Condition Useful information First line Second line Duration. Co-amoxiclav IV 1.2g 8hourly. PLUS Gentamicin* IV 5mg/Kg STAT

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1 Bacterial Gastroenteritis Bacillary Dysentery Fluid replacement essential. Send stool samples. Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 days and can cause resistance. If the patient is systemically unwell, or if Salmonella / Shigella are suspected: discuss with cons microbiologist and report to the Health Protection Unit (HPU) on Cholecystitis Calculous or acalculous inflammation of the Gallbladder Likely to be caused by coliforms and enterococci. A positive Murphy s sign has a specificity of 79% 96% for acute cholecystitis. Co-amoxiclav IV 1.2g 5mg/Kg STAT CONSIDER continuing Gentamicin based on clinical condition, culture results and/or clinical response 960mg (or 400mg 5mg/Kg STAT CONSIDER continuing Gentamicin based on clinical condition, culture results and/or clinical response 7 days Cholangitis Biliary sepsis with abnormal liver function. Usually occurs in patients with biliary obstruction. 4.5g 960mg (or 400mg 7 days Can present with the triad of jaundice, rigors and fever but not exclusively. Spontaneous Bacterial Peritonitis In addition to Enterobacteriaecae, pneumococci is a major cause. 4.5g alone 960mg (or 400mg 7-14 days 3rd Line: Moxifloxacin Q PO 400mg advice required. For dosing in renal / hepatic failure, seek advice from a pharmacist Page 1 of 5

2 Peritonitis Moderate/ severe diverticulitis If known or suspected MRSA/ESBL or AmpC carrier then treat accordingly see guidance in other parts of this document 4.5g CONSIDER ADDING Gentamicin* IV 5mg/Kg True penicillin allergy Co-trimoxazole # IV 960mg CONSIDER adding Gentamicin* IV 5mg/Kg Review Mild diverticulitis, Drained perirectal abscess Can be managed in the community under close monitoring Co-amoxiclav PO 625mg 960mg (or 400mg 7-10 days 3rd Line: Moxifloxacin Q PO 400mg Enteric Fever Typhoid / Paratyphoid Caused by Salmonella typhi / paratyphi. Discuss with the microbiologist. Report to HPU If patient is septic, discuss with microbiologist: Consider Ceftriaxone IV 2 4g Azithromycin PO 1g on day 1 then 500mg for 6 days (ie 7days in total) Campylobacter Usually resolves spontaneously. Antibiotics only required if immunocompromised or severe (severe abdominal pain, fever, bloody diarrhoea) Azithromycin PO 500mg Ciprofloxacin PO 500mg 3-5 days Liver Abscess (Not Amoebic) For amoebic liver abscess please discuss with Consultant Microbiologist Discuss with Gastroenterologist or Microbiologist. Aspirate if accessible. Co-amoxiclav IV 1.2g alone Co-trimoxazole # IV 960mg advice required. For dosing in renal / hepatic failure, seek advice from a pharmacist Page 2 of 5

3 Neutropenic enterocolitis typhlitis Surgical resection might be required. Protective isolation required 4.5g Meropenem IV 1-2g True Penicillin allergy Ciprofloxacin IV 400mg (or PO 750mg ) Eradication of Helicobacter pylori Eradication is beneficial in Duodenal Ulcer, Gastric Ulcer and low grade MALTOMA, but NOT in Gastro- Oesophageal Reflux Disease. Omeprazole PO 20mg PLUS Amoxicillin PO PLUS Metronidazole PO 400mg Omeprazole PO 20mg PLUS Metronidazole PO 400mg PLUS Clarithromycin PO 250mg 12 hourly 10 days Triple treatment attains >90% eradication. Threadworms Treat household contacts. Advise morning wash and hand hygiene. Mebendazole PO 100mg STAT (single dose) Repeat therapy after 2-3 weeks if re-infection occurs. advice required. For dosing in renal / hepatic failure, seek advice from a pharmacist Page 3 of 5

4 Diarrhoea caused by Clostridium difficile Send liquid stool for toxin test before starting therapy. Wash your hands: alcohol gel is ineffective against C difficile spores If there is clinical suspicion of infection, start treatment and isolate the patient. Control risk factors: review antibiotic therapy and need for PPI. Keep patient well hydrated and avoid antimotility and promotility agents eg. loperamide, codeine, metoclopramide. Vancomycin injection may be given orally Vancomycin is not usually absorbed via the GIT therefore measurable levels may indicate that dose adjustment is required to prevent toxicity (maintain levels below 10mg/L) Mild / Moderate 3 loose stools/day WCC normal Metronidazole PO 400mg for 14 days Severe/ fulminant infection Severe: WCC > 15 Rise in creatinine Severe colitis Partial ileus Vancomycin PO mg 6hourly (check random levels) CONSIDER ADDING Metronidazole IV 500mg Contact microbiologist or gastro-enterologist and lower GI surgeons to discuss additional therapy and/or IV immunoglobulin see protocol Intracolonic Vancomycin (enema) may be an effective adjunctive therapy: 500mg in 250ml Sodium Chloride 0.9% via flexiseal device 4-. Clamp device for 60min and then release. (Check random levels ) Moderate 4-6 loose stools/day WCC < 15 Vancomycin PO 125mg 6hourly for days Severe/ fulminant infection If concurrent antibiotics are required to treat a different infection then use: Vancomycin PO mg 6hourly for 2 weeks (check random levels) FOLLOWED BY Rifaximin PO mg for 2weeks OR after discussion with a Cons Microbiologist Fidaxomicin PO 200mg for 10days (available in UK from Sept 2012) Relapse Vancomycin PO mg 6hourly for 14days Recurrent relapses Vancomycin PO tapered dosing: Week 1&2: 125 mg 6hourly Week 3: 125 mg Week 4: 125 mg Week 5: 125 mg alt. days Week 6&7: 125 every 3days advice required. For dosing in renal / hepatic failure, seek advice from a pharmacist Page 4 of 5

5 more advice required. For dosing in renal / hepatic failure, seek advice from a pharmacist. Page 5 of 5