons for Production or Revision

15 Feb 2016

Amendment of teicoplanin doses and teicoplanin appendix added Amendment of severe CAP recommendation New surgical prophylaxis recommendation for bone surgery and prosthetic joint surgery Removal of gentamicin dose recommendations and link to Trust Policy for Gentamicin Dosing and Monitoring for Adults made Penicillin allergy poster updated Antimicrobial pharmacist name and bleep number update List of authors amended

16 June 2017

Updated respiratory guideline

Alternatives to piperacillin-tazobactam during supply shortage

Antibiotic prophylaxis for permanent pacemaker insertion updated

17 Nov 2017

Uncomplicated UTI in pregnancy

CAP CURB 65 1

Neutropenic sepsis guideline update

Caesarean Section prophylaxis Guideline no 427 hyperlink




Contents

Section Page

1 Introduction and General Principles 4

2 Useful Telephone Numbers 7

3 Restricted Antibiotics 8

4 Conditions and Recommended Treatment 9

Skin and Soft Tissue Infections 9

Urinary Tract Infections 13

Respiratory Tract Infections 14

GastrointestinalIntra-abdominal Infections 30

Central Nervous System Infections 34

Bone and Joint Infections 35

Endocarditis 36

Septicaemia (including Neutropenic Sepsis) 37

ENT (Oropharyngeal) Infections 39

Ophthalmic Infections 40

Genitourinary Tract InfectionsSexually Transmitted Diseases 41

5 Antibiotic Prophylaxis for Surgery 43

GastrointestinalIntra-abdominal 44

Genitourinary 45

Obstetric amp Gynaecological 46

Plastic and Reconstructive 46

Orthopaedic 47

Vascular Surgery 48

Thoracic Surgery amp Head amp Neck Surgery 48

6 Other Antibiotic Prophylaxis 49

7 Further reading 50

Appendix 1 Guideline for Switch Antibiotic Therapy 51

Appendix 2 Penicillin Allergy and Poster General Points on Allergies 53

Appendix 3 Protocol for Vancomycin Administration in Adults 55

Appendix 4 Teicoplanin dose banding in adults with good renal function 56

Appendix 5 Extended Interval Gentamicin Dosing 59

Appendix 6 Extended Interval Amikacin Dosing 60

Appendix 6a Calculation of Corrected Body Weight (CBW) for Dosing in Obese Patients

63





1 INTRODUCTION

This document is the Trustrsquos Guideline for the use of antibiotics If deviation from this Guideline

is clinically indicated a Consultant Microbiologist must be informed to assess the need and to authorise any deviation agreed to be necessary

This Guideline is for antibiotic use in non-pregnant adults (ie aged 16 years and over) with normal renal and liver function unless specifically stated All doses given therefore assume normal renal function If renal function is impaired please discuss appropriate dosing with the Pharmacist

For pregnant women children and neonates please refer to the appropriate Guidelines on the Knowledge Centre

Sections of this Guideline may be revised in times of outbreaks or drug shortages

General Principles of Antimicrobial Prescribing

Avoid unnecessary antibiotic use

Antibiotics have harmful effects eg allergy toxicity superinfection (eg Clostridium difficile colitis) and the generation of microbial resistance in the individual and the community at large

Appropriate microbiological samples must be taken before starting antibiotic therapy

A microbiological diagnosis is vital for optimal treatment of severe infections such as meningitis osteomyelitis endocarditis and septicaemia

Effective therapy should be commenced promptly in patients with life-threatening infection

When there is a critical need eg clinical diagnosis of meningococcal disease antibiotic therapy should be started without delay Prescribing should be in accordance with this Guideline which takes account of local resistance patterns Deviations from this Guideline should be discussed with the Consultant Microbiologist

Consider patient-specific factors when prescribing antibiotics

Choice of initial (or empirical) antibiotics will depend on whether the infection is hospital or community acquired severity site of infection colonisation with multi-resistant organisms recent antibiotic history immune-competence pregnancy allergies and drug interactions

All antibiotics should be clearly prescribed giving dosage frequency and duration

The dedicated antimicrobial section of the drug chart should be used for all antibiotic prescriptions with the exception of gentamicin and amikacin The diagnosisreason for antimicrobial therapy and anticipated duration of therapy should be clearly documented in the patientrsquos medical notes AND on the drug chart




Use oral antibiotics whenever possible in preference to intravenous antibiotics

Intravenous therapy can be given at a much higher dose achieve higher drug concentration in blood and tissue and is more reliably absorbed than oral antibiotics However it has important disadvantages such as the risk of super infections (eg cannula-related wound infection and septicaemia) and greater expense Therefore the intravenous route should be reserved for patients with severe infections threatening life or major disability (eg endocarditis meningitis and septicaemia) patients who cannot tolerate or absorb oral medication or when no oral antibiotic alternative is available

Surgical prophylaxis should be administered as a single IV dose

Where antibiotics have been shown to be effective for surgical prophylaxis they should be given as a single dose 30 minutes prior to incision With the exceptions given in this Guideline (ie prolonged surgery gt5hr significant blood loss gt15L prosthetic implant surgery) further prophylactic doses are not indicated (See pages 41 ndash 46)

Antimicrobial Review and Stewardship

All antibiotics should be reviewed daily and the review documented in the patientrsquos medical notes

In particular the patient should be reviewed at 48 hrs and again at 5 days in

conjunction with culture results and then a clinical decision made and documented re whether to

Stop antibiotics (no evidence of infection)

Switch from intravenous to oral therapy (refer to the Guideline for Switch Antibiotic Therapy ndash see Appendix 1)

Change antibiotics (de-escalate switch or substitute based on culture results amp other investigations)

Continue (review again after a further 24 hours)

Refer to OPAT (Outpatient Parenteral Antibiotic Therapy)

The total duration of antibiotics should not normally exceed 5 to 7 days for acute infections

Cautions to Antimicrobial Prescribing

Clostridium difficile

The following antibiotic classes are strongly associated with C difficile infection and pseudomembranous colitis Cephalosporins Ciprofloxacin and Clindamycin Use of these antibiotics is strictly restricted They should ONLY be used for the specific indications in this Guideline OR upon the advice of the Consultant Microbiologist

With the exceptions given in this Guideline surgical prophylaxis should be single dose and should NOT continue after surgery Antibiotics continued after surgery have been shown to increase C difficile infection 3 times without any further reduction in infection




Multi-resistant organisms

Use of antibiotics in patients colonised or infected with meticillin resistant Staphylococcus aureus (MRSA) vancomycin resistant enterococci (VRE) or multi-resistant coliforms requires careful consideration of the predicted benefit of antibiotics against the potential disadvantages and also of the choice of antibiotic agent

Advice of a Consultant Microbiologist should always be sought prior to the initiation of such antibiotic courses

Prescribing in penicillin allergic patients

General guidance on appropriate antibiotics to use in the penicillin allergic patient is included at the end of this document (See Appendix 2)

A careful and thorough allergy history is important to differentiate true penicillin allergy from drug intolerance and other reactions (ie what was the reaction when was it to which drug) True penicillin allergy only occurs in 7 ndash 23 of those who give a history

Within this Guideline

Drugs in RED are contraindicated in penicillin allergy

Drugs in ORANGE should be prescribed with caution They may be appropriate for a mild allergy (eg rash delayed reaction) but should not be prescribed for patients with severe penicillin allergy (eg anaphylaxis angioedema) or cephalosporin allergy

Drugs in GREEN are considered safe in penicillin allergy Please note that a patient with penicillin allergy is three times more likely to react to ANY drug owing to the atopic nature of the condition

Therapeutic Drug Monitoring

Drugs such as vancomycin teicoplanin and the aminoglycosides (eg gentamicin amikacin) require careful monitoring of drug levels This is of particular importance when there is renal impairment (See Appendices 3 4 5 and 6 and Trust Policy for Gentamicin Dosing and Monitoring for Adults)

Use of a once ndash daily dose of gentamicin is now adopted in the Trust for serious Gram negative sepsis When this method of gentamicin administration is considered the Trust Policy for Gentamicin Dosing and Monitoring for Adults should be adhered to

NB When in doubt about any aspect of the use of antibiotics always ask a Consultant

Microbiologist for advice




2 USEFUL TELEPHONE NUMBERS Microbiology Laboratory This department has now moved to Cambridge University Hospitals NHS Trust and is based at Addenbrookersquos Hospital For urgent results call 01223 257037

For queries around samples contact The Pathology Partnership (TPP) via email between 0800

and 2000 at thepartnershelpdesknhsnet or call 0333 1032220

NB Always telephone the laboratory at Lister on ext 4694 when sending urgent

specimens that require immediate processing Consultants Between 9am ndash 5pm Monday ndash Friday

The Consultant Microbiologist taking telephone enquiries during the day may be contacted via the daytime Microbiology mobile (07500 975834)

Out of hours (including weekends Bank Holidays)

Contact the Consultant Medical Microbiologist on call via hospital switchboard This is also the route for contacting the on-call Biomedical Scientist

Antimicrobial Pharmacist bleep 5933 Other Numbers

Public Health England 0300 303 8537 (Notification of infectious diseases)




3 RESTRICTED ANTIBIOTICS

A number of antibiotics are restricted and should ONLY be used for the indications outlined in the following chapters OR with input from a Consultant Microbiologist The list includes the following agents Quinolones (ciprofloxacin and levofloxacin)

Glycopeptides (vancomycin and teicoplanin)

Aminoglycosides (gentamicin amikacin streptomycin)

Cephalosporins (eg cefuroxime)

Carbapenems (imipenem meropenem and ertapenem)

Colistin (nebulisedintravenous)

Piperacillintazobactam

Temocillin

Fosfomycin (except Urology)

Rifampicin (except by Respiratory Team for TB)

Azithromycin

Tigecycline

Daptomycin

Linezolid If any of the above are prescribed for an indication outside this Guideline the Ward Pharmacist will contact the prescriber and a Consultant Microbiologist to ensure they are authorised for use Where these antibiotics are held as stock in defined areas (eg Theatres ITU Renal) they must not be supplied to other wards or clinical areas without the authorisation of a Consultant Microbiologist Out of hours the Duty Matron will not supply a restricted antimicrobial agent from the emergency drug cupboard or authorise its ldquoloanrdquo from a defined area other than for a use outlined in this Guideline without the approval of a Consultant Microbiologist The Emergency Duty Pharmacist will not attend to supply a restricted antimicrobial agent without the authorisation of a Consultant Microbiologist

ANTIBIOTIC GUIDELINES FOR ADULTS East amp North Herts NHS Trust



Skin amp Soft Tissue Infections

Infection Category Antimicrobials Comments

Cellulitis

Mild Flucloxacillin 1g qds PO Aetiology Group A Streptococcus Staph aureus

Duration 7 ndash 10 days

Discuss with Consultant Microbiologist if no response after 72 hours

There is no evidence to support the addition of Benzylpenicillin to Flucloxacillin for the empirical treatment of cellulitis (Emerg Med J 200522342ndash346)

Doxycycline is only active against selected strains of MRSA Tetracycline sensitivity MUST be confirmed by reviewing culture results prior to prescribing If Tetracycline resistant please discuss with the Consultant Microbiologist

Mild (penicillin allergy)

Clarithromycin 500mg bd PO

Mild (MRSA colonised)

Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive

Severe Flucloxacillin 1 ndash 2g qds IV

Severe (penicillin allergy MRSA colonised)

Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter

Cellulitis due to IV cannula

Remove cannula and manage as for lsquoCellulitisrsquo

Leg Ulcers pressure sores (non-diabetic)

No clinical evidence of

infection No antibiotics required

Chronic wounds and ulcers are frequently colonised with faecal flora and Pseudomonas aeruginosa These are rarely pathogenic and should not be treated and are often of little help for guiding empirical therapy If there is demarcated cellulitis or systemic infection treatment should be as given in the cellulitis section above Clinically cellulitic Manage as for lsquoCellulitisrsquo

Surgical wound infection (Clean surgery)

Manage as for lsquoCellulitisrsquo Aetiology Group A Streptococcus Staph aureus

Surgical wound infection (contaminated

abdomino-pelvic surgery)

Mild Manage as for lsquoCellulitisrsquo

Aetiology Group A Streptococcus Staph aureus Occasionally Coliforms amp anaerobes in severe infection

Severe Co-amoxiclav 12g TDS IV


Teicoplanin IV (see Appendix 4 for dosing) load bd for three doses then od thereafter + Doxycycline 100mg bd PO




Skin amp Soft Tissue Infections contdhellip


Necrotising fasciitis

1st Line

Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV

Aetiology Group A Streptococcus Staph aureus mixed coliforms anaerobes

Duration 14 days

All cases should be discussed with the Consultant Microbiologist

An urgent surgical review should be sought with a view to debridement of the necrotic tissue Repeated debridement may be required to control the infection

Alternative during piperacillin-tazobactam supply shortage

Flucloxacillin 2g QDS IV +

Gentamicin STAT IV ( see Trust Policy for Gentamicin Dosing and Monitoring for Adults)+

Clindamycin 600mg QDS IV

If MRSA colonised add


Penicillin allergy Contact Consultant Microbiologist

MRSA colonised

Piperacillin-tazobactam 45g TDS IV + Clindamycin 600mg QDS IV + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter






Diabetic foot infections

Refer to the current Trust Guidelines on

Management of Active Diabetic Foot Infections

CGSG No 092

Uninfected Colonised ulcer

No antibiotics Diabetic ulcers are invariably colonised with mixed skin flora coliforms and Pseudomonas Antibiotics are not indicated in the absence of purulent discharge or inflammation

Mild

Flucloxacillin 1g QDS PO

Penicillin allergy Doxycycline 100mg BD PO

MRSA colonised Doxycycline 100mg bd PO if colonising MRSA strain is Tetracycline sensitive If resistant then discuss with Consultant Microbiologist

Aetiology Staph aureus Group A Streptococcus occasionally Coliforms Pseudomonas aeruginosa Anaerobes

Mild infection

- Presence of ge2 or more signs of inflammation - Erythema extends le2cm around ulcer - Limited to skinsuperficial tissues - No systemic compromise


Moderate

Co-amoxiclav 12g TDS IV

Penicillin allergyMRSA colonised Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO

Moderate infection ndash systemically stable but one of more features present

- Cellulitis extending gt2cm around ulcer - Lymphangitis streaking - Spread beneath superficial fascia - Deep tissue abscess or gangrene - Involvement of muscle bone tendon or joint

Severe

Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)

MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter

Penicillin allergy Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)

+ Metronidazole 500mg TDS IV

Discuss ongoing therapy with Consultant Microbiologist

Severe Infection

- Infection in a patient with systemic toxicity or metabolic instability

(eg tachycardia hypotension confusion vomiting acidosis etc)

Collect wound swabs and blood cultures prior to commencing antibiotics

Suspected Osteomyelitis

See ldquoBone and Joint Infection

Discuss with Consultant Microbiologist

Perform appropriate imaging to confirm the diagnosis

Obtain bone biopsydeep tissue specimens for culture






Animal or Human Bites

Mild Co-amoxiclav 625mg tds PO Aetiology Staphylococci Streptococci anaerobes fastidious Gram negatives eg Pasteurella Eikenella

Duration 7 days

Wound toilet and surgical debridement may be required

For animal bites acquired outside the UK urgently discuss with a Consultant Microbiologist as anti-rabies treatment may be indicated

Human bites pose a risk of inoculation of blood-borne viruses The Trust Policy on Needle Stick Injury though not designed especially for the purpose provides relevant guidance Contact Consultant Microbiologist to discuss


Doxycycline 100mg bd PO + Metronidazole 400mg tds PO

Severe Co-amoxiclav 12g tds IV

Severe (penicillin allergy)

Discuss with the Consultant Microbiologist




Urinary Tract Infections


Uncomplicated UTI (eg simple cystitis without fever or loin

pain)

1st Line

Nitrofurantoin 50mg QDS PO

(avoid if creatinine clearance lt45mlmin G6PD deficiency porphyria)

Aetiology E coli other coliforms Enterococcus spp Staph saprophyticus (young women)

Treatment should be modified according to the most recent culture amp sensitivity test

2nd

amp 3rd

line treatment is indicated if

- 1st line therapy contraindicated or non-tolerated

- Treatment failure - Microbiological cultures indicate resistance to 1

st line but

susceptibility to 2nd

or 3rd

line treatment

If none of the given regimens are suitable discuss with Consultant Microbiologist

Duration Non-pregnant women 3 days Men 7 days

2nd

Line Trimethoprim 200mg BD PO

Unable to swallowtolerate oral

therapy


If no response after 48hr ADD Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)

Penicillin allergy Discuss with Microbiology Consultant

Pregnant

Nitrofurantoin 50mg PO QDS

If Nitrofurantoin contra-indicated

Cefalexin 500mg TDS PO

Avoid Nitrofurantoin

- impaired renal function (creatinine clearance lt45mlmin) - from 3640 weeks pregnancy

Duration 7 days

Indwelling urinary catheter

Asymptomatic patient with

colonised catheter Antibiotic treatment not indicated

Aetiology Catheters are frequently colonised with mixed gram negatives Enterococci amp skin flora

Symptomatic patient

Change catheter

Discuss empirical therapy with Consultant Microbiologist

Acute Pyelonephritis

Urosepsis

1st Line

Co-amoxiclav 12g TDS IV + Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) Empirical treatment should be modified according to the most recent

culture amp sensitivity test

Review antibiotics at 48hr with the culture results

Duration Women 7 days Men 14 days Penicillin allergic

Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)

Pregnancy Discuss with Consultant Microbiologist




Respiratory Tract Infections

A Community acquired pneumonia (CAP)

Definition

Symptoms and signs consistent with an acute lower respiratory tract infection eg fever cough pleuritic chest pain dyspnoea ANDOR

New focal chest signs on examination PLUS

New radiographic shadowing for which there is no other explanation (eg not pulmonary oedema or infarction)

The illness is the primary reason for hospital admission and is managed as pneumonia

The possibility of aspiration pneumonia should be considered in the presence of risk factors such as altered level of consciousness neurological disorders (eg stroke multiple sclerosis motor neuron disease) dysphagia and gastric disorders such as gastro-oesophageal reflux Pathogens

Streptococcus pneumoniae is the most frequently isolated pathogen hence recommended antimicrobial regimens primarily target this organism Less than 4 of pneumococcal isolates in the UK exhibit intermediate or high level resistance to penicillin

Atypical pathogens - Mycoplasma pneumoniae Occasionally Legionella pneumophila Chlamydophyla psittaci Chlamydophyla pneumoniae Coxiella burnetii Mycoplasma pneumoniae and Legionella sp infections are less common in the elderly population The incidence of Mycoplasma pneumoniae infections may rise in epidemic years particularly in the younger age group

Patients with co-morbidities or risk factors o Alcoholism ndash Strep pneumoniae anaerobes coliforms Mycobacterium tuberculosis o Bronchiectasis - Strep pneumoniae H influenza Klebsiella pneumoniae Pseudomonas aeruginosa o COPD ndash H influenza M catarrhalis Strep pneumoniae Staph aureus o IVDU - Staph aureus Strep pneumoniae o Aspiration pneumonia ndash oral flora including Strep pneumoniae anaerobes o Post influenza ndash Strep pneumoniae Staph aureus Group A strep o HIV infection - Strep pneumoniae Mycobacterium tuberculosis o Animal exposureoccupational ndash C psittaci (poultry workers pet birds) C burnetti (abattoir workers and sheep farmers)

Assessment of Severity

The CURB-65 scoring system is a useful indicator for severity but only in the absence of underlying respiratory illness eg COPD (see section C of respiratory guidelines) CURB-65 is also not validated in patients with other co-morbidities eg significant heart failure (discuss with Consultant Microbiologist) or renal disease (see CP 187 Antimicrobials for Renal Patients Policy)

Score one point for each of the following

Confusion

Urea gt 7 mmolL

Respiratory rate gt 30 breathsmin

Blood pressure Systolic lt90 mm Hg or Diastolic lt 60 mm Hg

Age gt 65 years




Respiratory Tract Infections contdhellip

Patients with a CURB-65 score of 3 or more are at high risk of death and should be managed promptly as severe pneumonia consider referral to Intensive Care Where CURB-65 score is not applicable criteria such as respiratory failure multi-lobar involvement severe co-morbidity and evidence of sepsis should suggest the need for aggressive management as severe pneumonia Investigations The following tests should be performed on admission

Oxygen saturation and where necessary arterial blood gases (ABGs) to assess requirements for and manage supplemental oxygen

Chest X-ray

Urea and electrolytes

Sputum samples should be sent for culture from patients with moderate to high severity CAP (CURB-65 ge2) who are able to expectorate and preferably have not received antibiotic therapy

CRP

Full blood count

Viral nose and throat swab for respiratory viruses especially during the winter influenzae season

Liver function tests ndash derangement seen with atypical infections

Blood cultures are recommended for all patients with moderate and high severity CAP preferably before antibiotic therapy is commenced

Legionella urine antigen for high severity CAP (CURB-65ge3) and patients with other risk factors eg foreign travel and immunosuppression

Acute and convalescent (7-10 days later) serum for respiratory serology if atypical pneumonia is judged highly likely or if the illness is unresponsive to beta lactam therapy

Management Consider pneumococcal vaccination and influenza vaccine upon clinical improvement in line with national guidelines





Infection Category Antimicrobials Duration and Comments

Community-acquired Pneumonia

Mild (CURB ndash 65 0-1)

Amoxicillin 500mg TDS POIV

Penicillin allergy

Doxycycline 200mg stat then 100mg OD (NB including patients colonised with MRSA)

Or Clarithromycin 500mg BD PO

5 days

Mild to Moderate (CURB ndash 65 2)

Amoxicillin 500mg ndash 1 g TDS POIV + Clarithromycin 500mg BD POIV

Penicillin allergy


Or Clarithromycin 500mg BD POIV

Mild CURB-65 1 ndash 5 days

Moderate CURB-65 2 - 7 days

Mycoplasma Chlamydia and Legionella may require longer treatment ndash discuss with Consultant Microbiologist

Severe (CURB ndash 65 ge3)

Co-amoxiclav 12g TDS IV + Clarithromycin 500mg BD POIV

Review within 48 hours for IV to oral switch Co-amoxiclav 625mg TDS PO + Clarithromycin 500mg BD PO

Penicillin allergy

Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Clarithromycin 500mg BD POIV

or

Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Levofloxacin 500mg BD POIV

Necrotising pneumonia Discuss with Consultant Microbiologist

MRSA colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter (unless already included in empirical regimen)

7-10 days


Levofloxacin use only for adults aged 18 years old and over

Aspiration pneumonia

Co-amoxiclav 625mg TDS PO or 12g TDS IV

Penicillin allergy

Levofloxacin 500mg BD POIV + Metronidazole 400mg TDS PO or 500mg TDS IV

5 days Levofloxacin use only for adults aged 18 years old and over





Tuberculosis

Admit suspected or confirmed cases into a side room with barrier nursing with respiratory precautions until Acid- Fast Bacilli (AFB) results available or patient risk assessed and not at risk of open tuberculosis

Refer all cases to Chest Team for diagnosis and management

Send 3 good quality sputum specimens on consecutive days for acid-fast bacilli (AFB) to exclude lsquoopenrsquo TB





B Hospital acquired pneumonia Definition

Hospital acquired pneumonia (HAP) is a pneumonia that develops 48 hours or more after hospital admission and did not appear to be incubating at the time of admission It includes patients presenting with pneumonia within 10 days of discharge from hospital

Ventilator ndash associated pneumonia (VAP) is a form of HAP that develops 48 hours or more after endotracheal intubation Pathogens

Within the first 4 days of admission commonly Strep pneumoniae occasionally Haemophilus influenzae Staph aureus and Moraxella catarrhalis

From the 5th day of admission as above but more commonly coliforms and Pseudomonas aeruginosa occasionally Staph aureus (including MRSA) anaerobes

(complicating aspiration of upper respiratory tract secretions or gastric contents)

Also consider hospital acquired Legionella pneumophila and viral Influenza (especially as a part of an outbreak)

Assessment of severity Please see the section in Community acquired pneumonia Investigations Please see the section in Community acquired pneumonia Management Intravenous antibiotic therapy should be reserved for severe infections those patients with impaired consciousness and if unable to tolerate or absorb oral medicines Convert to oral therapy after 24 to 48 hours if clinically stable and can tolerate and absorb oral medication






If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay (suggest duration) and colonisation with resistant organisms (eg MRSA ESBL producers)

Current or previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)

Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients)


Hospital Acquired Pneumonia

Mild


Penicillin allergic

Clarithromycin 500mg BD POIV

Or

Doxycycline 200mg stat then 100mg PO OD

If patient is MRSA colonised add Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter

7 days

Severe

Piperacillin-tazobactam 45g TDS IV


Penicillin allergic

Levofloxacin 500 mg POIV BD +


If aspiration likely add

Metronidazole 500mg IV TDS 400mg PO TDS

7-10 days


As per penicillin allergic





C Chronic Obstructive Pulmonary Disease (COPD) Definition

COPD exacerbation is defined as an acute increase in symptoms beyond the normal day-to-day variation usually manifesting as changes in cough frequency or severity sputum volume or colour and respiratory rate

Up to 30 of ldquoexacerbationsrdquo can be due to non-infective causes

Pathogens

It is estimated that 70 of exacerbations are due to infective causes o Viruses in a third to two-thirds of cases o Bacterial pathogens include H influenzae Strep pneumoniae Moraxella catarrhalis occasionally Mycoplasma pneumoniae and Chlamydophyla

pneumoniae

The presence of Pseudomonas aeruginosa or other gram negative organisms requires careful clinical interpretation (particularly if associated with bronchiectasis) As they may represent chronic colonisation

Investigations Please see the section in Community acquired pneumonia Severity Consider using the DECAF score to assess exacerbation severity in COPD

Dyspnoea (eMRCD)

5a=1 5b=2 DECAF score In hospital mortality

Eosinopenia (lt005)

1 0 0

Consolidation 1 1 15

Acidaemia pHlt73

1 2 54

Fibrillation (atrial) 1 3 153

4 31

5 405

6 50

eMRCD or extended MRC Dyspnoea score refers to the patients level of stable state dyspnoea 5a is too breathless to leave the house unassisted but independent in washing andor dressing 5b is too breathless to leave the house unassisted and requires help with washing and dressing





Management

Convert to oral therapy as soon as well enough and able to swallow (commonly by 24 hours rarely longer than 48 hours) If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)

Current of previous episode of Gram-negative infection with a multi-resistant organism (eg ESBL producers)

Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of treatment (add Teicoplanin IV in MRSA positive patients) Use of a prophylactic antibiotic is not recommended in the management of a person with stable COPD


Chronic Obstructive Pulmonary Disease

(COPD)

Mild


Penicillin allergy

Doxycycline 200mg stat then 100mg - 200mg OD

7 days

Severe



Penicillin allergy


7-10 days






D Bronchiectasis (non-CF) Definition

A disorder of the bronchi and bronchioles bronchiectasis is characterised by irreversible dilatation and destruction of the bronchial walls resulting in repeated pulmonary infections airflow obstruction and impaired drainage of secretions

Bronchiectasis may be acquired (eg as a result of pulmonary infections) or congenital (eg cystic fibrosis immune disorder or structural lung disease) The aim of treatment is prevent complications This is achieved by reducing the frequency and severity of infections and controlling bronchial secretions

Acute exacerbations are characterised by the presence of worsening cough and increased sputum volume and purulence with or without increased breathlessness wheeze reduced pulmonary function new chest infiltrates and pyrexia

Criteria for hospital admission include

Unable to cope at home

Cyanosis or confusion

Febrile temp gt38ordmC

Signs of cardiorespiratory failure

Unable to take oral drugs

Failure to respond to adequate oral therapy or no suitable oral therapy available

Pathogens

Intermittent and chronic colonisation (defined as at least 3 isolates of the same organism over a 3 month period) is common

In both adults and children H influenza is the most frequently isolated pathogen (35 of adult patients)

Pseudomonas aeruginosa is seen in 5-31 of cases followed by Strep pneumoniae Staph aureus Moraxella catarrhalis and Klebsiella pneumoniae

Mycobacterium avium complex (MAC) and Aspergillus sp are usually associated with longterm colonisation and can be difficult to eradicate

Investigations

All patients should have a respiratory specimen sent (prior to commencing antibiotics if acute exacerbation)

Consider sending at least 3 sputum samples for culture (to improve the yield) in patients lacking a prior positive culture result

Consider sending sputum samples for mycobacterial culture particularly if no standard pathogens isolated Management

Knowledge of previous sputum culture is essential in deciding an optimum empiric regimen

Initial treatment should be with oral antibiotics intravenous antibiotics should be considered when patient is particularly unwell has resistant organisms or has failed to respond to oral therapy (this is more likely with P aeruginosa infections)






Bronchiectasis

Acute exacerbation

(Inpatient) Mild

Amoxicillin 05g -1g TDS IV

Substitute amoxicillin with co-amoxiclav 625 mg PO TDS if patient has already received (and failed) amoxicillin treatment within this episode If penicillin allergic Doxycycline 200mg stat then 100 ndash 200mg PO OD or

Clarithromycin 500mg PO BD

10-14 days

Acute exacerbation

(Inpatient) Severe

Co-amoxiclav 12g IV TDS Substitute Co-amoxiclav with Piperacillin-tazobactam 45g IV TDS if patient is more severely ill or has already received (and failed) Co-amoxiclav treatment If penicillin allergy Levofloxacin 500 mg POIV BD + Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter Substitute levofloxacin with Ciprofloxacin 400mg IV BD if Pseudomonas spp isolated from sputum previously

10-14 days Levofloxacin use only for adults aged 18 years old and over Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+ Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter



Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation of therapy (add Teicoplanin IV in MRSA positive patients)




Patients experiencing frequent (ge 4year) or severe (requiring hospital admission ge 2year) may be candidates for antibiotic prophylaxis Please discuss with the respiratory team and microbiology



Bronchiectasis Acute exacerbation

(Outpatient)

Amoxicillin 500mg TDS PO

Duration 14 days

2nd

line (failure of 1st linePenicillin allergy)

Doxycycline 100mg BD PO

Duration 14 days

3rd

line (sequential failure of 1st amp 2

nd line

therapy) Azithromycin 500mg OD for 3 days then 250mg OD for 4 days

Colonised with Pseudomonasmulti-resistant organism Discuss with Consultant Microbiologist

Aetiology H influenzae Strep pneumoniae Moraxella catarrhalis Staph aureus Pseudomonas aeruginosa

Send sputum for culture prior to starting antibiotic therapy Empirical antibiotics should be based on recent sputum culture results where available





E Non-resolving pneumonia and empyema

Definition

Non-resolving pneumonia lack of clinical improvement failure of CRP to fall within 72 hours Investigation

Perform a full clinical re-assessment and obtain repeat posterior-anterior (PA)

Refer all cases to Respiratory Medicine and discuss additional investigations eg mycobacterial culture with Microbiology

If pleural effusion is seen or suspected on CXR request chest ultrasound

if fluid confirmed ultrasound-guided sampling should be performed with fluid sent for pH (sample in arterial blood gas syringe on ice to biochemistry) glucose (in a glucose blood bottle) LDH protein cytology and microscopy with culture

Remember the possibility of less common organisms including M tuberculosis (usually causes a lymphocyte-predominant effusion) and opportunistic infection in the immunocompromised

Management

All cases of empyema (pus on aspiration) loculated or complicated effusions (pleural fluid pH lt72) or large effusions should be referred to Respiratory Medicine for consideration of intercostal tube drainage

Antibiotics should target common pathogens including anaerobic organisms unless Strep pneumoniae isolated

Macrolides are not indicated routinely as infection with atypical organisms causing empyema is uncommon

Avoid aminoglycosides as poor penetration into pleural cavity and increased risk of nephrotoxicity





Change to targeted antibiotics once microbiology results are available Initial antibiotic management of empyema usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)


Sepsis is worsening despite 24 hours treatment with any of the above antibiotics or there has been no improvement after 48 hours treatment Then please contact Microbiology Consultant via switch board as the patient may likely require escalation therapy (add Teicoplanin IV in MRSA positive patients)


Non- resolving pneumonia and

empyema

1st line (IV antibiotics

are always required initially)



Penicillin allergic

Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg IV BD +

Metronidazole 500mg IV TDS

Minimum 3 weeks often requires 6-8 weeks





F Lung abscess and necrotising pneumonia Definition

Lung abscess thick-walled cavity that contains purulent material It may arise due to necrosis of infected lung tissue or secondary to haematogenous spread from a distant focus

In necrotising pneumonia widespread necrosis of lung tissue with liquefaction may lead to multiple areas of cavitation within the area of consolidation

Clinical features may be similar to CAP haemoptysis and large volume sputum production may occur Patients with necrotising pneumonia may deteriorate very rapidly

Pathogens

Lung abscess infections are usually mixed obligate anaerobes are almost always present often with alpha-haemolytic streptococci Escherichia coli and other coliforms Pseudomonas spp and Staph aureus also seen

o Multiple abscesses are typical of haematogenous seeding in association with injection drug use right sided endocarditis intravascular device related infections and bacteraemia

o Lung abscess secondary to distant infection Staph aureus Fusobacterium necrophorum (Lemierrersquos syndrome) Streptococcus lsquomillerirsquo group

Necrotising pneumonia Staph aureus (particularly strains positive for Panton-Valentine Leukocidin (PVL) Klebsiella pneumoniae obligate anaerobes (aspiration pneumonia) Pseudomonas and MRSA also seen in hospital-acquired infections

Remember the possibility of less common organisms including M tuberculosis and opportunistic infection in the immunocompromised





Management

Change to targeted antibiotics once microbiology results are available Initial antibiotic management usually requires the intravenous route consider changing to oral antibiotics when evidence of clinical improvement (resolution of fever falling CRP) Prolonged antibiotic treatment usually required with careful clinical and radiological follow-up If the patient has presence of risk factors for infection with antibiotic-resistant organisms including prolonged hospital stay and colonisation with resistant organisms (eg MRSA ESBL producers)




Lung abscess and necrotising pneumonia




Substitute co-amoxiclav with

Piperacillin-tazobactam45g IV TDS if patient is more severely ill or has already received (and failed) co-amoxiclav treatment

Alternative during piperacillin-tazobactam supply shortage Discuss with Consultant Microbiologist


Penicillin allergic



2-4 months PVL-SA necrotising pneumonia is strongly suspected or confirmed clinicians should liaise urgently with microbiology in relation to further antibiotic management Current recommendation is the addition of a combination of intravenous linezolid 600mg twice daily intravenous clindamycin 12g four times a day and intravenous rifampicin 600mg twice daily to the initial empirical antibiotic

regimen





References

Lim et al British Thoracic Society (2009) BTS guidelines for the management of community acquired pneumonia in adults update 2009 httpwwwbrit-thoracicorgukPortals0Clinical20InformationPneumoniaGuidelinesCAPGuideline-fullpdf

Maskell N on behalf of the British Thoracic Society Pleural Disease Guideline Group British Thoracic Society Pleural Disease Guidelines - 2010 update Thorax 2010 Aug65(8)667-669

httpwwwbrit-thoracicorgukPortals0Clinical20InformationPleural20DiseasePleural20Guideline202010Pleural20disease20201020pleural20infectionpdf

National Clinical Guideline Centre (2010) Chronic obstructive pulmonary disease management of chronic obstructive pulmonary disease in adults in primary and secondary care London National Clinical Guideline Centre httpguidanceniceorgukCG101GuidancepdfEnglish

British Thoracic Society (2010) Guideline for non-CF bronchiectasis British Thoracic Society httpwwwbrit-thoracicorgukPortals0Clinical20InformationBronchiectasisnon-CF-Bronchiectasis-guidelinepdf




GastrointestinalIntra-abdominal Infections


Abdomino-pelvic sepsis (including

post-operative biliary tree amp Diverticulitis)

For suspected STI-related infection

please see section ldquoGenitourinary

Infectionsrdquo

1st Line

Co-amoxiclav 12g TDS IV + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)

Aetiology Coliforms Streptococci Enterococci Anaerobes

Identify and eliminate source Antibiotics are no substitute for surgical endoscopic or radiological intervention to drain a collection or relieve biliary obstruction

2nd

line therapy is indicated if

- Failure to respond to 1st line antibiotics after 48 ndash 72hr

- Evidence of severe sepsis (see section lsquoSepticaemiarsquo for definition)

- 1st line therapy is contraindicated

- Microbiological cultures reveal resistance to 1st line but sensitivity to

2nd

line antibiotic

Discuss with Consultant Microbiologist if severely unwell or not responding to therapy

Duration Depends on underlying source Discuss with Consultant Microbiologist

2nd

Line

Piperacillin-Tazobactam 45g TDS IV


Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter +

Ciprofloxacin 400mg BD IV +

Metronidazole 500mg TDS IV

Penicillin Allergy

Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) +

Metronidazole 400mg TDS PO500mg TDS IV

Spontaneous Bacterial Peritonitis

1st Line


Alternative during piperacillin-tazobactam supply shortage Ceftazidime 1-2g IV TDS+


Aetiology Coliforms Strep pneumoniae Enterococci

Primarily occurs in patients with decompensated cirrhosis with ascites


Penicillin allergy Discuss with Consultant Microbiologist




GastrointestinalIntra-abdominal Infections contdhellip


Liver Abscess

1st Line

Co-amoxiclav 12g TDS IV + ndash Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)

Aetiology Coliforms Streptococci Anaerobes

Foreign Travel Consider Entamoeba Hydatid disease

Refer patient to Gastroenterology

Antibiotics are not a substitute for adequate drainage of an abscess Drainage of liver abscesses provides specimens for culture reduces the required duration of antibiotics and reduces the chance of relapse post therapy

2nd Line



Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Ciprofloxacin 400mg BD IV + Metronidazole 500mg TDS IV


Suspected Amoebic Liver Abscess







Necrotising Pancreatitis

Mild ndash Moderate disease without

necrosis Antibiotic therapy is NOT indicated

Aetiology Most cases non-infective

Prophylactic antibiotics in acute pancreatitis are controversial There is no good quality evidence to show a reduction in mortality or surgical intervention Some studies offer weak evidence of a reduction in complications but this is not a universal finding A Cochrane Review does NOT support the routine use of prophylactic antibiotics (Villatoro et al Cochrane Database Syst Rev 2010) Antibiotics should therefore be reserved for severe infection with necrosis on CT Prolonged use of antibacterials increases the risk of fungal super-infection


Severe disease with pancreatic necrosis

on CT

Consider prophylaxis with Piperacillin-tazobactam 45g TDS IV


Discuss with Consultant Microbilogist


Cirrhosis with Acute Variceal Bleeding

1st Line Piperacillin-tazobactam 45g TDS IV Duration 5 days


Co-amoxiclav 12g TDS IV +

Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)

Penicillin Allergy Discuss with Consultant Microbiologist

Acute Infective Diarrhoea

(Gastroenteritis)

Antibiotic therapy is NOT routinely indicated

Ensure adequate rehydration (oral or IV)

Suspected faecal parasites Treat according to causative agent Discuss with Consultant Microbiologist

Aetiology Viruses Salmonella spp Shigella spp Campylobacter spp E coli O157 Cryptosporidium

Recent Travel Consider Entamoeba amp Giardia

Most cases are self-limiting in the immunocompetent and antibiotics are of little or no benefit even in proven bacterial infection






C difficile Infection (CDI)

Refer to

The Trust Policy for The Prevention and Management of Clostridium difficile Infection (CP 102)

Mild CDI Metronidazole 400mg TDS PO

Assess severity of CDI each day as follows

Mild CDI Not associated with a raised WCC it is typically associated with lt3 stools of type 5ndash7 on the Bristol Stool Chart per day

Moderate CDI Associated with a raised WCC that is lt15 109L it is

typically associated with 3ndash5 stools per day

Severe CDI Associated with a WCC gt15 109L or an acute rising

serum creatinine (ie gt50 increase above baseline) or a temperature of gt385degC or evidence of severe colitis (abdominal or radiological signs) The number of stools may be a less reliable indicator of severity

Life-threatening CDI Includes hypotension partial or complete ileus or toxic megacolon or CT evidence of severe disease

Ensure all suspected cases of C difficile infection are promptly isolated and discussed with an Infection Prevention and Control Nurse and Consultant Microbiologist Exclude alternative causes of diarrhoea C diff toxin assays can be positive in both colonisation and disease

The precipitating antibiotic should be stopped wherever possible agents with less risk of inducing CDI can be substituted if an underlying infection still requires treatment please discuss with a Consultant Microbiologist

Discuss all concurrentfuture antibiotics with a Consultant Microbiologist to minimise the risk of recurrent infection


Moderate CDI Metronidazole 400mg TDS PO

Severe CDI

Vancomycin 125mg QDS PO

High-dosage oral Vancomycin (up to 500mg QDS) PO +- Metronidazole 500mg TDS IV is recommended in severe cases not responding to Vancomycin 125mg QDS PO

The addition of Rifampicin 300 mg BD PO or iv immunoglobulin (400 mgkg based on dose determining weight) may also be considered

Life-threatening CDI


via naso-gastric tube or rectal installation + Metronidazole 500mg TDS IV




Central Nervous System Infections


Bacterial Meningitis

Community-acquired

Ceftriaxone 2g BD IV + Dexamethasone 015mgkg IV QDS Severe penicillin allergy Discuss with Consultant Microbiologist

Aetiology N meningitidis Strep pneumoniae H influenzae

Consider Listeria monocytogenes if age gt55yr pregnant or immunocompromised

Send blood culture amp CSF (if LP not contraindicated amp patient is systemically stable) prior to the first dose of antibiotics However do NOT delay treatment if an LP cannot be performed in a timely manner

Dexamethasone should be given for 4 days starting with or just before the first dose of antibiotic

All cases should be notified to Public Health

Duration

N meningitidis ndash 7 days

Strep pneumoniae ndash 10 ndash 14 days

H influenzae ndash 10 days

L monocytogenes ndash 21 days

gt55yrs Pregnant

Immunocompromised

ADD Amoxicillin 2g 4hrly IV Penicillin allergy Discuss with Consultant Microbiologist

Post neurosurgical head injury


CNS shunt in-situ Discuss with Consultant Microbiologist Discuss with Neurosurgical team at Tertiary centre

Brain Abscess

1st Line

Ceftriaxone 2g BD IV + Metronidazole 500mg TDS IV400mg TDS PO Aetiology Staph aureus Streptococci Coliforms Anaerobes

Take blood cultures prior to antibiotic therapy

All cases should be discussed with the Consultant Microbiologist and Neurosurgical team

Penicillin allergic Discuss with Consultant Microbiologist

MRSA Colonised ADD Vancomycin 1g BD adjusted to renal function (see appendix 3)

Viral Encephalitis Aciclovir 10mgkg TDS IV

Aetiology Herpes Simplex Virus Varicella Zoster Virus

Travel-associated Consider arboviral infections eg West Nile Virus Japanese Encephalitis






Bone and Joint Infections


Septic Arthritis (Native joint no

prosthesis in situ)

1st Line

Flucloxacillin 1 ndash 2g QDS IV Aetiology Staph aureus Group A Streptococcus N gonorrhoeae (if at

risk for STDs) occasionally Coliforms (iatrogenic immunosuppressed) Salmonella spp (Sickle Cell) Blood cultures and a joint aspirate should be performed prior to antibiotic therapy in all patients with suspected Septic Arthritis All cases should be managed with advice from Orthopaedics Microbiology amp Rheumatology Repeated washouts may be required Duration 6 weeks (minimum 2 weeks IV antibiotics)

Penicillin Allergy


N gonorrhoeae likely

Ceftriaxone 2g OD IV Severe penicillin allergy Discuss with Consultant Microbiologist

Septic Arthritis (prosthetic joint in

situ)

All cases of suspected prosthetic joint infection should be discussed with the Consultant Microbiologist and an Orthopaedic referral should be made Empirical therapy is not normally indicated unless the patient is septic and may confuse the diagnostic picture Treatment guided by microbiology is based on culture amp sensitivity results of multiple (ideally 5) appropriate deep tissue specimens

Osteomyelitis

1st Line

Flucloxacillin 1 ndash 2g QDS IV + Sodium Fusidate 500mg TDS PO

Aetiology Staph aureus Streptococci rarely Coliforms Pseudomonas amp Salmonella spp

Discuss all patients with Microbiology amp Orthopaedics

Bone biopsy or radiologically-guided needle aspiration is valuable for guiding therapy In the well systemically stable patient withhold antibiotic therapy until deep sampling has been performed

Duration 6 weeks

Penicillin Allergy

Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Sodium Fusidate 500mg TDS PO




Endocarditis


Infective Endocarditis (IE)

In ALL cases of suspected IE a minimum of three sets of blood cultures should be taken using aseptic technique from different sites at least 30 minutes apart before commencing antibiotic therapy If a patient with suspected IE is clinically stable wait for results of blood cultures before starting antibiotics

Native valve indolent presentation

Amoxicillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV Penicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD

Aetiology Viridans type Strep Enterococcus spp Staph aureus Coagulase negative Staphylococci (Prosthetic valve) HACEK group Discuss ALL cases with the Consultant Microbiologist amp Cardiology Team Consider early Cardiothoracic input in patients with a prosthetic valve or rapidly deteriorating cardiac function Gentamicin monitoring in endocarditis

- Pre-dose (trough) lt1 mgL - Post-dose (peak) 3 ndash 5 mgL

See Trust Policy for Gentamicin Dosing and Monitoring for Adults Modify antibiotics in discussion with Consultant Microbiologist in light of culture results Duration Varies according to causative organism valve type (native or prosthetic)

Native valve acute presentation

Flucloxacillin 2g 4 hourly IV + Gentamicin 1mgkg BD IV MRSA colonisedPenicillin allergy Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD Severe sepsisRisk factor for gram negative infection Discuss with Consultant Microbiologist

Prosthetic valve

Vancomycin IV (see appendix 3) + Gentamicin 1mgkg BD + Rifampicin 300mg ndash 600mg BD POIV




Septicaemia (including Neutropenic Sepsis)


Septicaemia

Clinical source of infection present

See relevant section of this guideline for antimicrobials targeted against the clinical source of infection

Clinical source of infection unknown ndash Community onset

1st Line Co-amoxiclav 12g TDS IV +


2nd

Line Piperacillin-tazobactam 45g TDS IV

MRSA Colonised ADD Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter

Penicillin allergic Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO

The diagnosis of lsquosepsisrsquo required the presence of ge2 of the following in the presence of infection

- Temperature gt38ordmC or lt36ordmC - Heart rate gt90bpm - Respiratory rate gt20 breathsmin - WBC gt12 or lt4

See Trust Policy for Managing Sepsis 2

nd Line therapy is indicated if - Failure to respond to 1

st line therapy

- Microbiology results indicated resistance to 1st line but

susceptibility to second line agent(s) - Severe sepsis (ge2 of SBP lt90mmHg pO2 lt8kPa Lactate

gt2mmolL reduced GCS oliguria lt30mlhr other evidence of end organ failure)

Discuss with Consultant Microbiologist if not responding to empirical regimen

Clinical source of infection unknown ndash Hospital onset

1st Line Piperacillin-tazobactam 45g TDS IV

Persistent hypotension after 1hr aggressive fluid resuscitation ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)






Septicaemia (including Neutropenic Sepsis) contd


Neutropaenic Sepsis Community amp Hospital

onset

1st Line Piperacillin-tazobactam 45g

QDS IV

Penicillin allergic (MILD eg rash)

Meropenem 1g TDS IV



Penicillin allergic (SEVERE) Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Gentamicin IV (see Trust Policy for Gentamicin Dosing and Monitoring for Adults) + Metronidazole 500mg TDS IV400mg TDS PO

See Trust Guidelines for Management of Febrile Neutropaenia in Adults who had Systemic Anti-cancer Therapy CGSG 106 Empirical glycopeptide therapy (teicoplanin or vancomycin) are NOT usually indicted in patients who are not MRSA colonised even in the presence of an indwelling central venous cannula (CVC) or CVC infection

Catheter-related Blood Stream

Infection (CRBSI)

Peripheral Venous Cannula (PVC)

See section Skin amp Soft Tissue Infection

Central Venous CatheterTunnelled Line Discuss with Consultant Microbiologist




Ear Nose amp Throat (Oropharyngeal) Infections


Streptococcal Pharyngitis Tonsillitis

1st Line

Penicillin V 500mg QDS PO

Unable to swallow Benzylpenicillin 12g QDS IV

Aetiology Commonly viral Group A Streptococcus

Most ENT infections are viral for which antibiotics are NOT indicated

Duration 10 days Penicillin allergy Clarithromycin 500mg BD POIV

Acute Bacterial Sinusitis

1st Line

Outpatient Amoxicillin 500mg TDS PO

Severe infection requiring hospitalisation Co-amoxiclav 12g TDS IV

Aetiology Commonly viral Strep pneumoniae H influenzae Anaerobes

Most infections are viral and self-limiting Antibiotics should be reserved for those who are systemically unwell or are not resolving after 7 days conservative management

Duration 5 ndash 7 days Penicillin allergy Clarithromycin 500mg BD POIV

Otitis Media 1

st Line Amoxicillin 500mg TDS PO Aetiology Commonly viral Strep pneumoniae H influenzae


Acute Epiglottitis

Ceftriaxone 2g OD IV

Severe penicillin allergy Discuss with Consultant Microbiologist

Aetiology H influenzae Strep pneumoniae Staph aureus

Do NOT attempt a throat swab ndash risk of airway obstruction

Refer to ENT




Ophthalmic Infections


Conjunctivitis 1st Line

Chloramphenicol 0middot5 eye drops

One drop at least every 2 hours reducing frequency as infection is controlled

The majority of infections are viral therefore consider whether giving antibiotics Aetiology Viral Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis

Duration Continue for 48hr after resolution

Suspected herpetic conjunctivitis Refer to Ophthalmologist

Contact Lens Keratitis

Aetiology Pseudomonas aeruginosa Staph aureus Acanthamoeba

Refer to Ophthalmologist

OrbitalPeriorbital Cellulitis

1st Line



Aetiology Staph aureus Strep pneumoniae H influenzae Moraxella catarrhalis Group A Streptococcus Anaerobes occasionally Coliforms (post trauma)

Consider CT scan to exclude orbital abscesses CNS or sinus involvement Surgical intervention may be required if a collection is present

Duration 7 ndash 14 days Penicillin allergic

Teicoplanin IV (see Appendix 4 for dosing) ndash load bd for three doses then od thereafter + Doxycycline 100mg BD PO

Severe sepsis OR post-traumatic OR failure to respond after 48hr Discuss with Consultant Microbiologist

Ophthalmic ZosterHSV

Aciclovir 800mg 5 times daily PO

+ topical Aciclovir eye ointment 3 applied 5 times daily

Aetiology VZV HSV





Genitourinary Tract Infections Sexually Transmitted Diseases


Gonococcal Infection

1st Line

Ceftriaxone 500mg IM STAT

+ Azithromycin 1g PO STAT (single dose)

Severe penicillin allergy Discuss with Consultant Microbiologist Refer all cases of suspected or confirmed STDs to GUM clinic

If GUM referral is not possibleappropriate take a urethral swab for gonorrhoeal culture and specific urethral swab (women) or MSU in diluent (men) for Chlamydia Specific containers are required from microbiology Gonorrhoea amp Chlamydia co-infections are common consider treating both if one or the other is suspected

2nd

Line

(IM injection contraindicated or refused by patient)

Cefixime 400 mg PO STAT


Chlamydia

1st Line Doxycycline 100mg BD PO for 7 days

Alternative

Azithromycin 1g PO STAT (single dose)

[Reserved if concerns regarding poor compliance]

Epididymo-orchitis

lt35yrs sexually active

STD likely

Ceftriaxone 500mg IM STAT + Doxycycline 100mg BD PO

Aetiology N gonorrhoea Chlamydia trachomatis

Refer to the GUM clinic


gt35yrs not sexually active

STD unlikely

Outpatient

Ciprofloxacin 500mg BD PO

Inpatient


Aetiology Coliforms

Duration 10 days Alternative during piperacillin-tazobactam supply shortage Ciprofloxacin 400mg BD IV

Prostatitis

1st Line Ciprofloxacin 500mg BD PO Aetiology Coliforms Enterococci Staph aureus Anaerobes If sexually

active N gonorrhoea Chlamydia trachomatis

Duration Acute prostatitis 14 ndash 28 days Chronic prostatitis 28 days

Alternative (intolerant of 1

st line)

Trimethoprim 200mg BD PO

If septic ADD Gentamicin IV stat (see Trust Policy for Gentamicin Dosing and Monitoring for Adults)




Genitourinary Tract Infections Sexually Transmitted Diseases contd


Pelvic Inflammatory

Disease

Outpatient


followed by

Doxycycline 100mg BD PO +

Metronidazole 400mg BD PO Aetiology N gonorrhoeae Chlamydia trachomatis Coliforms Streptococci

Anaerobes

Refer to Obs amp Gynae

If pregnant these regimens are NOT suitable Please discuss with

Consultant Microbiologist

Duration 14 days

Inpatient

Ceftriaxone 2g OD IV +


Metronidazole 400mg BD PO

Once afebrile 24hr with sustained clinical

improvement switch to



Severe Penicillin

allergy

Ofloxacin 400mg BD POIV +

Metronidazole

400mg BD PO500mg TDS IV

High risk of gonococcal infection Discuss

with Consultant Microbiologist




5 ANTIBIOTIC PROPHYLAXIS FOR SURGERY

General Considerations 1 Effective prophylaxis

Is achieved by a single dose of an antibacterial with activity against the organisms most likely to cause infection with a few notable exceptions (SIGN Guidelines 2008)

Should be given intravenously in a fully therapeutic dose

Should be given around 30 minutes before the first incision (usually with induction of anaesthesia)

2 An additional intra-operative dose should only be considered if the operation

Is long (gt5 hours)

Involves substantial blood loss (gt15L)

Involves substantial haemodilution (gt15 mlkg) 3 Continuing prophylaxis into the postoperative period

Is no more effective for preventing surgical site infections than a single preoperative dose

Encourages the emergence of resistant bacteria (eg MRSA and VRE)

Increases the likelihood of adverse effects such as C difficile diarrhoea 4 Surgical prophylaxis is not recommended for ldquocleanrdquo surgery 5 The doses of all antibiotics may need adjustment depending upon the patientrsquos renal

function Discuss with a Consultant Microbiologist




TYPE OF OPERATION (SITE) RECOMMENDED ANTIMICROBIALS

GASTROINTESTINALINTRA-ABDOMINAL

1 Colorectal Hepatobiliary Appendicectomy Oesophagogastricduodenal

Co-amoxiclav 1middot2g IV at induction

Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV at induction

MRSA Colonised ADD Teicoplanin 400mg IV

2 Laparoscopic cholecystectomy

Usually antibiotics are not recommended unless there is recent or current jaundice or recent pancreatitis and bile spillage

Gentamicin 120mg IV single dose at induction

3 Gastrointestinal endoscopy

As per BSG Guidelines (2009)

- Antibiotic prophylaxis is NOT routinely indicated - Antibiotic prophylaxis is no longer indicated in patients with valvular heart disease or prosthetic valves - If neutropaenic (neut lt05 x 10

9L) AND procedure is

considered high risk for bacteraemia (eg sclerotherapy dilatation ERCP with obstructed system) consider prophylaxis with - Amoxicillin 1g IV plus Gentamicin 120mg IV single dose plus Metronidazole 500mg IV single dose just before procedure - Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV single dose just

before procedure

4 ERCP With bile stasis or pancreatic pseudocyst or previous cholangitis

Piperacillintazobactam 2middot25g IV single dose just before the procedure


Ciprofloxacin 400mg stat dose before procedure

Penicillin allergy Gentamicin 120mg IV

5 PEG insertion

Co-amoxiclav 1middot2g IV just before the procedure

Penicillin allergyMRSA colonised Teicoplanin 400mg IV plus Gentamicin 120mg IV





GENITOURINARY

If preoperative urine is positive treat according to culture result for 48 hrs before operation

1 Cystoscopy

Rigid cystoscopy Gentamicin 120mg IV just before procedure

Flexible cystoscopy for patients with high risk of infection only ndash Gentamicin as above

2 Urodynamics Trimethoprim 200mg PO bd 37

3 Transrectal ultrasound scan (TRUS) and biopsy of prostate

Ciprofloxacin 1g PO just before procedure

Followed by Gentamicin 120mg IV plus Metronidazole 1g PR after biopsy Followed by Ciprofloxacin 500mg PO at 12 hours post procedure

4 Transurethral resection of

prostate (TURP)

Transurethral resection of bladder tumour (TURBP)

Open renal surgery

Radical retropubic prostatectomy

Stent insertionchangeremoval

Stone removal (open)

Shock wave lithotripsy

Gentamicin 120mg IV at induction

(if CSUMSU positive treat according to sensitivity)

8 Radical perineal prostatectomy

Co-amoxiclav 1middot2g IV TDS for 48 hours

Penicillin allergic discuss with Consultant Microbiologist

9 Cystectomy + ndash reconstruction

Gentamicin 120mg IV plus Metronidazole 1g PR at induction

Followed by Metronidazole 1g PR12 hours post procedure





OBSTETRIC amp GYNAECOLOGICAL SURGERY

1 Vaginal abdominal or laparoscopic hysterectomy


A second dose may be needed if significant blood loss or prolonged operation (ie gt5 hours)

Penicillin allergy Gentamicin 120mg IV plus Metronidazole 500mg IV


2 Termination of pregnancyERPC

Metronidazole 1g PR at induction

Followed by

Doxycycline 100mg BD for 7 days

OR

Azithromycin 1g PO stat (use only if likely poor compliance

unless patient was screened negative for chlamydia)

3 Trans vaginal tape Gentamicin 120mg IV single dose at induction

4 Caesarean section Refer to Caesarean Section Guideline no 427

5 Prevention of perinatal infection with Group B Streptococcus

Refer to Departmental guidelines

PLASTIC AND RECONSTRUCTIVE SURGERY

1 Clean surgery

Antibiotic prophylaxis not routinely required

Extensivelengthy operations (gt3hr) graft of prosthetic surgery



Penicillin allergy Teicoplanin 400mg IV

2 Clean Contaminated surgery


MRSA Colonised ADD Teicoplanin 400mg IV Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV





ORTHOPAEDIC

1 Clean orthopaedic surgery without implant

Antibiotic prophylaxis is NOT routinely recommended

2 Bone surgery

Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV

MRSA colonised Teicoplanin IV (see Appendix 4 Table 3 for dosing) plus Gentamicin 120mg IV

These doses provide 24 hours prophylaxis Comments Repeat doses of teicoplanin amp gentamicin are not required due to their long half-life

If infection possible take ge5 samples before giving prophylaxis

These regimens may need modification to cover resistant pathogens in individual cases

Revision arthroplasty for suspected or confirmed infection do NOT follow these guidelines (refer to the trust PJI treatment guidelines or speak to the Consultant microbiologist

NB Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt30 mlminute) Contact Microbiology to discuss alternatives

3 Prosthetic joint surgery

Primary arthroplasty

Single stage revision arthroplasty

(infection not suspected)








4 Compound fracture repair

Co-amoxiclav 1middot2g IV at induction Followed by 2 further doses at 8 hourly intervals

Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV plus Metronidazole 500mg IV at induction




Repeat all three 12 hours later

5 Amputation

For prevention of gas gangrene in high (lower limb) amputations or following major trauma

Benzylpenicillin 600mg QDS IV for 5 days

Penicillin allergy Metronidazole 500mg TDS IV for 5 days

VASCULAR SURGERY

All Vascular Surgical Procedures


MRSA colonised ADD Teicoplanin 400mg IV

Penicillin allergy Teicoplanin 400mg IV plus Gentamicin 120mg IV at induction

Vascular graft Continue antibiotics for 24 hours post-op

Amputation Requires gas gangrene prophylaxis post-op ndash see under Orthopaedic Surgery

THORACIC and HEAD amp NECK SURGERY

Thoracic Surgery

Head amp Neck Surgery




plus Gentamicin 120mg IV at induction




6 OTHER ANTIBIOTIC PROPHYLAXIS

OTHER ANTIBIOTIC PROPHYLAXIS

PROCEDURE RECOMMENDED ANTIMICROBIALS

1 Endocarditis prophylaxis for patients with structural cardiac conditions

(acquired valvular disease with stenosis or regurgitation valve replacement structural congenital heart disease hypertrophic cardiomyopathy previous infective endocarditis)

Antibiotic prophylaxis no longer indicated (NICE Clinical Guideline 64 March 2008) for most procedures (Discuss with a Consultant Cardiologist if unsure)

EXCEPT

If patients at risk of endocarditis are undergoing a gastro-intestinal or genito-urinary tract procedure at a site where infection is suspected they should receive appropriate antibacterial therapy that includes cover against organisms that cause endocarditis

(Discuss with a Consultant Microbiologist)

2 Permanent Pacemaker Insertion

Refer to the current Department Guideline

For

Antibiotic Guidelines for Permanent Pacemaker (PPM) insertion in Adults

CARD 018

Flucloxacillin 1g IV and Gentamicin 80 mg IV at induction (30 min prior to procedure)

A second dose of Flucloxacillin 1g IV should be given

intra-operatively if procedure lasts ge 2 hours

Penicillin allergic or MRSA positive patients Teicoplanin 400mg IV and Gentamicin 80mg IV at induction (30 min

prior to procedure)

Second dose of Teicoplanin not required as very long

half-life

Comments

Gentamicin should be omitted in those with severe renal failure (creatinine clearance lt10 mlminute)

Post-procedure antibiotics are not necessary

Local instillation of antimicrobials or antiseptics should be avoided until evidence of benefit has been demonstrated

3 Splenectomy or dysfunctional spleen

Penicillin V 500mg PO bd (life long)

Penicillin allergy Erythromycin 500mg PO od (life long)

Ensure vaccinations against Streptococcus pneumoniae H influenzae and N meningococcus have been completed in line with the Trust Guideline 077 for the Management of Patients with an Absent or Dysfunctional Spleen




7 FURTHER READING Early Management of Meningitis in Immunocompetent Patients (British Infection Society) 2003 Guidance for Public Health Management of Meningococcal Disease in the Community (HPA) 2011 Tunkel AR Hartman BJ Kaplan SL et al Practice guidelines for the management of bacterial meningitis Clin Infect Dis 2004 391267 ndash 84 Tunkel AR Glaser CA Bloch KC et al The Management of Encephalitis Clinical Practice Guidelines by the Infectious Diseases Society of America Clin Infect Dis 2008 47303 ndash 27 National Institute for Health and Clinical Excellence (2004) Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care NICE Clinical Guideline 12 Web link httpwwwniceorguknicemediapdfCG012_niceguidelinepdf Crosbie P A J Woodhead M A Long-term Macrolide Therapy in Chronic Inflammatory Airway Diseases Eur Respir J 2009 33 171 ndash 181 Scottish Intercollegiate Guidelines Network (SIGN) Antibiotic Prophylaxis in Surgery A National Clinical Guideline July 2008 ISBN 978 1 905813 34 6 Johnson CD Charnley RB et al UK Guidelines for the Management of Acute Pancreatitis Gut 2005541 ndash 9 httpwwwbsgorgukpdf_word_docspancreaticpdf Pasteur MC Bilton D Hill AT British Thoracic Society Bronchiectasis non-CF Guideline Group Thorax 201065 Suppl 1i1 ndash 58 Gould FK Denning DW Elliott TSJ et al Guidelines for the Diagnosis and Antibiotic Treatment of Endocarditis in Adults A report of the Working Party of the British Society for Antimicrobial Chemotherapy JAC 2012 67269 ndash 289 Villatoro E Mulla M Larvin M Antibiotic Therapy for Prophylaxis Against Infection of Pancreatic Necrosis in Acute Pancreatitis Cochrane Database Syst Rev 2010 May 12(5) P Leman D Mukherjee Flucloxacillin Alone or Combined with Benzylpenicillin to Treat Lower Limb Cellulitis A Randomised Controlled Trial Emerg Med J 2005 22342ndash346 NICE Surgical Site Infection Quality Standard Oct 2013 Antimicrobial prophylaxis in orthopaedic surgery the role of teicoplanin Piero et al Journal of Antimicrobial Chemotherapy (1998) 41 329ndash340 Pharmaceutical Press British National Formulary 72




APPENDIX 1

Guideline for Switch Antibiotic Therapy

Converting from intravenous (IV) antibiotics to oral therapy is known as switch therapy Switch antibiotic therapy in appropriate situations offers the same quality of care as IV therapy but with

Increased patient convenience (eg increased mobility comfort and quality of life)

Ease of administration

Reduced hospital resources (eg nursing time drug costs consumables IV equipment)

Reduced frequency of adverse drug reactions (ADRs) (eg phlebitis and venflon site infections)

Earlier patient discharge

IV antibiotics should be used if the clinical condition justifies their use but review is necessary for IV administration on a daily basis and formally at 48 hours and five days

Prescriptions for IV therapy that are to continue beyond 48 hours must have a counter signature from a Registrar or Consultant unless one or more of the exclusions listed below are endorsed in the comments box on the prescription

House Officers and Senior House Officers may switch IV to oral therapy

Normally there should be a switch from IV to oral therapy at 48 hours providing that The patient is afebrile

The patient is able to take oral medication

Clinically the patient is improving satisfactorily

An equivalent oral formulation is available

If in doubt contact Consultant Microbiologist for advice

There is no oral form of piperacillintazobactam Available microbiology results should be reviewed before prescribing co-amoxiclav NB Not all organisms are sensitive to co-amoxiclav

(eg pseudomonas and other multi-drug resistant organisms) Clinicians may choose to prescribe co-amoxiclav but the response should be carefully monitored If difficulties are encountered please discuss the patient with a Consultant Microbiologist




Exclusions from Switch Therapy

Switch Therapy will not be appropriate at 48 hours for infections that may require prolonged IV therapy or high tissue antibiotic concentrations such as

Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis

Cellulitis with spreading lymphadenopathy and high fever

Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis

Switch Therapy may also not be appropriate in circumstances where oral absorption may be compromised such as

Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea

Malabsorption syndromes

Nasogastric suctioning

NB This list is not exhaustive




APPENDIX 2

Penicillin Allergy

a) Serious reactions such as anaphylaxis or angioneurotic oedema constitute a serious penicillin allergy In such situations avoid using all beta lactam antibiotics (penicillins and cephalosporins) and other chemically related antibiotics such as imipenem meropenem and aztreonam as there is a chance of cross-reaction1 (1-Terico et al Journal of Pharmacy Practice 2014 Beta-

Lactam Hypersensitivity and Cross-Reactivity)

Alternative antibiotics can be used for patients with such a history depending on the clinical situation eg clarithromycin trimethoprim clindamycin teicoplanin or gentamicin

b) For mild penicillin allergies (not anaphylaxis or serum sickness) a cephalosporin or a carbapenem is appropriate to use (lt10 cross reactivity between penicillins and cephalosporins) Discuss with Consultant Microbiologist if concerned

c) In serious infections or if you are unsure always discuss with Consultant Microbiologist

General Points on Allergies

The prescriber is responsible for completing the drug sensitivity allergy box on all relevant drug charts

Pharmacists and nursing staff may complete the drug sensitivity allergy boxes if they can reasonably establish the allergy status

Reports (previous prescriptionmedical notes) from patientscarersrelatives should be discussed with prescribers and a confirmation sought before adding to records Any concerns must be drawn to the attention of the prescriber

Only true allergies should be documented in the drug sensitivity allergy box ndash not side effects such as nausea etc

If an allergy is documented it should also include information on the drug and the reaction that occurred The entry should be dated and signed

If there is no information re allergies then the drug sensitivity allergy box should be completed with lsquonil knownrsquo This should also be signed and dated

The allergy box should be completed BEFORE drugs are administered or dispensed In cases where the box is not completed ALL staff have a responsibility to determine allergy status so that patients may safely receive required treatments

Patients identified as having a drug allergy should wear an allergy wristband

All wristbands should be checked BEFORE any drug is administered

On no account may allergy bands be used as name bands

A Trust Incident Form should be completed if a patient is prescribed a drug to which they are known to be allergic

Patients should be informed if they are known or suspected to have developed a drug allergy




Beta-lactam antibiotics

Amoxicillin

Benzylpenicillin (Penicillin G)

Co-amoxiclav (Augmentinreg)

Flucloxacillin

Phenoxymethylpenicillin (Penicillin V)

Piperacillin plus tazobactam (Tazocinreg)

Pivmecillinam

Temocillin

CONTRA-INDICATED History of penicillin allergy

with life threatening reaction eg anaphylaxis

angioedema immediate

rash urticaria

CAUTION History of non-severe penicillin

allergy

eg Delayed or minor rash

Avoid if severe penicillin allergy- anaphylaxis

angioedema urticaria

CONSIDERED SAFE

In patients with penicillin

allergy however consider

allergies to other drugs

Cephalosporin and beta-lactam antibiotics

Cefaclor Aztreonam Cefadroxil Meropenem

Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime

Other antibiotics Gentamicin

Azithromycin Levofloxacin Ciprofloxacin Linezolid

Clarithromycin Metronidazole Clindamycin Nitrofurantoin Chloramphenicol Oxytetracycline Co-trimoxazole Rifampicin Colistin Sodium fusidate Doxycycline Teicoplanin

Daptomycin Tobramycin

Erythromycin Trimethoprim

Fosfomycin Vancomycin

Please check BNF

for a full list of

these antibiotics

PENICILLIN ALLERGY ndash Antibiotic Prescribing in Penicillin Allergic Patients

ALWAYS ask for DESCRIPTION OF THE REACTION experienced Document in medical notes and on drug chart the name of

medicine and the type of allergic reaction

Individuals with a history of anaphylaxis urticaria or rash immediately after penicillin administration are at risk of immediate

hypersensitivity to penicillin these individuals should not receive penicillin a cephalosporin or another beta-lactam antibiotic

If necessary please discuss alternative therapy with Consultant Microbiologist extension (Lister 4043 ndash Microbiology Secretary)

or Antimicrobial Pharmacist (bleep 5933)

(Adapted from Luton and Dunstable NHS Trust)

ENSURE ANTIBIOTIC GUIDELINES ARE FOLLOWED

IN ALL CASES




APPENDIX 3

Protocol for Vancomycin Administration in Adults

Vancomycin is an antibiotic given intravenously with activity against Gram positive infection including MRSA Excessive vancomycin can lead to nephrotoxicity or ototoxicity (although with modern highly purified preparations such toxicity is almost never seen) Monitoring of serum levels is required for efficacy as well as to avoid toxicity Oral vancomycin is NOT absorbed but can be effective against colonic infections due to C difficile In this situation assay of the blood levels is not required

Dose and

Monitoring

Normal adult dose (normal renal function) is 1g BD

Check pre-dose (trough) level before the 4th dose

The 4th dose should be given while awaiting results

If the level is 10 ndash 15 mgL give the next dose and continue to monitor the pre-dose level twice weekly If gt15 mgL discuss with Consultant Microbiologist

For adults 75 years and for patients with mild renal impairment (ie creatinine 120 ndash 200 micromolL) reduce the dose to 1g every 24 hours

For moderate to severe renal impairment (ie creatinine gt200 micromolL) give a stat dose of 1g and take blood 24 hours post dose

If the vancomycin level is lt15mgL give the next dose

If vancomycin level 15mgL contact Consultant Microbiologist

Administration

Dilute each reconstituted 500mg vial with at least 100mL sodium chloride 09 or glucose 5

Rate should not exceed 10mg per minute

Reference

Rybak M J Lomaestro B M Therapeutic monitoring of vancomycin in adult patients A consensus review of the American Society of Health-System Pharmacists the Infectious Diseases Society of America and the Society of Infectious Diseases Pharmacists CID 2009 49325ndash7




APPENDIX 4

Teicoplanin dose banding in adults with good renal function

Table 1 ndash Treatment of skin and soft tissue infections Respiratory Tract Infections

Intra-abdominal Infections Septicaemia Neutropenic sepsis

Table 2 ndash Treatment of bone and joint infections Infective endocarditis Actual body weight (Kg) Loading dose Maintenance dose

ge80 1000mg 12 hourly for 3 doses 1000mg once a day

65-799 800mg 12 hourly for 3 doses 800mg once a day


le499 400mg 12 hourly for 3 doses 400mg once a day

Table 3 ndash Surgical Prophylaxis of Prosthetic Joint Surgery

Actual body weight (Kg) Single dose

ge80 1000mg (needs to be given as an infusion see below)

65-799 800mg

50-649 600mg

le499 400mg

Actual body weight (Kg) Loading dose Maintenance dose








Therapeutic Dose Monitoring for Teicoplanin

Loading dose See table

Maintenance dose See table

Renal dose adjustments (GFR mLmin) Give normal loading dose and then reduce after 4th day according to degree of renal impairment Check with pharmacist what dose to use

Method of administration IV Injection (doses le800mg) Slowly add entire content of ampoule of water for injections to teicoplanin vial Gently roll vial to dissolve teicoplanin Avoid foam formation do not shake vial If solution becomes foamy allow to stand for 15 minutes to allow foam to subside Give as IV bolus over 4-5 minutes IV Infusion (doses gt 800mg) Once dissolved in the diluent provided diluted to 100mL with sodium chloride 09 or glucose 5 Give doses higher than 800mg (12mgkg) over 60 minutes

Therapeutic Levels - MONITOR LEVELS Take TROUGH level (ie immediately prior to giving a dose) around the 6th or 7th dose (including loading dose) Consider doing a level sooner andor more often in renal impairment Teicoplanin assays are sent to Bristol with a turnaround time of 3-7 days Do not withhold doses pending results

Trough level for complicated skin and soft tissue infections 15 - 20mgmL Trough level for bone and joint infections 20 - 40 mgmL

Dose adjustment (always check is level is true trough level before interpreting the result)

Trough level Dose adjustment Comment

˂20mgmL Increase dose by one dose band

Re-assay after 5 days

NOTEFor complicated skin and soft tissue infections therapeutic level 15-60mgmL

20-60mgmL Continue current dose Re-assay not required within 4 weeks if no change in renal function

˃60mgmL Above recommended target level Reassess if dose appropriate according to renal function Extend the dosage interval or reduce dose

Re-assay in 5-7 days




Further reading

Electronic Medicine Compendium (eMC) Summary of Product Characteristics for Targocid 400mg powder for solution for injectioninfusion or oral solution Sanofi Last updated on eMC 27 May 2016 Medusawalesnhsuk (2017) Medusa Logon page - WB10 [online] Available at httpwwwmedusawalesnhsuk [Accessed 13 January 2017]

Anon (2015) [online] Available at httpwwwbcarenbtnhsukwp-contentuploadsAntibiotic-Assay-Guideline-Ranges-20151pdf [Accessed 26 Jan 2017]




APPENDIX 5

Adult Extended Interval Gentamicin dose Dosing

See CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults




APPENDIX 6

Adult Extended Interval Amikacin Dosing

1 General Principles

All IV antibiotics should be reviewed after 48 hours

Patients should not be given more than 5 days of amikacin therapy without explicit approval from a Consultant Microbiologist

The patientsrsquo weight and renal function is required for dose determination

eGFR is not sufficiently accurate for amikacin dosing and so the creatinine clearance must be calculated before selecting the dose

11 Check for exclusionscontraindications to amikacin therapy Discuss therapy with a Consultant Microbiologist if it is thought that the use of amikacinis indicated in a patient within any of the groups below

Known renal impairment

Patients gt75yrs of age

Pregnancy

Patients with extensive burns (gt20 of body surface area)

Blind patients

Patients with endocarditis

Patients with a history or signs of hearing loss or vestibular dysfunction

Patients with a family history of maternal early-onset deafness

Patients with myasthenia gravis

Patients known to be hypersensitive to aminoglycosides or excipients

12 Determine the weight for dosing

For non-obese patients use the actual body weight (ABW) in Kg to determine the dose For overweight patients (BMI gt25) use the adjusted body weight (AdjW) - (See Appendix 1)

13 Determine the renal function for dosing

Calculate creatinine clearance (CrCl) using the following (Cockcroft-Gault) equation

Use actual body weight or adjusted body weight if BMIgt25

Male patient Female patient

CrCl= (140-age (years)) x weight (Kg) x 1middot23

Serum creatinine (micromoll)

CrCl = (140-age (years)) x weight (Kg) x 1middot04





14 Monitoring of therapy Amikacin requires careful monitoring to ensure adequate treatment with minimal risk of adverse effects Renal function should continue to be assessed throughout therapy and adequate hydration should be maintained Side effects such as ototoxicity may occur despite ldquonormalrdquo levels especially if used in combination with other ototoxic drugs (eg furosemide) Auditory and vestibular function should be monitored during treatment Serum samples for monitoring of levels (brown top bottle) should be sent to Biochemistry




2 Amikacin Therapy

21 Dose selection The standard treatment dose is 15mgKg (based on ABW or AdjW as in Appendix 5a) which should be rounded down to the nearest 50mg Where the renal function is severely impaired (CrCl lt20mlmin) it is imperative that the dose of amikacin is reduced to 75mgKg (see Table 1) Regardless of the patientrsquos weight no single dose of amikacin should exceed 1300mg

22 Prescribe amikacin The initial dosing regimen frequency and timing of the sample is specified in Table 1

23 Monitoring amikacin The frequency and timing of the sample is specified in the following table (see Table 1)

Table 1 Dose interval and monitoring for amikacin based on calculated CrCl

Renal function

Initial IV amikacin dose Monitoring

CrCl ge40mlmin

15mgKg every 24 hours

Max dose 1300mg

Take trough level before 2nd dose then give the 2nd dose

Check result BEFORE giving 3rd dose

If the level lt5mgL give the 3rd dose and monitor levels twice weekly

If the level ge 5mgL check the level every 12-24

hrs until lt5mgL then give 3rd dose Call microbiology for advice regarding ongoing

therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat

Take trough level 24 hours later Check result before next dose

Only give next dose if level lt5mgL Repeat this daily

Note This table assumes that the patient has no contra-indication to amikacin therapy and that their renal function remains stable during therapy For obese patients use corrected body weight

24 Administration Amikacin is given as a slow intravenous bolus over 3 ndash 5 minutes




APPENDIX 6a

Calculation of Adjusted Body Weight AdjW) for Dosing in Obese Patients

Useful Calculation Guides and Links to determine renal function and dosing Creatinine clearance Cockcroft and Gault should always be used for calculating the doses of potentially toxic drugs with a narrow therapeutic index (eg amikacin) Do NOT use eGFR for this purpose as it is likely to underestimate or overestimate renal function in obese or underweight patients respectively According to the patientrsquos BMI either the actual body weight (ABW) or adjusted body weight (AdjW) will be used to calculate the creatinine clearance and determine amikacin dose


CrCl= (140-age) x weight (kg) x 1middot23


CrCl = (140-age) x weight (kg) x 1middot04


The weight used for calculating creatinine clearance will be based on BMI as below

BMI (kgm2) Weight to use when calculating Creatinine

Clearance

lt 185 ndash 249

Actual Body Weight (ABW)

gt25 Adjusted Body Weight (AdjW)

Ideal Body Weight (IBW)

Males IBW = 50 kg + 23 kg for each inch over 5 feet

Females IBW = 455 kg + 23 kg for each inch over 5 feet

Adjusted Body Weight (AjBW)

IBW + 04(actual weight - IBW)

Estimated Ideal Body Weight (IBW)




Sending Samples to Pathology Laboratory

8 FURTHER READING

Winter M Basic Clinical Pharmacokinetics 5th ed California Wolters Kluwer Health 2010 When should gentamicin levels be taken after once daily administration UKMi Medicines QampA QampA 1963 2013 How should antibiotics be dosed in obesity UKMi Medicines QampA QampA 3781 2013 Scottish Antimicrobial Prescribing Group [Internet] NHS Scotland 2009 [cited 13 October 2016] Available from httpmedusawalesnhsukdocsSAPG_Guidance_on_gentamicin_and_vancomycin_policies_revisedpdf Freeman C D et al Once-daily dosing of aminoglycosides review and recommendations for clinical practiceJ Antimicrob Chemother (1997)39 (6) 677-686 Gould K and Denning D et al (2012) Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults a report of the Working Party of the British Society for Antimicrobial Chemotherapy Journal of Antimicrobial Chemotherapy 67 pp 269 - 289 Kidney International Supplements (2012) KDIGO Clinical Practice Guidelines for Acute Kidney Injury [online] Available at httpwwwkdigoorgclinical_practice_guidelinespdfKDIGO20AKI20Guidelinepdf [Accessed 1 Nov 2016] Renaldrugdatabasecom (2016) The Renal Drug Database [online] Available at httpsrenaldrugdatabasecom [Accessed 4 Nov 2016] Pharmaceutical Journal (2015) Gentamicin dose regimens and monitoring [online] Available at httpwwwpharmaceutical-journalcomlearninglearning-articlegentamicin-dose-regimens-and-monitoring20069096article [Accessed 1 Nov 2016] Surrey and Sussex Healthcare NHS Trust Gentamicin Prescribing Guidelines March 2014 Hatala R Dinh T Cook DJ Once-daily aminoglycoside dosing in immunocompetent adults a meta-analysis Ann Intern Med 1996 124717 Zaske DE Aminoglycosides In Applied Pharmacokinetics 3rd Ed William EE Schentag EJ Jusko WJ (Eds) Applied Therapeutics Inc Vancouver WA 1994 Rybak MJ Abate BJ Kang SL et al Prospective evaluation of the effect of an aminoglycoside dosing regimen on rates of observed nephrotoxicity and ototoxicity Antimicrob Agents Chemother 1999 431549 Urban AW Craig WA Daily dosage of aminoglycosides In Remington JS Swartz MN Current Clinical Topics in Infectious Diseases Vol 17 Malden (MA)Blackwell Science 1997 p 236 Winter MA Guhr KN Berg GM Impact of various body weights and serum creatinine concentrations on the bias and accuracy of the Cockcroft-Gault equation Pharmacotherapy 2012 Jul32 (7) 604-12

The sample should be marked as URGENT Urgent samples will be processed within 1 hour

therefore please ensure the trough level is obtained 2 hours before the next dose so that a

level is obtained on time before the next dose can be given




Dissemination and Access This Guideline can only be considered valid when viewed via the East amp North Hertfordshire NHS Trust Knowledge Centre If this document is printed in hard copy or saved at another location you must check that it matches the version on the Knowledge Centre

Equality Impact Assessment This Guideline and its impact upon equality has been reviewed in line with the Trustrsquos Equality Scheme and no detriment was identified

Associated Documentation

Antimicrobial Agents in Neonates (Antibiotic Guidelines)

Neonatal Antibiotic Policy

CP 187 Antimicrobials for Renal Patients

CGSG 058 Childrenrsquos Antibiotic Guideline (Antimicrobial Agents in Children)

CP102 Trust Policy for The Prevention and Management of Clostridium difficile Infection (P 18)

Trust Policy for Gentamicin Dosing and Monitoring for Adults

CP 248 Trust Policy for Gentamicin Dosing and Monitoring for Adults

Caesarean Section Guideline no 427

Review This document will be reviewed within three years of issue or sooner in light of new evidence Version Control

Version No Issue Date Reasons for Production or Revision

15 Feb 2016

Amendment of teicoplanin doses and teicoplanin appendix added Amendment of severe CAP recommendation New surgical prophylaxis recommendation for bone surgery and prosthetic joint surgery Removal of gentamicin dose recommendations and link to Trust Policy for Gentamicin Dosing and Monitoring for Adults made Penicillin allergy poster updated Antimicrobial pharmacist name and bleep number update List of authors amended

16 June 2017

Updated respiratory guideline

Alternatives to piperacillin-tazobactam during supply shortage

Antibiotic prophylaxis for permanent pacemaker insertion updated

17 Nov 2017

Uncomplicated UTI in pregnancy

CAP CURB 65 1

Neutropenic sepsis guideline update

Caesarean Section prophylaxis Guideline no 427 hyperlink




Contents

Section Page











Endocarditis 36







Genitourinary 45



Orthopaedic 47

Vascular Surgery 48











63





1 INTRODUCTION
















































































Temocillin



Azithromycin

Tigecycline

Daptomycin







Cellulitis


































1st Line



Duration 14 days










MRSA colonised










CGSG No 092



Mild





Mild infection



Moderate





Severe






Severe Infection
















Duration 7 days















pain)

1st Line





2nd

amp 3rd




st line but


or 3rd

line treatment



2nd



therapy




Pregnant






Duration 7 days





Symptomatic patient

Change catheter



Urosepsis

1st Line












Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








Contents

Section Page











Endocarditis 36







Genitourinary 45



Orthopaedic 47

Vascular Surgery 48











63





1 INTRODUCTION
















































































Temocillin



Azithromycin

Tigecycline

Daptomycin







Cellulitis


































1st Line



Duration 14 days










MRSA colonised










CGSG No 092



Mild





Mild infection



Moderate





Severe






Severe Infection
















Duration 7 days















pain)

1st Line





2nd

amp 3rd




st line but


or 3rd

line treatment



2nd



therapy




Pregnant






Duration 7 days





Symptomatic patient

Change catheter



Urosepsis

1st Line












Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








1 INTRODUCTION
















































































Temocillin



Azithromycin

Tigecycline

Daptomycin







Cellulitis


































1st Line



Duration 14 days










MRSA colonised










CGSG No 092



Mild





Mild infection



Moderate





Severe






Severe Infection
















Duration 7 days















pain)

1st Line





2nd

amp 3rd




st line but


or 3rd

line treatment



2nd



therapy




Pregnant






Duration 7 days





Symptomatic patient

Change catheter



Urosepsis

1st Line












Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING




































































Temocillin



Azithromycin

Tigecycline

Daptomycin







Cellulitis


































1st Line



Duration 14 days










MRSA colonised










CGSG No 092



Mild





Mild infection



Moderate





Severe






Severe Infection
















Duration 7 days















pain)

1st Line





2nd

amp 3rd




st line but


or 3rd

line treatment



2nd



therapy




Pregnant






Duration 7 days





Symptomatic patient

Change catheter



Urosepsis

1st Line












Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING















































Temocillin



Azithromycin

Tigecycline

Daptomycin







Cellulitis


































1st Line



Duration 14 days










MRSA colonised










CGSG No 092



Mild





Mild infection



Moderate





Severe






Severe Infection
















Duration 7 days















pain)

1st Line





2nd

amp 3rd




st line but


or 3rd

line treatment



2nd



therapy




Pregnant






Duration 7 days





Symptomatic patient

Change catheter



Urosepsis

1st Line












Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING





























Temocillin



Azithromycin

Tigecycline

Daptomycin







Cellulitis


































1st Line



Duration 14 days










MRSA colonised










CGSG No 092



Mild





Mild infection



Moderate





Severe






Severe Infection
















Duration 7 days















pain)

1st Line





2nd

amp 3rd




st line but


or 3rd

line treatment



2nd



therapy




Pregnant






Duration 7 days





Symptomatic patient

Change catheter



Urosepsis

1st Line












Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING
















Temocillin



Azithromycin

Tigecycline

Daptomycin







Cellulitis


































1st Line



Duration 14 days










MRSA colonised










CGSG No 092



Mild





Mild infection



Moderate





Severe






Severe Infection
















Duration 7 days















pain)

1st Line





2nd

amp 3rd




st line but


or 3rd

line treatment



2nd



therapy




Pregnant






Duration 7 days





Symptomatic patient

Change catheter



Urosepsis

1st Line












Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING










Cellulitis


































1st Line



Duration 14 days










MRSA colonised










CGSG No 092



Mild





Mild infection



Moderate





Severe






Severe Infection
















Duration 7 days















pain)

1st Line





2nd

amp 3rd




st line but


or 3rd

line treatment



2nd



therapy




Pregnant






Duration 7 days





Symptomatic patient

Change catheter



Urosepsis

1st Line












Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING











1st Line



Duration 14 days










MRSA colonised










CGSG No 092



Mild





Mild infection



Moderate





Severe






Severe Infection
















Duration 7 days















pain)

1st Line





2nd

amp 3rd




st line but


or 3rd

line treatment



2nd



therapy




Pregnant






Duration 7 days





Symptomatic patient

Change catheter



Urosepsis

1st Line












Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING













CGSG No 092



Mild





Mild infection



Moderate





Severe






Severe Infection
















Duration 7 days















pain)

1st Line





2nd

amp 3rd




st line but


or 3rd

line treatment



2nd



therapy




Pregnant






Duration 7 days





Symptomatic patient

Change catheter



Urosepsis

1st Line












Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING












Duration 7 days















pain)

1st Line





2nd

amp 3rd




st line but


or 3rd

line treatment



2nd



therapy




Pregnant






Duration 7 days





Symptomatic patient

Change catheter



Urosepsis

1st Line












Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING











pain)

1st Line





2nd

amp 3rd




st line but


or 3rd

line treatment



2nd



therapy




Pregnant






Duration 7 days





Symptomatic patient

Change catheter



Urosepsis

1st Line












Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING










Definition












Confusion

Urea gt 7 mmolL



Age gt 65 years







Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING











Chest X-ray



CRP

Full blood count















Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING













Penicillin allergy



5 days



Penicillin allergy









Penicillin allergy


or




7-10 days





Penicillin allergy







Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING









Tuberculosis


























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING



























Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING














Mild


Penicillin allergic


Or



7 days

Severe



Penicillin allergic





7-10 days










Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING











Pathogens


pneumoniae



Dyspnoea (eMRCD)


Eosinopenia (lt005)

1 0 0


Acidaemia pHlt73

1 2 54


4 31

5 405

6 50






Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








Management






(COPD)

Mild


Penicillin allergy


7 days

Severe



Penicillin allergy


7-10 days

















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING




















Pathogens





Investigations











Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING










Bronchiectasis

Acute exacerbation

(Inpatient) Mild




10-14 days

Acute exacerbation

(Inpatient) Severe













(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING












(Outpatient)


Duration 14 days

2nd



Duration 14 days

3rd


nd line










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING










Definition







Management














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING














empyema





Penicillin allergic












Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING













Pathogens










Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING









Management













Penicillin allergic




regimen





References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING









References















Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING














Infectionsrdquo

1st Line




2nd






2nd

line antibiotic



2nd

Line






Penicillin Allergy




1st Line













Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING










Liver Abscess

1st Line






2nd Line



















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING

















on CT












(Gastroenteritis)













Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING











Refer to















Severe CDI













Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING











Community-acquired







Duration





gt55yrs Pregnant

Immunocompromised





Brain Abscess

1st Line

















prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING











prosthesis in situ)

1st Line



Penicillin Allergy





situ)


Osteomyelitis

1st Line





Duration 6 weeks

Penicillin Allergy





Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








Endocarditis











Prosthetic valve







Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING










Septicaemia






2nd








st line therapy
















onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING











onset


QDS IV


Meropenem 1g TDS IV






Infection (CRBSI)










1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING











1st Line







1st Line






Otitis Media 1



Acute Epiglottitis





Refer to ENT
















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING




















1st Line











Aetiology VZV HSV








1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING











1st Line





2nd

Line




Chlamydia


Alternative



Epididymo-orchitis


STD likely






STD unlikely

Outpatient


Inpatient


Aetiology Coliforms


Prostatitis





st line)








Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING










Pelvic Inflammatory

Disease

Outpatient


followed by



Anaerobes




Duration 14 days

Inpatient








Severe Penicillin

allergy


Metronidazole













Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING














Is long (gt5 hours)
























before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING






















before procedure






5 PEG insertion







GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING









GENITOURINARY


1 Cystoscopy








prostate (TURP)


Open renal surgery

























Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING

















Followed by


OR








1 Clean surgery













ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING









ORTHOPAEDIC



2 Bone surgery


























5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING









5 Amputation




VASCULAR SURGERY








Thoracic Surgery















EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING














EXCEPT





For


CARD 018





prior to procedure)


half-life

Comments















APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING












APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








APPENDIX 1























Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING










Endocarditis

Meningitis

Septicaemia

Osteomyelitis

Septic arthritis


Encephalitis

Infective gangrene

Peritonitis

Neutropenia

Line sepsis


Severe mucositis

Ileus

Protracted vomiting

Severe diarrhoea







APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








APPENDIX 2

Penicillin Allergy























Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING









Amoxicillin



Flucloxacillin



Pivmecillinam

Temocillin




rash urticaria


allergy




CONSIDERED SAFE






Cefalexin Ertapenem

Cefixime

Cefotaxime

Ceftazidime

Ceftriaxone

Cefuroxime







Please check BNF

for a full list of

these antibiotics










IN ALL CASES




APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








APPENDIX 3



Dose and

Monitoring









Administration



Reference





APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








APPENDIX 4












65-799 800mg

50-649 600mg

le499 400mg



























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING


























Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








Further reading






APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








APPENDIX 5






APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








APPENDIX 6










Pregnancy


Blind patients























2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING












2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








2 Amikacin Therapy





Renal function


CrCl ge40mlmin


Max dose 1300mg






therapy

CrCl 30-39mlmin


Max dose 1300mg

CrCl 20-

29mlmin


Max dose 1300mg

CrCl lt20 mlmin

75mgKg stat








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING








APPENDIX 6a










Clearance

lt 185 ndash 249













8 FURTHER READING









8 FURTHER READING





Documents

KC: Login Screen · General Principles of Antimicrobial Prescribing Avoid unnecessary antibiotic use Antibiotics have harmful effects e.g. allergy, toxicity, superinfection (e.g