GUH Antimicrobial Guidelines V6.1 June 2013

Microbiology, Infectious Diseases and Pharmacy Departments
Galway University Hospitals

Page 1 Antimicrobial Guidelines (Adults) GUH Cln-Path-001
Authorised for use on GUH patients only
Antimicrobial Guidelines for Galway University Hospitals
Version 6.1 (2013)

Summary Empiric Antimicrobial Guidelines (Adults) ................................................................. 2

Introduction
How to Contact Microbiology/ID/Pharmacy .................................................................... 5
Guideline Development Group ...................................................................................... 5
Statement of Purpose and Limitations ........................................................................... 6
Disclaimer ................................................................................................................. 6

Prescribing Principles
Antimicrobial Prescribing Principles ............................................................................... 8
Meticillin Resistant Staphylococcus aureus (MRSA) ......................................................... 8
Extended Spectrum Beta-Lactamase (ESBL) producing bacteria ....................................... 8
Documentation of Antimicrobial Use ............................................................................. 9
Reserve Antimicrobials .............................................................................................. 10
Topical Antibacterials ................................................................................................ 10
IV to Oral Switch Therapy ......................................................................................... 11
Penicillin Hypersensitivity .......................................................................................... 12

Vancomycin Dosing & Monitoring ........................................................................................ 14

Gentamicin Dosing and Monitoring ...................................................................................... 16

Empiric Guidelines by Infection (Adults)
1. Abdomen ............................................................................................................. 19
2. Bone and Joint ..................................................................................................... 21
3. Central Nervous System ........................................................................................ 22
4. Eye ..................................................................................................................... 23
5. Fungal................................................................................................................. 24
6. Gastrointestinal System ........................................................................................ 25
8. Heart .................................................................................................................. 28
9. Intravascular Line ................................................................................................. 30
10. Malaria .............................................................................................................. 33
11. Respiratory System ............................................................................................. 34
12. Sepsis ............................................................................................................... 38
13. Skin and Soft Tissue ........................................................................................... 43
14. Throat ............................................................................................................... 46
15. Urinary Tract ...................................................................................................... 47
16. Viral .................................................................................................................. 49

Antibiotic Prophylaxis in Surgery ......................................................................................... 50

Appendices
Appendix 1: Reserve Antimicrobial Agents Policy .......................................................... 65
Appendix 2: Antibiotics and Diarrhoea Patient Information Leaflet .................................. 66
Appendix 3: C. difficile Infection (CDI) Algorithms ........................................................ 67
Appendix 4: Management of patients with an absent or dysfunctional spleen ................... 69
Appendix 5: Rifampicin for Meningococcal & Hib prophylaxis .......................................... 73

Paediatric Antibiotic Guidelines ........................................................................................... 75

Antimicrobial Dosing in Renal Impairment (Adults) ................................................................ 81
Vancomycin, Cefazolin, Gentamicin in Haemodialysis ............................................................. 88

Index .............................................................................................................................. 89

Changes for this edition ..................................................................................................... 92
Summary Empiric Antimicrobial Guidelines (Adults)
Doses are for non-obese adults with normal renal and liver function.
This is a brief summary guideline. See full guidelines for further information.

Infection 1
st
Line Antibiotics
If penicillin allergy
minor/delayed onset
If penicillin allergy:
severe/immediate reaction
Duration
Abdomen
Intra-abdominal
Mild Community Acquired
Co-amoxiclav IV 1.2g q8h
CefUROXime IV 1.5g q8h +
Metronidazole** IV 500mg q8h
Ciprofloxacin** IV 400mg q12h
+
4 to 7 days
if adequate
source
control
Moderate to Severe
Community Acquired/
All Hospital Acquired
Piperacillin/tazobactam IV
4.5g q8h
Add Gentamicin* IV 5mg/kg
(max 400mg) one dose IF
haemodynamically unstable
CefTRIAXone IV 2g q24h +
+
Vancomycin* IV Infusion
25mg/kg loading dose, then
15mg/kg q12h (max 2g per
dose) +
severe infection &
Consult
Micro/ID

7 to 10 days
assuming
adequate
source
control
Bone & Joint
Septic Arthritis
Flucloxacillin IV 2g q6h Vancomycin
*
IV Infusion 25mg/kg loading dose, then 15mg/kg
q12h (max 2g per dose)
Minimum 2
weeks IV
Osteomyelitis/
Prosthetic Joint
Infection
Consult with Microbiology/ID
Central Nervous
System
Suspected Bacterial
Meningitis
dose)

Consider adding
Amoxicillin IV
2g q4h if risk of Listeria
dose)

Consider adding
Co-trimoxazole IV 60mg/kg
q12h if risk of Listeria
Chloramphenicol IV
25mg/kg q6h +
dose)
Give a stat dose, and consult
with Microbiology/ID
immediately. Consider adding
Co-trimoxazole IV 60mg/kg
q12h if risk of Listeria
Minimum
7 to 21 days
Herpes Simplex
Encephalitis
Aciclovir IV 10mg/kg q8h (use ideal body weight) 14 to 21
days
Eye See full guideline
Fungal See full guideline
GI System
Clostridium difficile
infection
Non-Severe Metronidazole PO/NG 400mg q8h
10 to 14
days Severe Vancomycin PO/NG 250mg q6h
Severe with ileus or toxic megacolon Vancomycin PO/NG 500mg every 6 hours +
Metronidazole IV 500mg every 8 hours
Heart Bacterial
Endocarditis
See full guideline
IV Line Infection See full guideline
Malaria See full guideline
Respiratory
System
Community
Acquired
Pneumonia
Signs/symptoms of
LRTI AND new
consolidation on
chest X-ray
Mild CURB-65 Score 0 or 1 7 days
Amoxicillin PO 1g q8h
For younger patient ADD
Clarithromycin PO 500mg
q12h
Doxycycline PO 200mg day one, then 100mg q24h
Moderate CURB-65 Score 2 7 days
Amoxicillin PO/IV 1g q8h +
Clarithromycin PO (IV if NPO)
500mg q12h
OR
Levofloxacin PO (IV if NPO) 500mg q12h

Infection 1
st
Line Antibiotics
minor/delayed onset
Duration
Severe CURB-65 Score 3 7 to 10 days

Co-amoxiclav IV 1.2g q8h +
Clarithromycin PO (IV if NPO)
500mg q12h
Clarithromycin PO
(IV if NPO) 500mg q12h
dose) + Levofloxacin PO (IV if
NPO) 500mg q12h
Aspiration
Pneumonia
Consult Microbiology/ID
7 to 10 days

COPD Exacerbation
without infiltrate
Amoxicillin PO 1g q8h OR
If recent (<2/52) course of
Amoxicillin:
Co-amoxiclav PO 625mg q8h
Clarithromycin PO 500mg q12h OR
7 days

Hospital Acquired
Pneumonia
Moderate
4.5g q8h
Moderate or severe
25mg/kg loading dose, then 15mg/kg q12h (max 2g per dose) +

If possible aspiraton
Add Metronidazole** IV 500mg q8h

If haemodynamically unstable
Add Gentamicin* IV 5mg/kg (max 400mg) one dose
8 days
(longer
duration
may be
required;
see full
guideline)
Severe
4.5g q8h
Consider adding
Clarithromycin
**
IV 500mg
q12h
If haemodynamically unstable
(max 400mg) one dose
At 24 to 48 hours consider
adding
dose)
Sepsis
Sepsis,
Source Unclear
No risk factors e.g. No CVC/No IV drug use Consult with Microbiology/ID
Ciprofloxacin** IV
400mg q12h +
Gentamicin
*
IV
5mg/kg (max 400mg) one
dose +
dose)
Duration is
decided on
a case by
case basis
4.5g q8h +
Gentamicin* IV
dose
Gentamicin* IV 5mg/kg (max
400mg) one dose
CVC/Inflammation at IV catheter site/IV drug use/Risk
factors for MRSA
4.5g 8h +
Gentamicin* IV
dose +
dose)
CefTRIAXoneIV 2g q24h +
Gentamicin* IV
5mg/kg (max 400mg)
one dose +
dose)
Haemodynamically unstable or other clinical evidence of severe infection
Consider cover for ESBL
Suspected
Meningococcaemia
CefTRIAXone IV 2g q12h CefTRIAXone IV 2g q12h Chloramphenicol IV 25mg/kg
q6h. Give a stat dose; consult
with Micro/ID immediately
7 days
Neutropenic Sepsis See full guideline
Skin & Soft
Tissue
Cellulitis/
Wound Infection
Mild
Flucloxacillin PO 500mg q6h

CefALEXin PO 500mg q6h

Clindamycin PO 450mg q6h
7 to 10 days
Moderate
Flucloxacillin IV 2g q6h

CefUROXime IV 1.5g q8h

Severe
Flucloxacillin IV 2g q6h +
Clindamycin** IV 600mg q8h
Vancomycin
*
IV Infusion 25mg/kg loading dose, then 15mg/kg
q12h (max 2g per dose) + Clindamycin**

IV 600mg q8h
Infection 1
st
Line Antibiotics
minor/delayed onset
Duration
Diabetic Soft Tissue
Infection
(without
osteomyelitis)
Mild

10 to 14
days. May
require up to
3 weeks for
severe
infection.
Moderate
Clindamycin** IV 600mg q8h +
Monitor for diarrhoea
Severe
4.5g q8h
VancomycinIV Infusion 25mg/kg loading dose, then 15mg/kg
q12h (max 2g per dose) +
Clindamycin** IV 600mg q8h +
If risk factors for MRSA in moderate to severe infection consider adding
Vancomycin
*
IV Infusion 25mg/kg loading dose, then 15mg/kg q12h (max 2g per dose)

Animal & Human
Bites, Prophylaxis
&Treatment
Co-amoxiclav PO 625mg q8h Metronidazole PO 400mg q8h +
7 days
Throat
Acute Pharyngitis/
Tonsillitis
Benzylpenicillin IV 1.2g q4h Clarithromycin** IV 500mg q12h

10 days
Peritonsillar
Abscess
Benzylpenicillin IV 1.2g q4h +
Cefuroxime IV 1.5g q8h +
Clindamycin** IV 600mg q8h

7 days

Severe Acute
Epiglottitis
CefTRIAXone IV 2g q24h


dose) +
7 to 10 days
Urinary Tract
Uncomplicated
Cystitis
1
st
line antibiotic
Nitrofurantoin*** PO 50mg q6h
If pregnant: Avoid
nitrofurantoin at term (38
weeks); consider
2
nd
line antibiotic
Ciprofloxacin PO 250mg q12h
If pregnant: Avoid ciprofloxacin in pregnancy. Discuss with
Microbiology/ID if treating a pregnant woman at term and with a
history of penicillin allergy
Non-
pregnant
women:
5 days for
nitrofurantoin
3 days for
ciprofloxacin
Pregnancy:
7 days
Pyelonephritis or
complicated UTI
Non-pregnancy
Co-amoxiclav IV 1.2g q8h +
400mg) one dose
Ciprofloxacin** IV 400mg (or
PO 500mg) q12h
Minimum 10
days.
Consider
oral switch.

Pyelonephritis
In Pregnancy
Add Gentamicin* IV 5mg/kg (pre-pregnancy weight; max
400mg) one dose IF haemodynamically unstable
Aztreonam IV 2g q8h
Add Gentamicin
*
IV 5mg/kg
(pre-pregnancy weight; max
400mg) one dose IF
Minimum 10
days.
Consider
oral switch.

Viral See full guideline

*Vancomycin & Gentamicin: Reduce dose in renal impairment. Therapeutic drug monitoring required. Review need for ongoing Gentamicin/Vancomycin on
a daily basis.Continue with once daily Gentamicin dosing ONLY if Consultant/Specialist Registrar recommended.
**Ciprofloxacin/Clarithromycin/Clindamycin/Metronidazole IV: Consider oral switch after 24 to 48 hours.
*** Nitrofurantoin: Avoid if eGFR < 60ml/min.
Introduction

How to contact Microbiology/ID/Pharmacy
Microbiology
Consultants: Prof. Martin Cormican 4146, Dr. Deirbhile Keady/Dr. Eithne
McCarthy 2013, Dr. na NRiain 3779, Dr. Teck Wee Boo 3783
Microbiology Registrars 4573
Infectious Diseases (ID)
Consultant: Dr. Catherine Fleming 2824 (or through hospital switch)
ID Registrar Bleep 671, SHO Bleep 814
Paediatrician
Consultant: Dr. Edina Moylett 4654
Pharmacy
Antimicrobial Pharmacist: Ms. Marie Tierney 3469 Bleep 224
Pharmacy UHG 4651/4205 Merlin Park 5682/5378

Out-of Hours: A Consultant Microbiologist is on call 24 hours per day 7 days per week
and can be contacted through switch board. In general, out of hours, the Consultant
Microbiologist should be contacted by the appropriate Registrar or Consultant.

Guideline Development Group
Development of these guidelines was led by a group comprised of Dr. Eithne Mc Carthy,
Ms. Marie Tierney, Prof. Martin Cormican, Dr na NRiain, Dr. Catherine Fleming, Dr.
Deirbhile Keady, Dr. Teck Wee Boo, Dr. Caroline Fielding, Dr Caitriona Hickey and Dr
Ciaran Bannan.

During the consultation process contributions and suggestions were received from
colleagues. Comments or suggestions for improvement for future editions can be sent
by email to Dr. Eithne Mc Carthy at Eithne.McCarthy@hse.ie

The guidelines have been approved by GUH Drug and Therapeutics Committee. See
QPulse or pharmacy intranet http://medinfo for the most up-to-date electronic version of
these guidelines.

The guidelines are now available as an application for Smartphones (Apple and Android).
Please contact Marie Tierney at marie.tierney@hse.ie for a password for the GAPP
(Galway Antimicrobial Prescribing Policy/Guidelines) app.

Effective from: July 2012
Review Date: July 2014


Statement of Purpose and Limitations
This document relates primarily to common conditions or to conditions that are
uncommon but associated with serious morbidity or mortality. It is intentional that this
empiric guideline document presents minimal background and explanation.
Dosage and dose intervals as specified are for adults with normal renal and
hepatic function. Although certain specific adverse effects are referred to, issues of
adverse effects, drug interaction and contraindications are not addressed in detail and
should be checked in an appropriate source such as the BNF.

Paediatric guidelines are included as a separate section.

Prescribers must use their professional judgement to identify circumstances in which
there are specific reasons why this general guidance is not appropriate. In such
circumstances please discuss treatment with the Departments of Microbiology, Infectious
Diseases or Pharmacy.

These empiric guidelines are designed in line with best practice in antimicrobial
prescribing and with national and international guidelines on antimicrobial
stewardship. As such, they support optimal antimicrobial selection, dosing, route and
duration of therapy to maximise clinical cure or prevention of infection, while limiting the
unintended consequences, such as the emergence of resistance, adverse drug events
(including C. difficile associated disease) and cost.

These guidelines are intended for initial empiric therapy. Empiric treatment is
choice of antibiotic prior to susceptibility results being available.
Regular review of the patients progress is essential and treatment should be
reviewed in the light of changes in clinical condition.
If a specific pathogen(s) is identified the treatment should be reviewed. The
least toxic, narrowest spectrum and least expensive agent or combination of
agents that is effective should be used for the treatment of specific pathogens.
Usual recommended duration of therapy is included for many conditions, and
assumes there is satisfactory clinical progress and response to therapy clearly if
clinical progress is slow or not satisfactory then individual patient management,
including the duration of therapy should be reviewed and discussed with
Microbiology/ID if required.
It may be possible to switch from IV to oral therapy after 24 to 48 hours.
Please discuss duration of therapy and potential for switch from IV to oral
therapy with Microbiology or Infectious Diseases if required.

Disclaimer

These guidelines are intended to guide and facilitate the care of patients at Galway
University Hospitals (GUH). The guidance contained therein is not intended to replace
individual assessment and personalised treatment of the patient. The authors have made
every reasonable effort to base the guidance on best available evidence and to ensure
accuracy of content at the time of going to press. However technical and clinical
information changes rapidly and it is not possible to guarantee that all items will be
accurate at all times. The application of the information in this guideline in clinical
situations remains the professional responsibility of the practitioner.

MSD provided a grant for the design and development of the Smartphone app version of
the guidelines. MSD makes no claim or warranties as to the accuracy or completeness of
this app.
Pharmacy Intranet
Access the pharmacy intranet at http://medinfo for:
Antimicrobial Guidelines
Most up to date version of GUH Intravenous Drug Administration Guide
Books e.g. BNF, BNF for Children, The Renal Drug Handbook

The GUH Intravenous Drug Administration Guide contains monographs for all IV
drugs, including antimicrobials in use in the hospital. Please consult the guide for
information to ensure safe prescription and administration of IV medicines.

Cost Indicator ()
Antimicrobials included in the guidelines which have acquisition costs of greater than
100 per day - based on an average treatment dose for an average 70kg patient - are
identified as follows:
: 100 to 300 e.g. Teicoplanin()
: greater than 300 e.g. Caspofungin() and Ambisome
()

I
N
T
R
O
D
U
C
T
I
O
N

Prescribing Principles

Antimicrobial Prescribing Principles
Doses are for non-obese adults with normal renal and liver function.
Antibiotics should only be started with clear clinical justification, and
documentation in patient notes.
Always culture (blood, sputum, pus etc) as appropriate prior to commencing or
changing antibiotics.
Review antimicrobial therapy daily with culture results and clinical progress. If
pathogen(s) identified, modify therapy accordingly.
Switch IV to oral as soon as possible (see IV to PO switch therapy).
Stop antibiotics as soon as possible based on clinical response.
For all patients labelled as penicillin allergic establish history, assess and document.
Cephalosporins may be given if minor allergy e.g. rash but not for patients with
documented anaphylactic response (see Penicillin Hypersensitivity).

Note Regarding Meticillin Resistant Staphylococcus aureus
(MRSA)
For infection at almost any site you should suspect infection with Meticillin resistant S.
aureus (MRSA) if:
I. Patient has been previously colonised with MRSA.
II. Patient has recently been hospitalised (within 90 days).
III. Patient has transferred from another hospital or long-term care facility.
IV. Patient is on a ward with a current epidemic or endemic MRSA problem.

For patients with serious/life threatening infection who are at risk for MRSA infection,
empiric treatment with Vancomycin is indicated in addition to the other components of
therapy recommended in this guideline. Please consult Microbiology or Infectious
Diseases as required.

Note Regarding Extended Spectrum Beta-Lactamase (ESBL)
producing bacteria
Extended-spectrum Beta-lactamase (ESBL) producing bacteria are an increasing
problem in this region and throughout the world. ESBL producing bacteria are mostly
E. coli or Klebsiella pneumoniae but other species of bacteria may also have this
mechanism of resistance.
The ESBL mechanism makes the bacteria resistant to many penicillins and
cephalosporins and many of these bacteria are also resistant to gentamicin and
ciprofloxacin.
Most are susceptible to nitrofurantoin (relevant to Urinary Tract Infection) and to
reserve agents such as Meropenem() and Tigecycline().
ESBL transmission associated with nursing homes has been a problem and therefore
empiric cover for ESBL blood stream infection with Meropenem should be
considered in patients admitted from nursing homes and patients who are critically ill
with sepsis.

Documentation of Antimicrobial Use
Accurate documentation is a key component of appropriate antimicrobial prescribing. It
improves communication between medical, nursing and pharmacy staff and between
different medical practitioners who may review therapy throughout the prescribed course
and subsequently. It also facilitates multidisciplinary audit of antimicrobial prescribing
within and between hospitals, to inform and improve education and action plans to
improve antimicrobial practices.

Key elements to consider and document when prescribing antimicrobials are:

R - Route: Please review all IV antibiotics DAILY

I - Indication for the antimicrobial e.g. pneumonia

D - Duration/Review Date e.g. 8 days for hospital acquired pneumonia

Document the indication and duration/review date in the appropriate box in the
antimicrobial section of the drug chart (example shown below) AND in the patients
medical notes.

Example of antimicrobial section of drug chart with indication and duration
documented

Reserve Antimicrobials
Over the years most colleagues in GUH have voluntarily participated in a process of
consultation with Microbiology or Infectious Diseases in respect of use of a number of
antimicrobial agents that have been regarded as reserve agents. The Medical Board
approved the following in 2008:
Reserve agents should only be prescribed by non-consultant hospital doctors (NCHD)
during normal working hours following consultation with Microbiology or ID for
any indication OTHER than those suggested in these guidelines.
When reserve agents are prescribed by an NCHD out of hours they are subject to an
automatic stop on the next working day unless there is documented (note in
patients medical record) consultation with Microbiology or Infectious Diseases.
A consultant order for a reserve antimicrobial agent without reference to Microbiology
or Infectious Diseases must be written and signed by the Consultant OR
supported by a note in the medical record written and signed by the Consultant.
See Appendix 1 for more information on Reserve Antimicrobial Agents policy.

Reserve Antimicrobials Table
Antifungals Broad Spectrum Gram Positive Gram Negative
Ambisome
() CefTAZIDime Daptomycin() Amikacin

Anidulafungin() CefTRIAXone Linezolid() Aztreonam
Caspofungin() CefoTAXime Teicoplanin()
Posaconazole Chloramphenicol Vancomycin
Voriconazole() Ciprofloxacin
Levofloxacin
Meropenem
Moxifloxacin
Tigecycline()

Topical Antibacterials

Topical Antibacterials Table
Not routinely
recommended
Rationale for
restricting use in
hospitals
Exceptions
Any topical
antibacterial e.g.
Bactroban

Flamazine

Fucidin

Naseptin

Polyfax

Emergence of resistance

If infection needs to be
treated, should generally
be treated systemically
Bactroban
nasal ointment as
first line treatment for MRSA
decolonization
Naseptin
as second line
treatment for MRSA
decolonization
Naseptin
use by ENT
Topical antibacterial use by
dermatology
Flamazine
use by Plastics

IV to Oral Switch Therapy
It is not necessary to treat every infection with parenteral antimicrobial agents. Even
where initial therapy with parenteral agents is necessary it may be possible to switch to
oral antimicrobial agents after 24 to 48 hours if the patient is responding well to
treatment. Switch to oral therapy has advantages for the patient, staff and hospital.

IV to Oral Switch Criteria: If in doubt consult with Microbiology/ID/Pharmacy

IV to Oral Switch Criteria
In favour of switching Reasons to avoid/delay switching
Clinically improving Potential GI absorption problems
Apyrexial for >24 hours Meningitis or CNS infection
Oral fluids, food & medication tolerated Acute osteomyelitis/septic arthritis
Suitable oral alternative Endocarditis
No reason to avoid/delay switching Severe soft tissue infections

If yes to all In favour of switching without
any Reasons to avoid/delay switching
consider switch to oral therapy.
Staph aureus bacteraemia
Inadequately drained abscess
Neutropenic sepsis/septic shock

Antimicrobials with excellent availability by the oral route
Ciprofloxacin Fluconazole Metronidazole
Clarithromycin Fusidic Acid/Sodium fusidate Rifampicin
Clindamycin Levofloxacin
Co-trimoxaxole Linezolid

There is no oral agent that represents an exact match for Piperacillin/tazobactam or for
CefTRIAXone. Please discuss with Microbiology or ID if required.

For Piperacillin/tazobactam it may be reasonable in some patients to switch to
oral Co-amoxiclav. Co-amoxiclav has a narrower spectrum of activity than
Piperacillin/tazobactam. However if the patient is making good progress and the
infection was community acquired or likely to be with a relatively susceptible
organism this may be a reasonable switch. In other patients a combination of Co-
amoxiclav and Ciprofloxacin may be required to maintain the spectrum of activity
of Piperacillin/tazobactam.

For CefTRIAXone, a switch to oral therapy depends on the indication, clinical
progress and suspected or confirmed bacterial pathogen. Discussion with
Microbiology or Infectious Diseases is recommended prior to oral switch.

Penicillin Hypersensitivity
An accurate patient history is important when evaluating allergy. Important details of
an allergic reaction include signs, symptoms, severity, prior reactions, time course of
allergic event, time and route of other administered drugs, other medicines being taken
and adverse drug reactions to other medicines.

1. Record allergies carefully on the front of the medical notes and on the drug chart.
2. Check with the patient and the allergy section of the drug chart prior to
prescribing and administering all antibiotics.
3. Transfer allergy information when re-writing the drug chart.
4. The Penicillin Allergy Traffic Light Poster lists antibiotics that are contraindicated,
can be used with caution and are considered safe to use in penicillin allergy.

Patients with a history of penicillin allergy should be reviewed to exclude a
non-allergic adverse reaction e.g. diarrhoea, vomiting, non-specific
maculopapular rash or a reaction wrongly attributed to the antibiotic e.g.
treatment with Amoxicillin is associated with rash in 80% of patients during Epstein-
Barr virus infection
Patients with a history of immediate or severe hypersensitivity reaction
(anaphylaxis, urticaria or immediate rash) to a penicillin OR for whom little or no
information is available (after making every effort to determine allergy history),
should not receive a penicillin, cephalosporin or carbapenem (e.g. meropenem).
If there is a compelling reason to consider use of a beta-lactam agent in such a
patient consult Microbiology or Infectious Diseases and contact the Department of
Immunology who may be able to assist by assessing if the patient is likely to be
hypersensitive.
Aztreonam can be used in patients with allergy to penicillin, but consider with caution
in patients who are allergic to cefTAZIDime due to similar side-chain.
Type 1 IgE mediated allergic reactions typically occur within minutes to an hour
following exposure, and up to 72 hours on re-exposure.
Patients with a history of a minor rash (i.e. a non-confluent, non-pruritic rash
restricted to a small area) or a rash with a delayed onset more than 72 hours after
penicillin may reasonably be prescribed a cephalosporin or carbapenem.
From 0.5 to 6.5% of penicillin sensitive patients will also be allergic to cephalosporins
(BNF Sept 2011).

Patients with a history of anaphylaxis, laryngeal oedema, bronchospasm,
hypotension, local swelling, urticaria or pruritic rash occurring immediately
after penicillin are potentially at increased risk of immediate hypersensitivity to
beta-lactams, and should not receive a penicillin, cephalosporin or carbapenem
(e.g. meropenem)

Refs:
1. SIGN Antibiotic Prophylaxis in Surgery July 2008
2. BNF 62 September 2011


Penicillin Allergy Traffic Light Poster

Gentamicin and Vancomycin Dosing and Monitoring (Adults)

Intravenous Vancomycin Dosing & Monitoring
1. Effective use of Vancomycin is complex and should normally be discussed with
Microbiology or Infectious Diseases. The following is provided for guidance.
2. The responsible clinical team must check reported Vancomycin levels regularly and adjust
dosing if required. The laboratory does NOT alert teams of out of range results.
3. A consultant microbiologist is on call 24 hours a day 7 days a week for clinical advice
regarding Vancomycin dosing and interpretation of levels.
4. The laboratory processes Vancomycin levels seven days a week.
5. The lab may not process any request which does not include a sampling time.
6. Do not hold doses pending levels unless specifically requested to do so or toxicity suspected.
This practice frequently results in sub-therapeutic levels.

Table 1: Vancomycin Dosing Guidelines
A Vancomycin Dosing Calculator is available on the GAPP app
Step 1 Estimate renal
function
Patient age, weight,
height & creatinine
required
Must use creatinine clearance (not eGFR) to dose
Vancomycin.
Calculate the patients estimated creatinine clearance using
Cockcroft & Gault equation.
Neither creatinine clearance or eGFR provide a perfect marker
of renal function, particularly if rapidly changing renal
function.
Step 2 Does the patient
need a loading
dose?
Initial loading dose of 25mg/kg (maximum 2g) by IV infusion
recommended for ICU patients, haematology/oncology
patients, and if recommended by Microbiology/ID.
Use actual body weight to calculate the dose.
Round dose to nearest 250mg.
Step 3 Select an initial maintenance dose based on renal function and actual body
weight
Creatinine
Clearance:
(ml/minute)
Dose:
Round to nearest 250mg Frequency:
Greater than 50 15mg per kg IV (max 2g) Every 12 hours
20 to 50 15mg per kg IV (max 2g) Every 24 hours
less than 20
15mg per kg IV (max 2g) Re-dose based on levels, generally
every 3 to 7 days; discuss with
Microbiology/ID/Pharmacy
Intermittent haemodialysis: See Haemodialysis Dosing Guidelines

Table 2: Vancomycin Administration and Monitoring Guidelines
Administration

Must be given by IV Infusion, maximum rate 10mg/min (otherwise risk of
anaphylactoid reactions, thrombophlebitis and red man syndrome). See IV
administration guide on ward or pharmacy intranet http://medinfo
Do not delay administration of the first dose.
Consider giving subsequent doses at 10am and 10pm for twice daily dosing.
Do not hold doses pending levels or if levels have not been sent, unless
specifically requested or toxicity suspected.
Monitoring The first trough level should be taken no later than before the 4
th
or 5
th

dose. Consider sending an earlier sample in elderly patients or patients
with impaired renal function. Complete the laboratory request form for
Vancomycin level when prescribing the first dose.
Take sample within the hour before dose is due.
Document on request form date and time sample was taken, date and time
of last Vancomycin dose.
If the level is acceptable check the trough level within the hour before dose
is due twice per week thereafter, or more often in patients with impaired
renal function, haemodynamically unstable patients, elderly patients or if
there has been difficulty in maintaining sufficiently high levels.
Peak levels should only be checked when recommended by Microbiology/ID.
It is important to monitor renal function in addition to monitoring
Vancomycin levels.


Table 3: Interpretation of Vancomycin Levels
Target trough level is 10 to 15mg/L but 15 to 20mg/L is recommended for
complicated infections e.g. endocarditis, osteomyelitis, bloodstream infection,
meningitis, or hospital acquired pneumonia caused by S. aureus
Level Advice
< 10mg/L

Subtherapeutic
1. Is Vancomycin still needed?
2. Is it a true trough (level taken within one hour before dose)?
3. Is dose correct for weight & renal function?
4. Are doses being held/have recent doses been given on time?
5. An increase in dose is likely to be needed see below.
6. Re-check level after 3 doses at new regimen.
10 to 20mg/L 1. Is Vancomycin still needed?
2. Is patient responding clinically?
3. Continue same dose.
4. Check level in 3 days.
>20mg/L 1. Is Vancomycin still needed?
3. Where was sample taken from? (falsely high levels can occur if taken from
same line used to give Vancomycin).
5. Is renal function stable?
6. Dose adjustment required see below.
7. Re-check level after 3 doses at new regimen.

Table 4: Vancomycin Dose Adjustment
The following is provided for guidance and assumes stable renal function. Contact
Microbiology/ID/Pharmacy to discuss individual patients if in doubt
If target level is 10 to 15mg/L

If target level is 15 to 20mg/L
Level Action Level Action
<10 Increase each dose by
250mg
<10 Increase each dose by 500mg
10 to 15 Continue same dose 10 to 15 Increase each dose by 250mg
15 to 20 Reduce each dose by 250mg 15 to 20 Continue same dose
>20 Consider omitting next dose
and decrease each
subsequent dose by 500mg
20 to 25 Reduce each dose by 250mg
>25 Consider omitting next dose and
decrease each subsequent dose by
500mg

Table 5: Cockcroft and Gault Equation
Creatinine clearance (CrCl) (ml/min)
Calculate Ideal Body Weight (IBW) in kg (see below)
Use the following equation to calculate estimated CrCl

(140 age) x (IBW in kg) x N
Serum creatinine (micromol/L)

1. N = 1.23 males & 1.04 females
2. If actual body weight < IBW, use actual body weight in this equation

Ideal Body Weight (IBW) (kg) =

MALE:
50kg + 2.3kg x inches over 5 feet OR 50kg + 0.9kg x cm over 152cm

FEMALE:
45.5kg + 2.3kg x inches over 5 feet OR 45.5kg + 0.9kg x cm over 152cm


Gentamicin Dosing and Monitoring
1. Effective use of Gentamicin is complex and should normally be discussed with
Microbiology or Infectious Diseases. The following is provided for guidance.
2. In general, treatment should be reviewed within 24 hours, and daily thereafter by
consultant/specialist registrar. Courses should not usually exceed 7 days.
3. In patients with impaired renal function (creatinine clearance less than 80mls/minute) avoid
aminoglycosides if possible. If Gentamicin is being considered discuss with Microbiology/ID.
4. Gentamicin is potentially nephrotoxic & ototoxic; monitor Gentamicin levels closely.
5. Prolonged duration of treatment and co-administration of nephrotoxins (e.g. diuretics,
NSAIDs, Vancomycin) increases risk of toxicity and should be avoided where possible.
6. The responsible clinical team must check reported Gentamicin levels regularly and adjust dosing if
required. The laboratory does NOT alert teams of out of range results.
7. A consultant microbiologist is on call 24 hours a day 7 days a week for clinical advice regarding
Gentamicin dosing and interpretation of levels.
8. The laboratory processes Gentamicin levels seven days a week.
9. The lab may not process any request which does not include a sampling time.
10. In a patient less than 65 years with good renal function (creatinine clearance greater than
80ml/minute) and with good urine output, do NOT hold Gentamicin doses pending Gentamicin
levels.
11. In a patient greater than 65 years old or with abnormal renal function (creatinine clearance
less than 80ml/minute), it is generally preferable to await the result of the first Gentamicin level
(i.e. before the second dose) before giving the second dose. If the level is less than 1mg/L and renal
function is stable it is not necessary to routinely hold subsequent doses pending levels.
12. Once daily dosing of Gentamicin is recommended for most patients. Discuss the following patients
with Microbiology/ID for advice on a case-by-case basis: patients with renal impairment (creatinine
clearance less than 30ml/minute), endocarditis, ascites, major burns, pregnancy.


Table 1: Once Daily Gentamicin Dosing Guidelines
A Gentamicin Dosing Calculator is available on the GAPP app
Step 1 Review for
exclusions/
cautions
The following patients should be discussed with
Microbiology/ID: Patients with renal impairment (CrCl
<30ml/min), endocarditis, ascites, major burns, pregnancy.
Cautions: Age 65, renal impairment (CrCl <80ml/min), obesity
(use adjusted dosing weight), other nephrotoxins.
Step 2 Calculate
patients ideal
body weight
(IBW)
Height required
Male: 50kg + (2.3kg x inches over 5 feet OR 0.9kg x cm over
152cm)
Female: 45.5kg + (2.3kg x inches over 5 feet OR 0.9kg x cm over
152cm)
Step 3 Dosing Weight/
Obesity
Adjustment

Weight required

Obesity adjustment:
Obese patient: If actual body weight exceeds IBW by 30%,
calculate Adjusted Dosing Weight:
Adjusted Dosing Weight (kg) =
Ideal Body Weight + 0.4 x (Actual Body Weight Ideal Body
Weight)
Non-obese patient: Use actual body weight to dose gentamicin.
Step 4 Estimate renal
function
Patient age,
weight, height, &
creatinine required
Must use creatinine clearance (not eGFR) to dose Gentamicin.
Calculate the patients estimated creatinine clearance using
Cockcroft & Gault equation.
Neither creatinine clearance or eGFR provide a perfect marker of
renal function, particularly if rapidly changing renal function.
Step 5 Select a dose based on renal function and weight. If obese use Adjusted Dosing
Weight; If non-obese use Actual Body Weight (See Step 3)
CrCl (ml/min)
Dose: round to nearest 40mg
NB: Doses above 400mg once daily rarely needed
Greater than 80 5mg per kg IV (up to a max of 400mg) every 24 hours
60 to 79 4mg per kg IV (up to a max of 400mg) every 24 hours
40 to 59 3.5mg per kg IV (up to a max of 400mg) every 24 hours
30 to 39 2.5mg per kg IV (up to a max of 400mg) every 24 hours
less than 30

Avoid if possible
2mg per kg IV (up to a max of 200mg)
Check level at 24 hours,
discuss need for second
dose with Micro/ID
Unknown but
renal impairment
likely
Give 2 to 3mg/kg as loading dose; review within 24 hours once
renal function known. Calculate subsequent doses according to
renal function as above
Intermittent
haemodialysis
See Haemodialysis Dosing Guidelines

Table 2: Once Daily Gentamicin Administration & Monitoring
Guidelines
Adminis-
tration

By IV infusion in 50 to 100ml of NaCl 0.9% over 20 to 30 minutes. See IV
administration guide on ward or pharmacy intranet http://medinfo
Give first dose immediately.
Monitoring Measure trough levels only.
The first trough level should be taken before the 2
nd
dose.
Take sample within the hour before dose is due.
Document on request form date and time sample was taken and date and time of
last dose.
If the level is less than 1mg/L, re-check trough levels twice per week thereafter,
or more often in patients with impaired or rapidly changing renal function,
haemodynamically unstable patients, elderly patients.
Note that monitoring of renal function in addition to monitoring of
aminoglycoside levels is important as toxicity may occur in patients in whom the
aminoglycoside levels have never exceeded the acceptable range.
With respect to ototoxicity, vestibular disturbance (vertigo, ataxia) often precedes
disturbance of hearing and should not be discounted because the patient has levels
within the acceptable range.


Table 3: Interpretation of Levels for Once Daily Gentamicin
Target trough level is <1mg/L
Level Advice
<1 mg/L 1. Is Gentamicin still needed?
2. Is patient responding clinically?
3. Continue same dose.
4. Check level in 3 days.
1 mg/L 1. Is Gentamicin still needed?
3. Where was sample taken from? (falsely high levels can occur if taken from same
line used to give Gentamicin).
5. Is renal function stable?
6. Dose adjustment required - contact Microbiology/ID/pharmacy to discuss on a
case-by-case basis.

Table 4: Multiple Daily Gentamicin Dosing Guidelines - for
Treatment of Endocarditis and Synergy Only.
Consult with Microbiology/ID recommended
Dose
CrCl
>70ml/min
Dose renal
impairment
Recommended
range for
levels
Timing and frequency of levels
1mg/kg
(maximum
80mg)
every 8 to 12
hours
depending on
renal function
and age

Contact
Microbiology/I
D
for advice
Trough:
<1mg/L

Peak:
3 to 5 mg/L
Take first trough level within one hour
before 3
rd
/4
th
dose
Take first peak level one hour after 3
rd
/4
th

dose
Repeat trough level every 3 days or more
often if high risk of accumulation
Peaks need only be taken once weekly from
week two onwards
Adjust dose according to levels
Monitor renal function
Contact Microbiology/ID for further advice
Other than for endocarditis and synergy, multiple daily dosing of Gentamicin is rarely
indicated. If being considered please discuss with Microbiology/ID.

References
1. The Renal Drug Handbook 3rd Edition 2009
2. The Sanford Guide to Antimicrobial Therapy 41
st
Edition 2011
3. Rybak et al Vancomycin Therapeutic Guidelines: A Summary of Consensus Recommendations from
IDSA/ASHP/SIDP Clin Infect Dis 2009 49;325-327.
4. Thomson et al Development and evaluation of vancomycin dosage guidelines designed to achieve new target
concentrations JAC 2009;63:1050-1057.


Empiric Guidelines by Infection (Adults)

1. Abdomen
1. The regimens below may NOT cover MRSA in all cases. Vancomycin may be required in
addition. See note on MRSA (page 8).
2. Fungal Infection is an important consideration in patients with intra-abdominal sepsis. In
patients at high risk of fungal infection e.g. upper GI perforation, consider antifungal therapy;
consult with Microbiology or Infectious Diseases recommended.
3. Most patients with acute pancreatitis do NOT have necrotising pancreatitis and do NOT require
antibiotic prophylaxis.
Empiric Antibiotics for Abdominal Infections
Infection 1
st
Line
Antibiotics
minor/
delayed onset
If penicillin
allergy:
severe/
immediate
reaction
Comment
Intra-abdominal
Mild Community
Acquired
e.g. cholecystitis/
appendicitis/
diverticulitis
Co-amoxiclav IV
1.2g every 8
hours

CefUROXime IV
1.5g every 8 hours
+
Metronidazole IV
500mg every 8 hours

Ciprofloxacin IV
400mg every 12
hours
+
Metronidazole IV
500mg every 8
hours
Duration
4 to 7
days
assuming
adequate
source
control
Intra-abdominal
Moderate to Severe
Community &
All Hospital Acquired
including
cholangitis/ intra-
abdominal
abscess/diverticulitis
Piperacillin/
tazobactam IV
4.5g every 8
hours

Add
Gentamicin* IV
5mg/kg (max
400mg) one
dose, IF
haemo-
dynamically
unstable

CefTRIAXone IV
2g every 24 hours
+
Metronidazole IV
500mg every 8 hours.

Add
Gentamicin* IV 5mg/kg
(max 400mg) one
dose, IF
haemodynamically
unstable

Ciprofloxacin IV
400mg every 12
hours
+
Vancomycin* IV
Infusion 25mg/kg
loading dose,
then 15mg/kg
every 12 hours
(max 2g per dose)
+
Metronidazole IV
500mg every 8
hours
Add
Gentamicin* IV
5mg/kg (max
400mg) one dose,
IF severe
infection &
haemo-
dynamically
unstable
Consult
Microbiol-
ogy/ID

Duration
7 to 10
days
assuming
adequate
source
control
Necrotising
Pancreatitis,
Prophylaxis
Patients with acute
pancreatitis admitted to
ICU or necrotising
pancreatitis confirmed by
imaging
CefTRIAXone IV 2g every 24 hours
+

Ciprofloxacin IV
400mg every 12
hours
+
Metronidazole IV
500mg every 8
hours
Review
need for
antibiotics
every 72
hours. See
note below
Consult Microbiology/ID if deterioration or requiring antibiotics for more than 5 days
Spontaneous
Bacterial Peritonitis

Ciprofloxacin IV
400mg every 12
hours

5 days

E
M
P
I
R
I
C

G
U
I
D
E
L
I
N
E
S


Empiric Antibiotics for Abdominal Infections
Infection 1
st
Line
Antibiotics
minor/
delayed onset
If penicillin
allergy:
severe/
immediate
reaction
Comment
Peritoneal Dialysis
Peritonitis
Vancomycin Intraperitoneally 30mg/kg (max. 3g) loading dose, then
30mg/kg (max. 2g) every 5 to 7 days + Ciprofloxacin PO 500mg every 12
hours
Patient to be treated in PD Unit
Protocol and detailed guidelines available on QPulse & in PD Unit
Cirrhosis with Acute
Variceal
Haemorrhage,
Prophylaxis
CefTRIAXone IV
2g every 24
hours
CefTRIAXone IV
2g every 24 hours

Ciprofloxacin PO
500mg every 12
hours

7 Days
Prophylaxis for
patients with an
absent or
dysfunctional spleen
Phenoxymethyl-
penicillin
(Calvepen
) PO
333 to 666mg
every 12 hours
(666mg once
daily may be
given if
compliance is a
problem)
OR
Amoxicillin PO
250 to 500mg
once daily
Erythromycin PO
250 to 500mg once
daily
Oral absorption of
phenoxymethylpenicillin is limited
and affected by a number of
variables. For emergency self
initiated therapy of a suspected
systemic infection treatment with
amoxicillin is preferable.
See Appendix 4 for guidelines for
management of patients with
absent or dysfunctional spleen
(adults only) including
recommended vaccines &
antibiotics.
Emergency treatment doses
Amoxicillin PO
500mg to 1g
every 8 hours
Erythromycin PO
500mg to 1g every
6 hours
* See dosing & monitoring guidelines Gentamicin & Vancomycin (pages 14 to 18); Review need for
ongoing Gentamicin/Vancomycin on a daily basis. Continue with once daily Gentamicin dosing
ONLY if Consultant/Specialist Registrar recommended.

Ref:
IDSA Guidelines for Diagnosis and Management of Complicated Intra-abdominal infections in Adults & Children.
Clin Infect Dis 2010;50:133-164



2. Bone and Joint
1. Microbiological diagnosis is essential, relevant bone and synovial fluid samples should be sent
prior to treatment. Treatment should be targeted at the infecting organism.
2. Consultation with Microbiology or Infectious Diseases is recommended in all cases.
3. The regimens below may NOT cover MRSA. Vancomycin may be required in addition. See
note on MRSA (page 8).
4. These guidelines are intended for adults. Refer to paediatric guidelines for children.

Empiric Antibiotics for Bone and Joint Infections
Infection 1
st
Line Antibiotics If pencillin allergy Comment

Septic Arthritis

See note on MRSA
(above)
Flucloxacillin IV
2g every 6 hours

Vancomycin* IV Infusion 25mg/kg
loading dose, then 15mg/kg every 12
hours (max 2g per dose)
Minimum
2 weeks
parenteral
therapy.

Consult
Microbiology/
ID
Osteomyelitis

Consult with Microbiology/ID.
Treat according to culture results

Prosthetic Joint
Infection

Consult with Microbiology/ID.
Treat according to culture results

*See dosing & monitoring guidelines Vancomycin (pages 14 to 15)

Ref:
The Sanford Guide to Antimicrobial Therapy 41
st
Edition 2011


3. Central Nervous System

Suspected Bacterial Meningitis
1. The most important aspect of treatment of suspected or confirmed bacterial meningitis is to
commence antibacterial therapy IMMEDIATELY.
2. Chloramphenicol is available in the Emergency Department and in the Pharmacy Department.
Meropenem may be an alternative in patients with a history of penicillin anaphylaxis, as
recommended in Irish guidelines, with close monitoring for cross-sensitivity e.g. in ICU.
3. See footnote on use of Dexamethasone.
4. Consult with Microbiology or Infectious Diseases recommended: essential if risk factors for
M. tuberculosis (alcohol, homelessness, immunocompromised host, recent immigration from
area of high incidence, recent contact with tuberculosis).
5. Risk factors for Listeria monocytogenes meningitis in adults include underlying neoplasm,
immunosuppressive treatment, age over 50, pregnancy and excessive alcohol use.
6. See Appendix 5 for management of contacts. The patient should be given chemoprophylaxis
before discharge from hospital UNLESS treated with cefTRIAXone.

Empiric Antibiotics for Suspected Bacterial Meningitis
Infection 1
st
Line
Antibiotics
If penicillin
allergy:
minor/delayed
onset
If penicillin
allergy:
severe/immediate
reaction
Comment
Suspected
Bacterial
Meningitis
CefTRIAXone IV
2g every 12 hours
+
Vancomycin* IV
Infusion 25mg/kg
loading dose, then
15mg/kg every 12
hours (max 2g per
dose)

Consider adding
AmoxicillinIV 2g
every 4 hours if at
risk for
L. monocytogenes

CefTRIAXone IV
2g every 12 hours
+
Vancomycin* IV
Infusion 25mg/kg
loading dose, then
15mg/kg every 12
hours (max 2g per
dose)

Consider adding
Co-trimoxazole IV
60mg/kg every 12
hours (round dose to
nearest 480mg) if at
risk for
L. monocytogenes

Chloramphenicol IV
25mg/kg every 6
hours
Give a stat dose, and
consult with
Microbiology/ID
immediately
+
Vancomycin* IV
Infusion 25mg/kg
loading dose, then
15mg/kg every 12
hours (max 2g per
dose)

Consider adding
Co-trimoxazole IV
60mg/kg every 12
hours (round dose to
nearest 480mg) if at
risk for
L. monocytogenes
Minimum
duration of
treatment

Meningococcal
meningitis:
7 days

Haemophilus
meningitis:
10 days

Pneumococcal
meningitis:
14 days

Listeria
meningitis:
21 days
* See dosing & monitoring guidelines Vancomycin (pages 14 to 15)
Dexamethasone
Consider adjunctive treatment with dexamethasone IV 0.15mg/kg every 6 hours for four days
(particularly if pneumococcal meningitis suspected in adults), preferably starting before or with first
dose of antibiotic, but no later than 12 hours after starting antibiotic.
Avoid dexamethasone in septic shock, meningococcal septicaemia, or if immunocompromised, or
in meningitis following surgery.
Some experts add Rifampicin to the antimicrobial regimen if Dexamethasone is given.
Refs:
1. IDSA Guidelines for the Management of Bacterial Meningitis. Clin Infect Dis 2004;39:126784
2. HPSC Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including
meningococcal disease) Jan 2012


Central Nervous System, contd

Suspected Herpes Simplex Encephalitis
1. Viral meningitis (as distinct from encephalitis) does NOT require treatment. Discuss with
Microbiology/ID.
2. Consult with Microbiology or Infectious Diseases recommended if patient has recent travel
history or is immunocompromised.

Antivirals for Suspected Herpes Simplex Encephalitis
Infection 1
st
Line

Comment
Suspected
Herpes Simplex
Encephalitis

Aciclovir IV
10mg/kg every 8 hours

Use ideal body weight to dose
obese patients

Confirmed HSV
encephalitis requires a total of 14
to 21 days IV therapy

Ref:
IDSA Guidelines for the Management of Encephalitis Clin Infect Dis 2008;47:303-27

4. Eye
Antimicrobial therapy is of very limited value in most cases of conjunctivitis.
Topical chloramphenicol or fusidic acid may be used. Note risk of local hypersensitivity
reaction to antimicrobial.

5. Fungal
1. Medical assessment is required before prescribing antifungal therapy.
2. For suspected oral candidiasis send a swab to microbiology to confirm fungal infection.
3. For recurrent or refractory infection send a repeat swab and consult with Microbiology or Infectious
Diseases.
4. In immunocompromised patients a high index of suspicion of infection is advised.

Empiric Treatment of Fungal Infections
Infection Treatment

Comment
Oropharyngeal
candidiasis
Mild
Nystatin suspension PO
5ml every 6 hours after food. Swish and
swallow, leaving in contact with mouth for at
least 30 seconds.
Duration usually for 7 days, continued for
48 hours after lesions have resolved

Moderate to severe
Fluconazole PO 100mg every 24 hours
Duration 7 to 14 days

Fluconazole refractory
Contact Microbiology/ID

Denture related
As above plus disinfection of dentures
Oesophageal
candidiasis
Fluconazole PO
200mg every 24 hours
Duration 14 days
Vulvovaginal
candidiasis
Vulvitis
Clotrimazole 1%
cream topically 2 to 3 times daily
Vaginitis
Clotrimazole 1%
cream topically 2 to 3 times daily
AND Clotrimazole pessary PV
500mg single dose at night
Duration continue cream for 7 to 14 days
Add Fluconazole PO 150mg single dose if
severe or not responding (avoid in
pregnancy)
Candida at urinary,
respiratory & other
sites

Contact Microbiology/ID Treatment not routinely indicated
Disseminated
candidiasis
Contact Microbiology/ID Choice of antifungal depends on
sensitivities
Fungal skin infection Contact Microbiology/ID/Dermatology for advice

Fungal nail infection Contact Microbiology/ID/Dermatology for advice
For all other
suspected fungal
infections e.g.
aspergillosis contact
Microbiology/ID
Contact Microbiology/ID for advice

Ref:
IDSA Candidiasis Guidelines Clin Infect Dis 2009;48:503-535



6. Gastrointestinal System

Clostridium difficile Infection (CDI)
1. See Appendix 3 for further information:
a. Treatment algorithms for initial and recurrent CDI.
b. Regimen for tapered pulsed oral Vancomycin (on Microbiology/ID advice only).
c. Regimen for intracolonic Vancomycin (on Microbiology/ID advice only).

CDI Severity Score (Zar et al)
CDI Severity Score (Zar et al)* <2 non-severe, 2 severe

Variable Points
Age >60 years
Temperature >38.3
o
C
WBC count >15X10
9
/L OR Albumin level <25g/L

1 point for each variable
Endoscopic evidence of pseudomembranous colitis
Treatment in ICU

2 points for each variable
*No widely accepted definition of CDI severity but Zar is referenced in Irish guidelines

Antibiotics for Clostridium difficile Infection
Infection 1st Line Antibiotics Comment

Clostridium difficile Non-severe
Metronidazole PO/NG 400mg every 8 hours

If severe or failure to respond -
consult Microbiology/ID
Maintain hydration
Avoid anti-diarrhoeal agents
Stop precipitating antibiotic(s) if
possible or switch to agents less
likely to be associated with CDI
Stop proton pump inhibitors (PPIs)
if possible
Use vancomycin injection to
prepare oral solution see IV
Guide
Prescribe vancomycin capsules if
required on discharge (expensive -
high tech prescription required)
Severe
Vancomycin PO/NG 250mg every 6 hours

Severe with ileus or toxic megacolon
Vancomycin PO/NG 500mg every 6 hours
+

First recurrence
Treat according to severity as above
Second or more
recurrence
Consider tapered pulsed oral Vancomycin
(See Appendix 3)

Ref:
Health Protection Surveillance Centre. Surveillance, Diagnosis and Management of Clostridium difficile - associated disease in
Ireland. May 2008

Gastrointestinal System, contd
Gastroenteritis
1. Avoid antimicrobial agents unless there is clinical evidence of invasive disease
2. Maintain hydration
3. Avoid anti-diarrhoeal agents

Antibiotics for Gastroenteritis with Invasive Disease
Infection 1st Line Antibiotics Comment

Gastroenteritis with
clinical evidence of
invasive disease/ colitis
(fever, bloody stool etc)

If there is a clinical
suspicion of Vero-toxin
producing E.coli, in the
absence of sepsis
antibiotics should be
avoided
Ciprofloxacin IV 400mg every 12 hours
OR

Consider adding Gentamicin* IV 5mg/kg (max
400mg) one dose, IF haemodynamically unstable

Switch to oral ciprofloxacin
(500mg every 12 hours) as
soon as possible
If there is a history of recent
foreign travel discuss
therapy/management with
Microbiology/ID. There is a
higher risk of associated
ciprofloxacin-resistant
pathogens.
Usual recommended duration
of therapy is 10 to 14 days
* See dosing & monitoring guidelines Gentamicin (pages 16 to 18); Review need for ongoing Gentamicin on a
daily basis. Continue with once daily Gentamicin dosing ONLY if Consultant/Specialist Registrar
recommended.


7. Genital System

Empiric Antibiotics for Genital System Infections
Infection 1
st
Line Antibiotics If penicillin allergy:
severe/immediate
reaction
Comment

Pelvic
Inflammatory
Disease -
Outpatient
Treatment
Send a full STI
screen including
Chlamydia &
Gonorrhoea
CefTRIAXone IM 500mg single dose
+
Doxycycline PO 100mg every 12 hours
+
Metronidazole PO 400mg every 12 hours

Ofloxacin PO 400mg
every 12 hours
+
Metronidazole PO
Duration
14 days
Pelvic
Inflammatory
Disease -
Inpatient
Treatment
Send a full STI
screen including
Chlamydia &
Gonorrhoea

+
+
Metronidazole PO 400mg every 12 hours

Clindamycin IV 900mg
every 8 hours
+
Gentamicin* IV 5mg/kg
(max 400mg) every 24
hours

Followed by
Doxycycline PO 100mg
every 12 hours
+
Metronidazole PO

Note: The initial IV
regimen does not cover
Chlamydia or
Gonorrhoea
Continue IV
treatment for 24
hours after clinical
improvement then
switch to oral to
complete 14 days

Acute
Prostatitis/
Epididymo-
orchitis
If Sexually
active
CefTRIAXone IM 500mg single dose
+
Send urethral swabs for Chlamydia & Gonorrhoea if sexually active in past
six months & refer to Sexually Transmitted Infection (STI) Clinic/Infectious
Diseases.
Duration
10 to 14 days.
If Chlamydia PCR
negative consider
stopping
doxycycline.
Consider mumps
as aetiology.
Acute
Prostatitis/
Epididymo-
orchitis
If NOT sexually
active
Ciprofloxacin PO 500mg every 12 hours
IF patient appears septic treat as suspected bloodstream infection:
Add Gentamicin* IV 5mg/kg (max 400mg) one dose

Duration
14 to 28 days.

*See dosing & monitoring guidelines Gentamicin (pages 16 to 18); Review need for ongoing Gentamicin on a daily
basis. Continue with once daily Gentamicin dosing ONLY if Consultant/Specialist Registrar recommended.

Refs:
1. IDSA/ESCMID Guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women. Clin Infect
Dis 2011;52:e103-e120
2. BASHH UK National Guideline for the Management of Pelvic Inflammatory Disease 2011
3. BASHH UK National Guideline for the Management of Epididymo-orchitis 2010
st
Edition 2011


8. Heart

Bacterial Endocarditis
1. The following is intended primarily to provide initial short-term guidance on empiric therapy of seriously ill
patients and those with prosthetic valves.
2. Immediate consultation or consultation on the next working day with Microbiology or Infectious Diseases
is recommended in all cases of suspected endocarditis.
3. In those with sub-acute presentation of suspected endocarditis, with a native valve and who are clinically
stable at presentation it is often preferable to send blood cultures (as below) and to withhold antibiotics
pending consultation and culture results.
4. If safe to do so take 3 sets of blood cultures (10ml into each of two bottles for each set) BEFORE any
antibiotics are given. If the patient is very ill the interval between cultures can be as short as 20 or 30 minutes.

Empiric Antibiotics for Bacterial Endocarditis
Infection 1
st
Line Antibiotics

Comment
Bacterial
Endocarditis
Native Valve or Prosthetic valve
Vancomycin* IV Infusion 25mg/kg loading
dose, then 15mg/kg every 12 hours (max 2g
per dose)
+
Gentamicin* IV 1mg/kg (maximum 80mg)
every 12 hours
Rifampicin PO 450mg every 12 hours may be
added for prosthetic valve endocarditis,
although it may be preferable to delay this for 48
hours after commencement of Vancomycin and
Gentamicin.

Once culture and sensitivity results are available
direct antibiotic therapy accordingly in
consultation with Microbiology/ID.

Duration as advised by Microbiology/ID.

* See dosing & monitoring guidelines Gentamicin & Vancomycin (pages 14 to 18)

Refs:
1. Gould et al. BSAC Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults. Journal of
Antimicrobial Chemotherapy 2012;67:269-289
2. Baddour et al. AHA Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications.
Circulation 2005;111:3167-3184
st
Edition 2011


Heart, contd
Prophylaxis of Infective Endocarditis
1. The routine use of antibiotics in most situations is NOT justified on the balance of risk and benefit.
2. Consult with Microbiology or Infectious Diseases recommended if infection at procedure site.

Only patients identified with the following cardiac conditions undergoing one of the following high risk
procedures should be considered for prophylaxis for infective endocarditis (IE):

Refs:
1. Wilson et al. AHA Guideline Prevention of Infective Endocarditis. Circulation 2007;116:1736
2. Habib et al. ESC Guidelines on the prevention, diagnosis & treatment of infective endocarditis 2009. European Heart
Journal 2009;30:2369-2413
3. NICE Guidance. Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing
interventional procedures. March 2008

Prophylaxis of Infective Endocarditis
Box 1: Cardiac conditions requiring endocarditis prophylaxis - for high risk procedures
1. Prosthetic valve or prosthetic material used for cardiac valve repair
2. Previous infective endocarditis
3. Cardiac transplantation recipients who develop cardiac valvulopathy
4. Congenital heart disease (CHD)
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired congential heart defect with prosthetic material or device, whether placed by surgery or
catheter intervention, during the first 6 months after the procedure
Repaired CHD with residual defects at or adjacent to the site of a prosthetic patch or prosthetic device (which
inhibit endothelialisation)
Box 2: Recommendations by procedure - for patients with identified cardiac conditions
A. Dental Procedures
Antibiotic prophylaxis should only be considered for dental procedures requiring manipulation of gingival or
periapical region of teeth or perforation of oral mucosa
Antibiotic prophylaxis is not recommended for local anaesthetic injections in non-infected tissue, removal of
sutures, dental X-rays, placement or adjustment of removable prosthodontic or orthodontic appliances or braces, or
following shedding of deciduous teeth, or trauma to lips or oral mucosa
B. Respiratory Tract Procedures
Antibiotic prophylaxis should only be considered for invasive procedures involving incision or biopsy of the
respiratory mucosa e.g. tonsillectomy or adenoidectomy, or to treat infection e.g. drainage of abscess or empyema
Antibiotic prophylaxis is not recommended for respiratory tract procedures, including bronchoscopy or larynoscopy,
transnasal or endotracheal intubation
C. Gastrointestinal or genitourinary tract procedures
Antibiotic prophylaxis is not recommended for any procedure
Box 3: Recommended prophylaxis for procedures at risk
Give as a single dose 30- 60 minutes before procedure
Procedure 1st line antibiotic Alternative if penicillin allergic
Dental Adults: Amoxicillin PO/IV 2g (can give 3g
sachet)

Children: Amoxicillin PO/IV 50mg/kg
Adults: Clindamycin PO/IV 600mg

Children: Clindamycin IV 20mg/kg OR
Azithromycin Suspension PO 15mg/kg
Respiratory As for dental


9. Intravascular Line
1. Blood cultures should be taken if the patient appears septic and/or if the patient has a central or
peripheral vascular catheter (CVC/PVC) exit site infection (one set from a peripheral vein and one set from
all lumens of central line). If evidence of exit site infection a swab should be taken from the site.
2. If blood cultures are positive liaise with Microbiology or Infectious Diseases.
3. Infection at the site of CVC/PVC, with no systemic features of sepsis and with negative blood cultures may
be treated as a skin/soft tissue infection
Removal of the catheter is essential
Initial therapy should be with Vancomycin
Review at 48 hours, and consider switch to Flucloxacillin or other antibiotic if appropriate, based on
culture and sensitivity results.
4. If an antibiotic lock solution is recommended by Microbiology or Infectious Diseases, contact Pharmacy for
protocol.

Refs:
1. SARI/HPSC Prevention of Intravascular Catheter-related Infection in Ireland 2009
2. IDSA Guidelines for the diagnosis and management of intravascular catheter-related infection. Clin Infect Dis
2009;49:1-45

Empiric Antibiotics for Intravascular Line Infections
Infection 1
st
Line Comment
Central and
Peripheral IV Catheter
Exit Site Infection
See notes (above)
Vancomycin* IV Infusion 25mg/kg loading dose, then
15mg/kg every 12 hours (max 2g per dose)
Review at 48 hours, change to directed therapy
based on culture & sensitivity
Peripheral Line-
related Sepsis and/or
Bacteraemia

Review at 48 hours, change to directed therapy
based on culture & sensitivity
Duration minimum 14 days, for
exceptions see algorithm for
NON-tunnelled CVC
bacteraemia (on next page).
Central Line-related
Sepsis and/or
Bacteraemia
Remove CVC and
send tip to
microbiology
+
Consider adding
Gentamicin* IV 5mg/kg (max 400mg) one dose

If blood cultures are positive treat as per
Microbiology/ID advice
Duration varies by type of line,
organism and complications. A
prolonged course may be
required.
See algorithms for NON-
tunnelled CVC and
tunnelled CVC/port bacteraemia
(on next pages).
When denoting duration of
antimicrobial therapy day 1 is the
first day on which negative blood
cultures are obtained.

* See dosing & monitoring guidelines Gentamicin & Vancomycin (pages 14 to 18); Review need for ongoing
Gentamicin/Vancomycin on a daily basis. Continue with once daily Gentamicin dosing ONLY if
Consultant/Specialist Registrar recommended.


Algorithm for Management of Non-Tunnelled CVC Bacteraemia


Algorithm for Management of Tunnelled CVC/Port Bacteraemia


10. Malaria
1. Species of infecting parasite is frequently uncertain.
2. Consult with Infectious Diseases or Microbiology recommended.
3. Severe malaria is a medical emergency. After rapid clinical assessment full doses of intravenous
antimalarial treatment should be started without delay with either Artesunate or Quinine.
4. In patients with clinically severe malaria or high parasitaemia (2% or greater) discuss the possible use of
Artesunate with the Consultant Microbiologist or Infectious Diseases Physician. A small supply of
intravenous Artesunate (unlicensed product with unreliable supply chain) may be available in the
Emergency Department.
5. Follow-on therapy Note for some kinds of malaria additional follow on therapy with Primaquine is
required to eradicate the persistent liver stage. All cases must be discussed with Infectious Diseases or
Microbiology.
6. Discharge prescriptions There can be problems with availability and medical card coverage of oral
treatment on discharge. Contact Pharmacy Dept. to discuss discharge medicines if required.
Malaria Treatment
Indication Oral Antimalarials If quinine hypersensitive (or ID
recommended) Determine nature of reaction:
dont withhold quinine if history of minor reaction
e.g. itching
Comment

Non-severe
malaria
Non-Pregnant
Adult

Quinine PO 600mg
every 8 hours
+
Doxycycline PO 200mg
every 24 hours
Consultation is essential
Malarone
PO 4 tablets every 24 hours for

3 days
(Four tablets of Malarone
contain 1g of
Atovaquone & 400mg of Proguanil)
OR
Riamet
PO (over 35kg body weight) 4

tablets every 12 hours for 3 days (total 24
tablets over 60 hours)
(Four tablets of Riamet
contain 80mg of
Artemether & 480mg of Lumefantrine)
Duration 7 days

When the oral
route is not
available or not
practical for
administration of
quinine the IV
route may be
used.

Non-severe
malaria
Pregnant Adult
Quinine PO 600mg
every 8 hours
+
Clindamycin PO 450mg
every 8 hours
Severe Malaria Intravenous Antimalarials: If seriously ill or unable to take tablets
Artesunate IV 2.4mg/kg at 0, 12, 24 hours,
then every 24 hours
OR
Quinine IV infusion
Loading dose*: 20mg/kg (maximum 1.4g)
infused over 4 hours, followed 8 hours after
start of the loading dose by
Maintenance dose: 10mg/kg (maximum
700mg) IV Infusion (over 4 hours) every 8
hours
Reduce maintenance dose to
5 to 7 mg/kg (maximum 700mg) every 8
hours in severe renal impairment, severe
hepatic impairment, or if IV treatment
continues for more than 48 hours.

*Do NOT give loading dose if patient has
received quinine or mefloquine in previous
12 hours
Give intravenous antimalarials in the treatment
of severe malaria for a minimum of 24 hours -
irrespective of the patients ability to tolerate
oral medication earlier.
Switch to oral therapy to complete the course
when the patient is able to swallow AND retain
oral medication reliably.
Complete treatment by giving a course of oral
quinine plus doxycycline or oral quinine plus
clindamycin (as above) to complete a total of 7
days treatment of each drug.
Quinine toxicity:
Elderly require ECG monitoring during IV
quinine administration.
Significant risk of hypoglycaemia with IV
quinine. Monitor blood glucose regularly (about
every 2 hours) in the acute situation.

Refs
1. WHO Guidelines for the Treatment of Malaria Second Edition 2010


11. Respiratory System

Community Acquired Pneumonia
1. The CURB-65 score, in conjunction with clinical judgement, is a severity assessment tool for Community
Acquired Pneumonia. See Clinical Pathway (next page) .
2. Detailed Respiratory Guidelines are available on QPulse (Cln-Resp-002).
3. Antibiotics are NOT usually recommended for exacerbation of asthma with normal chest X-ray.
4. Antibiotics are NOT generally recommended for acute bronchitis with normal CXR - but consider for patients
>75years, or those with diabetes, heart failure or immunocompromise.

Empiric Antibiotics for Community Acquired Pneumonia
Infection 1
st
Line Antibiotics If penicillin
allergy:
minor/
delayed onset
If penicillin
allergy:
severe/
immediate reaction
Comment
Community
Acquired
Pneumonia
Signs and
symptoms of LRTI
AND new
consolidation on
chest X-ray

Mild CURB-65 Score 0 or 1 Duration
7 days
Amoxicillin PO
1g every 8 hours

In younger patients
Add atypical cover with
Clarithromycin PO
Doxycycline PO
200mg day one, then 100mg every 24 hours

Avoid Doxycycline in pregnancy or breast-feeding
Moderate CURB-65 Score 2 Duration
7 days

Most patients
can be treated
with oral
antibiotics
Amoxicillin PO/IV
1g every 8 hours
+
Clarithromycin PO
(IV if NPO) 500mg every
12 hours

Doxycycline PO
200mg day one, then 100mg every 24 hours
OR
Levofloxacin PO (IV if NPO)

Avoid doxycycline and Levofloxacin in pregnancy
or breast-feeding. Caution Levofloxacin if risks for
prolonged QT interval
Severe CURB-65 Score 3

Co-amoxiclav IV
1.2g every 8 hours
+
Clarithromycin PO
(IV if NPO) 500mg every
12 hours
CefTRIAXone IV
2g every 24 hours
+
Clarithromycin PO
(IV if NPO) 500mg
every 12 hours
Vancomycin* IV
Infusion 25mg/kg
loading dose, then
15mg/kg every 12
hours (max 2g per
dose)
+
Levofloxacin PO
(IV if NPO) 500mg
every 12 hours

Caution levofloxacin if
risks for prolonged QT
interval
Duration**
7 to 10 days

* See dosing & monitoring guidelines Vancomycin (pages 14 to 15)
**May need to be extended to 14 or 21 days according to clinical judgement e.g. if Legionella pneumophila,
Staphylococcus aureus or Gram negative enteric bacilli suspected or confirmed.

Refs:
1. British Thoracic Society Guidelines for the management of community acquired pneumonia in adults 2009
2. American Thoracic Society/Infectious Diseases Society of America Consensus guidelines on the management of
community-acquired pneumonia in adults. Clin Infect Dis 2007;44 (suppl 2) S27-72
3. GUH Respiratory Guidelines for Community Acquired Pneumonia 2012 (QPulse)


Algorithm for Management of CAP

Respiratory System, contd

Aspiration Pneumonia
Empiric Antibiotics for Aspiration Pneumonia
Infection 1st Line Antibiotics If penicillin allergy Comment
Aspiration
Pneumonia
Co-amoxiclav IV
1.2g every 8 hours
Consult Microbiology/ID Duration
7 to 10 days

Chronic Obstructive Pulmonary Disease (COPD)
Empiric Antibiotics for COPD
Infection 1st Line Antibiotics If penicillin allergy Comment
COPD
Exacerbation
without infiltrate

Amoxicillin PO
1g every 8 hours
OR If recent (<2/52) course of
amoxicillin: Co-amoxiclav PO
625mg every 8 hours
Clarithromycin PO 500mg every 12 hours
OR
Doxycycline PO 200mg day one, then
Duration
7 days

Hospital Acquired Pneumonia
1. The regimens below may NOT cover MRSA. Vancomycin may be required in addition. See note on MRSA
(page 8).
2. Pneumonia should be treated as hospital acquired if the clinical features of pneumonia become apparent from
5 days after hospital admission. Patients recently discharged from hospital within the previous 14 days, or
resident in a nursing home may also be at risk of infection with antimicrobialresistant bacteria and may
require treatment with this regimen.
3. Review previous results for resistant organisms e.g. ESBL, MRSA.
4. ICU patients should be discussed with Microbiology or Infectious Diseases
Empiric Antibiotics for Hospital Acquired Pneumonia
Infection 1
st
Line Antibiotics If penicillin allergy Comment

Hospital
Acquired
Pneumonia

Moderate
4.5g every 8 hours
Moderate or severe
Vancomycin* IV Infusion 25mg/kg
loading dose, then 15mg/kg every
12 hours (max 2g per dose)
+
Ciprofloxacin** IV

If possible aspiration
Add
Metronidazole IV
500mg every 8 hours

Add Gentamicin* IV 5mg/kg (max
400mg) one dose, IF

Duration
8 days

May need to be
extended to 14
or 21 days
according to
clinical
judgement e.g.
if Legionella
pneumophila,
Staphylococcus
aureus or Gram
negative
enteric bacilli
suspected or
confirmed.
Severe
4.5g every 8 hours

Consider adding
Clarithromycin** IV
500 mg every 12 hours

(max 400mg) one dose, IF

At 24 to 48 hours consider adding
Vancomycin* IV infusion 25mg/kg
loading dose, then 15mg/kg every 12
Gentamicin/Vancomycin on a daily basis. Continue with once daily Gentamicin dosing ONLY if Consultant/Specialist
Registrar recommended.
**Switch from IV to oral Clarithromycin (500mg PO every 12 hours) & from IV to oral Ciprofloxacin (500mg PO every 12 hours)
as soon as possible.
Refs:
1. ATS/IDSA Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-
associated pneumonia. Am J Respir Crit Care Med 2005:171;388-416
2. BSAC Guidelines for the management of hospital-acquired pneumonia in the UK. JAC 2008;62:5-34

Respiratory System, contd

Pneumocystis jirovecii pneumonia (PJP)
1. Consult with Microbiology or Infectious Diseases recommended.
2. Co-trimoxazole in high dosage is the treatment of choice for mild, moderate and severe PJP.
3. For moderate to severe disease (Pa02 9kPa on room air), high dose steroids should be co-
administered with anti-pneumocystis therapy and should be discontinued before anti-pneumocystis therapy
is complete: Prednisolone 40mg PO twice daily for 5 days, then 40mg once daily for 5 days, then 20mg
once daily to complete a total of 14 to 21 days (depending on duration of PJP treatment).

PJP Treatment
Infection 1
st
Line 2
nd
line

Comment
PJP

Co-trimoxazole* IV/PO 120mg/kg/day
divided into a 6 to 8 hourly dosing
regimen
e.g. 30mg/kg every 6 hours*

e.g. 70kg patient: 70x120 = 8,400mg
daily, dosing regimen would be
2,100mg every 6 hours (round dose to
nearest 480mg=1920mg)

In severe disease consider oral switch
at same dose when clinically
improving.
In mild to moderate disease consider
oral route from outset.

Severe disease:
Pentamidine IV 4mg/kg once daily
Only to be used if intolerant or
unresponsive to co- trimoxazole. Risk
of significant adverse events including
severe hypotension and
hypoglycaemia with administration

Non-severe disease:
Atovaquone
OR
Dapsone + Trimethoprim
OR
Clindamycin + Primaquine

Contact Microbiology/ID/Pharmacy for
advice and dosing.

Duration:
14 days non-HIV
infected;
21 days HIV
infected

*Please note the co-trimoxazole dose is a combined trimethoprim/sulfamethoxazole dose
Caution with dose calculation as errors have occurred when dosing is based on the trimethoprim component (as
recommended in US literature)

Ref:
Catherinot et al. Pneumocystis jirovecii pneumonia. Infect Dis Clin North Am 2009;24:107-138



12. Sepsis

Sepsis - Source Unclear
1. The following is intended for patients with no specific localising features, after a full evaluation.
2. Consult with Microbiology or Infectious Diseases recommended.
3. There may be a requirement for additional targeted treatment of infection at specific sites.
4. If a central venous catheter is in place, consider need for removal.
5. See Note on ESBL (page 8). In critically ill patients in particular from nursing homes consult with
Microbiology or Infectious Diseases and consider early use of Meropenem 1g IV every 8 hours.
6. Persistent fever or other features of continuing infection at 48 hours - consult Microbiology or Infectious
Diseases.
7. Duration of treatment is decided on a case-by-case basis depending on subsequent diagnosis as well as
clinical progress.

Empiric Antibiotics for Sepsis Source Unclear
Infection 1
st
allergy:
minor/
delayed onset
If penicillin
allergy:
severe/
immediate reaction
Sepsis - Source
Unclear

No risk factors e.g.
No CVC/
No IV Drug Use
4.5g every 8 hours
+
Gentamicin* IV
dose

CefTRIAXone IV
2g every 24 hours
+
Gentamicin* IV
dose

Ciprofloxacin IV
+
Gentamicin* IV
5mg/kg (max 400mg)
one dose
+
25mg/kg loading dose,
then 15mg/kg every 12
Consult with
Microbiology/ID

Sepsis - Source
Unclear
CVC in situ/
Inflammation at
intravascular catheter
insertion site/IV Drug
Use/
Risk factors for MRSA
Piperacillin/tazobactam
IV 4.5g every 8 hours
+
400mg) one dose
+
15mg/kg every 12 hours (max
2g per dose)

CefTRIAXone IV
2g every 24 hours
+
400mg) one dose
+
(max 2g per dose)

Haemodynamically
unstable or other
evidence of severe
infection
Consider cover for ESBL (see note above).
Avoid Meropenem in severe penicillin allergy.
Gentamicin/Vancomycin on a daily basis. Continue with once daily Gentamicin dosing ONLY if
Consultant/Specialist Registrar recommended.


Sepsis, contd
Suspected Meningococcaemia (without features of meningitis)
1. Consult with Microbiology or Infectious Diseases recommended
2. When infection with N. meningitidis is confirmed, therapy with Benzylpenicillin alone is appropriate.
3. See Appendix 5 for management of contacts. The patient should be given chemoprophylaxis before
discharge from hospital UNLESS treated with cefTRIAXone.

Empiric Antibiotics for Suspected Meningococcaemia
Infection 1
st
allergy:
minor/delayed
onset
If penicillin
allergy:
severe/immediate
reaction
Comment
Suspected
Meningoccaemia
(without features of
meningitis)
CefTRIAXone IV 2g
every 12 hours
CefTRIAXone IV 2g
every 12 hours
Chloramphenicol IV
Give a stat dose, and
consult with
Microbiology/ID
immediately
Duration
7 days

Neutropenic Sepsis
1. Assess immediately as an emergency.
2. The goal is a door to needle time of 60 minutes or less for administration of IV antibiotics
3. Fever means temperature 38.3C on one occasion or sustained temperature greater than 38C.
4. Neutropenia means an absolute neutrophil count of less than 0.5 X 10
9
/l.
5. Note frequent review is essential. The time frames suggested for addition of additional empiric therapy may
need to be shortened if the patients condition is deteriorating.
6. Consider risk for fungal infection and viral infection.
7. If the infection is CVC associated - remove the CVC.
8. Consider risk for ESBL producing bacteria See Note on ESBL (page 8).
9. Detailed Haematology Guidelines are available on QPulse (Cln-Path-001)

Summary treatment algorithms:
Initial management of neutropenic sepsis in ED
Initial management of neutropenic sepsis for in-patient
Continuing management of neutropenic sepsis

Refs
1. IDSA Guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2011;52:e56-93
2. National Comprehensive Cancer Network Prevention and Treatment of Cancer-Related Infections. Version 2.2011
3. British Committee for Standards in Haematology. Guidelines for the management of invasive fungal infection during
therapy for haematological malignancy 2008
st
Edition 2011
5. GUH Haematology Guidelines for the management of febrile neutropenic patients 2012 (QPulse)



Algorithm for Management of Neutropenic Sepsis in ED


Algorithm for Management of Neutropenic Sepsis for In-patient


Algorithm for continuing management of neutropenic sepsis

13. Skin and Soft Tissue

Skin and Soft Tissue Infections
1. The regimens below may NOT cover MRSA in all cases. Vancomycin may be required in addition. See
note on MRSA (page 8).
2. Blood cultures should be performed before starting antimicrobial treatment if all possible for a patient with
a severe infection, especially if the patient is systemically ill.
3. Please avoid the prescription of antibiotics and submission of swabs for uninfected ulcers.

Empiric Antibiotics for Skin and Soft Tissue Infections
Infection 1
st
minor/
delayed onset
If penicillin
allergy:
severe/immediate
reaction
Comment
Cellulitis/
Wound Infection

Mild
Flucloxacillin PO
500mg every 6 hours
CefALEXin PO
500mg every 6 hours
Clindamycin PO
450mg every 6
hours
Duration
7 to 10 days
Moderate
Flucloxacillin IV
2g every 6 hours
CefUROXime IV 1.5g
every 8 hours
Clindamycin PO
450mg every 6
hours
Severe
Flucloxacillin IV
2g every 6 hours
+
Clindamycin** IV 600mg
every 8 hours
25mg/kg loading dose, then 15mg/kg every 12
+
Clindamycin** IV 600mg every 8 hours
For severe if involving abdominal wall or groin or water exposure
Consider adding Ciprofloxacin** IV 400mg every 12 hours
Diabetic Soft
Tissue Infection
(without
osteomyelitis)

Mild
Co-amoxiclav PO 625mg
every 8 hours

Clindamycin PO 450mg every 6 hours
Usual
duration
10 to 14
days.
May require
up to 3
weeks for
severe
infection.
Moderate
Co-amoxiclav IV 1.2g
every 8 hours
+
Ciprofloxacin** IV 400mg every 12 hours
Severe
4.5g every 8 hours

25mg/kg loading dose, then 15mg/kg every 12
+
+
If risk factors for MRSA in moderate to severe infection consider
adding Vancomycin* IV Infusion 25mg/kg loading dose, then 15mg/kg
every 12 hours (max 2g per dose)


Empiric Antibiotics for Skin and Soft Tissue Infections
Infection 1
st
minor/
delayed onset
If penicillin
allergy:
severe/immediate
reaction
Comment
Necrotising
fasciitis/gas
gangrene

Immediate surgical
debridement is
essential
Immediate consult
with Microbiology/ID

Flucloxacillin IV
2g every 4 hours
+
Benzylpenicillin IV 2.4g
every 4 hours
+
Clindamycin IV
1.2g every 6 hours

For necrotising fasciitis
of the abdominal wall or
groin
Consider adding
Ciprofloxacin** IV 400mg
every 8 hours
+
Metronidazole IV 500mg
every 8 hours


Consider
Vancomycin* IV Infusion 25mg/kg loading
dose, then 15mg/kg every 12 hours (max 2g
per dose)
+
Clindamycin** IV 1.2g every 6 hours
+

Usual
duration 14
days
Orbital and
Periorbital
Cellulitis
Treat non-orbital
facial cellulitis as
celluliltis

CefTRIAXone IV
2g every 24 hours
+
every 8 hours

Addition of Flucloxacillin
IV
2g every 6 hours may be
considered if
S. aureus suspected

Addition of
Ciprofloxacin** IV 400mg
every 12 hours may be
appropriate if condition is
considered sight
threatening

CefTRIAXone IV
2g every 24 hours
+
Metronidazole IV
500mg every 8 hours

Addition of
Vancomycin* IV
Infusion 25mg/kg
loading dose, then
15mg/kg every 12
hours (max 2g per
dose) may be
considered if
S. aureus suspected

Addition of
Ciprofloxacin** IV
400mg every 12
hours may be
appropriate if
condition is
considered sight
threatening
Consult with
Microbiology/ID

Vancomycin* IV
Infusion 25mg/kg
loading dose, then
15mg/kg every 12
hours (max 2g per
dose)
+
Clindamycin** IV
600mg every 8 hours
+
Ciprofloxacin** IV
400mg every 12
hours
Duration 10
to 14 days
**Switch from IV to oral clindamycin (450mg every 6 hours) & from IV to oral ciprofloxacin (500mg every 12 hours)
as soon as possible

Refs:
1. IDSA Guidelines for Diagnosis & Management of Skin & Soft-Tissue Infections. Clin Infect Dis 2005;41:1373-406
2. IDSA Guidelines for Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54:132-173
3. Lehman. Flucloxacillin alone or combined with benzylpenicillin to treat lower limb cellulitis: a randomised controlled trial.
Emerg Med J 2005;22:342-346


Skin and Soft Tissue, contd
Bites, Animal and Human, Prophylaxis and Treatment
1. This provides recommendations on choice of antibiotic prophylaxis of bite wounds. It is not a comprehensive
guide to the care of bite wounds. Depending on the nature of the injury, the type of bite, the country in which
the bite occurred and previous immunization history issues such as prophylaxis against HIV virus infection,
tetanus immunization, immunization against hepatitis B and rabies may all merit consideration in addition to
the issue of antibiotic prophylaxis addressed here.
2. Application of topical antiseptics is NOT of value and should be avoided. Sterile water is appropriate for
wound irrigation.
3. Antibiotic prophylaxis is generally NOT appropriate for animal bites more than 2 days old OR human
bites more than 3 days old at time of presentation. If there are signs of infection, the issue is one of
treatment rather than prophylaxis. In the absence of previous appropriate prophylaxis the regimens below are
generally appropriate for treatment of infected bites however the dose, route of administration and choice of
agents may require adjustment based on severity of infection.
4. Antibiotic prophylaxis is appropriate for
All human bites less than 3 days old, all cat bites less than 2 days old and other animal bites less than
2 days old to the hand, foot and face; puncture wounds; wounds that require surgical debridement or
involving joints, tendons, ligaments or fractures.
Wounds that have undergone primary closure.
People at risk of serious wound infection (e.g. those who are immunocompromised, diabetic, asplenic or
cirrhotic).
People with a prosthetic valve or prosthetic joint.
5. In the case of bites from monkeys seek to get as much information as possible about the species of monkey
and discuss promptly with Microbiology or Infectious Diseases.

Empiric Antibiotics for Animal and Human Bites
Infection 1
st
line Antibiotics If penicillin allergy Comment

Animal & human
bites, prophylaxis
and treatment
Co-amoxiclav PO 625mg every
8 hours

Metronidazole PO 400mg every 8
hours
+
Doxycycline PO 200mg day one,
then 100mg every 24 hours

Duration 7 days

Ref:
NHS Clinical Knowledge Summaries Human & Animal Bites Accessed 28/5/12


14. Throat
1. Antibiotic therapy is generally NOT indicated for acute pharyngitis/tonsillitis in the community as most throat
infections are viral.
2. This recommendation is for patients requiring hospitalisation.
3. Avoid Amoxicillin if glandular fever is considered likely.
4. If condition is considered life threatening treat as for acute epiglottitis.

Empiric Antibiotics for Throat Infections
Infection 1
st
allergy:
minor/
delayed onset
If penicillin
allergy:
severe/
immediate
reaction
Comment
Acute Pharyngitis/
Tonsillitis

Benzylpenicillin IV
1.2g every 4 hours

If there is a good response
to initial IV therapy consider
switch to oral therapy with:
Phenoxymethylpenicillin PO
666mg every 6 hours OR
Amoxicillin PO 500mg every
8 hours
Clarithromycin IV 500mg every 12
hours

Consider switch to oral therapy if good
response to initial IV therapy
Duration 10
days.
If failure to
respond to initial
therapy consider
Co-amoxiclav IV
1.2g every 8
hours (if no
allergy to
penicillin)

Peritonsillar
abscess
Consult ENT re
early surgical
drainage of abscess
Benzylpenicillin IV
1.2g every 4 hours
+
every 8 hours
OR
If failure to respond to initial
therapy
Co-amoxiclav IV 1.2g every
8 hours
CefUROXime IV
1.5g every 8 hours
+
Metronidazole IV
500mg every 8
hours
Clindamycin IV
600mg every 8
hours

Duration usually
7 days.
Consider oral
switch when
appropriate -
discuss with
Micro/ID
Severe Acute
Epiglottitis
Consult
Microbiology/ID
CefTRIAXone IV
2g every 24 hours
CefTRIAXone IV
2g every 24 hours
Vancomycin* IV
Infusion 25mg/kg
loading dose,
then 15mg/kg
every 12 hours
(max dose 2g)
+
Ciprofloxacin IV
400mg every 12
hours

Optimal duration
of treatment not
established.
Generally treat
for 7-10 days.
Longer duration
may be indicated
in selected
patients
Consider oral
switch when
appropriate -
discuss with
Micro/ID

Refs:
st
Edition 2011
2. Bisno et al IDSA Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis Clin
Infect Dis 2002;35:113-25


15. Urinary Tract

Urinary Tract Infections
1. Bacteriuria in a patient with an indwelling urinary catheter is NOT an indication for treatment unless there
are specific clinical features of infection.
2. Removal of the urinary catheter at the earliest possible time is the best approach to dealing with catheter-
associated bacteriuria.
3. A practice of routine antimicrobial prophylaxis with gentamicin or other agents at the time of catheterisation is
generally NOT appropriate. (See surgical prophylaxis section for note related to recent urological surgery).
4. ESBL bacteria are relatively common in patients with UTI from a nursing home setting. See Note on ESBL
(page 8).
5. Detailed Obstetrics/Gynaecology document on Management of Urinary Tract Infections in Pregnancy is
available on QPulse (CLN-OGCP-227)

Empiric Antibiotics for Urinary Tract Infections
Infection

1
st
Line Antibiotics 2
nd
Line Antibiotic Comment
Uncomplicated
Cystitis

Nitrofurantoin PO
50mg every 6 hours

If pregnant: Avoid
nitrofurantoin at term
(38 weeks); consider
Co-amoxiclav PO
625mg every 8 hours

Avoid nitrofurantoin in
renal impairment
(eGFR<60ml/minute)
as ineffective

Ciprofloxacin PO 250mg every 12 hours

If pregnant: Avoid ciprofloxacin in pregnancy.
Discuss with Microbiology/ID if treating a
pregnant woman at term and with a history of
penicillin allergy
Duration for non-
pregnant women:
5 days for
nitrofurantoin
3 days for
ciprofloxacin
Duration in
pregnancy:
7 days

Adjust initial treatment
based on culture/
sensitivity results
Infection 1
st
allergy: minor/
delayed onset
If penicillin
allergy: severe/
immediate reaction
Comment
Pyelonephritis
or
Complicated
UTI
Non-pregnancy
Co-amoxiclav IV
1.2g every 8 hours
+
Gentamicin* IV
5mg/kg (max 400mg)
one dose
CefTRIAXone IV
2g every 24 hours

Add Gentamicin*
IV 5mg/kg (max
400mg) one dose
IF haemo-
dynamically
unstable
Ciprofloxacin IV 400mg
(or PO 500mg) every 12
hours (consider oral
route from outset)

Add Gentamicin* IV
5mg/kg (max 400mg)
one dose, IF haemo-
dynamically unstable
Minimum duration of
treatment is 10 days.

Consider switch to oral
therapy if good early
clinical response to IV
therapy.

Review need for
continuing Gentamicin
after 24 hours.

Acute
Pyelonephritis
In pregnancy

Add Gentamicin* IV 5mg/kg (pre-pregnancy
weight; max 400 mg) one dose, IF

Aztreonam IV 2g every 8
hours
Add Gentamicin* IV
5mg/kg (pre-pregnancy
weight; max 400mg) one
dose, IF
haemodynamically
unstable
* Gentamicin is generally NOT recommended in pregnancy unless benefit outweighs risk. See dosing & monitoring
guidelines Gentamicin (pages 16 to 18); Review need for ongoing Gentamicin on a daily basis. Continue with once
daily Gentamicin dosing ONLY if Consultant/Specialist Registrar recommended.
Ref:
GUH Obstetrics/Gynaecology Guidelines on Management of Urinary Tract Infections in Pregnancy 2012 (QPulse)

Urinary Tract, contd

Prophylaxis of Recurrent Urinary Tract Infections

Discussion with Microbiology or Infectious Diseases is recommended. In the absence of a correctable anatomical
or other predisposing factor for recurrent UTI, prophylaxis for a period of 3 to 6 months may be considered. The
most appropriate agent for prophylaxis is nitrofurantoin PO 50 to 100 mg at night.

CAUTION: Monitor lung and liver function in patients on long-term nitrofurantoin therapy. Avoid in renal impairment
(eGFR less than 60ml/minute).



16. Viral
Treatment of Viral Infections
Infection Treatment

Comment
Herpes simplex -
Cold sores
Aciclovir 5% cream every 4 hours
(5 times daily) for 5 to 10 days, starting at
first sign of attack
Most effective when applied at the earliest
possible stage - at prodromal stage before
vesicles appear
Systemic treatment necessary if frequent
recurrences or for infections in the mouth
Herpes simplex

Including
Mouth/lips
and
Gential herpes
Treatment:
ValACIclovir PO
500mg every 12 hours (1g every 12 hours in
imunocompromised)

Initial: Treat for 5 to 10 days
Recurrent: Treat for 5 days

Suppression:
ValACIclovir PO
500mg every 24 hours (500mg every 12
hours in immunocompromised)
interrupted every 6 to 12 months
If IV treatment needed
e.g. herpes simplex in
immunocompromised, severe genital
herpes or prophylaxis in
immunocompromised give

Aciclovir IV 5mg/kg every 8 hours

Herpes zoster
(shingles)
ValACIclovir PO 1g every 8 hours for 7 days
(in immunocompromised continue for 2 days
after crusting of lesions)

If IV treatment needed
Aciclovir IV 5mg/kg every 8 hours
(10mg/kg every 8 hours in
immunocompromised)
Herpes simplex
encephalitis

See encephalitis (page 19)

Antibiotic Prophylaxis in Surgery

Principles of Antibiotic Prophylaxis in Surgery
Antibiotic prophylaxis in surgery is the use of antibiotics to prevent post-operative infection.

Are prophylactic antibiotics needed?
Prophylaxis is recommended for patients undergoing:
Clean-contaminated and contaminated surgical procedures.
Clean surgical procedures with increased infection risk/devastating consequences of infection
such as lower limb vascular surgery, insertion of prosthetic material or on immunocompromised
patients.

Choice of antibiotic
The choice of agent will be determined by the procedure and the likely potential pathogens. These
guidelines generally apply to procedures in patients admitted from the community.
Erythromycin should be avoided - it is not a suitable agent for prophylaxis for a number of reasons
including poor tissue penetration.

Timing of administration
The aim of prophylaxis is to have maximum tissue antibiotic levels at the time of first incision.
Therefore prophylaxis should be administered between 30 and 60 minutes before skin incision and is
usually given in theatre at induction of anaesthesia.

Duration of prophylaxis
In most situations there is no value in continued prophylaxis after wound closure and prophylaxis is usually
given as a single dose unless otherwise specified below. Additional intra-operative doses of prophylactic
antibiotic may be necessary in the following situations:
Prolonged surgical procedures. Some antibiotics such as cephalosporins (e.g. CefUROXime) are
short-acting and therefore an additional dose may be needed during surgery in procedures lasting
> 3 hours. Re-dosing is not recommended for antibiotics such as gentamicin, vancomycin or
teicoplanin.
Blood loss/fluid replacement: In the event of major intra-operative blood loss (>1.5Litres) additional
doses of prophylactic antibiotic should be considered after fluid replacement. Caution is needed
in patients with renal impairment.

Documenting antibiotic use
Prophylactic antibiotics should be prescribed in the appropriate section of the patients drug chart.
Patients should ideally be informed prior to surgery, wherever possible, if they will need antibiotic
prophylaxis, and afterwards if they have been given antibiotics during their operation.

Post-operative infection
If infection is suspected during surgery or post-operatively within 24 hours, appropriate
microbiological samples should be sent. An agent that is appropriate for prophylaxis may not
be the optimal agent for treatment of established infection and treatment guidelines should
be consulted.



Antibiotic Prophylaxis in Surgery contd

Complex prophylaxis issues
For patients with complex clinical situations e.g. those with resistant organisms, renal failure,
immunocompromise or allergy to agents listed, please obtain advice from Microbiology or Infectious
Diseases if necessary.
Patients at risk for development of endocarditis may require modification of standard antimicrobial
prophylaxis regimens. See Prophylaxis of Infective Endocarditis. Please discuss with Microbiology or
Infectious Diseases if necessary.

MRSA
For patients requiring specific surgical prophylaxis against MRSA see Note Regarding Risk Factors for
MRSA

Note Regarding Risk Factors for MRSA

Teicoplanin() IV 10mg/kg (800mg) should be ADDED to the recommended regimens (unless teicoplanin
or vancomycin are already included) if the patient:
Is known to be colonized with MRSA
Was recently colonised with MRSA
Was an inpatient for more than 72 hours before the procedure and has not had a recent confirmed
negative MRSA screen result
Was admitted from another hospital or nursing home and has not had a recent confirmed negative
MRSA screen result.
Is at high risk for colonisation with MRSA for other reasons and has not had a recent confirmed
negative MRSA screen result.
In the case of patients known to be colonised with MRSA who are undergoing cardiac, major orthopaedic
implant or other complex surgery, it may be advisable to discuss an MRSA eradication protocol with
Microbiology or Infectious Diseases in advance of the surgery.
The recommended dose of teicoplanin (10mg/kg) is higher than the licensed dose to ensure adequate
tissue levels. The calculated dose is 700mg for an average 70kg patient - the dose is rounded to 800mg (2
x 400mg vials) for practical reasons.
Teicoplanin is used in surgical prophylaxis in preference to vancomycin in most cases, due to ease of
administration, as doses up to 800mg can be given by slow intravenous injection over 3 to 5 minutes.
Doses over 800mg should be given by infusion (in 50ml NaCl 0.9% or Glucose 5%) over 30 minutes.
If continued antibiotic treatment is necessary post surgery, switch to vancomycin.

S
U
R
G
I
C
A
L

P
R
O
P
H
Y
L
A
X
I
S



Antibiotic Prophylaxis in Surgery contd

Classification of Surgical Procedures
Classification of Surgical Procedures
Clean Clean-contaminated Contaminated/Dirty
No breach of respiratory, alimentary
or genito-urinary tracts
Non-traumatic
No inflammation
No break in aseptic technique
Non-traumatic but with break
in aseptic technique or
breach of respiratory,
alimentary or genito-urinary
tract
No significant spillage
Contaminated: Major break in aseptic
technique; acute inflammation (without pus);
operations where there is visible
contamination of wound e.g. gross spillage
from a hollow viscus during surgery or fresh
traumatic wound from relatively clean
source.

Dirty: operations in the presence of pus e.g.
where there is a previously perforated
hollow viscus or compound/open injuries
that are old or from a dirty source.
Prophylaxis NOT usually
recommended UNLESS clinical
setting indicates an increased
infection risk e.g. lower-extremity
vascular procedures, or where
infection may have devastating
consequences e.g. orthopaedic
implant surgery or placement of
other prosthetic devices).
Prophylaxis indicated (see
individual specialty below)
Prophylaxis indicated (see individual
specialty below).

Treatment course may be required
(usually 5 to 7 days - duration will depend
on clinical response)


Breast Surgery

Antibiotics for Breast Surgery
Type of
Surgery
Procedure 1
st
Line Antibiotic Penicillin allergy:
minor/
delayed onset
Penicillin allergy:
severe/
immediate reaction
Number &
Timing of Doses
Prophylaxis in
Breast
Surgery

See Note
Regarding
Risk Factors
for MRSA

Breast surgery (including mastectomy,
wide local excision, axillary clearance,
breast reduction, duct excision)
Flucloxacillin IV
1g

CefUROXime IV
1.5g
Teicoplanin() IV
10mg/kg (800mg)
1 dose at induction
Reconstructive Breast surgery with or
without tissue expander
Co-amoxiclav IV
1.2g every 8 hours

CefUROXime IV
1.5g every 8 hours

Teicoplanin() IV
10mg/kg (800mg)
every 12 hours up to 2
doses (24 hour cover)
+
Gentamicin IV 5mg/kg
(max 400mg) (1 dose)
Give dose at
induction:
maximum 24
hours duration.


Cardiothoracic Surgery

Antibiotics for Cardiothoracic Surgery
Type of Surgery Procedure 1
st
Line Antibiotic Penicillin allergy Number &Timing of
Doses
Prophylaxis in
Cardiothoracic
Surgery

See Note
Regarding Risk
Factors for MRSA
Coronary artery bypass graft
(CABG)
CefUROXime IV 1.5g every 8 hours

If risk factors for or colonised with
MRSA Add Teicoplanin() IV 10mg/kg
(800mg) every 12 hours for a total of 3
Severe/immediate reaction only:
Teicoplanin() IV
10mg/kg (800mg) every 12 hours
for a total of 3 doses (48 hour
cover)
+
Gentamicin IV
5mg/kg (max 400mg) every 24
hours for a total of 2 doses
At induction &
continued for 48
hours. If impaired
renal function
discuss with
Micro/ID before 2
nd

dose gentamicin
Prosthetic valve surgery
As for CABG
Cardiovascular Implantable
Electronic Device placement
(including permanent
pacemakers and Implantable
cardioverter-defibrillator (ICD))
Flucloxacillin IV 1g; continue 1g PO
every 6 hours for another 3 doses
MRSA Replace Flucloxacillin with
Teicoplanin() IV 10mg/kg (800mg)
every 12 hours for a total of 2 doses
(24 hour cover)
Any history of penicillin allergy:
Teicoplanin() IV
cover)
1 dose 30-60mins
prior to skin incision
& continued for 24
hours
Pulmonary resection CefUROXime IV 1.5g every 8 hours Severe/immediate reaction only:
Teicoplanin() IV
cover)
+
Gentamicin IV
5mg/kg (max 400mg) (one dose)
1
st
dose at induction
& continued for 24
hours

Ear, Nose and Throat (ENT) Surgery

Antibiotics for Ear, Nose and Throat (ENT) Surgery
Type of
Surgery
Procedure 1st Line Antibiotic Penicillin allergy:
minor/
delayed onset
Penicillin allergy:
severe/
immediate reaction
Number &
Timing of Doses
Prophylaxis in
Ear, Nose, &
Throat (ENT)
Surgery

See Note
Regarding
Risk Factors
for MRSA

ENT: Complex septo-rhinoplasty
including grafts

Note: prophylaxis NOT recommended
for routine nose, sinus, endoscopic
sinus surgery, tonsillectomy or
adenoidectomy
Co-amoxiclav IV
1.2g every 8 hours

CefUROXime IV
1.5g every 8 hours
+
Metronidazole IV
500mg every 8 hours
Teicoplanin() IV
10mg/kg (800mg)
every 12 hours for 2
+
Metronidazole IV
500mg every 8 hours
1
st
dose at
induction.
Continue for 24
hours


Gastrointestinal Surgery

Antibiotics for Gastrointestinal Surgery
st
Line
Antibiotic

Penicillin allergy:
minor/
delayed onset
Penicillin allergy:
severe/
immediate reaction
Number &
Timing of
Doses
Prophylaxis in
Gastro-
intestinal
Surgery

See Note
Regarding Risk
Factors for MRSA
Upper GIT: (including oesophageal, gastro-
duodenal, small-intestinal, gastric bypass)
Co-amoxiclav IV
1.2g

CefUROXime IV
1.5g
+
Metronidazole IV
500mg
Ciprofloxacin IV
400mg
+
Metronidazole IV
500mg

1 dose at
induction
Lower GIT (colon, rectum, appendix*)
Gallbladder surgery (open)
Gall-bladder surgery (laparoscopic)-prophylaxis
recommended for high-risk** patients only
Pancreatic
Percutaneous endoscopic gastrostomy (PEG)
Hernia repair: antibiotic prophylaxis NOT
recommended unless mesh insertion
ERCP-antibiotic prophylaxis NOT recommended
unless high-risk** patient
Ciprofloxacin PO 750mg 60 to 90 minutes prior to procedure OR
Gentamicin IV 5mg/kg (max 400mg) at induction
1 dose
Diagnostic laparoscopy Prophylaxis NOT recommended
* If appendix perforated or associated with peritonitis, treatment course may be required.
**Consider antibiotic prophylaxis for high-risk patients: intra-operative cholangiogram, pancreatic pseudo-cyst, immunosuppression, incomplete biliary drainage, bile spillage,
conversion to laparotomy, acute cholecystitis/pancreatitis, jaundice, pregnancy (avoid ciprofloxacin and gentamicin in pregnancy, discuss with Microbiology/ID), insertion of
prosthetic device e.g. T-tube, primary sclerosing cholangitis


Head and Neck Surgery

Antibiotics for Head and Neck Surgery
Type of
Surgery
Procedure 1st Line Antibiotic Penicillin allergy:
minor/
delayed onset
Penicillin allergy:
severe/
immediate reaction
Number &
Timing of Doses
Prophylaxis in
Head &
Neck
Surgery

See Note
Regarding
Risk Factors
for MRSA

Head and neck surgery (including
radical neck dissection)
Co-amoxiclav IV
1.2g every 8 hours

CefUROXime IV
1.5g every 8 hours
+
Metronidazole IV
500mg every 8 hours

Teicoplanin() IV
10mg/kg (800mg)
every 12 hours up to 2
+
Metronidazole IV
500mg every 8 hours
Duration no longer
than 24 hours
unless extensive
head and neck flap
reconstruction



Maxillofacial Surgery

Antibiotics for Maxillofacial Surgery
st
minor/delayed onset
Penicillin allergy:
severe/immediate
reaction
Number &
Timing of Doses
Prophylaxis in
Maxillofacial
Surgery

See Note
Regarding Risk
Factors for
MRSA
Open reduction and internal
fixation of compound mandibular
fractures, orthognathic surgery,
intraoral bone grafting
procedures.
Facial plastic surgery with
implant (consider prophylaxis)
Co-amoxiclav IV
1.2g every 8 hours

CefUROXime IV
1.5g every 8 hours
+
Metronidazole IV
500mg every 8 hours
Teicoplanin() IV
10mg/kg (800mg) every 12
hours up to 2 doses (24
hour cover)
+
Metronidazole IV
500mg every 8 hours
1
st
dose at induction.
Duration usually no
longer than 24
hours.


Obstetric and Gynaecological Surgery
Antibiotics for Obstetric and Gynaecological Surgery
st
Line
Antibiotic

Penicillin allergy:
minor/
delayed onset
Penicillin allergy:
severe/
immediate reaction
Number &
Timing of
Doses
Prophylaxis in
Obstetric &
Gynaecological
Surgery

See Note
Regarding Risk
Factors for MRSA

Hysterectomy:
Vaginal and total abdominal hysterectomy
Co-amoxiclav IV
1.2g

CefUROXime IV
1.5g
+
Metronidazole IV
500mg
Ciprofloxacin IV
400mg
+
Metronidazole IV
500mg
1 dose at
induction

Caeserian section (elective and emergency) Co-amoxiclav IV
1.2g

CefUROXime IV 1.5g
+
Metronidazole IV
500mg
Clindamycin IV
900mg
+
Gentamicin IV
5mg/kg (max 400mg)
1 dose at
induction

3
rd
and 4
th
degree post-partum perineal tears

Instrumental vaginal delivery and manual
evacuation of placenta (prophylaxis should be
considered especially if difficult procedure )

Co-amoxiclav IV
1.2g

CefUROXime IV 1.5g
+
Metronidazole IV
500mg
Clindamycin IV
900mg
+
Gentamicin IV
5mg/kg (max 400mg)
1 dose at
induction


Ophthalmic Surgery

Antibiotics for Ophthalmic Surgery
Type of
Surgery
Procedure 1
st
minor/
delayed onset
Penicillin allergy:
severe/
immediate reaction
Number &
Timing of Doses
Prophylaxis in
Ophthalmic
Surgery

See Note
Regarding
Risk Factors
for MRSA

Ophthalmology: Cataract surgery

Povidone Iodine 5% solution topically to lids,
lashes and to irrigate conjunctival sac
Plus
Consider intracameral CefUROXime 1mg in
0.1mls sodium chloride 0.9% as per surgeon
Penicillin allergy:
severe/immediate

Further
management as
per ophthalmology
team.
Discuss with micro/ID
Open lacrimal surgery

1
st
line antibiotic Penicillin allergy:
minor/delayed onset
Penicillin allergy:
severe/immediate
1 dose at induction
Co-amoxiclav IV
1.2g
CefUROXime IV
1.5g
Discuss with micro/ID


Orthopaedic and Trauma Surgery

Antibiotics for Orthopaedic and Trauma Surgery
st
Number &
Timing of Doses
Prophylaxis in
Orthopaedic
and Trauma
Surgery

See Note
Regarding Risk
Factors for
MRSA

Arthroscopy Antimicrobial prophylaxis NOT required

Minor metalwork insertion
(e.g. K-wires, screws, small
orthopaedic plates)
CefUROXime IV 1.5g

Teicoplanin() IV
10mg/kg (800mg)
1 dose at induction
Orthopaedic implant surgery
(total joint replacement or
revision).
Open reduction with internal
fixation of closed fractures.
Spinal surgery (with or without
implant).


MRSA Add Teicoplanin() IV
10mg/kg (800mg) every 12 hours for a
total of 2 doses (24 hour cover)

Teicoplanin() IV
cover).
Give first dose at
induction. Continue
for 24 hours
Give antibiotic
prophylaxis at least
15 minutes prior to
tourniquet inflation
Open fracture intervention +/-
insertion of nail/screw (includes
acute trauma with contaminated
wounds)

+
Metronidazole IV 500mg every 8
hours

Teicoplanin() IV
for 3 doses then every 24 hours
+
Gentamicin IV
5mg/kg (max 400mg) every 24
hours
+
Metronidazole IV
500mg every 8 hours
Give 1
st
dose at
induction.
Duration usually 3
to 5 days
maximum 24 hours
post final wound
closure.
It is vital that any
patient with an
open fracture be
closely observed
for signs of sepsis
Please discuss with
Microbiology/ID if
necessary.
Debridement surgery/patients
with chronic bone infection
Prophylactic antibiotic depends on infecting organism(s).Check results of
previous cultures if available. Discuss with Microbiology /ID if necessary
Discuss with
Microbiology/ID if
necessary


Plastic Surgery

Antibiotics for Plastic Surgery
Type of
Surgery
Procedure Recommendation
Prophylaxis in
Plastic
Surgery

See Note
Regarding
Risk Factors
for MRSA

Plastic surgery Choice depends on previous microbiological cultures.
Discuss with Microbiology/ID if necessary

Urological Surgery
Antibiotics for Urological Surgery
st
any history
Number &
Timing of Doses
Prophylaxis in
Urological
Surgery
Whenever
possible submit a
pre-operative/pre-
catheter removal
urine sample. If
urine culture is
positive, base
prophylaxis on the
susceptibility
report

See Note
Regarding Risk
Factors for
MRSA

Transrectal prostatic biopsy Ciprofloxacin PO 750mg every 12 hours
+
Gentamicin IV 3mg/kg (max 240mg)

Ciprofloxacin PO: 1
st
dose 60-90
minutes prior to procedure for a
total of 2 doses. Gentamicin IV:1
dose 30 to 60mins before biopsy
Transurethral resection of prostate (TURP),
nephrectomy, percutaneous nephrolithotomy
(PCNL) changing of stents/nephrostomy
change
Gentamicin IV
3mg/kg (max 240mg)
+
Amoxicillin IV 1g
Gentamicin IV
3mg/kg (max 240mg)
+
Teicoplanin() IV
10mg/kg (800mg)

1 dose at induction
Radical cystectomy Gentamicin IV 3mg/kg (max 240mg) 1 dose at induction
Extracorporeal shock wave lithotripsy Gentamicin IV 3mg/kg (max 240mg) 1 dose at induction
Cystourethroscopy with manipulation
(includes transuretheral resection of bladder
tumour-TURBT, any biopsy, resection,
fulguration, foreign body removal, urethral
dilatation, ureteral instrumentation including
catheterisation, stent placement/removal,
stone removal)
Gentamicin IV 3mg/kg (max 240mg) 1 dose at induction
Urological procedures
involving bowel
1
st
line antibiotic Penicillin allergy:
minor/delayed onset
Penicillin allergy:
Severe/immediate

Co-amoxiclav IV
1.2g

CefUROXime IV
1.5g
+
Metronidazole IV
500mg

Teicoplanin() IV
10mg/kg (800mg)
+
Gentamicin IV 5mg/kg
(max 400mg)
+
1 dose at induction
1. Routine prophylaxis is NOT appropriate for urethral catheterisation or removal of urinary catheter. However, on removal of urinary catheter following recent
urological surgery it is appropriate to give gentamicin 3mg/kg IV as a single dose (200mg for an average 70kg patient with CrCl greater than 80ml/min), infusion to be
completed within one hour of catheter removal.
2. Cystoscopy: antibiotic prophylaxis generally NOT indicated for simple cystoscopy in the absence of risk factors. Prophylaxis, where indicated, should be guided by the
results of urine microbiological cultures. Patients at increased risk of infection include those with pre-existing UTI, immunodeficiency and where additional procedures are
performed during cystoscopy.

Vascular Surgery and Limb Amputation

Antibiotics for Vascular Surgery and Limb Amputation
st
Line Antibiotic Penicillin allergy Number &Timing of
Doses
Prophylaxis in
Vascular
Surgery &
Limb
Amputation

See Note
Regarding Risk
Factors for
MRSA

Vascular surgery
(incl.abdominal and lower limb
arterial reconstruction eg. aortic
aneurysm repair)
&
Lower limb amputation

+
Metronidazole IV 500mg every 8
hours

MRSA Add Teicoplanin() IV 10mg/kg
(800mg) every 12 hours for total 2

Severe/immediate reaction only:
Teicoplanin() IV
for total 2 doses (24 hour cover)
+
Gentamicin IV
5mg/kg (max 400mg) (one dose)
+
Metronidazole IV
500mg every 8 hours
At induction and
continued for 24
hours

References

1. Bratzler et al.Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgery Infection Prevention Project. Am J Surg 2005;189:395-404
2. SIGN (Scottish Intercollegiate Guidelines Network). Antibiotic Prophylaxis in Surgery. July 2008
st
Edition 2011
4. Bennett and Brachman's " Hospital Infections" Lippincott, Williams and Wilkins. 5th edition 2007.

Full list of references available on request

Appendices

Appendix 1: Reserve Antimicrobial Agents Policy
The following was approved by the Medical Board of GUH in August 2008:

The recent cluster of cases of infection with Clostridium difficile has emphasised
the need for care in the use of broad-spectrum antimicrobial agents in the
hospital. As antimicrobial resistant organisms can spread readily in a hospital
setting the antimicrobial prescribing practice of each individual impacts on the
care of all patients. The existing antimicrobial prescribing guidelines are widely
available and generally accepted as useful; however the evidence of a number of
audits of specific antimicrobial agents (Linezolid and Ciprofloxacin) suggests that
there are instances in which use of broad spectrum and reserve agents is not
strictly necessary or appropriate.
The use of antimicrobial agents on the following list of reserve antimicrobial
agents should be restricted to indications in the hospital antimicrobial guidelines
or as follows:
The Consultant with lead responsibility for care of the patient has the right to
prescribe the agent he/she considers in the best interest of the patient contrary
to the advice of the Specialist Registrar or Consultant medical staff of the
Department of Microbiology or Department of Infectious Diseases. This
prescription must be written and signed by the Consultant herself/himself OR
supported by note in the medical record written and signed by the Consultant
herself/himself. This authority to override the policy on reserve antimicrobial
agents may not be delegated to non-consultant staff.

For indications other than those specified in the hospital antibiotic guidelines
Non-Consultant Hospital Doctors should not prescribe reserve agents during
normal working hours without consultation with the Specialist Registrar or
Consultant medical staff of the Department of Microbiology or Department of
Infectious Diseases. A note of this consultation should be made in the patients
medical record.

When reserve antimicrobial agents are prescribed by non-consultant medical staff
out of hours they should be subject to an automatic stop order on the next
working day unless there is documented (note in patients medical record)
consultation with the Specialist Registrar or Consultant medical staff of the
Department of Microbiology or Department of Infectious Diseases.
Reserve Antimicrobials Table
Antifungals Broad
Spectrum
Gram
Positive
Gram Negative
Ambisome
() CefTAZIDime Daptomycin() Amikacin

Anidulafungin() CefTRIAXone Linezolid() Aztreonam
Caspofungin() CefoTAXime Teicoplanin()
Posaconazole Chloramphenicol Vancomycin
Voriconazole() Ciprofloxacin
Levofloxacin
Meropenem
Moxifloxacin
Tigecycline()

Document prepared for submission to the Medical Board by M. Cormican in consultation
with colleagues.

Appendix 2: Antibiotics and Diarrhoea Patient Information
Leaflet

Copies of the leaflet are available on wards and from Pharmacy (Oct 2009)
Introduction
Antibiotics are important medicines that can cure serious infections caused by bacteria (germs),
such as bacterial meningitis and pneumonia. In serious infections antibiotics can be live saving.

Antibiotics do not cure infections caused by viruses (viral infections), like the flu and the
common cold.

Antibiotics, like all medicines, have side effects. These may be mild, such as minor stomach
discomfort or may be more serious.

Overuse of antibiotics is a cause for concern as some germs can become resistant to
antibiotics if they are prescribed too often. This means that the antibiotic may not work the
next time you or someone else takes it.

Using antibiotics is a balance between curing infections and avoiding/reducing the risk of
side effects. It is important to use antibiotics when needed but they must not be used if not
essential, so that they can be used to treat infections in the future.

Antibiotic Use in GUH
Galway University Hospitals has antibiotic treatment guidelines that recommend the most
suitable antibiotics to use to treat specific infections. The guidelines take into account the
side effects of different antibiotics and the potential risk of promoting Clostridium difficile
infection.

The hospital is committed to safe use of antibiotics, prescribing antibiotics cautiously only
when necessary and using them for the shortest effective duration.

Further Information
You can get further information from the HPSC Information Leaflet on Clostridium difficile or
from the Health Protection Surveillance Centre (HPSC) website www.hpsc.ie

Antibiotic Associated Diarrhoea:
Many patients require treatment with antibiotics during their hospital stay.
Diarrhoea is a common side-effect of antibiotic therapy.
In most people, this is mild and settles quickly.
In about 1 in 4 people who get diarrhoea after antibiotic treatment, it can be caused by a
germ called Clostridium difficile.
Often this also settles quickly without specific treatment.
However it can cause more severe diarrhoea in some people, especially if you are over
65 years old or have a serious underlying illness.
Symptoms usually start within a few weeks of antibiotic treatment but can still develop up
to 3 months later.

Contact your GP or come back to hospital if you have any of the following:
The diarrhoea is severe e.g. more than 4 times a day or lasting for more than 2 days.
You have a temperature or feel hot/sweaty etc.
You have pain in your tummy.

What will happen next?
A stool sample will usually be sent to the laboratory for testing.
You may need to have blood tests as well.
Mild cases usually do not need antibiotic treatment.
More severe cases will require an antibiotic.
Rarely patients need to be readmitted to hospital for further management. Your doctor will
discuss this with you if this happens to you.

A
P
P
E
N
D
I
C
E
S


Appendix 3: C. difficile Infection (CDI)

For paediatric doses refer to the British National Formulary for Children

1. First-line treatment of CDI

The precipitating antibiotic(s) should be stopped if possible
If antibiotics must be continued for clinical reasons, antibiotic(s) with a lower propensity
to induce CDI should be substituted
Supportive therapy: replacement of fluid and electrolytes and nutrition review as
clinically indicated
Isolate patient
Non-severe CDI Severe CDI
Early surgical review is
recommended
Vancomycin PO/NG 250mg QDS
for 10-14 days
Severe CDI with ileus or toxic
megacolon Vancomycin PO/NG
500mg QDS PLUS
Metronidazole IV 500mg TDS for
10-14 days
Inability to take oral medication:
IV metronidazole 500mg TDS or
QDS
In the setting of failing therapy,
adjunctive intracolonic
vancomycin may be considered
(see below)

Oral (PO)/Naso-gastric (NG)
metronidazole 400mg TDS for 10
days
Inability to take oral medication:
Intravenous (IV) metronidazole
500mg TDS for 10 days
Metronidazole intolerance or
contraindication: Oral vancomycin
125-250mg QDS for 10 days

Patients on CDI therapy should be
observed closely for possible
deterioration
If deteriorates treat as severe CDI as
appropriate
Algorithm for First-line Treatment of CDI

C. difficile Infection (CDI) contd

2. Treatment of recurrent CDI

3. Tapered pulsed oral Vancomycin (requires microbiology/ID approval)
- Use vancomycin injection to prepare oral solution for inpatients see IV Guide
- Prescribe vancomycin capsules on discharge (note: expensive - high tech prescription
required)
Vancomycin 125mg every 6 hours for 7 days
125mg every 12 hours for 7 days
125mg once daily for 7 days
125mg every other day for 7 days
125mg every three days for 7 days

4. Intra-colonic Vancomycin (University of Washington) (requires microbiology/ID
approval)
Adjunctive therapy for failing Vancomycin therapy in severe CDI
500mg of Vancomycin injection is reconstituted and added to 100ml of NaCl 0.9%
An 18G Foley catheter is inserted per rectum and the balloon is inflated
The Vancomycin solution is instilled into the rectum and retained for 60 minutes by
clamping the catheter
Once retention time complete, the catheter is unclamped, the balloon deflated and the
catheter removed
The process is repeated every 6 hours
Treatment is for 10 days
The precipitating antibiotic(s) should be stopped if possible
If antibiotics must be continued for clinical reasons, antibiotic(s) with a lower propensity to
induce CDI should be substituted
Supportive therapy: replacement of fluid and electrolytes and nutrition review as clinically
indicated
Isolate patient

First recurrence of CDI Second or more CDI recurrence

Consider tapered pulsed oral vancomycin (see
below)
Use first-line specific therapy of CDI i.e.
1. Oral/NG metronidazole 400mg TDS
for 10 days (if not severe CDI)
If inability to take oral medication: IV
metronidazole 500mg TDS for 10
days
2. Vancomycins superiority over
metronidazole to treat recurrent CDI
remains unproven. The decision to
use vancomycin to treat a first
recurrence should be based on the
presence of markers of severe CDI,
rather than previous metronidazole
exposure
Patients on CDI therapy should be
observed closely for possible
deterioration

Patients on CDI therapy should be observed
closely for possible deterioration

Algorithm for Treatment of Recurrent CDI

Appendix 4: Guidelines for Management of Patients with an
Absent or Dysfunctional Spleen (Adults)

Important Information
See numbers 1 to 4 below for vaccines which may be required, and number 5
below for prophylactic antibiotics needed
Ideally give required vaccinations two weeks before splenectomy
For emergency splenectomy or if prior vaccination is overlooked, administration two
weeks after splenectomy is recommended
However, if waiting until 2 weeks post surgery (to optimise immune response to
vaccine) take care that vaccination is not missed entirely, especially if the patient is
being discharged in the interim
If the patient is being sent home before vaccinations are given, make sure the GP is
fully informed about the vaccines required, and the date on which they are due.
If concerned that the patient may not present to the GP for vaccination or for any
other reason, vaccination prior to discharge may merit consideration, even if it is
before the required 14 day gap.
In general, wait at least 3 months after immunosuppressive chemotherapy or
radiotherapy (or give two weeks before such treatment). Prophylactic antibiotics
should be given during the time when patients are not vaccinated, as well as on a life-
long basis post vaccination)
Where a patient has had a splenectomy in the past, and has not received the
required vaccines at the time, they should be immunised at the earliest possible
opportunity.
A patient information leaflet is available from this link www.patient.co.uk

1: Pneumococcal Vaccine

Pneumovax II
0.5ml by intramuscular or subcutaneous injection

All patients who are previously unimmunised should receive vaccine, and those
whose last dose Pneumovax II was more than 5 years ago
Ideally give vaccine at least 2 weeks before splenectomy- but see under Important
Information
Re-immunise every five years. However, antibody levels may decline more rapidly,
particularly in patients with Sickle cell anaemia or lymphoproliferative disorders.
Measurement of antibody levels in these cases may help to guide decisions on earlier
re-immunisation e.g. every 3 years. However, reimmunisation with the polysaccharide
vaccine (Pneumovax II) has produced severe reactions, especially if less than three
years have elapsed since the first injection

2: Haemophilus Influenza Serotype B Vaccine

Hiberix 0.5ml by intramuscular injection
All patients who are previously unimmunised should be given two doses at a two-
month interval
Previously immunised patients who develop splenic dysfunction should be give one
additional dose of Hib vaccine.
First dose at same time as Pneumococcal vaccine (at a different site of injection)
Second dose (if indicated) - two months later
There are no data to support routine reimmunisation at the present time although
some other health authorities have recommended reimmunisation every 10 years.
Hib antibody levels can be checked if in doubt

Guidelines for Management of Patients with an Absent or
Dysfunctional Spleen contd

3: Meningococcal Vaccine

Menveo
(NB: meningococcal A,C,W135Y conjugate vaccine) 0.5ml by intramuscular

injection
All patients irrespective of their previous immunisation status should be vaccinated
First dose at same time as Pneumococcal and Hib vaccine (at a different site of
injection)
Second dose - at least one month later (For patients also getting a second dose of
Hib vaccine, it may be practical to give both vaccines at the same time i.e. two
months after the first dose)
Reimmunisation: the need for and the timing of booster dose has not been
determined

4: Influenza Vaccine

Brand: Whatever influenza vaccine is recommended for the current year
Dose: As per product guidelines
All patients should receive an annual vaccination annually at start of flu season
Initial dose - at same time as other vaccines (separate site of administration)
Re-immunisation- annually for hypo or asplenic patients


5: Lifelong Prophylactic Antibiotics

All patients should receive prophylactic antibiotics for two years post
splenectomy.
Lifelong prophylaxis is recommended for high-risk patients. See risk factors below.
Risk assessment is recommended for low risk patients. Such patients should be
counselled regarding the risks and benefits of lifelong antibiotics and may choose to
discontinue prophylaxis.

Risk factors associated with high risk of invasive pneumococcal disease in hyposplenism
include:
Immediate post-operative period
Age less than 16 or greater than 50 years
Inadequate serological response to pneumococcal vaccination
A history of previous invasive pneumococcal disease
Splenectomy for underlying haematological malignancy particularly in the context of
on-going immunosuppression

Recommended antibiotics:

Prophylactic Antibiotics for Patients with an Absent or
Dysfunctional Spleen
Infection First line antibiotics If penicillin
allergy
Comment
Prophylaxis
for patients
with an absent
or
dysfunctional
spleen
Phenoxymethylpenicillin
333 to 666mg twice
daily (Calvepen) (666mg
daily may be given if
compliance is a
problem) or Amoxicillin PO
250 to 500mg daily
Erythromycin PO
250 to 500mg
daily
Oral absorption of
phenoxymethylpenicillin is
limited and affected by a
number of variables. For
emergency self initiated
therapy of a suspected
systemic infection treatment
doses of amoxicillin are
preferable.

Treatment
doses
Amoxicillin PO 500mg to 1g
three times daily
Erythromycin PO
500mg to 1g four
times daily
Amoxicillin advantages: absorption not affected by food, broader spectrum
A supply of treatment doses of amoxicillin should be kept at home (and on holidays) and used
immediately should infective symptoms of raised temperature or malaise develop. In such a
situation, the patient should seek urgent medical attention


6: Other Information

Patients developing infection, despite measures, must be given systemic antibiotics and
admitted urgently to hospital
Patients should be given written information and carry a card to alert health professionals to
the risk of overwhelming infection. Patients may wish to invest in alert bracelet or pendant.
Patients should be educated as to the potential risks of overseas travel, particularly regarding
malaria and unusual infections, for example resulting from animal bites. Coamoxiclav (or
erythromycin in pencillin allergic patients) is recommended after dog-bites to protect against C
canimorsus
Patient records should be clearly labelled to indicate the underlying risk of infection
Vaccination and revaccination status should be clearly and adequately documented
It may be appropriate to advise people that they are at risk of infection with the agent
associated with red water fever in cattle and that they should take precaution against tick
exposure (wear protective clothing in tick infested areas) when walking in the countryside

References

These guidelines are, in the most part, based on updated British Committee for Society in
Haematology (BCSH) guidelines 2011
However, where the BCSH recommendations differ from Immunisation guidelines for Ireland
(on-line only update 2011) in relation to vaccination for Hib and meningitis, the Irish guidelines
have been followed

1. Davies et al. Review of guidelines for the prevention and treatment of infection in patients with
an absent or dysfunctional spleen: Prepared on behalf of the British Committee for Standards
in Haematology by a Working party of the Haemato-Oncology Task Force British Journal of
Haematology 2011;155:208-317
2. Immunisation Guidelines for Ireland Online-only update September 2011
http://www.immunisation.ie/en/HealthcareProfessionals/ImmunisationGuidelines2008/
Appendix 5: Rifampicin for Meningococcal & Hib Prophylaxis

Management of Contacts of Meningococcal Disease
(Meningitis/Septicaemia)

Public Health & GUH Microbiology/ID/Pharmacy Depts
April 2010 (updated June 2012)
1. For a laboratory proven case of meningococcal meningitis or a case in which the
clinical suspicion is very high (eg purpura fulminans) the medical/paediatric team
should notify public health immediately 091-775200.
2. Public health can be contacted out-of-hours through Ambulance Control.
3. The following is provided for information:
3.1. Close contacts are defined as those with prolonged close contact in a
household setting in the seven days prior to the index case becoming unwell e.g:
People living/sleeping in the same house; includes babysitters
Mouth kissing contacts
Mouth-to-mouth resuscitation or airways management (when a mask/
protective barrier has not been worn and within three feet of the case)
3.2. Close contacts should be advised to seek medical advice immediately if they
develop symptoms, even if they have already received chemoprophylaxis
3.3. Rifampicin is the recommended chemoprophylaxis and should be offered to
close contacts irrespective of vaccination status. It should be given as soon as
possible.
3.4. Pregnancy: CefTRIAXone (single 250mg intramuscular dose) is the preferred
chemoprophylactic agent for pregnant women.
3.5. Chemoprophylaxis packs are available in A+E, paediatric dept and the pharmacy
dept (including patient information leaflets)
3.6. Prescriber should be aware of potential interactions with other medications
including anticonvulsants, anticoagulants and hormonal contraceptives
(additional precautions required)
3.7. Side effects of rifampicin should be explained: staining of urine, tears, and
contact lenses. Written information should be supplied to patients on symptoms
and treatment
3.8. Ciproflaxacin may also be used. Contact Microbiology or Infectious Diseases to
discuss in certain cases
3.9. For more comprehensive guidance see Immunisation Guidelines for Ireland
Dose of Rifampicin* for Meningococcal Chemoprophylaxis
Age Dose
Adults & children >12 years 600mg BD for two days
Children 1-12 years 10mg/kg BD for two days
Children <1 year 5mg/kg BD for two days
*Rifampicin is contraindicated in the presence of severe liver disease

Dose of Rifampicin for Meningococcal Prophylaxis in Children 12
Age Dose in mg Dose in mls
0-2 months 20mg 1ml*
3-11 months 40mg 2ml*
1-2 years 100mg 5ml*
3-4 years 150mg 7.5ml*
5-6 years 200mg 10ml*
7-12 years 300mg 15ml* or as capsule
*Rifampicin syrup contains 100mg/5ml
Rifampicin for Meningococcal & Hib Prophylaxis contd

Management of Contacts of Invasive Haemophilus Influenzae B
Disease

1. For a laboratory proven case of Haemophilus influenzae B meningitis or other
invasive infection the medical/paediatric team should notify public health
immediately 091-775200
2. The following is provided for information:
a. Chemoprophylaxis: Only indicated for household contacts (irrespective of age
or immunisation history) in the following situations:
i. If there are any unvaccinated children under the age of 10 years or
incompletely vaccinated children under 4 years
ii. If there are any persons at increased risk of invasive Hib disease
(asplenia, hyposlenism, immunocompromised etc.) irrespective of
their age or immunisation status
b. Vaccination: In addition to prophylaxis non-immune contacts under 10 years
should be given Hib vaccine
c. Chemoprophylaxis is NOT recommended for pregnant women who are
contacts of cases
3. For more comprehensive guidance see Immunisation Guidelines for Ireland

Dose of Rifampicin* for Invasive Hib chemoprophylaxis
Age Dose
Infants under 1 year of age 10mg/kg OD for four days
Children and adults 20mg/kg OD for four days
(max. 600mg/day)
*Rifampicin is contraindicated in the presence of severe liver disease

References

1. Immunisation Guidelines for Ireland Online-only update September 2011
2. HPSC Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including
meningococcal disease) Jan 2012

Page 75 Paediatric Guidelines GUH 2009 Cln-Paed-0012
Paediatric Antibiotic Guidelines
Lead Contact: Dr. Edina Moylett
Empiric Antibiotic Guidelines Paediatrics* (1 month to 18 years) GUH Rev 5 2013
(*Refer to NICU prescribing guidelines for Neonates)

Empiric Antibiotic Guidelines (Paediatrics)
Always check paediatric doses in the BNF for Children
NB: These doses are for children >1 month (with the exception of meningitis). For children <1
month, see BNF for Children
Infection 1
st
Line Antibiotics
Alternative if penicillin
allergic (non-urticarial
rash only; otherwise
consult senior colleague)
Suggested minimum duration of
antibiotic therapy/Comments
Antibiotics should only be started with clear clinical justification, and documentation in patient notes.
Stop antibiotics if viral infection suspected or confirmed as antibiotics are NOT effective for viral infections.
Always culture (blood, urine, CSF, pus, etc.) as appropriate prior to commencing or changing antibiotics. 1 to 3ml
of blood is required for blood culture.
Review antimicrobial therapy daily with culture results and clinical progress. If pathogen(s) identified, modify
therapy accordingly.
For all patients labelled as penicillin allergic establish history, assess and document. Cephalosporins may be given
if minor allergy e.g. rash.
Immediate penicillin hypersensitivity is uncommon in young children. Cefotaxime and other 3
rd
generation
cephalosporins may be given with caution, if considered essential. If history of true anaphylaxis, consult paediatric
consultant or microbiology.
Doses are for children with normal renal function, and for children over 1 month.
For neonates, refer to Neonatal Formulary and antibiotic prescribing guideline.
Bone and
Joint
<3 months old
Flucloxacillin IV
+
CefoTAXime IV
(check neonatal formulary for infants
<4 wks old)

<3 months old
Vancomycin* IV
+
CefoTAXime IV
(check neonatal formulary for
infants <4 wks old)
Ensure blood cultures (and bone/joint
cultures if clinically necessary) prior to
antibiotic therapy unless critically
unwell. Baseline CRP/FBC/SMAC/ESR.
Septic arthritis: up to 1-2 weeks IV
initially, change to oral once clinical and
laboratory resolution, total duration 3 to 4
weeks
Osteomyelitis: up to 1-2 weeks IV
initially, treat for 4 to 6 weeks, monitor
weekly FBC/ESR/CRP plus additional
labs as indicated by antibiotic side effect
profile
Typical pathogens in neonates and young
infants up to 3 mo old include, Staph
aureus, Gp B strep and E. coli
Outside of neonatal age Staph aureus
typical pathogen.
Kingella kingae associated with bone and
joint infection in crche age children,
resistant to
clindamycin/vancomycin/flucloxacillin;
sensitive to penicillin, cefuroxime
>3 months old
Flucloxacillin IV
Add CefTRIAXone IV
50mg/kg (max 4g) every 24 hours
for: Gram-neg bacilli on synovial fluid
Gram stain; Children at risk of
Salmonella infection e.g.
hyposplenism; Sickle cell disease;
Incomplete Hib vaccination in older
children up to 5 yrs
>3 months old
Vancomycin* IV
Add CefTRIAXone IV
50 mg/kg (max 4g) every 24
hours for: Gram-neg bacilli on
synovial fluid Gram stain;
Children at risk of Salmonella
infection e.g. hyposplenism;
Sickle cell disease; Incomplete
Hib vaccination in older
children up to 5 yrs
Central
Nervous
System
Meningitis

See Paediatric
Meningo-
coccal
Guideline
2011
for additional
information.
Available on
QPulse
0 to 4 weeks
Amoxicillin IV
<7 days: 100mg/kg every 12 hours
7 to 28 days: 100mg/kg every 8 hours
+
CefoTAXime IV
<7 days: 50mg/kg every 12 hours
0 to 4 weeks
Penicillin allergy rare in this
age group discuss with Paed
ID/Microbiologist.

Substitute chloramphenicol IV if history of
anaphylaxis to penicillin or cephalosporin
discuss with paed ID/microbiology
immediately after first dose given

Vancomycin is recommended if
pneumococcal meningitis suspected or
possible

Consider Grp B streptococcus, Listeria, E.
coli.

Review and modify therapy at 48 hours
according to culture and sensitivity report

Duration of therapy outlined in paediatric
meningococcal guideline (Q pulse)
> 1 month
CefTRIAXone IV
+/-
Vancomycin* IV
(Add vancomycin if clinical meningitis
without a rash)
> 1 month
CefTRIAXone IV
80mg/kg (max 4g) every 24
hours
+/-
Vancomycin* IV
(Add vancomycin if clinical
meningitis without a rash)

Infection 1
st
Line Antibiotics
Ear
Otitis Media
Amoxicillin PO
40 to 45mg/kg (max 1.5g) every 12
hours
CefUROXime PO
See dose table
Co-amoxiclav is preferable for children
treated with amoxicillin in prior 30 days,
history of recurrent OM, children on
amoxicillin prophylaxis for UTI.
Duration: 5 to 7 days (over 2 years); 10
days (under 2 years)

Malaria See Paediatric Malaria Guidelines
Respiratory
System
Community
Acquired
Pneumonia
Mild to moderate
Amoxicillin IV
OR
Co-amoxiclav IV
30mg/kg every 8 hours (twelve hourly
if < 3 months)
(if prior treatment with amoxicillin)

Mild to moderate
Clarithromycin IV
7.5mg/kg every 12 hours
12 to 18 yrs: 500mg every 12
hours
OR
Azithromycin PO for 3 days
See dose table
Most CAP in children younger than 5
years is caused by viruses. Auscultatory
findings are usually diffuse and bilateral.
Infiltrates are usually interstitial.
Clues to bacterial pneumonia include
alveolar infiltrate, lobar or segmental
consolidation, large pleural effusion,
elevated CRP, leukocytosis, signs of
sepsis, and chills.
Switch to oral therapy once afebrile 24 to
48 hours and tolerating oral fluids.

Duration of 7 to 10 days for mild to
moderate infection.
Severe or complicated, typically 4 weeks
total antibiotic therapy.

3 days of azithromycin provides 7 days
cover due to long half-life.

Review need for continued vancomycin at
24 to 48 hours according to culture and
sensitivity report.
Consider changing vancomycin to
flucloxacillin IV 50 mg/kg every 6 hours if
sensitive S. aureus confirmed.

Complicated or severe (ICU)
CefTRIAXone IV
50 mg/kg (max 4g) every 24 hours
+
Clarithromycin IV
12 to 18 yrs: 500mg every 12 hours
OR
See dose table
+
Flucloxacillin IV
OR
Consider Vancomycin* IV
15 mg/kg every 8 hours if MRSA risk.
Complicated or severe (ICU)
CefTRIAXone IV
hours
+
Clarithromycin IV
12 to 18 yrs: 500mg every 12
hours
OR
See dose table
+
Vancomycin* IV
15 mg/kg every 8 hours

Sepsis
Meningo-
coccal
septicaemia
> 1 month
CefTRIAXone IV
> 1 month
CefTRIAXone IV
hours

Substitute chloramphenicol IV 25mg/kg
every 6 hours if history of anaphylaxis to
penicillin or cephalosporin discuss with
paed ID/microbiology immediately after first
dose given
Sepsis
Septic
shock of
unknown
cause

CefTRIAXone IV
80 mg/kg (max 4g) every 24 hours
+
Vancomycin* IV

CefTRIAXone IV
hours
+
Vancomycin* IV

Suggest discuss with Paediatric or
Microbiology Consultant on call.

Infection 1
st
Line Antibiotics
Skin & Soft
Tissue
Infection
Cellulitis

Mild
Flucloxacillin PO
See dose table
Mild
CefALEXin PO
See dose table
Oral therapy suitable in patient > 12
months, afebrile without
lymphadenopathy, Ensure compliance
and tolerance.10-day course.
Moderate
Flucloxacillin IV

Moderate
Clindamycin IV

Moderate does not meet criteria above.
Change to oral dosing, as above for mild,
once clinical/laboratory response and
compliance assured.
14 days from last positive blood culture,
Severe
Flucloxacillin IV
+
Clindamycin IV
10 mg/kg every 6 hours
+
Benzylpenicillin IV
Severe
Vancomycin* IV
Severe includes severe toxic shock
syndrome, necrotizing fasciitis, Grp A
streptococcus. For necrotizing fasciitis
surgical debridement essential seek
surgical review immediately if suspected.

14 days from last positive blood culture
or debridement culture
Skin & Soft
Tissue
Infection
Orbital
Cellulitis

The orbital
septum is a
connective
tissue
extension of
the
periosteum
that is
reflected into
the upper and
lower lid.

Pre-septal Cellulitis
Co-amoxiclav PO
See dose table
OR
Co-amoxiclav IV
if < 3 months)

Pre-septal Cellulitis
CefPODOXime PO
See dose table
OR
CefUROXime IV
50mg/kg (max 1.5g) every 8
hours

Oral therapy suitable in patient > 12
months, afebrile without
lymphadenopathy,
Change to oral once clinical/laboratory
response and compliance assured.
10-day course.
Orbit Infection (eg, those with proptosis,
globe displacement, limitation of eye
movements, double vision, or vision loss)
Imaging of orbit to be considered (unable
to assess vision, gross proptosis,
ophthalmoplegia, bilateral oedema,
deteriorating visual acuity, no change
after 24 hr appropriate antibiotic therapy,
CNS sign/symptoms, need for surgical
intervention).
Once CNS/orbit infection effectively ruled
out may step down to co-amoxiclav
Duration, 3-4 weeks, IV until clinical
resolution
Orbital Cellulitis
CefTRIAXone IV
+
Metronidazole IV
+
Flucloxacillin IV

Orbital Cellulitis
CefTRIAXone IV
hours
+
Metronidazole IV
+
Vancomycin* IV

Urinary
Tract
Urinary
Tract
Infection
Co-amoxiclav PO
See dose table
OR
Co-amoxiclav IV
if < 3 months)
+/-
Gentamicin** IV
(<1mo: 4 to 5 mg/kg every 24 hours)
CefUROXime PO
See dose table

OR
CefTRIAXone IV
hours
+/-
Gentamicin** IV
(<1mo: 4 to 5 mg/kg every 24
hours)

Oral therapy suitable in patient > 12 months,
ability to take PO (not vomiting) and
compliance assured.
Always follow culture identification and
sensitivity report.
Add gentamicin if clinically unwell or
suspected bloodstream infection
Review gentamicin/ check susceptibility at
48 hours
Consider oral switch after 48 hours, once
afebrile and clinically improved.
Duration 7-10 days.
Minimum 14 days for pyelonephritis.
Urinary
Tract
MCUG
prophylaxis

Co-amoxiclav PO
See dose table

CefUROXime or
CefPODOXime PO
See dose table

OR
Trimethoprim PO
See dose table
First dose is to be administered as soon
as patient presents to the paediatric ward
on morning of MCUG (Micturating
Cystourethrogram)
Co-amoxiclav first choice, alternatives
listed for resistant isolates; prophylaxis to
be guided by susceptibility profile for
highly resistant isolates.
Dosing to be continued for 48 hours.
Oral dosing standard approach.
* Vancomycin: Reduce dose in renal impairment. Trough level before 4
th
/5
th
dose, then every 3 days if renal function stable. Target trough
10 to 15 mg/L; 15 to 20 for severe infection. ** Gentamicin: Reduce dose in renal impairment. Trough level before 3
rd
dose, then every 3
days if renal function stable. Target trough <1mg/L

Paediatric Antibiotic Guidelines contd
Malaria Treatment (Paediatrics)
Summary of essential information only - see Paediatric Malaria guidelines on QPulse for further info
Indication First line agent Alternative Comments
Uncomplicated
malaria,
P. falciparum
malaria
or species not
identified

Oral quinine, 10mg/kg/dose
(maximum 600mg) every 8
hours, for 7 days
Plus
Age < 12 years
Oral Clindamycin,
10mg/kg/dose (max 450mg)
every 8 hours, for 7 days
Or
Age > 12 years
Doxycycline 200mg once
daily for 7 days
Atovaquone-proguanil (Malarone)
5-8 kg, 2 paediatric tabs daily x 3d
9-10kg, 3 paediatric tabs daily x 3d
11-20kg, 1 standard tab daily x 3d
21-30kg, 2 standard tabs daily x 3d
31-40 kg, 3 standard tabs daily x 3d
> 40 kg, 4 standard tabs daily x 3d
Quinine and clindamycin
may be given IV if oral
route is not available.

Tetracycline should not be
given to children < 12 yrs
because of risk of dental
hypoplasia and permanent
discoloration of teeth.

Severe,
complicated P.
falciparum
malaria

Treat as a
medical
emergency.
After rapid
clinical
assessment
commence IV
antimalarial
treatment
without delay
with either
artresunate or
quinine
IV Artesunate 2.4mg/kg at
time 0, 12 and 24 hrs then
once daily thereafter

Plus

IV clindamycin, 10mg/kg
loading dose, followed by
5mg/kg/dose every 8 hours
IV quinine, loading dose, 20mg/kg
quinine dihydrochloride, (maximum
1400mg) in 0.45%/5% Sodium
chloride/glucose over 4 hours, then 8
hours after the start of the loading
dose..
Maintenance, 10mg/kg (maximum
700mg), every 8 hours (over 4 hours).
See full guideline for possible
maintenance dose reductions
required.
Plus
IV clindamycin, 10mg/kg loading dose,
followed by 5mg/kg/dose every 8
hours
Children managed in a
paediatric ICU setting with
expert ID input.
Continue IV antimalarials
until patient able to
tolerate/swallow oral
medication. Switch to oral
quinine plus clindamycin
or quinine plus doxycyline
(as above) to complete 7
days treatment of each
drug.
IV Quinine: Baseline ECG
and monitor blood glucose
every 2 hours.
P. vivax or
ovale

Chloroquine 10mg base/kg (max 620mg) orally immediately followed
by, 5mg base/kg orally at 6, 24 and 48 hours
Plus
P. ovale: Primaquine 0.25mg/kg /dose (max 15mg), daily for 14 days
after completion of therapy above

P. vivax: Primaquine 0.5mg/kg/day (max 30mg) daily for 14 days after
completion of initial therapy as outlined above.
Always check for G6PD
deficiency before
commencing primaquine
treatment as may result in
severe haemolysis in
susceptible patients.
If unable to take oral
therapy, quinine IV may
be used. The dose is
10mg/kg (max 700mg)
every 8 hours (four hour
infusion)- changed to oral
chloroquine as soon as
the childs condition
permits.


Oral Antibiotic Dose Table
Antibiotic Age Dose
Augmentin Duo or Augmentin
Paediatric Suspension
See Augmentin Suspension Dose Table

Azithromycin (>6 months) <15kg (unlicensed in children <6 months) 10mg/kg once daily
15 to 25kg 200mg once daily
>45kg 500mg once daily

CefALEXin (Keflex) 1 month to 1 year 125mg bd
First generation cephalosporin 1 to 5 years 125mg tds
5 to 12 years 250mg tds
12 to 18 years 500mg tds

CefUROXime (Zinnat) 3 months to 2 years 10mg/kg (max 125mg) bd
Second generation cephalosporin 2 to 12 years 15mg/kg (max 250mg) bd
Unlicensed in children <3 months 12 to 18 years 250mg bd

CefPODOXime (Cefodox) 15 days to 6 months 4mg/kg bd
Third generation cephalosporin 6 months to 2 years 40mg bd
3 to 8 years 80mg bd

Flucloxacillin 1 month to 2 years 125mg qds
2 to 10 years 250mg qds
10 to 18 years 500mg qds

Trimethoprim 6 weeks to 6 months 25 mg bd
6 months to 6 years 50mg bd

Please note that clindamycin oral suspension is unlicensed and difficult to source in the community. If discharging a
patient on clindamycin please contact pharmacy prior to discharge to arrange supply.


Augmentin Suspension Dose Table

Augmentin Paediatric 125/31 suspension
(contains amoxicillin 125mg/clavulanic acid 31mg per 5ml)
For use in infants < 2 months
Age Mild to moderate infection Severe infection (not for use in
neonates)
Less than 2 months 0.25ml/kg tds of Augmentin
paediatric 125/31 per 5ml
0.5ml/kg tds of Augmentin paediatric
125/31 per 5ml
Augmentin Duo Suspension
(contains amoxicillin 400mg/clavulanic acid 57mg per 5ml)
For use in infants over 2 months and older children
Age Weight
Mild to moderate infection
(14.3mg/kg bd)

Severe infection
(25.7mg/kg bd)

2 months to 2 years
5kg
0.8ml bd 1.4ml bd
6kg
0.9ml bd 1.7ml bd
7kg
1.1ml bd 2ml bd
8kg
1.3ml bd 2.3ml bd
9kg
1.4ml bd 2.5ml bd
10kg 1.6ml bd 2.8ml bd
13kg 2ml bd 3.7ml bd
2 to 6 years 2.5ml bd 5ml bd
7 to 12 years 5ml bd 10ml bd
Doses taken from manufacturers SPC and the Crumlin formulary 2007/2008
Doses rounded for ease of measurement
Prepared by Pharmacy Department May 2013

Guideline Development Group:
These guidelines were agreed by a group comprised of a consultant paediatrician, consultant microbiologist, antimicrobial
pharmacist and paediatric pharmacist. Comment or suggestions for improvement for future editions may be e-mailed to Dr. Edina
Moylett at edina.moylett@nuigalway.ie The guidelines have been approved by GUH Drug and Therapeutics Committee.

References:
1. BNF for Children 2011
2. Oxford Radcliffe Hospitals Guidelines for the use of Antibacterials in Paediatrics March 2009
3. Paediatric Infectious Diseases. Long, Pickering, Prober. 3
rd
Edition 2008
4. www.uptodate.com 2011

Microbiology, Infectious Diseases, Pharmacy & Nephrology Departments

Page 81 Antimicrobial Dosing in Renal Impairment (Adults)
Antimicrobial Dosing in Renal Impairment (Adults)

General Principles
1. Many medications are excreted by the kidneys and require dose adjustment in renal impairment.
2. Antimicrobial dosage depends on the type and severity of the infection, sensitivity of the causative
organism and the general condition of the patient.
3. For severe infections the higher end of the dose range should be used.
4. Caution if concomitant hepatic and renal impairment a further reduction in dosing may be
indicated.
5. Recommendations in these guidelines are largely derived from The Renal Drug Handbook, and in
some cases from the BNF

and Summary of Product Characteristics (SPC) for the drug. There is
inconsistency among published sources of information on drug dosing in renal impairment. The
BNF

and manufacturers recommendations (SPC) tend to be more conservative than The Renal
Drug Handbook.
6. Usual dose refers to the dose and interval recommended for adults with normal renal and hepatic
function e.g. in GUH Antimicrobial Guidelines, BNF or SPC.

Assessing Renal Function
1. Published information on the effects of renal impairment on drug elimination has historically been
stated in terms of creatinine clearance, calculated using Cockcroft & Gault equation.

2. The PAS system reports renal function as eGFR (estimated glomerular filtration rate) normalised
to a body surface area of 1.73m
2
, calculated using the MDRD equation.

3. Although the two equations are NOT interchangeable, there is relatively good correlation between
the two for calculation of renal function in patients of average build and height, and either could be
used for the majority of drugs.

4. The BNF now uses eGFR for dose reduction for most (but not all) drugs.

5. However, the BNF advises that creatinine clearance (Cockcroft & Gault equation) must be
calculated:
i. For dose reduction of all drugs in patients who are under or overweight (BMI less than
18.5kg/m
2
or greater than 30kg/m
2
).
ii. For certain drugs with a narrow therapeutic index e.g.
Gentamicin
Vancomycin
Foscarnet
Ganciclovir
Valganciclovir

6. Neither creatinine clearance or eGFR provide a perfect marker of renal function- particularly in the
case of rapidly changing creatinine levels e.g. an increasing creatinine may reflect renal function
that is markedly worse than it appears. The clinical picture should always be taken into account.

Cockcroft and Gault Equation
Creatinine Clearance (CrCl) (ml/min)
Calculate Ideal Body Weight (IBW) in kg (see below)

(140 age) x (IBW in kg) x N
Serum creatinine (micromol/L)
1. N = 1.23 males & 1.04 females
2. If actual body weight < IBW, use actual body weight in this equation
Male:
50kg + 2.3kg x inches over 5 feet OR 50kg + 0.9kg x cm over 152cm
Female:
45.5kg + 2.3kg x inches over 5 feet OR 45.5kg + 0.9kg x cm over 152cm

Antimicrobial Dosing in Renal Impairment (Adults) contd

Renal Replacement Therapy

See The Renal Drug Handbook or ask pharmacy for advice

Haemodialysis/CAPD: Assume GFR <10ml/min. Many drugs are removed by haemodialysis. It is
recommended to time administration to take place post dialysis every day including dialysis days (to
avoid the need to give a supplemental dose post dialysis).

See GUH guidelines for Vancomycin, Cefazolin & Gentamicin dosing in haemodialysis

Continuous renal replacement: In general assume GFR <30ml/min. Ask ICU pharmacist for
advice.

References
1. The Renal Drug Handbook 3
rd
Edition 2009
3. Summary of Product Characteristics (SPC): www.medicines.ie
4. Vidal et al. Systematic comparison of four sources of drug information regarding adjustment of dose
for renal function. BMJ 2006;331:263
5. Dowling. Evaluation of renal drug dosing: Prescribing information and clinical pharmacist
approaches. Pharmacotherapy 2010;30:776-786
6. Nottingham University Hospital Antimicrobial Doses for adults in renal impairment Jan 2010

Further information
The IV guide includes information on renal dosing for individual drugs. Available on pharmacy intranet
http://medinfo

Acknowledgements
This document was reviewed by pharmacists and nephrologists in GUH. Special thanks to David Walsh
for producing the first draft. The document is based on a similar one from Nottingham University
Hospital
(6)

Written by Marie Tierney & Dr. na NRiain May 2012. Approved by Antimicrobial Management Team


Doses of Antimicrobials in Renal Impairment (Adults)
Table: Doses of Antimicrobials in Renal Impairment (Adults)
Antimicrobial eGFR (ml/min/1.73m
2
) Comment
20 to 50 10 to 20 <10
Aciclovir IV eGFR 25 to 50
Usual dose
every 12h
eGFR 10 to 25
Usual dose
every 24h
eGFR <10
50% of usual dose
every 24h
Maintain
adequate
hydration
Aciclovir PO eGFR 25 to 50
Usual
eGFR 10 to 25
Simplex:200mg
q6h
Zoster: 800mg q8h
eGFR <10
Simplex:200mg
q12h
Zoster: 800mg
q12h
Maintain
adequate
hydration
Amikacin CrCl 30 to 80: Reduce dose. See amikacin page in IV
guide for information.
CrCl <30: Avoid use if possible/consider alternatives
CrCl 10-30: 4mg/kg (max 320mg) one dose, check level
at 24 hours. Discuss with Micro/ID before 2
nd
dose.
CrCl <10: 3mg/kg (max 240mg) one dose), check level
at 24 hours. Discuss with Micro/ID before 2
nd
dose.
Monitor levels.
Must use CrCl
(not eGFR). If
obese use
adjusted dosing
weight
Amoxicillin
IV/PO
eGFR 10 to 50
Usual

eGFR <10
250mg to 1g q8h
Endocarditis: max
2g q8h

Amphotericin
Liposomal
Ambisome
IV
Usual Highly
nephrotoxic
monitor renal
function.
Anidulafungin Usual

Artesunate Usual

Azithromycin Usual

Aztreonam eGFR 30 to 50
Usual

eGFR 10 to 30
Usual first dose,
then 50% of dose
eGFR <10
Usual first dose,
then 25% of dose

Benzylpenicillin eGFR 20 to 50
Usual
eGFR 10 to 20
600mg to 2.4g q6h
eGFR <10
600mg to 1.2g q6h
Increased risk of
neurotoxicity in
renal
impairment.
Use higher doses for severe infection
e.g. endocarditis
Caspofungin Usual

CefALEXin eGFR 20 to 50
Usual
eGFR 10 to 20
500mg q8h
eGFR <10
250 to 500mg q8h

CeFAZolin eGFR 30 to 50
Usual
eGFR 10 to 30
Usual dose q12h

eGFR <10
Usual dose q24h
HD
2g/2g/3g three
times weekly. See
Haemodialysis
Dosing Guidelines

CeFIXime eGFR 20 to 50
Usual
eGFR 10 to 20
Usual
eGFR <10
Max 200mg q24h


2
) Comment
20 to 50 10 to 20 <10
CefoTAXime eGFR 10 to 50
Usual
eGFR <10
1g q8-12h
For severe/life-
threatening
infection contact
Micro/ID

CefPODOXime eGFR 10 to 50
Usual
eGFR <10
100 to 200mg
q24h

CefTAZIDime eGFR 31 to 50
1 to 2g q12h
eGFR 16 to 30
1 to 2g q24h
eGFR 6 to 15
500mg to 1g q24h
eGFR <5
500mg to 1g q48h

CefTRIAXone eGFR 10 to 50
Usual
eGFR <10
Max 2g q24h
Monitor levels if
both renal &
hepatic
impairment
CefUROXime IV eGFR 20 to 50
Usual
eGFR 10 to 20
750mg to 1.5g
q8-12h
eGFR <10
750mg to 1.5g
q12-24h

CefUROXime PO Usual

Chloramphenicol eGFR 10 to 50
Usual
eGFR <10
Usual - but use
only if no
alternative
Monitor levels in
renal
impairment (but
not routinely
available)
Ciprofloxacin
IV/PO
eGFR 20 to 50
Usual
eGFR 10 to 20
50 to 100% of
usual dose
IV: 200 to 400mg
q12h
PO: 250 to 500mg
q12h
eGFR <10
50% of dose but if
severe infection
discuss with
Micro/ID (may
consider higher
dose for short
period)
Use higher end
of dose range
for severe
infection
Clarithromycin
IV/PO
eGFR 30 to 50
Usual
eGFR<30
250 to 500mg q12h. Use higher end of
dose range for severe infection.

Clindamycin
IV/PO
Usual

Co-amoxiclav IV eGFR 30 to 50
Usual
eGFR<30
1.2g q12h

Co-amoxiclav
PO
Usual

Colistin IV eGFR 20 to 50
Usual
eGFR 10 to 20
50% of usual dose
eGFR <10
30% of usual dose
Monitor levels in
renal
impairment (but
not routinely
available)

2
) Comment
20 to 50 10 to 20 <10
Co-trimoxazole
IV/PO
Treatment doses
only

eGFR 30 to 50
Usual
eGFR 15 to 30
50% of dose
PJP: Usual dose
for 3 days, then
30mg/kg q12h
eGFR <15
50% of dose
PJP: 30mg/kg
q12h (Use only if
haemodialysis
facilities available)

Monitor levels in
renal
impairment (but
not routinely
available)
Daptomycin eGFR 30 to 50
Usual
eGFR <30
Usual dose q48h
Caution in renal
impairment-
monitor renal
function & CPK
closely if
eGFR<80
Doxycycline Usual
All other
tetracyclines
contraindicated in
renal impairment
Erythromycin
IV/PO
eGFR 10 to 50
Usual
eGFR <10
50 to 75% of usual
dose. Max 2g/day

Ertapenem eGFR 30 to 50
Usual
eGFR 10 to 30
500mg to 1g q24h

eGFR <10
500mg q24h OR
1g three times
weekly

Ethambutol

eGFR 20 to 50
Usual
eGFR 10 to 20
7.5 to 15mg/kg
q24h
eGFR <10
5 to 7.5mg/kg
q24h
Monitor levels if
eGFR <30 (but
not routinely
available)
Famciclovir eGFR<60
Reduce dose. See Renal Drug Handbook.

Flucloxacillin
IV/PO

eGFR 10 to 50
Usual
eGFR <10
Usually max 1g
q6h but may
require 2g q6h if
recommended by
Micro/ID e.g. for
endocarditis
Use with caution
if concomitant
liver impairment/
consider lower
doses
Fluconazole
IV/PO

eGFR 10 to 50
Usual
eGFR <10
Give usual initial
dose as a loading
dose, then 50% of
dose

Flucytosine eGFR 20 to 40
Dose q12h

eGFR 10 to 20
Dose q24h

eGFR <10
50mg/kg stat, then
dose according to
levels
Monitor pre-
dialysis levels
Foscarnet Reduce dose. See SPC/Renal Drug Handbook - note various
regimens. Contact Micro/ID/Pharmacy for advice.
Must use CrCl
(not eGFR)
Fusidic Acid Usual


2
) Comment
20 to 50 10 to 20 <10
Ganciclovir CrCl <70
Reduce dose. See ganciclovir page in IV guide for
information.
Must use CrCl
(not eGFR).
Maintain
adequate
hydration.
Gentamicin

CrCl 30 to 80: See Dosing Table (on page 17)
CrCl <30: Avoid use if possible/consider alternatives
2 mg/kg (max 200mg) one dose, check level at 24 hours,
discuss need for 2
nd
dose with Micro/ID
CrCl <10 on haemodialysis: See Haemodialysis Dosing
Guidelines
Monitor levels.
Must use CrCl
(not eGFR). If
obese use
adjusted dosing
weight.
Isoniazid eGFR 10 to 50
Usual
eGFR <10
200 to 300mg
q24h

Itraconazole PO Usual

Itraconazole IV eGFR 30 to 80
Use with caution
eGFR<30
Avoid
Excipient may
accumulate
Levofloxacin
IV/PO
eGFR 20 to 50
500mg stat, then
250mg q12h
eGFR 10 to 20
500mg stat, then
125mg q12h
eGFR <10
500mg stat, then
125mg q24h
Based on usual
dose of 500mg
q12h
Linezolid IV/PO Usual
Monitor FBC closely if eGFR <10
Metabolites with
MAOI activity may
accumulate if
eGFR<30
Meropenem eGFR 26-50
500mg to 2g
q12h
eGFR 10 to 25
500mg to 1g
q12h
eGFR <10
500mg to 1g
q24h
Higher doses may
be needed in CNS
infection discuss
with Micro/ID
Metronidazole
IV/PO
Usual

Moxifloxacin
IV/PO
Usual

Nitrofurantoin eGFR<60
Contraindicated
Ineffective; risk
of peripheral
neuropathy
Oseltamivir Reduce dose.
See GUH guidelines on pharmacy intranet http://medinfo

Pentamidine eGFR 10 to 50
Usual
eGFR <10
Severe infection:
4mg/kg/day IV for
7-10 days, then on
alternate days to
complete minimum
14 days.
Non-severe
infection:
4mg/kg/day IV on
alternate days for
minimum 14 days


2
) Comment
20 to 50 10 to 20 <10
Phenoxymethyl-
penicillin
Usual

Piperacillin/
tazobactam
eGFR 20 to 40
4.5g q8h
eGFR 10 to 20
4.5g q8-12h

eGFR <10
4.5g q12h

Posaconazole
Usual

Pyrazinamide
Usual

Quinine IV/PO

eGFR 10 to 50
Usual
eGFR <10
Reduce
parenteral
maintenance dose
to 5 to 7mg/kg
(max 700mg) q8h
Ref: BNF/WHO
Rifampicin
eGFR 10 to 50
Usual
eGFR <10
50 to 100% of
dose to max
600mg.
TB: 600mg
Other infections:
150 to 300mg
q12h

Teicoplanin eGFR 40 to 60
From Day 4 give
usual dose q48h
eGFR <40
From Day 4, give usual dose q72h
Levels are not
routinely
available
Tetracycline Contraindicated. Can use doxycycline

Tigecycline Usual

Tobramycin

CrCl <80: Reduce dose.
Contact Micro/ID/Pharmacy
.
Monitor levels.
Must use CrCl
(not eGFR).
If obese use
adjusted dosing
weight
Trimethoprim
Usual but if eGFR <10 discuss with Micro/ID likely to be ineffective
ValACIclovir eGFR 30 to 50
Usual
eGFR<30
Reduce dose. See Renal Drug
Handbook.
Maintain
adequate
hydration
ValGANCIclovir CrCl <60
Reduce dose. See Renal Drug Handbook.
Must use CrCl
(not eGFR).
Maintain
adequate
hydration
Vancomycin CrCl 10 to 50: See Dosing Table (on page 14)
CrCl <10 on haemodialysis: See Haemodialysis Dosing
Guidelines

Monitor
levels.Must use
CrCl (not
eGFR).Can give
during dialysis.
Voriconazole
IV/PO
Usual. Use IV with caution Excipient may
accumulate
Nephrology, Microbiology, Infectious Diseases and Pharmacy Departments

Page 88 Vancomycin, Cefazolin, Gentamicin in Haemodialysis Cln-Pharm/MP-029
Vancomycin, Cefazolin & Gentamicin Dosing in Haemodialysis
Vancomycin, Cefazolin & Gentamicin Dosing Guidelines for Patients on Intermittent Haemodialysis
Loading dose Maintenance dose Administration
For inpatients, administer in
haemodialysis unit and record
on inpatient drug chart
Monitoring

Not usually necessary to hold the dose
pending levels unless previous level
high or toxicity suspected
Vancomycin
A loading dose
is essential to
ensure
adequate
plasma levels
Give
20mg/kg
loading dose
rounded to
nearest
250mg
Weight Dose 500mg with each dialysis During latter part of dialysis, by
infusion
Pre-dialysis trough level
Check first trough level before the
second dose, then once weekly
Target trough 15 to 20mg/l
The goal is to ensure effective
plasma levels
<50kg 750mg 500mg in 100ml NaCl 0.9%
or glucose 5% over 60 mins
50-69kg 1g 750mg to 1g in 250ml NaCl
0.9% or glucose 5% over 100
minutes
70-100kg 1.5g 1.5g in 250ml NaCl 0.9% or
glucose 5% over 150 minutes
>100kg 2g 2g in 500ml NaCl 0.9% or
glucose 5% over 200 minutes
Cefazolin
No loading dose required Give 2g/2g/3g three times
weekly with each dialysis:
2g when next dialysis 2
days later, and 3g when
next dialysis 3 days later
Post dialysis, by IV infusion in
50ml NaCl 0.9% or glucose 5%
over 15 minutes
Reconstitute each 1g vial with
2.5ml Water for Injection
None required
Gentamicin
2mg/kg
to max 160mg

Use ABW, unless ABW
>30% above IBW,
then use dosing wt =
IBW + 0.4 (ABW-IBW)*
1mg/kg with each dialysis
(max 80mg)

Use ABW unless ABW
>30% above IBW,
then use dosing wt =
IBW + 0.4 (ABW-IBW)*
Post dialysis, by slow IV push
over 2 minutes in wash back
Trough level at end of dialysis but
immediately prior to dose
Target trough less than 2mg/l
The goal is to minimise toxicity and
to ensure effective plasma levels
*IBW ideal body weight; ABW actual body weight. IBW (kg) = 50 (45.5 for women) + 2.3 x (inches over 5 feet)
Further Information: Vancomycin: 80-90% excreted unchanged by the kidneys. Not significantly removed by conventional HD, removal increased by
high flux HD. Gentamicin: 100% excreted unchanged by the kidneys. 30% removed during 4 hour HD
GUH Pharmacy & Nephrology Depts June 2010
Refs:
1. IDSA Guidelines for the diagnosis and management of intravascular catheter-related infection. Clin Infect Dis 2009;49:1-45
2. GUH Guidelines (Version 5 June 2010) Cln-Pharm/MP-029

Index
Abdominal infection ................................................. 19
Aciclovir
encephalitis, herpes simplex ................................... 23
herpes simplex ........................................................ 49
herpes zoster ........................................................... 49
Amoxicillin
absent or dysfunctional spleen ................................ 20
community acquired pneumonia ............................. 34
COPD exacerbation without infiltrate ...................... 36
endocarditis prophylaxis .......................................... 29
meningitis ................................................................ 22
pharyngitis/tonsillitis ................................................ 46
surgical prophylaxis ................................................. 50
Antibiotic prophylaxis in surgery ............................ 50
breast surgery ......................................................... 53
cardiothoracic surgery ............................................. 54
ear, nose & throat surgery ....................................... 55
gastrointestinal sugery ............................................ 56
head & neck surgery ............................................... 57
maxillofacial surgery ................................................ 58
obstetric & gynaecological surgery ......................... 59
ophthalmic surgery .................................................. 60
orthopaedic & trauma surgery ................................. 61
plastic surgery ......................................................... 62
urological surgery .................................................... 63
vascular surgery & limb amputation ........................ 64
Antibiotics and diarrhoea patient information leaflet
................................................................................. 66
Appendicitis .............................................................. 19
Artemether
malaria ..................................................................... 33
Artesunate
malaria ..................................................................... 33
Aspergillosis ............................................................. 24
Aspiration Pneumonia .............................................. 36
Asplenia ..................................................................... 69
Atovaquone
malaria ..................................................................... 33
Pneumocystis jirovecii pneumonia (PJP) ................ 37
Aztreonam
neutropenic sepsis ............................................ 40, 41
pyelonephritis, acute in pregnancy .......................... 47
Bactroban .................................................................. 10
Benzylpenicillin
necrotising fasciitis/gas gangrene ........................... 44
peritonsillar abscess ................................................ 46
Bites, animal & human, prophylaxis & treatment .. 45
Bone & Joint Infection .............................................. 21
Calculator, dosing
gentamicin ............................................................... 17
vancomycin ............................................................. 14
Candidiasis ................................................................ 24
Caspofungin
neutropenic sepsis .................................................. 42
Catheter-related bloodstream infection .................. 30
CDI .............................................................................. 25
CefALEXin
wound infection/cellulitis .......................................... 43
CefAZOLin
in haemodialysis ...................................................... 88
CefTRIAXone
acute prostatitis ....................................................... 27
cirrhosis with acute variceal haemorrhage .............. 20
epiglottitis ................................................................ 46
gastroenteritis .......................................................... 26
intra-abdominal infection ......................................... 19
meningitis ................................................................ 22
meningococcaemia ................................................. 39
meningococcal prophylaxis ..................................... 73
necrotising pancreatitis............................................ 19
orbital and periorbital cellulitis ................................. 44
pelvic inflammatory disease .................................... 27
pyelonephritis or complicated UTI ........................... 47
sepsis - source unclear ........................................... 38
spontaneous bacterial peritonitis ............................. 19
CefUROXime
Cellulitis ..................................................................... 43
Central & peripheral IV catheter exit site infection 30
Central line-related sepsis ....................................... 30
Central nervous system infection ........................... 22
Chloramphenicol
meningitis ................................................................ 22
meningococcaemia ................................................. 39
Cholangitis ................................................................ 19
Cholecystitis .............................................................. 19
Ciprofloxacin
cirrhosis with acute variceal haemorrhage .............. 20
diabetic soft tissue infection .................................... 43
epiglottitis ................................................................ 46
hospital acquired pneumonia .................................. 36
peritoneal dialysis peritionitis .................................. 20
sepsis source unclear .......................................... 38
septicaemia ............................................................... 3
spontaneous bacterial peritonitis ............................. 19
uncomplicated cystitis ............................................. 47
Cirrhosis with acute variceal haemorrhage,
prophylaxis ............................................................ 20
Clarithromycin
Clindamycin
endocarditis prophylaxis .......................................... 29
malaria ..................................................................... 33

Clostridium difficile infection ............................ 25, 67
Clotrimazole
vaginitis, vulvitis ....................................................... 24
Co-amoxiclav
animal & human bites .............................................. 45
aspiration pneumonia .............................................. 36
pharyngitis/tonsillits ................................................. 46
Cold sores ................................................................. 49
Community acquired pneumonia ............................ 34
Conjunctivitis ............................................................ 23
COPD exacerbation .................................................. 36
Cost Indicator .............................................................. 7
Co-trimoxazole
meningitis ................................................................ 22
Creatinine clearance ........................................... 15, 81
Cystitis ....................................................................... 47
Dapsone
Dexamethasone
meningitis ................................................................ 22
Diabetic soft tissue infection ................................... 43
Disclaimer .................................................................... 6
Diverticulitis .............................................................. 19
Documentation of antimicrobial use ......................... 9
Doxycycline
malaria ..................................................................... 33
Encephalitis - herpes simplex ................................. 23
Endocarditis
bacterial ................................................................... 28
prophylaxis .............................................................. 29
Epididymo-orchitis ................................................... 27
Epiglottitis ................................................................. 46
Erythromycin
ESBL ............................................................................. 8
Extended-spectrum beta-lactamase ......................... 8
Eye infection .............................................................. 23
Flamazine ................................................................... 10
Flucloxacillin
septic arthritis .......................................................... 21
Fluconazole
oesophageal candidiasis ......................................... 24
oropharyngeal candidiasis ...................................... 24
vaginitis, vulvitis ....................................................... 24
Fungal Infection ........................................................ 24
Fungal nail infection ................................................. 24
Fungal skin infection ................................................ 24
Gas gangrene ............................................................ 44
Gastroenteritis .......................................................... 26
Gastrointestinal Infection ........................................ 25
Genital Infection ........................................................ 27
Gentamicin
dosing and monitoring ............................................. 16
endocarditis ............................................................. 28
interpretation of levels ............................................. 18
intravascular line infection ....................................... 30
Gential herpes ........................................................... 49
Haemodialysis
vancomycin, gentamicin, cefAZOLin ....................... 88
Heart infection ........................................................... 28
Herpes simplex ......................................................... 49
Herpes zoster ............................................................ 49
Hospital acquired pneumonia ................................. 36
Intra-abdominal abscess .......................................... 19
Intra-abdominal infection ......................................... 19
Intravascular line infection ...................................... 30
IV to oral switch criteria ........................................... 11
Levofloxacin
Lower respiratory tract infection ............................. 34
Lumefantrine
malaria ..................................................................... 33
Malaria ........................................................................ 33
Malarone
malaria ..................................................................... 33
Meningitis .................................................................. 22
Meningococcaemia ................................................... 39
Meningococcal & Hib prophylaxis .......................... 73
Meropenem
Meticillin resistant S. aureus ..................................... 8
Metronidazole
clostridium difficile ................................................... 25

MRSA ............................................................................ 8
Naseptin ..................................................................... 10
Necrotising fasciitis .................................................. 44
Necrotising pancreatitis, prophylaxis ..................... 19
Neutropenic Sepsis .................................................. 39
Nitrofurantoin
recurrent UTI prophylaxis ........................................ 48
Nystatin
oropharyngeal candidiasis....................................... 24
Ofloxacin
Orbital and periorbital cellulitis ............................... 44
Osteomyelitis ............................................................ 21
Paediatric guidelines ................................................ 75
Pelvic inflammatory disease .................................... 27
Penicillin allergy ........................................................ 12
Pentamidine
Peripheral line-related sepsis .................................. 30
Peritonitis - bacterial spontaneous ......................... 19
Peritonitis - peritoneal dialysis ................................ 20
Peritonsillar abscess ................................................ 46
Pharyngitis ................................................................ 46
Phenoxymethylpenicillin
Piperacillin/tazobactam
sepsis source unclear........................................... 38
Pneumocystis jirovecii pneumonia (PJP) .............. 37
Pneumonia ................................................................. 34
Prednisolone
Prescribing Principles ................................................ 8
Primaquine
malaria ..................................................................... 33
Proguanil
malaria ..................................................................... 33
Prostatitis .................................................................. 27
Prosthetic joint infection .......................................... 21
Pyelonephritis or complicated UTI, non-pregnancy
................................................................................. 47
Pyelonephritis, acute in pregnancy ........................ 47
Quinine
malaria ..................................................................... 33
Renal impairment, dosing ........................................ 81
Reserve antimicrobial agents ............................ 10, 65
Respiratory infection ................................................ 34
Riamet
malaria ..................................................................... 33
Rifampicin
endocarditis ............................................................. 28
meningitis ................................................................ 22
meningococcal and Hib prophylaxis ........................ 73
Sepsis ........................................................................ 38
Sepsis - source unclear ........................................... 38
Septic arthritis ........................................................... 21
Shingles ..................................................................... 49
Skin and soft tissue infection .................................. 43
Spleen, absent or dysfunctional ............................. 69
Spleen, absent or dysfunctional, prophylaxis . 20, 71
Surgical prophylaxis................................................. 50
Teicoplanin
surgical prophylaxis ........................................... 50, 51
Throat infection ......................................................... 46
Tonsillitis ................................................................... 46
Topical antibacterial ................................................. 10
Trimethoprim
Urinary tract infection............................................... 47
Urinary tract infection, recurrent, prophylaxis ...... 48
Vaccines for asplenia ............................................... 69
Valaciclovir
herpes simplex ........................................................ 49
Vancomycin
clostridium difficile ................................................... 25
dose adjustment ...................................................... 15
dosing and monitoring ............................................. 14
endocarditis ............................................................. 28
epiglottitis ................................................................ 46
interpretation of levels ............................................. 15
intracolonic .............................................................. 25
intravascular line infection ....................................... 30
meningitis ................................................................ 22
peritoneal dialysis peritionitis .................................. 20
septic arthritis .......................................................... 21
wound infection/cellulitis .................................... 43, 44
Viral infection ............................................................ 49
Wound infection/cellulitis ........................................ 43


Changes for this edition

Significant Changes 2012

Duration: Added usual recommended duration of therapy wherever possible.

Documentation of antimicrobial use: New section in Introduction (RID: Route. Indication. Duration). Document
indication and duration/review date on the drug chart and review all IV antibiotics daily.

Ceftriaxone replaces cefotaxime as preferred parenteral 3
rd
generation cephalosporin in most instances (excluding
neonates less than 1 month).

New sections:
Empiric treatment of intravenous line infection
Prophylaxis and treatment of human and animal bites
Treatment of Pneumocystis jirovecii pneumonia (PJP)
Peritonsillar abscess
Antimicrobial dosing in renal impairment (adults)

Vancomycin and Gentamicin:
The onus is on the responsible clinical team to check vancomycin and gentamicin levels, as the laboratory no
longer alerts teams to out-of-range results.
Emphasis on safe use of gentamicin; where indicated give one dose (chart in stat section of drug chart) and
continue with once daily gentamicin dosing ONLY if consultant/specialist registrar recommended.
Review need for ongoing vancomycin and gentamicin at 24 hours and daily thereafter.
New table with recommendations for dose adjustment of vancomycin.
Added usual maximum doses for vancomycin and gentamicin.

Sepsis source unclear: Dual therapy recommended (one dose of gentamicin).

Neutropenic sepsis: Dual therapy for patients in ED (one dose of gentamicin) and monotherapy for in-patients with
new presentation of neutropenic sepsis.

Bacterial endocarditis: Emphasis on early consult with Microbiology/ID. Start empiric treatment with vancomycin and
gentamicin for both native and prosthetic valve unless subacute presentation, when may be preferable to hold off on
antibiotic treatment pending consultation and culture results. Dose of gentamicin changed to 1mg/kg every 12 hours.

Osteomyelitis/septic arthritis: Separated septic arthritis and osteomyelitis. Consult with Microbiology/ID in all cases.
Treat all osteomyelitis according to culture results. For septic arthritis fucidin no longer recommended and dose of
flucloxacillin is now 2g qds.

Skin and soft tissue infection: Dose of IV clindamycin reduced to 600mg tds. For severe SSTI dose of flucloxacillin
reduced to 2g qds. Changes to diabetic soft tissue infection: separate categories for mild, moderate and severe. For
severe diabetic soft tissue infection in patient with penicillin allergy added vancomycin to treatment regimen.

Uncomplicated cystitis: Removed beta-lactams (co-amoxiclav and cefuroxime), unless pregnant.

Pyelonephritis: Separate regimens for pregnancy and non-pregnancy. Ceftriaxone replaces cefuroxime.

Pelvic Inflammatory Disease Inpatient Treatment: Minor change added metronidazole to doxycycline for oral
follow on if penicillin allergy.

Acute Prostatitis/Epididymo-orchitis: Separate regimens for sexually active and non-sexually active.

Intra-abdominal: Categories changed from mild to moderate and severe to mild and moderate to severe. Added
diverticulitis.

Necrotising pancreatitis: Ceftriaxone replaces cefuroxime.

Clostridium difficile: Added new category severe with ileus or toxic megacolon - treat with vancomycin +
metronidazole. Changed PO to PO/NG for administration of oral antibiotics.


Malaria: For non-severe malaria added Riamet
as alternative second line option.

Viral: Valaciclovir instead of famciclovir for herpes zoster.

Fungal: Expanded section

Surgical antibiotic prophylaxis
New section: Maxillofacial surgery.
Major changes to gynaecological, urology sections.
Minor changes to gastrointestinal, ophthalmology sections.
Teicoplanin prophylaxis: emphasise need for weight based dosing: 10mg/kg (round to 800mg for average 70kg
patient).
Teicoplanin doses over 800mg should be given by infusion over 30 minutes.

Splenectomy prophylaxis: Men ACW135Y recommended for meningococcal vaccination. Risk assessment
recommended for antibiotic prophylaxis.

Paediatric guidelines: Changes to bone/joint infection; new section on otitis media; ceftriaxone
replaces cefotaxime (except in neonates less than 1 month).

New Drugs:
Riamet
for malaria
Menveo
for splenectomy vaccination.

No longer recommended:
Removed famciclovir for herpes zoster.

Document History

Document History
Version date
Document
version
Changes from previous version Edited by
2004 Version 1

May 2006 Version 2
Updated clinical information and compliance with new intranet
publication standards
MM/PK
July 2006 Version 2.2
Review by pharmacy for omission errors relating to dosage
ROUTES e.g. ciprofloxacin 750mg BD. Complete independent
check by two pharmacists
MM/TW
Updated guidelines (clinical information and re-formatting)
following meetings of Guideline Development Group.
MC/MM/MT
March 2009 Version 4.1
MC/MT

July 2010

Version 5
MT/UNiR
March 2011 Version 5.1
Page 21. Updated treatment of moderate and severe CAP for
patients with penicillin allergy. Levofloxacin replaced
moxifloxacin as respiratory quinolone on IMB safety advice.
Page 37. Amended surgical prophylaxis in cardiothoracic
surgery: pacemaker/ICD insertion. If MRSA suspected
teicoplanin to replace flucloxacillin. For penicillin allergy removed
gentamicin (teicoplanin & gentamicin both still indicated for
pulmonary resection).
MT/UNiR
Pages 10-12. Text/layout changes for clarity
Pages 54-58. Paediatric guidelines Rev 3 2011 (Updated
meningitis guidelines, added meningococcal septicaemia, MCUG
prophylaxis & malaria)
MT
July 2012 Version 6
MT/EMcC
June 2013 Version 6.1
Re-organised content for app development (all sections). Added
disclaimer & prescribing principles. Changed CDAD to CDI.
Paediatric guidelines Rev 5 (Augmentin dosing)
MT/EMcC

GUH Antimicrobial Guidelines V6.1 June 2013

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Microbiology, Infectious Diseases and Pharmacy Departments

Galway University Hospitals

() CefTAZIDime Daptomycin() Amikacin

PO 4 tablets every 24 hours for

PO (over 35kg body weight) 4

() CefTAZIDime Daptomycin() Amikacin

0.5ml by intramuscular or subcutaneous injection

(NB: meningococcal A,C,W135Y conjugate vaccine) 0.5ml by intramuscular

as alternative second line option.

for splenectomy vaccination.

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