Professional Documents
Culture Documents
July 2010
Contents
Page
1. Introduction...3 1.1 Principles of antimicrobial prophylaxis...3 1.2 MRSA screening of surgical patients.....3 2. Classification of surgical procedures4 3. Timing of prophylaxis..4 4. Contact details..5 5. Choice of agent6 5.1 Prevention of infection in thoracic surgery ...6 5.2 Prevention of infection in vascular surgery...7 5.3 Prevention of infection in trauma and orthopaedic surgery.8 9 5.4 Prevention of infection in gynaecological surgery...9 5.5 Prevention of infection in ear, nose, throat & endocrine surgery........10 5.6 Prevention of infection in gastrointestinal surgery 11 5.7 Prevention of infection in urological procedures ...12 6. Splenectomy: vaccination and antibiotic prophylaxis....................13 6.1 Perioperative vaccination......14 6.2 Annual vaccination..14 7. Empirical treatment guidelines for surgical infections..16 Skin and soft tissue infections..16 18 Bone and joint infections19 21
2
Septicaemia.....21 Lower respiratory tract infections....22 24 Genitourinary infections....25 26 Gastrointestinal tract infections...27 28 Bites and stings..........29 8. Intravenous to oral switch of antimicrobial therapy.30 9. Therapeutic drug monitoring...30
1. Introduction
1.1 Principles of antimicrobial prophylaxis Antibiotic prophylaxis is the use of antimicrobial agents to prevent infection or to prevent the clinical manifestations, if infection is incubating. There are a number of situations where prophylactic antibiotics may be indicated e.g. various types of surgery (Section 2) or the insertion of a medical device or prosthesis. All patients with contaminated wounds (e.g., following trauma) should have their tetanus status assessed. The choice of agent will be governed by the procedure and the likely potential pathogens. These guidelines apply to patients admitted from the community for clean, clean-contaminated and contaminated surgical procedures. The guidelines do not cover transplant and neurosurgical specialities. If the patient has been in hospital or has a history of MRSA colonisation, please contact the microbiologists for advice, as the patients antibiotic prophylaxis will need adjustment. Surgical prophylaxis should be prescribed in the appropriate section of the drug Kardex. The duration of antimicrobial surgical prophylaxis should be a SINGLE dose, except in certain circumstances. An agent that may be appropriate for surgical prophylaxis may not be the optimal agent for the treatment of an established infection. Therefore, the continuation of an agent to treat established infection that was initially used for prophylaxis may represent suboptimal therapy. If concerned, contact the microbiologists for advice. If the patient is allergic to one of the recommended agents, please contact the microbiologists for advice Please refer to the paediatric BNF for advice on dosing of antimicrobials in paediatric patients. 1. 2 MRSA screening of surgical patients who to screen Patients known to be MRSA colonised and who are being re-admitted to hospital Patients admitted from another hospital or health-care facility (e.g., nursing home) Patients with non-intact skin, including wounds and ulcers Patients due to undergo elective high-risk surgery (e.g. vascular and orthopaedic implant surgery)
Clean-Contaminated
Non-traumatic but break in technique or breach of respiratory, alimentary or genitourinary tract No significant spillage
Contaminated
Major break in technique Gross spillage from a viscus that may include purulent material Dirty traumatic wounds, faecal contamination, foreign body, de-vitalised viscus Pus encountered from any source during surgery
No Prophylaxis (usually)
3. Timing of prophylaxis
The aim of prophylaxis is to have maximum tissue antibiotic levels at the time of the first incision - For this reason, prophylaxis is administered AT INDUCTION (30 to 60 MINUTES BEFORE SKIN INCISION) - The duration of surgical prophylaxis should be a SINGLE dose, except in two circumstances. These are: A. Blood loss fluid replacement - Serum antibiotic concentrations are reduced by blood loss and fluid replacement, especially during the first hour of surgery when antibiotic levels are high. In the event of major intra-operative blood loss (>1.5 litres) additional doses of prophylactic antibiotic should be considered after fluid replacement. B. Prolonged surgical procedures - Many antibiotics, such as cephalosporins like cefuroxime, are short acting and therefore an additional dose should be administered during the surgery if the procedure lasts longer than 3 hours.
4. Contact details
Medical enquiries Consultant Microbiologists Dr E Smyth Prof H Humphreys Dr F Fitzpatrick Phone Ext 2017 Ext 3312 Ext 2938 Ext 2667/3320/3321 Bleep 319/443/323 Consultant-on-call via switch Ms. Sarah Foley Bleep 046 sarahfoley2@beaumont.ie E mail edmondsmyth@beaumont.ie hilaryhumphreys@beaumont.ie fidelmafitzpatrick@beaumont.ie
Registrars office
5. Choice of agent
5.1 Prevention of infection in THORACIC Surgery
PROCEDURE Breast reconstruction with implant Breast cancer surgery Breast reshaping procedures Implantable cardiac device (ICD) Screen patients for MRSA at least 5 days before surgery according to MRSA guidelines MRSA-negative REGIMEN CO-AMOXICLAV 1.2g IV Penicillin allergy TEICOPLANIN 400mg IV CEFUROXIME 1.5g IV STAT at induction Inpatient: give two further doses 8 hours apart Day case: two doses of CEFUROXIME 500mg po 8 hours apart for patient to take at home following ICD insertion TEICOPLANIN 400mg IV (Further antibiotic prophylaxis is NOT required due to extended duration of action) CO-AMOXICLAV 1.2g IV Penicillin allergy TEICOPLANIN 400mg IV 1 dose at induction Number and timing of doses** 1 dose at induction
1 dose at induction
Pulmonary resection
**For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)
CO-AMOXICLAV 1.2g IV Penicillin allergy CEFUROXIME 1.5g IV plus METRONIDAZOLE 500mg IV Penicillin allergy severe immediate hypersensitivity reaction *Contact Microbiology to discuss antibiotic choice*
1 dose at induction
TEICOPLANIN 400mg IV plus CEFUROXIME 1.5g IV plus METRONIDAZOLE 500mg IV Penicillin allergy severe immediate hypersensitivity reaction *Contact Microbiology to discuss antibiotic choice*
**For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)
CEFUROXIME 1.5g IV Penicillin allergy Severe immediate hypersensitivity reaction *Contact Microbiology to discuss antibiotic choice* 1 dose at induction
Major procedures involving metalwork including joint, pelvic or spinal implants carried out as emergencies and/or on patients who have not been screened
**For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)
**For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours) N. B. In distal limb surgery antibiotics should be administered at least 15 minutes before inflation of the tourniquet, i.e., before induction of anaesthesia.
**For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)
10
Complex septorhinoplasty
CO-AMOXICLAV 1.2g IV Penicillin allergy CEFUROXIME 1.5g plus METRONIDAZOLE 500mg IV Penicillin allergy severe immediate hypersensitivity reaction *Contact Microbiology to discuss antibiotic choice* OFLOXACIN 0.3% drops topically post operatively
1 dose at induction
Grommet insertion
**For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)
11
1 dose at induction
ANTIMICROBIAL PROPHYLAXIS IS NOT RECOMMENDED unless immunosuppression (COAMOXICLAV 1.2g IV Penicillin allergy CEFUROXIME 1.5g plus METRONIDAZOLE 500mg IV) Please see pages 12 13 for advice on perioperative vaccination and post-splenectomy antibiotic prophylaxis
1 dose at induction
*Antibiotic prophylaxis should be considered for high risk patients {intraoperative cholangiogram, pancreatic pseudo-cyst, immunosupression, incomplete biliary drainage, bile spillage, conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, pregnancy, immunosupression and insertion of prosthetic devices, T tube} **For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)
12
1 dose at induction
CIPROFLOXACIN 500mg PO bd for one week preoperatively 1 week Percutaneous nephrolithotomy Preoperative Antibiotic prophylaxis recommended with stone >20mm or with pelvicalyceal dilation **For prolonged operative procedures (>4 hours) and/or major blood loss, additional intra-operative doses should be administered (this excludes TEICOPLANIN which has a prolonged duration of action 24 hours)
13
Documentation
Document that patient has had a splenectomy and that vaccination and advice regarding antibiotics has been instituted On the front of the patients chart
Patient Counselling infective symptoms Please inform the patient that should infective symptoms such as a raised temperature, malaise, or shivering develop, the patient should seek immediate medical help.
14
No
No
No
15
Reference 1. British Committee for Standards in Haematology. Update of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. 2001. http://www.bcshguidelines.com/pdf/SPLEEN96.pdf 2. British Committee for Standards in Haematology. Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. BMJ. 1996; 312(7028): 430-34. 3. National Immunisation Advisory Committee. Immunisation Guidelines for Ireland. Royal College of Physicians, 2008 4. Immunisation against infectious diseases. The Green Book. Department of Health United Kingdom. 2006 (updated April 2010)
16
7. Empiric treatment guidelines (before microbiology results available) for surgical patients with infection These guidelines are designed for use by admitting doctors for common infectious conditions encountered in adult
surgical patients admitted from the community. If the patient has had a recent hospital admission or recent antibiotics, please contact the microbiologist for advice as antibiotic therapy may have to be modified. Please refer to the above guidelines for advice on surgical prophylaxis. ILLNESS SKIN & SOFT TISSUE Cellulitis -Mild COMMENTS ANTIBIOTIC DURATION OF Tx
Investigations: Blood cultures, swab if exudates present, CRP/ESR/WBC, check for underlying DVT or diabetes Investigations: Blood cultures, swab if exudates present, CRP/ESR/WBC, check for underlying DVT or diabetes
FLUCLOXACILLIN 500mg PO qds Penicillin allergy DOXYCYLINE 100mg bd or CLINDAMYCIN 450mg PO qds Oral therapy: FLUCLOXACILLIN 500mg PO qds Intravenous therapy: FLUCLOXACILLIN 1 2g IV qds Penicillin allergy CLINDAMYCIN 450mg PO qds (or IV if required)
7 days
Cellulitis -Moderate
10 14 days
17
Cellulitis -Severe
Patient may be in septic shock If suspected gas gangrene or necrotising fasciitis urgent surgical debridement necessary send pus or tissue (not swab) from surgery for culture and susceptibility testing. If out of hours, please contact On-Call Microbiologist
FLUCLOXACILLIN 2g IV qds plus CLINDAMYCIN 450mg IV qds Penicillin allergy VANCOMYCIN 15mg/kg bd in place of flucloxacillin above Contact the microbiologists if gas gangrene/necrotising fasciitis
10 14 days
Investigations: Blood cultures, swab if exudates present, CRP/ESR/WBC Surgical drainage may be required if severe or deep infection send pus or tissue from surgery for culture and susceptibility testing
18
Investigations: Blood cultures, swab if exudates present, CRP/ESR/WBC Surgical drainage may be required if severe or deep infection send pus or tissue from surgery for culture and susceptibility testing Commonly colonised with multiple organisms. Clinically non-infected ulcers should not be cultured
5 7 days
DO NOT TREAT WITH ANTIBIOTICS UNLESS CLINICAL EVIDENCE OF INFECTION Topical antiseptics and wound care usually sufficient Antibiotics only indicated if there is evidence of cellulitis or deeper infection
Superficial swabs from infected ulcers are not ideal for culturing, as both colonising and infecting organisms are recovered. Pathogens are more reliably detected in specimens obtained by curettage.
19
COMMENTS
ANTIBIOTIC
DURATION OF Tx
Investigations: Blood cultures, CRP/ESR/WBC. Bone biopsy do not rely on the results of superficial swabs of ulcers to identify the cause(s) of the bone infection
FLUCLOXACILLIN 2g qds IV plus SODIUM FUSIDATE 500mg tds PO Penicillin allergy CLINDAMYCIN 450mg IV qds plus SODIUM FUSIDATE 500mg tds PO
20
Chronic osteomyelitis
Investigations: Blood cultures, CRP/ESR/WBC, bone biopsy for C&S, AFB & mycobacterial culture Bone biopsy do not rely on the results of superficial swabs of ulcers to identify the cause(s) of the bone infection. The range of potential pathogens (including mycobacterial species) is extensive. Patients (usually diabetics) with infected foot ulcers, multiple bacterial species may be implicated. It is ESSENTIAL therefore to identify the microbiological cause(s).
21
Investigations: Blood cultures, CRP/ESR/WBC Joint aspirate (urgent gram stain)- if possible take before antibiotics Treatment requires adequate drainage of joint fluid and antibiotics If gonoccocal infection suspected - STD screen
FLUCLOXACILLIN 2g qds IV plus SODIUM FUSIDATE 500mg tds PO Penicillin allergy CLINDAMYCIN 450mg IV qds plus SODIUM FUSIDATE 500mg tds PO
Add CEFTRIAXONE 1g IV od or CEFOTAXIME 1g tds IV *Contact microbiology for advice on treatment options & duration*
Investigations: Blood cultures, CRP/ESR/WBC Joint aspirate (gram stain and culture) If possible take before antibiotics
COMMENTS ILLNESS SEPTICAEMIA (blood stream infection) no obvious source Investigations: - WCC, send full septic screen ie. [MSU, blood cultures (2 sets), sputum, wound swab] - Check operative site? collection? surgical site/wound infection - CXR & other radiological investigations are indicated - If suspect semi permanent line/catheter sepsis take central & peripheral blood cultures, remove line send tip for C&S - Consider or rule out infective endocarditis
ANTIBIOTIC
DURATION OF Tx
22
ILLNESS
COMMENTS
ANTIBIOTIC
DURATION OF Tx
LOWER RESPIRATORY TRACT INFECTIONS CURB-65 score <3 Community-acquired pneumonia (seek medical advice) CURB-65 score >3 CURB-65 Severity assessment
score for CAP Score 1 for each feature present - Confusion - Urea >7mmol/L - Respiratory rate > 30/min - Blood pressure SBP < 90mmHg +/or DBP< 60mmHg - Age > 65 years
CLARITHROMYCIN 500mg PO bd CO-AMOXICLAV 1.2g tds IV plus CLARITHROMYCIN 500mg PO bd Oral Switch: CO-AMOXICLAV 625mg tds PO plus CLARITHROMYCIN 500mg PO bd Penicillin allergy CLARITHROMYCIN 500mg bd IV plus CEFUROXIME 750mg 1.5g tds IV Penicillin allergy Severe immediate hypersensitivity reaction *Contact Microbiology to discuss treatment options*
Investigations: sputum C&S, BAL, Blood culture, CXR, FBC, U&E, ?TB, urine Legionella & pneumococcal antigen, serum for Q fever, mycoplasma & chlamydia serology
23
>5 days in hospital or from longterm care, nursing home, or recent hospital admission previous 6 weeks Community acquired aspiration pneumonia
Investigations: Sputum C&S, BAL (if intubated), blood culture, CXR, FBC Treat according to cultures Review at 48 hours
PIPERACILLIN/TAZOBACTAM 4.5g tds IV Penicillin allergy *Contact Microbiology to discuss treatment options* BENZYLPENICILLIN 1.2g qds IV plus METRONIDAZOLE 500mg IV tds Penicillin allergy CEFOTAXIME 2g tds IV plus METRONIDAZOLE 500mg tds IV PIPERACILLIN/TAZOBACTAM 4.5g tds IV Penicillin allergy *Contact Microbiology to discuss treatment options*
7 days
Investigations: Sputum C&S, BAL (if intubated), Blood culture, CXR, FBC & SALT assessment (speech & language therapy)
Healthcare associated aspiration pneumonia >5 days in hospital or from longterm care, nursing home, or recent hospital admission previous 6 weeks Empyema Investigations: Sputum C&S, Blood Culture, CXR, FBC +/- drainage (fluid C&S)
14 days
24
Tonsillitis
BENZYLPENICILLIN 1.2g qds IV Or if patient can tolerate oral therapy Oral Switch: AMOXICILLIN PO 500mg tds CO-AMOXICLAV 1.2g tds IV for 48 hours then Oral Switch: CO-AMOXICLAV 625mg tds PO
10 14 days
Quincy
25
COMMENTS
ANTIBIOTIC
DURATION OF Tx
Investigations: MSU/CSU, WBC (?pyelonephritis/obstruction) Rationalise treatment choice based on urine C&S results Investigations: blood cultures, MSU/CSU, WBC, renal U/S Review any previous urine C&S results
Pyelonephritis/complicated UTI
CO-AMOXICLAV 1.2g tds IV plus # GENTAMICIN 5mg/kg IV od (use for 3 5 days only) Penicillin allergy *Contact Microbiology to discuss treatment options* DOXYCYCLINE 100mg PO bd
Acute epididymorchitis
Investigations: Blood Culture, MSU, WBC +/- urethral swab, STI screen
14 days
26
Contact tracing is recommended if STI documented *Refer to Gynaecology for advice* If patient has an IUCD or IUS in place, consider removal discuss alternative contraception.
DOXYCYCLINE 100mg PO bd plus METRONIDAZOLE 400mg PO tds (plus CEFTRIAXONE 250mg IM STAT if infection with gonorrhoea likely) If unable to tolerate oral therapy, pregnant, systemically unwell or examination suggests presence of tubo-ovarian abscess, discuss management with Microbiology.
14 days 10 days
27
ILLNESS
COMMENTS
ANTIBIOTIC
DURATION OF Tx
GASTROINTESTINAL/ABDOMINAL Cholangitis Investigations: Blood cultures, WBC, CRP If patient has percutaneous drain or abscess, send sample Investigations: Blood cultures, WBC, CRP Send pus or tissue from surgery for culture & sensitivity testing Investigations: Blood cultures, WBC, CRP Send operative/radiological pus sample for culture & sensitivity testing Investigations: Blood cultures, WBC, CRP Send operative/radiological pus sample for culture & sensitivity testing Investigations: Blood cultures, WBC, CRP Send operative/radiological pus sample for culture & sensitivity testing PIPERACILLIN/ TAZOBACTAM 4.5g tds IV Penicillin allergy *Contact Microbiology to discuss treatment options* CO-AMOXICLAV 1.2g IV tds +/# GENTAMICIN 5mg/kg od Penicillin allergy CEFUROXIME 750mg 1.5g tds plus METRONIDAZOLE 500mg IV tds PIPERACILLIN/ TAZOBACTAM 4.5g tds IV +/- #GENTAMICIN 5mg/kg od *Contact Microbiology to discuss treatment options* Treat as for community acquired peritonitis above 7 days
5 10 days
Diverticulitis
Intra-abdominal collection
28
CO-AMOXICLAV 1.2g IV tds plus FLUCONAZOLE 400mg IV od +/# GENTAMICIN 5mg/kg od Penicillin allergy *Contact Microbiology to discuss treatment options* *Contact Microbiology to discuss treatment options* CO-AMOXICLAV 1.2g IV tds Oral Switch: CO-AMOXICLAV 625mg tds PO 7 10 days
Hospital acquired GI perforation Investigations: Blood cultures Cholecystitis Investigations: Blood cultures
Pancreatitis
Investigations: Blood cultures, aspirates, tissue First line agent Severe infection WCC >20x109/L Serum lactate 2.2 4.9mmol/L Sepsis
Clostridium difficile infection ISOLATE PATIENT! Review concurrent antibiotic treatment, PPIs or laxatives & discontinue where appropriate
METRONIDAZOLE PO 400mg tds VANCOMYCIN 125mg PO qds plus METRONIDAZOLE 500mg tds IV if not tolerating oral intake plus Surgical review *Always contact Microbiologist if severe symptoms*
10 days
29
ILLNESS
COMMENTS
ANTIBIOTIC
DURATION OF Tx
BITES & STINGS Adult: Animal bites First line 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. Human bites Antibiotic prophylaxis advised. Risk assess for relevant blood borne viruses e.g. hepatitis B Treat only if clinically infected Penicillin allergy CLINDAMYCIN 450mg PO qds CO-AMOXICLAV 625mg PO tds 7 days
CO-AMOXICLAV 625mg PO tds Penicillin allergy CLINDAMYCIN 450mg PO qds Treat as for mild to moderate Cellulitis PAGE 2.
7 days
7 days
30
Pre-dose: 10 15mg/L in uncomplicated Serum level pre 4th dose, then Check pre-dose levels every 2 3 days infections. Impaired renal function check predose levels daily Pre-dose: 15 20mg/L in complicated infections such as osteomyelitis, meningitis, bacteraemia, infective endocarditis and healthcare associated pneumonia. Pre-dose: <1mg/L
Serum level 18 24 hours after 1st dose, then check pre-dose levels every 2 3 days Impaired renal function check predose levels daily
31