STANDARD OPERATING EMERGENCY FLOOR … · Wounds and Lacerations 5 7. Bites and Stings ... conditions seen in the Accident and Emergency Department. ... Wherever possible give antibiotics

Your hospitals, your health, our priority

DATES PREVIOUS VERSION(S) RATIFIED

Version: 1 2 3 4 5 5.1 5.2 6 7 7.1 7.2 7.3 8

Date: June 2004 June 2006 November 2007 October 2009 August 2010 February 2011 March 2011 June 2011 May 2013 April 2014 March 2015 June 2015 June 2016

DATE OF NEXT REVIEW July 2019

MANAGER RESPONSIBLE FOR REVIEW

Consultant Microbiologist

STANDARD OPERATING PROCEDURE:

EMERGENCY FLOOR ANTIBIOTIC SOP

SOP ID NUMBER TW10-136 SOP 4

VERSION NUMBER 8.1

APPROVING COMMITTEE DIVISIONAL QUALITY EXECUTIVE COMMITTEE (DQEC) - MEDICINE

DATE VERSION APPROVED June 2016

RATIFYING COMMITTEE: PARC (Policy Approval and Ratification Committee)

DATE VERSION RATIFIED July 2016

DATE THIS VERSION AMENDED

(February 2017) Page 13: Aspiration pneumonia section added.

AUTHOR(S) CONSULTANT MICROBIOLOGIST

DIVISION/DIRECTORATE MEDICINE

ASSOCIATED TO WHICH POLICY?

Antimicrobial Prescribing Policy TW10-136

Clostridium difficile Infection (CDI) Treatment for Adults TW10-042 SOP 13

Trust Antibiotic Treatment TW10-136 SOP 1

Emergency Floor Antibiotic SOP - Version 8.1 Consultant Microbiologist Ratified PARC July 2016

Next Review Date: July 2019

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CONTENTS PAGE NUMBER

1. Statement 2

2. Key Principles 2

3. Limitations 2

4. Skin and Soft Tissue Infections 3

5. Hand and Finger Infections 5

6. Wounds and Lacerations 5

7. Bites and Stings 6

8. Ear Infections 7

9. Throat Infections 8

10. Orbital Cellulitis 10

11. Maxillo-Facial 11

12. Chest and Lower Respiratory Tract Infections 11

13. Diarrhoea 14

14. Urinary Tract Infection (UTI) 15

15. Genitourinary Infections 16

16. Trauma and Orthopaedics 16

17. Central Nervous System 17

18. Abdominal Infections 18

19. Sepsis Immunocompetent Host 18

20. Febrile Neutropenia 20

21. Prophylaxis 20

22. Human Rights Act 21

23. Accessibility Statement 21

APPENDICES PAGE

NUMBER

1 References 22

2 Glossary of Terms 24

AT ALL TIMES, STAFF MUST TREAT EVERY INDIVIDUAL WITH RESPECT AND UPHOLD THEIR RIGHT TO PRIVACY AND DIGNITY.



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1. STATEMENT 1.1. This Standard Operating Procedure (SOP) incorporates information regarding appropriate

selection, dosing, route and duration of antimicrobial therapy and prophylaxis for common conditions seen in the Accident and Emergency Department.

1.2. The primary goal of this SOP is to inform prescribers in order to optimise clinical outcome

while minimising unintended consequences of antimicrobial use, including Clostridium difficile associated disease, toxicity and the emergence of resistance.

2. KEY PRINCIPLES 2.1. Send pus for culture and sensitivity only when you expect the management to be altered as a

result of the test.

2.2. Ensure that any necessary specimens for microbiology are taken before commencing

treatment.

2.3. All regimes are for 7 days unless stated otherwise. Doses are for adults. See the British

National Formulary (BNF) for Children for childhood doses. 2.4. Wherever possible give antibiotics by the oral route. Intravenous antibiotics should be

reserved for those patients who are unable to take tablets (unconscious/vomiting) or who are systemically unwell and/or present with a severe infection (meningitis, infective endocarditis, septicaemia).

2.5. Do not use antibiotics by the topical or intramuscular route. The former is ineffective (with

the exception of some minor infections), and the latter is unduly painful for the patient.

2.6. Penicillin allergy. It is important to establish the true nature of a reported “allergy” to

penicillin, as the alternative antibiotics may not be as effective or have a higher rate of side effects than penicillin. A history of rash or gastrointestinal symptoms with amoxicillin may not indicate true allergy. Unless signs of immediate type hypersensitivity (anaphylaxis, angio-oedema, bronchospasm, urticaria) were reported, a trial with penicillin may be warranted.

2.7. Always ask about drug allergy and record details in the notes. Consider drug interactions,

liver or renal impairment, pregnancy etc. Patients need clear instructions on how to take their antibiotic.

3. LIMITATIONS 3.1. This SOP is not intended to be comprehensive. Prescribers are advised to consult the BNF

and the manufacturer’s summary of product characteristics for additional information. This is especially relevant for side effects, contraindications, interactions with other drugs and the use of antimicrobials in pregnancy.

3.2. Advice about individual patients on clinical problems may be obtained from the Consultant

Microbiologists: Dr C Faris extension: 2153 or Dr R Nelson ext 2943, or via switchboard outside normal working hours.



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4. SKIN AND SOFT TISSUE INFECTIONS ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx Abscess. Incision and drainage. Antibiotics are

not indicated.

Impetigo. Minor Lesions. Fusidic acid. Topically 6 hourly. 5 days.

If widespread.

Flucloxacillin oral OR If penicillin allergic, clarithromycin oral.

500mg 6 hourly. 500mg 12 hourly.

7 days.

7 days.

Cellulitis.

See: Community Parenteral Antibiotic Therapy and Formulary on Microbiology Intranet site. NB. Providing there is clinical improvement IVs should be continued until cellulitis subsides, then change to oral antibiotics for 5 further days.

First line - Mild to Moderate:



7 days.

Outpatient management of severe cellulitis. Refer to Management of Cellulitis in Adults TW10-136 SOP 8 and Junior Doctors’ Guide to Antibiotic Treatment for Adults on the Policy Library.

Ceftriaxone intravenous (IV).

1-2g daily.

Severe/spreading with systemic symptoms: Admit ill patients for IV antibiotics:

Flucloxacillin IV OR If penicillin allergic, teicoplanin IV.

1-2g 6 hourly. 400mg every 12 hours for 3 doses then 400mg once daily.

7 days.

Cellulitis in patients with a history of Methicillin-resistant Staphylococcus aureus (MRSA) colonisation or risk factors such as several hospital colonisations within 6 months of nursing home residency.

Teicoplanin IV. 400mg every 12 hours for 3 doses then 400mg once daily.

7 days.

Necrotising fasciitis. Prompt surgical debridement is essential, plus combination antibiotic treatment.

Tazocin IV plus clindamycin IV.

4.5g 8 hourly 900mg 6 hourly.

Pressure sores – Uncomplicated. Pressure relief and wound toilet only.

Consult Microbiologist for advice if history of life-threatening allergy to beta-lactams (for example: anaphylaxis, angioedema, facial/throat swelling).



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ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

Pressure sores with progressing cellulitis. First line.

Flucloxacillin IV (oral) ± metronidazole oral OR If penicillin allergic,

ceftriaxone IV ± metronidazole oral.

1g (500mg) 6 hrly 400mg 8 hourly. 1g once daily 400mg 8 hourly.

7 days.

Pressure sores with progressing cellulitis and systemic symptoms.

First line. Tazocin IV. Add teicoplanin if at high-risk of MRSA*.

4.5g 8 hourly. 7 days.

Diabetic foot – Mild infection Cellulitis/erythema < 2cm AND infection limited to skin or superficial subcutaneous tissue AND NO PREVIOUS antibiotic treatment.

First line.

Flucloxacillin oral or IV OR If penicillin allergic, clindamycin oral.

1g 6 hourly. 450mg 6 hourly.

7-14 days.

Diabetic foot –Moderate infection Cellulitis extending >2cm OR Lymphangitis OR Deep tissue abscess OR failure of previous antibiotic.

Co-amoxiclav IV (oral) OR If allergic to penicillin, clindamycin IV (oral) plus ciprofloxacin IV (oral).

1.2g (625mg) 8 hourly. 600mg (oral 450mg) 6 hourly 400mg (oral 750mg) 12 hourly.

Parenteral therapy until stable then oral antibiotics for up to 4 weeks in the absence of osteomyelitis.

Diabetic foot – Severe infection with systemic symptoms (fever, white blood cell (WBC), C-reactive protein (CRP)), necrosis or osteomyelitis.

Polymicrobial infections. Debridement indicated.

Tazocin IV plus clindamycin IV OR If allergic to penicillin, ciprofloxacin IV (oral) plus clindamycin IV (oral).

4.5g 8 hourly. 900mg 6 hourly. 400mg (oral 750mg) 12 hourly 900mg (oral 450mg) 6 hourly.

2-4 weeks.

* Previous MRSA, hospital admissions within 6 months, nursing home resident.


IV therapy until stable, then oral antibiotics for 2 to 4 weeks in the absence of osteomyelitis. Note: < = less than > = greater than < = less than or equal to > = greater than or equal to ± = plus minus (See Appendix 2 for glossary of terms).



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5. HAND AND FINGER INFECTIONS ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

Acute paronychia. Incision and drainage. Antibiotics usually not necessary.

Pulp space infection. X-ray to exclude osteomyelitis. Incision and drainage under ring or wrist block. A wide elliptical incision is required. Review in Accident and Emergency Clinic after 48 hours. Antibiotics usually not necessary.

Web space infection. Urgent referral to Orthopaedic Surgeons.

Deep palmar space. Urgent referral to Orthopaedic Surgeons.

Suppurative tenosynovitis. Urgent referral to Orthopaedic Surgeons.

6. WOUNDS AND LACERATIONS ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

Less than 6 hours old. NO ANTIBIOTICS Clean, debride and do Primary Closure. Consider antitetanus vaccination.

Delayed presentation. If cellulitis is present treat with flucloxacillin.



7 days. 7 days.

Puncture wounds. Consider anti-tetanus vaccination. Flucloxacillin oral OR If penicillin allergic, clarithromycin oral.


7 days 7 days.

Wound infections. No cellulitis equals No antibiotics. Consider antitetanus vaccination.



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7. BITES AND STINGS ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

Animal bites. Adult: First line: Surgical toilet most important. Assess tetanus and rabies risk. Antibiotic prophylaxis may not be indicated for all cases. Antibiotic prophylaxis advised for – puncture wound, bite involving hand, foot, face, joint, tendon, ligament, immunocompromised, diabetic, elderly, asplenic.

Child <6 years:

6-12 years:

Co-amoxiclav oral OR If penicillin allergic, ciprofloxacin oral plus clindamycin oral. Co-amoxiclav oral. If penicillin allergic, seek Microbiology advice. Co-amoxiclav oral.

625mg 8 hourly. 500mg 12 hourly. 450mg 6 hourly. 125/31 SF suspension 5ml 8 hourly or 0.25ml/kg 8 hourly. 250/62 SF suspension 5ml 8 hourly or 0.15ml/kg 8 hourly.

7 days. 7 days. 7 days. 7 days. 7 days.

Human bites. Antibiotic prophylaxis advised. Assess Human Immunodeficiency Virus (HIV)/ hepatitis B and C risk.

See above.

Insect bites. Treat only if clinically infected. Flucloxacillin oral OR If penicillin allergic, clarithromycin oral.


7 days. 7 days.



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8. EAR INFECTIONS ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

Acute otitis Media (OAM).

Otitis media (OM) resolves in 60% in 24hrs without antibiotics. Consider antibiotics if <2yrs and bilateral AOM; all ages with otorrhoea. Optimise analgesics and target antibiotics.

Amoxicillin oral OR Co-amoxiclav oral if previously failed on amoxicillin. Alternative: Clarithromycin oral.

500mg 8 hourly. 625mg 8 hourly. 500mg 12 hourly.

7 days. 7 days. 7 days.

Acute otitis externa (diffuse). Aural toilet and analgesia recommended.

Mild:

Moderate: (Cellulitis or disease extending

outside ear canal).

Acetic acid 2%. Alternative: Neomycin sulphate with corticoid steroid OR any other topical drops at the discretion of the Ear Nose and Throat Consultant. Topical antibiotics plus Flucloxacillin oral. Alternative: Topical antibiotics plus Clarithromycin oral.

1 spray 8 hourly. 3 drops 8 hourly. 500mg 6 hourly. 500mg 12 hourly.

7 days. 7 days. 7 days. 7 days.

Necrotising/Malignant otitis externa (Pseudomonas).

Oral step down:

Tazocin IV plus topical treatment. Ciprofloxacin plus Clindamycin. Alternative: Discuss with a Microbiologist.

4.5g 8 hourly. 750mg 12 hourly. 450 mg 6 hourly.

4-6 weeks.



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Acute Mastoiditis.

Oral step down:

Cefuroxime IV plus Metronidazole IV. Co-amoxiclav. Alternative: Discuss with a Microbiologist.

1.5g 8 hourly. 500mg 8 hourly. 625mg 8 hourly.

24-48 hours. 10-14 days.

Traumatic rupture of tympanic membrane.

Flucloxacillin oral. OR If penicillin allergic, clarithromycin oral.


5 days. 5 days.

9. THROAT INFECTIONS ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

Tonsillitis.

Antibiotic is recommended only for patients who have three or four criteria (Centor).

History of fever.

Tonsillar exudate.

Absence of cough.

Tender anterior cervical lymphadenopathy.

Or are immunosuppressed. Or have valvular heart disease.

Mild: Penicillin V oral. Alternative: Clarithromycin oral. Severe: Benzyl Penicillin IV. Oral step down: Penicillin V. Alternative: Clarithromycin IV. Oral step down: Clarithromycin PO.

500mg 6 hourly. 500mg 12 hourly. 1.2g 6 hourly. 500mg 6 hourly. 500mg 12 hourly. 500mg 12 hourly.




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Quinsy. (Peri-tonsillar Abscess). Incision and drainage.

Benzyl Penicillin IV plus Metronidazole IV. Oral step down: Co-amoxiclav. Alternative: Clindamycin IV. Oral step down: Clindamycin.

1.2g 6 hourly. 500mg 8 hourly. 625mg 8 hourly. 900mg 6 hourly. 450mg 6 hourly.

10 days. 10 days.

Parapharyngeal Abscess.

Ceftriaxone IV plus Metronidazole. Oral step down: Co-amoxiclav. Alternative: Ciprofloxacin oral plus Clindamycin IV. Oral step down: Ciprofloxacin plus Clindamycin.

2g once daily. 500mg 8 hourly. 625mg 8 hourly. 750mg 12 hourly. 900mg 6 hourly. 750mg 12 hourly. 450mg 6 hourly.

10-14 days. 10-14 days.

Parotitis (Suppurative).

Mild: Flucloxacillin oral. Alternative: Clarithromycin oral. Severe: Flucloxacillin IV. Oral step down: Flucloxacillin. Alternative: Clarithromycin IV. Oral step down: Clarithromycin PO.

500mg 6 hourly. 500mg 12 hourly. 1g 6 hourly. 500mg 6 hourly. 500mg 12 hourly 500mg 12 hourly.

7 days.



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ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx Epiglottitis.

Ceftriaxone IV. Oral step down: Co-amoxiclav. Alternative: Ciprofloxacin IV plus Clindamycin IV. Oral step down: Ciprofloxacin plus Clindamycin.

2g once daily. 625mg 8 hourly. 400mg (or oral 750mg) 12 hourly 900mg 6 hourly. 750mg 12 hourly. 450mg 6 hourly.

24-48 hours. 7-10 days.

Acute bacterial sinusitis. Amoxicillin oral. Alternative: Doxycycline oral.

500mg 8 hourly. 200mg stat day 1 then 100mg 12 hourly.

7 days. 7 days.

10. ORBITAL CELLULITIS ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx Peri-orbital cellulitis. Refer to Ophthalmology Department

immediately for children, use doses at higher end of cefuroxime dosage range.

Cefuroxime IV plus Metronidazole IV. Oral step down: Co-amoxiclav. Alternative: Ciprofloxacin oral plus Clindamycin IV. Oral step down: Ciprofloxacin plus Clindamycin.

1.5g 8 hourly. 500mg 8 hourly. 625mg 8 hourly. 750mg 12 hourly. 900mg 6 hourly. 750mg 12 hourly. 450mg 6 hourly.

14 days. 24-48 hours. 14 days.



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11. MAXILLO-FACIAL ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx Fractures of maxilla.

Co-amoxiclav oral OR If penicillin allergic, clarithromycin oral.


5 days. 5 days.

Dental infection/Abscess.

First line: Abscess will need drainage. Refer.

Penicillin V oral OR If penicillin allergic, metronidazole oral.


5 days. 5 days.

12. CHEST AND LOWER RESPIRATORY TRACT INFECTIONS ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx Croup. Most are viral. No antibiotics

indicated.

Laryngitis. Most are viral. No antibiotics indicated.

Tracheitis. Most are viral. No antibiotics indicated.

Infective bronchitis in healthy adults. Most are viral. No antibiotics indicated.

Infective exacerbations of Chronic Obstructive Pulmonary Disease (COPD). Non-pneumonic chest infections (both community and hospital acquired). Antibiotics indicated if 2 or more of the following: increase in purulence of sputum; increase in volume of sputum; increase in breathlessness.

Most valuable if increased dyspnoea and purulent sputum. If consolidation on CXR treat as for pneumonia (see below).

Consider if antibiotics are needed. Patient not responding to or failed a recent course of doxycycline. If nil by mouth.

Doxycycline oral OR

trimethoprim oral. co-amoxiclav oral. co-amoxiclav IV.

200mg stat on day 1 then 100mg 12 hourly. 200mg 12 hourly. 625mg 8 hourly. 1.2g 8 hourly.





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Community-acquired pneumonia (CAP). Evidence of consolidation on CXR. Clinical findings and severity rating using CURB-65 score must be documented: C = New confusion (AMTS<8) 1 point. U = Urea >7 1 point. R = Respiratory Rate >30 1 point. B = SBP <90 or DBP <60 1 point. 65 = Age >65 1 point.

CURB – 65 = 0-1.

Amoxicillin oral OR If penicillin allergic, doxycycline oral. OR clarithromycin oral.

500mg 8 hourly. 200mg stat on day 1 then 100mg 12 hourly. 500mg 12 hourly.


Children less than 6 months: treat as for severe CAP. 6 months - 5 years: 5 years – 18 years:

Amoxicillin oral Clarithromycin oral/IV.

Consult BNFc for dosage instructions.

7-14 days.

Community-acquired pneumonia.

CURB – 65 = 2. Amoxicillin (oral or IV) Plus clarithromycin oral OR If penicillin allergic,

ceftriaxone IV plus clarithromycin (oral or IV).

500mg –1g 8 hourly. 500mg 12 hourly. 1g once daily. 500mg 12 hourly.


Severe Community-acquired pneumonia. Collect sputum and blood cultures if pyrexial. Legionella and pneumococcal urinary antigen and nose and throat swabs (VTM) for respiratory viruses. All patients with pneumonia should receive treatment within one hour of diagnosis.

CURB – 65 3-5.

Co-amoxiclav IV Plus clarithromycin (IV or oral) OR If penicillin allergic,

ceftriaxone IV Plus clarithromycin (IV or oral).

1.2g 8 hourly. 500mg 12 hourly. 1-2g once daily. 500mg 12 hourly.

7–10 days. 7–10 days. 7–10 days. 7–10 days.

Neonates and children less than 6 months: 6 months - 18 years (atypical pathogens more common in over 5 years).

Cefuroxime IV monotherapy. Cefuroxime IV ± clarithromycin.


7-14 days.

Post Influenza pneumonia. Flucloxacillin IV plus amoxicillin IV OR If penicillin allergic, clindamycin IV.

2g 6 hourly. 1g 8 hourly. 600mg 6 hourly.




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Community acquired aspiration pneumonia.

Benzylpenicillin IV plus metronidazole IV OR If penicillin allergic,

ceftriaxone IV plus metronidazole IV.

1.2g 6 hourly. 500mg 8 hourly. 1g once daily. 500mg 8 hourly.


HOSPITAL ACQUIRED PNEUMONIA: Pneumonia diagnosed more than 5 days from admission. Patients admitted from Nursing Homes do not need to be treated as HAP unless they meet the criteria.




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13. DIARRHOEA ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx Viruses. Salmonella sp. Campylobacter sp. Shigella sp.

Antibiotic therapy is not usually recommended for cases with mild or moderate diarrhoea. Infection prevention and control procedures should be followed in all cases to reduce cross infection (isolation).

Severe diarrhoea (> 6 unformed stools/day, and/or pyrexia, tenesmus, blood in stool).

Campylobacter or shigella suspected. Ciprofloxacin oral. 500mg 12 hourly. 5 days.

Clostridium difficile infection (CDI) Review concurrent antibiotic treatment, PPIs or laxatives and discontinue them where possible. For full details, please refer to ‘Clostridium difficile infection: Treatment TW10-042 SOP 13.

Initial episode in patient age <75 years with NO severe co-morbidities. Initial episode in patient age ≥75 years and/or with severe co-morbidities (immunocompromised, organ failure).

Severe CDI.

Life threatening CDI (hypotension, partial or complete ileus or toxic megacolon or CT evidence of severe disease). If ileus is present, then add vancomycin as a retention enema (500mg in 100ml normal saline per rectum 6 – 12 hourly).

Metronidazole oral/nasogastric (NG). If oral route is compromised:

Metronidazole IV.

Vancomycin oral/NG.

Vancomycin oral/NG. If no clinical response, vancomycin dose may be increased. If oral route is compromised:

Metronidazole IV plus intracolonic vancomycin. OR Vancomycin (NG tube). Vancomycin oral/NG plus

metronidazole IV.

400mg 8 hourly. 500mg 8 hourly. 125mg 6 hourly. 125mg 6 hourly. 500mg 6 hourly. 500mg 8 hourly. 500mg in 100ml of normal saline every 6 to 12 hours. 500mg 6 hourly. 500mg 6 hourly. 500mg 8 hourly.

10 - 14 days. 10 - 14 days. 10 - 14 days. 10 - 14 days. 10-14 days.

10 – 14 days.



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14. URINARY TRACT INFECTION (UTI) Condition Regimen Penicillin allergy/ Alternative regimens Uncomplicated lower UTI. Nitrofurantoin # oral 50mg 6 hourly for 3-7 daysŦ.

Patient with eGFR < 45ml/min, co-amoxiclav oral 375mg 8 hourly for 3-7 daysŦ. OR

Cefalexin oral 500mg 12 hourly for 3-7 daysŦ.

UTI in children. Trimethoprim 5 - 7 days. Consult BNFc for dosage instructions.

Complicated UTI/Pyelonephritis.

Factors suggesting a complicated UTI:

Male patients, pregnant, diabetes mellitus, renal tract abnormalities, recent urinary surgery/instrumentation (excluding urinary tract catheterisation), indwelling urinary catheter, symptoms persisting for over 7 days, recent broad spectrum antibiotics.

Empirical co-amoxiclav oral 625mg (or IV 1.2g) 8 hourly + IV gentamicin* 7mg/kg/day (max dose 560mg). Duration of treatment: for complicated UTI: 7 days for pyelonephritis: 14 days. Gentamicin indicated if there are concerns of multi-drug resistant organisms.

Known sensitivity – trimethoprim oral 200mg 12 hourly. Duration of treatment: 10 days.

Severely ill child.

Ceftriaxone IV for 7 – 14 days.


Severe sepsis associated with UTI. Tazocin IV 4.5g 8 hourly + IV gentamicin* 7mg/kg/day (max dose 560mg).

Ceftriaxone IV 1-2g once daily + IV gentamicin*

7mg/kg/day (max dose 560mg).

Catheter-associated UTI (CAUTI).

All catheters become colonised by bacteria and growth of organisms from a CSU is NOT an indication for antibiotic treatment in the absence of clinical evidence of infection. DO NOT DIPSTIX ON CSUs.

Symptoms suggestive of CAUTI

New loin or suprapubic tenderness

Rigors

New onset delirium

Fever >38oC or 1.5

oC above baseline on two occasions

during 12 hours.

Send urine for culture only if clinically indicted by above symptoms.

Obtain sample from new catheter and await culture results if possible.

Co-amoxiclav PO 625mg 8 hourly + gentamicin* IV 7mg/kg/day (max 560mg). Duration of treatment: 7 days. Gentamicin indicated if there are concerns of multi-drug resistant organisms.

CAUTI with systemic features of sepsis (Systemically unwell 2 or more of following: Temperature>38 or <36, HR >90, RR>20, WBC >12 or <4).

IV tazocin 4.5g 8 hourly + IV gentamicin* 7mg/kg/day (max dose 560mg).

# Nitrofurantoin - Contraindicated if eGFR <45ml/min. Ŧ For uncomplicated cystitis in women without a catheter, give 3 day course; for all other patients give 7 days. Consult Microbiologist for advice if history of life threatening allergy to beta-lactams (for example: anaphylaxis, angioedema, facial/throat swelling).

* Consultant Microbiologist/Antimicrobial Pharmacist for dosing advice for patients with renal failure.



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15 GENITOURINARY INFECTIONS ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

Epididymo-orchitis. Age < 35yrs. Age > 35yrs.

Ceftriaxone IM or IV

plus doxycycline oral. Ciprofloxacin oral.

500mg stat dose. 100mg 12 hourly. 500mg 12 hourly.

10-14 days. 10 days.

Prostatitis. Ciprofloxacin oral. 500mg 12 hourly. 28 days.

Pelvic Inflammatory Disease. Empirical treatment: Do full investigation including endocervical swabs for Chlamydia and gonorrhoea. Arrange follow-up with GUM clinic 01942 483188.

If pregnancy test negative:

Ceftriaxone IM or IV

Doxycycline oral plus metronidazole oral. If pregnancy test positive: Seek Microbiology advice.

500mg stat dose. 100mg 12 hourly. 400mg 12 hourly.

14 days. 14 days.

† Consult Microbiologist or Antimicrobial Pharmacist for dosing advice for patients with renal failure.

Consult Microbiologist for advice if history of life threatening allergy to beta-lactams (for example:. anaphylaxis, angioedema, facial/throat swelling).

16 TRAUMA AND ORTHOPAEDICS ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

Acute septic arthritis and osteomyelitis.

Ideally blood cultures, joint aspirates or biopsy material should be taken prior to starting antibiotics. IV antibiotics are indicated for minimum 2 weeks. Child:

Flucloxacillin IV plus gentamicin

† IV

OR If penicillin allergic, teicoplanin IV. plus Gentamicin

† IV.

Flucloxacillin plus amoxicillin OR Cefuroxime.

2g 4-6 hourly 7mg/kg once-daily (max dose 560mg). 10-12mg/kg 12 hourly for three doses then same dose once daily 7mg/kg once-daily (max dose 560mg). See BNF for Children for dosage information.

42 days.



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Compound fractures. Consider tetanus vaccine. Co-amoxiclav IV. If penicillin allergic, teicoplanin IV. ± gentamicin IV. Plus metronidazole IV.

1.2g 8 hourly. 400mg 12 hourly. 1.5mg/kg 12hourly. 500mg 8 hourly.

1-2 days. 3 doses. 1-2 days. 1-2 days.


17 CENTRAL NERVOUS SYSTEM ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

Meningitis. Neonates (0-3 months). 3 month – 18 years. Adults: If over 50 years of age, pregnant or immunocompromised, consider Listeria (add amoxicillin 2g 4 hourly). Consider ciprofloxacin prophylaxis for contacts of cases with meningococcal meningitis.

Cefotaxime IV plus

amoxicillin IV.

Ceftriaxone IV.

Ceftriaxone IV. If penicillin allergic, Seek Microbiology advice.

See BNF for Children for dosage information.

2g 12 hourly.

Variable according to pathogen.

Encephalitis. Mostly viral. Herpes simplex encephalitis.

Aciclovir IV.

10mg/kg 8 hourly.

14 - 21 days.



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18 ABDOMINAL INFECTIONS ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

Acute appendicitis. Antibiotics are NOT indicated for uncomplicated cases but should be given if patient is unwell and/or septic.

Co-amoxiclav IV OR If penicillin allergic, Tigecycline IV.

1.2g 8 hourly. 100mg once then 50mg 12 hourly.

5 days.

5 days.

Perforated abdominal viscus. Localised abdominal abscess. Generalised peritonitis.

Co-amoxiclav IV OR If penicillin allergic, Tigecycline IV.

1.2g 8 hourly. 100mg once then 50mg 12 hourly.

5 days.

5 days.

Cholecystitis, Cholangitis. Tazocin IV OR If penicillin allergic, Tigecycline IV.

4.5g 8 hourly. 100mg then 50mg 12 hourly.

7 days. 7 days.

Diverticulitis. Tazocin IV. If penicillin allergic, Tigecycline IV.

4.5g 8 hourly. 100mg then 50mg 12 hourly.

7 days. 7 days.


19 SEPSIS IMMUNOCOMPETENT HOST ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

No obvious focus of infection. Add teicoplanin if at high risk of MRSA*.

Tazocin IV +

gentamicin† IV

OR If penicillin allergic, teicoplanin IV for 3 doses then once daily plus gentamicin

† IV plus

metronidazole IV.

4.5g 8 hourly 7mg/kg once-daily (max dose 560mg). 10-12mg/kg 12 hourly. 7mg/kg/day (max dose 560mg) 500mg 8 hourly.

7-14 days.

Associated with intra-abdominal source. Tazocin IV + gentamicin

† IV

OR If penicillin allergic, tigecycline IV AND gentamicin

† IV.

4.5g 8 hourly 7mg/kg once-daily (max dose 560mg). 100mg once then 50mg 12 hourly 7mg/kg once-daily (max dose 560mg).

7 days.




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Associated with soft tissue/ skin infections.

Flucloxacillin IV OR If penicillin allergic, teicoplanin IV.

1-2g 6 hourly. 600mg 12 hourly for 3 doses then 600mg daily.

7-14 days.

Associated with urinary tract. Tazocin IV + gentamicin† IV OR If penicillin allergic,

ceftriaxone IV ± gentamicin† IV.

4.5g 8 hourly 7mg/kg once-daily (max dose 560mg). 1-2g once daily 7mg/kg once-daily (max dose 560mg).

7-14 days.

Associated with chest infection. See recommendations for severe CAP or Hospital acquired pneumonia (HAP).

Septicaemia in IV drug users. Flucloxacillin IV plus gentamicin† IV.

2g 6 hourly 7mg/kg once-daily (max dose 560mg).

7-14 days.

Neonatal sepsis (< 3 months).

Group B Streptococcus (GBS) suspected. Listeria, GBS or coliforms suspected.

Benzylpenicillin IV plus gentamicin IV OR Amoxicillin IV plus

cefotaxime IV.

See BNF for Children for dosage information.

Septicaemia in children (3 months – 18 years).

Ceftriaxone IV. See BNF for Children for dosage information.

* Previous MRSA, hospital admissions within 6 months, nursing home resident. † Consult Microbiologist or Antimicrobial Pharmacist for dosing advice for patients with renal failure.




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20 FEBRILE NEUTROPENIA ILLNESS COMMENTS ANTIBIOTIC DOSE DURATION OF Tx

Low-risk patient. Refer to full Management of Adults with Neutropenic Sepsis TW11-006 SOP.

Co-amoxiclav oral plus ciprofloxacin oral.


High-risk patient.

Indications for teicoplanin: severe mucositis, history of ciprofloxacin prophylaxis, IV catheter sepsis, known/suspected MRSA colonisation.

Meropenem IV +/- teicoplanin IV. If penicillin allergic seek microbiology advice.

1g 8 hourly 10mg/kg 12 hourly for 3 doses, then 10mg/kg once-daily.

21 PROPHYLAXIS

Prevention of infective endocarditis.

Refer to “Antibiotic Prophylaxis for Splenectomy, Meningococcal disease, H Influenzae type b disease and Endocarditis”. TW10-136 SOP 2.

Prevention of secondary cases of meningococcal disease.

Adult and children over 12 years. Pregnancy. Children 5-12 years. Children 1 month to 4 years. If ciprofloxacin is contraindicated consider Rifampicin.

Ciprofloxacin oral.

500mg. 500mg. 250mg. 125mg.

STAT.

HIV Post exposure prophylaxis.

Refer to Post exposure Prophylaxis for Health Care Workers Occupationally Exposed to HIV TW10-042 SOP 2. Refer to Post Exposure Prophylaxis for HIV following Non-Occupational Needle Stick or Bite Injury TW10-042 SOP 47.

Truvada (containing 300mg tenofovir plus 200mg emtricitabine) plus Raltegravir.

One tablet once daily. 400mg 12 hourly.

28 days.

Hepatitis B prophylaxis following percutaneous injury.

Refer to Post exposure Prophylaxis for Health Care Workers Occupationally Exposed to HIV TW10-042 SOP 2. Refer to Post Exposure Prophylaxis for HIV following Non-Occupational Needle Stick or Bite Injury TW10-042 SOP 47.


http://intranet/Library/Departments/Infection_Control/Guidelines/2015/pop_hiv_bite_v2_1_may15.pdf






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22. HUMAN RIGHTS ACT Implications of the Human Rights Act have been taken into account in the formulation of

this policy and they have, where appropriate, been fully reflected in its wording.

23. ACCESSIBILITY STATEMENT This document can be made available in a range of alternative formats e.g. large print,

Braille and audio cd. For more details please contact Human Resources Department on 01942 77(3766) or

email [email protected]



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APPENDIX 1 REFERENCES: BNF 66; March – September 2013. Infections; 338-442. BNF for Children, 2013-2014. Infections; 244-348. Bone and Joint Infection: Anon. The Management of Septic Arthritis. Drug and Therapeutics Bulletin, 2003; 41:65-68. Bone and Joint Infections in: Antibiotic and Chemotherapy. Edited by O’Grady F, Lambert H, Finch RG, Greenwood D. 7th Ed, Churchill Livingstone, Edinburgh 1997. CNS Infection: McGrath N, Andeson NE, Croxson Mc and Powell KF. Herpes simplex encephalitis treated with acyclovir, diagnosis and long term outcome. J Neurol Neurosurg Psychiatry, 1997; 63: 321-326. Heydermnan RS, Lamber HP, O’Sullivan I, et al. Early Management of Suspected Bacterial Meningitis and Meningococcal Septicaemia in Adults. Journal of Infection, 2003; 46(2): 75-77. British Infection Society. Consensus statement on diagnosis, investigation, treatment and prevention of acute bacterial meningitis in immunocompetent adults. Journal of Infection 1999; 39; 1-15. Gastrointestinal Infection: British Society for the Study of Infection. The Management of Infective Gastroenteritis in Adults. Journal of Infection. 1996; 33: 143-152. Genitourinary Infection: Anon. Guideline No.32: Management of Acute Pelvic Inflammatory Disease. Royal College of Obstetricians and Gynaecologists, London 2003. Foster G. Treatment of pelvic inflammatory disease in primary care. Prescriber’s Journal. 1998; Vol. 38 No. 2. Anon. SIGN 88. Management of suspected bacterial urinary tract infections in adults, July 2012. Respiratory Infection: Anthonisen MD, Manfreda J, Warren CPW, Hershfield ES, Harding GKM, Nelson A. Antibiotic Therapy in Exacerbations of Chronic Obstructive Pulmonary Disease. Annals of Internal Medicine, 1987; 106: 196-204. Anon. British Thoracic Society Guidelines on Management of Community-acquired Pneumonia in Adults. Thorax, 2001; 56 (suppl 4) - 2004 Update and 2009 Update. Kozyrski AL, Hildes Ristein E, Longstaffe SEA, Wincott JL, Sitar DS, Klassen TP. Treatment of acute otitis media with a shortened course of antibiotics: a meta-analysis. JAMA, 1998; 279: 1736-1742. O’Neill P and Roberts R. Acute Otitis Media, in Clinical Evidence, London, BMJ Publishing Group, 2003; 9: 274-286.



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Swart Sjoerd, Saches APE, Ruijs G, Gubbels JW, Hoes AW, de Melker RA. Penicillin for acute sore throat: randomised double blind trial of seven days versus three days treatment or placebo in adults. British Medical Journal, 2000; 320: 150-154. Del Mar C and Glaziou P. Upper respiratory tract infections, in Clinical Evidence, London, BMJ Publishing Group, 2003; 9: 1701-1711. Skin and Soft Tissue Infection: Morgan M. The bacteriology and clinical aspects of bites. CPD Infection, 2003; 4(2): 44-48. Cummings PL. Antibiotics to prevent infection in patients with dog bites wounds – a meta-analysis of randomized trials. Annals of Emergency Medicine, 1994; 23: 535-540. Antibiotic prophylaxis for mammalian bites. (Cochrane Review). Cochrane Library, Issue 3, 2003, Update Software. Anon. Dilemmas when managing cellulitis. Drug and Therapeutics Bulletin, 2003, 41: 43-46. HIV: British Association of Sexual Health and HIV. UK Guidelines for the use of HIV Post-exposure Prophylaxis following Sexual Exposure (PEPSE) 2015.



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APPENDIX 2

GLOSSARY OF TERMS ATMS Ataxia Telangiectasia Mutated

BNF British National Formulary

BNFc British National Formulary for children

CAP Community acquired pneumonia

CAUTI Catheter-associated UTI

COPD Chronic obstructive pulmonary disease

CRP C-reactive protein

CSU Catheter specimen urine

CT Computerised tomography

CURB 65 Index for measuring severity of CAP by assessing for presence of Confusion, serum urea, respiratory rate, blood pressure and age

CXR Chest x-ray

DBP Diastolic blood pressure

eGFR Estimated glomerular filtration rate

GUM Genito-urinary Medicine

HAP Hospital acquired pneumonia

HIV Human immunodeficiency virus

HR Heart rate

IM Internal medicine

IV Intravenous

KG Kilogram

MG Milligram

ML Millilitre

MRSA Methicillin resistant staphylococcus aureus

NG Nasogastric

OD Once a day

PO By mouth

QDS Four times a day

RR Respiratory rate

SBP Systolic blood pressure

STAT Immediately

TDS Three times a day

UTI Urinary tract infection

VTM Viral transport medium

WBC White blood cell

Documents

STANDARD OPERATING EMERGENCY FLOOR … · Wounds and Lacerations 5 7. Bites and Stings ... conditions seen in the Accident and Emergency Department. ... Wherever possible give antibiotics