Guidelines for first-line empirical antibiotic therapy in adults

INFECTION SYNDROME / INDICATION

Community Acquired Pneumonia

Pneumonia is typically an acute febrile illness with cough, breathlessness, often
productive of sputum and pleurisy in a patient with or without existing chest
disease and new shadowing on CXR.

CURB 65 0-1
CURB 65 2

CURB 65 3-5
Assess severity using CURB 65 score: new Confusion, Urea >7mmol, Respiratory
rate >30 / min, BP <90 systolic or 60 diastolic, Age 65 (Each criterion scores 0
or 1. Therefore, max score = 5).
Community Acquired Aspiration Pneumonia
When patients aspirate gastric contents, they develop aspiration pneumonitis for which antimicrobial chemotherapy is NOT
required. Pneumonitis does not require treatment in first 48 hours unless there is a change in sputum quality to purulent /
mucopurulent, fever and new CXR changes which usually occur after 48hrs.
Bronchitis (Chronic) OR Infective Exacerbation of COPD
No pneumonic changes on CXR. For infective exacerbations of COPD, only prescribe for patients with two of the following:
increased SOB, increased sputum volume, increased sputum purulence.
Hospital Acquired Pneumonia including Hospital Acquired Aspiration
Pneumonia
HAP is over diagnosed clinically. HAP diagnosis requires radiological evidence of
new pulmonary infiltrates. Alternative diagnoses should be actively excluded.

< 4 days post admission

or > 4 days and non-severe

4 days post admission if severe

Uncomplicated (Lower) UTI

ASYMPTOMATIC BACTERIURIA; do not treat unless pregnant or urology procedures planned, even if catheter present.
Complicated (Upper) UTI

Risks for complicated UTI include: structural abnormality of the renal tract, male sex, recent urinary tract instrumentation,
symptoms> 7days at presentation, diabetes, immunosuppression.
Catheter associated UTI
Patients with urinary catheter invariably develop bacteriuria after a few days. However, treatment with an antibiotic is required only
if there are signs & symptoms of systemic infection.
Neutropenic sepsis
Neutrophil count of 1.0 x 109/l + Temp > 38C.

Sepsis of unknown origin

SEPSIS Criteria: Clinical impression of infection + 2 of; Temp >38C or < 36C ,
pulse > 90bpm, resp rate > 20/min, WCC >12 or <4 x 109/l.
SEVERE SEPSIS: Sepsis + organ dysfunction or hypoperfusion or hypotension.
Intra-abdominal sepsis (including biliary tract infections)

PREFERRED REGIMEN
Review antibiotic therapy once culture results known

ALTERNATIVE REGIMEN
including patients with serious penicillin allergy

SUGGESTED
DURATION

Amoxicillin 500mg 1g 8 hourly PO

Doxycycline 100mg 12 hourly PO

5 7days

Levofloxacin 500 mg 12 hourly IV + Clarithromycin 500mg 12 hourly IV

Consider referral to ICU: If paO2 < 8kPa despite high FiO2; Progressive Hypercapnia; pH <
7.26; hypotension; GCS falling

7 10 days

Send blood cultures, Legionella and

Pneumococcal urinary antigen tests and sputum
culture.

5 7 days

Only treat if clinical / CXR evidence of pneumonia.

5 7 days

A cough of less than 2 weeks duration in healthy

adults with no co-morbidities or systemic illness
does not require antibiotics. Consider antibiotic
use in >60 years or if underlying chest disease.
Pseudomonas or staphylococcal pneumonia may
require a longer duration of therapy.

Amoxicillin 1g 8 hourly IV / PO + Clarithromycin 500mg 12 hourly PO

Co-amoxiclav 1.2g 6 hourly IV + Clarithromycin 500mg 12 hourly IV.

Consider referral to ICU: If paO2 < 8kPa despite high FiO2; Progressive Hypercapnia; pH <
7.26; hypotension; GCS falling

Amoxicillin 1g 8 hourly IV + metronidazole 500mg 8 hourly IV

Patient with no recent exposure to amoxicillin: amoxicillin 1g 8 hourly PO

Previous recent amoxicillin: Doxycycline 100mg 12 hourly PO OR
Clarithromycin 500mg 12 hourly PO / IV
This should be guided by previous sputum / endotracheal culture results
Co-amoxiclav 625mg 8 hourly PO or 1.2g 8 hourly IV
Piperacillin-tazobactam 4.5g 8 hourly IV Gentamicin 5mg / kg 24 hourly IV (if severe)
Nitrofurantoin 100mg 6 hourly PO with food
Antibiotic therapy should be guided by previous urine culture results
Gentamicin 5mg / kg 24 hourly IV
OR
Piperacillin-tazobactam 4.5g 8 hourly IV if gentamicin inappropriate
Antibiotic therapy should be guided by previous urine culture results

Gentamicin 5mg / kg 24 hourly IV

Piperacillin-tazobactam 4.5g 6 hourly IV + gentamicin 5mg / kg 24 hourly IV
Piperacillin-tazobactam 4.5g 8 hourly IV + gentamicin 5mg / kg 24 hourly IV

PLUS:
If patient has risk factors for MRSA then add: Teicoplanin 10mg / kg 12 hourly IV x 3
doses then 10mg / kg 24 hourly IV
Community acquired non-severe:
Co-amoxiclav 1.2g 8 hourly IV

Bacterial meningitis
Clostridium difficile-Associated Diarrhoea
Mild / moderate Disease: WCC < 15, CRP < 150 Normal Abdominal XR.
Severe disease: WCC > 15, CRP > 150, Abnormal Abdominal XR, Distended Abdomen.

Clarithromycin 500mg 12 hourly IV

+ Metronidazole 500mg 8 hourly IV

Doxycycline 100mg 12 hourly PO

Vancomycin 1g 12 hourly IV (see therapeutic drug monitoring)

+ Ciprofloxacin 400mg 12 hourly IV + metronidazole 500mg 8 hourly IV
NB - This should be guided by previous sputum / endotracheal culture results
Trimethoprim 200mg 12 hourly po
Antibiotic therapy should be guided by previous urine culture results
Gentamicin 5mg / kg 24 hourly IV
OR
Ciprofloxacin 400mg 12 hourly IV only if gentamicin inappropriate
If Gentamicin therapy is inappropriate:
Ciprofloxacin 400mg 12 hourly IV or
Ciprofloxacin 500mg 12 hourly PO
Ciprofloxacin 600mg 12 hourly IV
+ Teicoplanin 10mg / kg 12 hourly IV x 3 doses then 10mg / kg 24 hourly IV
+ Gentamicin 5mg / kg 24 hourly IV
Ciprofloxacin 600mg 12 hourly IV
+ Teicoplanin 10mg / kg 12 hourly IV x 3 doses then 10mg / kg 24 hourly IV
+ Gentamicin 5mg / kg 24 hourly IV

Mild: Flucloxacillin 750 mg-1g 6 hourly PO

Community acquired non-severe:

Vancomycin 1g 12 hourly IV (see therapeutic drug monitoring) +
Metronidazole 500mg 8 hourly IV + Aztreonam 2g 8-hourly IV
Hospital acquired / Severe:
Vancomycin 1g 12 hourly IV (see therapeutic drug monitoring) +
Metronidazole 500mg 8 hourly IV + Ciprofloxacin 400mg 12 hourly IV
Mild: Doxycycline 100mg 12 hourly PO

Severe eg. necrotising fasciitis- Urgent Micro / ID and Surgery advice

Severe e.g. necrotising fasciitis- Urgent Micro / ID and Surgery advice

Hospital acquired / Severe:

Piperacillin-tazobactam 4.5g 8 hourly IV Gentamicin 5mg / kg 24 hourly IV
Cellulitis / soft tissue infections: No MRSA
Note: If symptoms bilateral, cellulitis unlikely
Mild: no signs of systemic toxicity, have no uncontrolled co- morbidity.
Moderate: either
systemically well, but with a co-morbidity eg. peripheral vascular disease, chronic venous insufficiency or morbid obesity, which
may complicate or delay resolution of their infection. OR
may have a significant systemic upset such as acute confusion, tachycardia, tachypnoea, hypotension or may have unstable comorbidities that may interfere with a response to therapy or have a limb threatening infection due to vascular compromise.
Severe: have sepsis syndrome or severe life threatening infection e.g. necrotising fasciitis.
Cellulitis / soft tissue infections: Known MRSA

Doxycycline 100mg 12 hourly PO

Moderate- Severe: Flucloxacillin 2g 6 hourly IV

Moderate- Severe: Clindamycin 900mg 8-hourly IV

Mild: Doxycycline 100mg 12 hourly PO sodium fusidate 500mg 8 hourly PO

Moderate: Teicoplanin 10mg / kg 12 hourly IV x 3 doses then 10mg 24 hourly IV
+ Sodium fusidate 500mg 8 hourly PO
OR
Vancomycin 1g 12 hourly IV (see therapeutic drug monitoring)
+ Sodium fusidate 500mg 8 hourly PO
Ceftriaxone 2g 12 hourly IV
If >55 years, immunocompromised or pregnant add Amoxicillin 2g 4 hourly IV
Mild / moderate: Metronidazole 400mg 8 hourly PO. Refer to full guidance

Chloramphenicol 25mg / kg 6 hourly IV.

If > 55yrs or immunocompromised add co-trimoxazole 1.44g 12 hourly IV

Severe disease: Refer to full local guidance

Review suitability for IV to oral switch within 48 hours and daily thereafter.
Criteria:

hydrated and drinking

adequate GI absorption

temperature <38C for >48 hrs

pulse <100 beats/min or return to baseline

resolution of tachypnoea and hypotension or return to baseline

no hypoxia or return to baseline

resolving WCC / CRP

no standing instruction for prolonged IV therapy e.g. osteomyelitis,

endocarditis, meningitis, bacteraemia

Oral formulation or suitable alternative is available

When prescribing
1.

2.
3.

4.

Must document in the medical notes and on the kardex the indication, drug
prescribed, dose, frequency, route and planned duration or review date.
Document baseline investigations requested.
Obtain samples for microbiological culture before administration of antibiotics
(where possible)
Review microbiology results and de-escalate therapy as appropriate (contact
micro if advice required)

Prudent antibiotic prescribing

To reduce emergence of multi resistant organisms and Clostridium difficile

associated diarrhoea:

De-escalate to narrow spectrum from broad spectrum empirical regimens

based on cultures where possible.

Avoid clindamycin, cephalosporins and fluoroquinolones outside guideline

limitations. Minimise carbapenems and long courses of antimicrobials

Penicillin allergy

Obtain a reliable history & document exact nature in case notes and on kardex
High risk:
History of: anaphylaxis, urticaria, early onset rash, angioedema, bronchospasm,
hypotension, laryngeal oedema, Stevens-Johnston or toxic epidermal necrolysis

Avoid penicillins, cephalosporins and other beta- lactam antibiotics.

Aztreonam may be less likely to cause hypersensitivity in penicillin sensitive

patients and can be used with caution (avoid aztreonam if allergic to
ceftazidime)
Low risk:
Minor non confluent, non pruritic rash restricted to a small area of the body, rashes
>72 hours after administration, nausea, diarrhoea:

Life threatening allergy very unlikely, therefore a trial of beta-lactam therapy

under observation may be considered as appropriate.

Consideration should be given to immunological proof of allergy (RAST test)

once patient has recovered from their infection.

5 7 days
5 7 days
Female 3 days/Male 7 days

7 10 days
Pyelonephritis 14 days

Depending on severity of
infection

Nitrofurantoin not advised in severe renal

impairment.
Review gentamicin requirement at day 3 4
followed by oral step down therapy to a
susceptible oral agent
Re-assess need for catheter; if it is required
change/remove under antibiotic cover.
Review gentamicin requirement at day 3.

Review at 48 hours

5 10 days
Depends on source &
severity
7 14 days
Depending on severity

Clinical features of NF are:

constant pain, bullous lesions, gas in the soft
tissues, systemic toxicity & rapid spread along the
facial planes.
NF is life-threatening, (take blood cultures and
send wound swab/debrided pus or tissue for
culture).

7 14 days

All dosing regimens assume normal renal and hepatic function. Check suitability of proposed regimen in pregnancy and breast-feeding
IV / Oral antibiotic switch guideline

7 days

COMMENT

Depends on pathogen
isolated

10 14 days
review daily refer to local
guidance

Therapeutic drug monitoring

Antibiotic

Teicoplanin levels

Only required for patients receiving prolonged courses > 7 days therapy
(assuming normal renal function). Patients with renal impairment and reduced
dose may need levels earlier.
Loading dose:
10 mg / kg doses 12-hourly for 3 doses (Round to nearest 200mg).
Maintenance dose:
10mg / kg / day 24-hourly in normal renal function. Adjust dose if renal
impairment.
Timing of first level:
Trough (pre dose) after 5-7 days of therapy completed. Give dose while
awaiting results of levels in normal renal function.
Expected range: 20-60mg / L.

Consult microbiologist.

Dosage

5mg / kg
Gentamicin
(once daily regimen) (in 100ml 5% glucose or 0.9% NaCl over 30-60
minutes)

Expected levels (mg/l)

Trough before 2nd dose i.e.

18-24 hours after first infusion

2-3
<1 (19-24 hours)
<2 (18 hours)
Levels prior to 18 hours after
last dose are not suitable

After 2- 3 doses

Gentamicin
(divided dosing)

Refer to local guidance

Vancomycin
*Monitor only if
given IV*

Creatinine Clearance (Cr Cl)

Cr Cl

Cr Cl < 50mL / min:

25mg / kg (up to 1g) stat then check levels at
24 hours before adjusting 2nd dose
accordingly

Give dose while awaiting results

of levels and adjust subsequent
dose accordingly

15mg / kg
Amikacin
(once daily regimen) (in 100ml 5% glucose or 0.9% NaCl over 1 hour)

> 50mL / min:

25mg / kg (up to 1g)
12-hourly

NB: slow infusion at a rate not to exceed 10mg / min

Re assay
interval (days)#

Timing of first level

Trough before 2nd dose i.e.

18-24 hours after first infusion

> 50mL / min only:

Trough before 3rd or 4th dose i.e.
>10 hours after 2nd or 3rd dose

Trough <2
Peak 5-10

2-3

Trough 10-15

2-3

2-3
<5
Levels prior to 18 hours after
last dose are not suitable
Trough 10-20 for more severe
infections

Levels sent <10 hours after

last dose are not suitable

Assuming renal function not impaired and initial results are within expected range and/or no other changes affecting levels e.g. changes in renal / hepatic function
drug interactions etc.

BT13-802

2010/2014