EMPIRICAL USE OF ANTIBIOTICS POCKET GUIDELINES FOR PRESCRIBING IN ADULTS 2014/2015

Transcription

1 EMPIRICAL USE OF ANTIBIOTICS POCKET GUIDELINES FOR PRESCRIBING IN ADULTS 2014/2015 Full guidelines are available on the intranet (the HUB) All doses are based on NORMAL RENAL FUNCTION For dosing in renal impairment contact you ward pharmacist This is an aid for initial antibiotic prescribing. All antibiotic prescriptions should be reviewed daily and consider further discussion with Microbiology, particularly if the initial presentation is complex (e.g. immunocompromised patients outside of the neutropenic sepsis protocol, returning traveler etc.) or if there is poor clinical response. Indication and duration / review date must be written on the drug chart at time of prescribing. For further advice contact Consultant Microbiologist: Dr Cherian (ext3342) Dr Edwards (ext 1249) Antimicrobial Pharmacist: Sarah Zeraschi (bleep 6347) Pharmacy Medicines Information: (ext 3788) Out of hours, contact switchboard for on-call Microbiology and/or Pharmacist Produced by: Antimicrobial Stewardship Committee Approved: June 2014 Review: June 2015 (adapted from UCLH antimicrobial pocket guide) EMPIRICAL TREATMENT PRINCIPALS OF GOOD ANTIBIOTIC PRESCRIBING START SMART: Take cultures before antibiotic administration Check allergy history and document nature of severity Prescribe in line with BTUH policies / guidelines Give first dose of antibiotic within 1 hour for severe / life-threatening infections Document indication for antibiotic in medical notes and on drug chart Record duration of therapy (stop / review date) on drug chart Consult microbiology when appropriate THEN FOCUS: At 48 hours review diagnosis and need for antibiotics. STOP antibiotics if no evidence of infection SWITCH from IV to oral therapy CHANGE antibiotics: de-escalate / substitute / add agents as per culture results CONTINUE and review again after a further 24 hours Document decisions in medical notes. For hospital acquired infections check culture and sensitivity results before starting antibiotics. PRESCRIBING IN PENICILLIN ALLERGY Drugs in RED are contra-indicated in penicillin allergy Drugs in ORANGE should be prescribed with caution Drugs in GREEN are considered safe - See Penicillin allergy (PenA) table for more information

2 Start antibiotics within 1 hour for severe / life-threatening infections Blood Cultures must be taken Mandatory Sepsis criteria See Sepsis Care pathway Suspicion of infection AND 2 or more of the following: Temperature <36oC or >38oC Respiratory rate >20 BPM Heart rate >90 BPM WCC <4 or >12 x 109/L Septicaemia (unknown source) Severe systemic infection before results available Refer to surviving sepsis guideline 1st line: Piperacillin/ tazobactam 4.5g IV TDS + Gentamicin 5mg/kg IV stat Non-severe Penicillin allergy (e.g. delayed rash): Meropenem 1g IV TDS + Gentamicin 5mg/kg IV stat Severe Penicillin allergy (i.e. anaphylaxis): Ciprofloxacin 400mg IV BD + Teicoplanin 400mg IV BD for 3 doses then 400mg IV OD + Gentamicin 5mg/kg IV stat Neutropenic sepsis (Full guidance available on HUB) Febrile neutropenia is defined as Temperature >38oC for more than 1 hour or a single reading >38.5oC and Neutrophil count of <0.5x109/litre or count of <1x109/litre with predicted decrease to <0.5x109/litre 1st line: Meropenem 1g IV TDS SEPSIS Penicillin allergy: Ciprofloxacin 400mg IV BD + Teicoplanin 400mg IV BD for 3 doses and then 400mg IV OD + Gentamicin 5mg/kg IV if patient remains hypotensive after IV fluid resuscitation For all other groups of patients, refer to full guideline on the HUB Community Acquired Pneumonia (CAP) See CAP care pathway Severity of CAP criteria (CURB-65) - 1 point for each C onfusion (new onset) U rea > 7mmol/L R espiratory rate 30/minute B lood pressure (SBP < 90mmHg; DBP 60mmHg) 65 age 65 years Mild CAP (CURB-65 score 0-1) 1st line: Amoxicillin 500mg PO TDS Penicillin allergy: Clarithromycin 500mg PO BD Total duration: 5-7 days Moderate CAP (CURB-65 score 2) 1st line: Amoxicillin 500mg - 1g PO TDS + Clarithromycin 500mg PO BD Penicillin allergy: Clarithromycin 500mg PO BD RESPIRATORY

3 Total duration: 7-10 days Severe CAP (CURB -65 score 3) 1st line: Co-amoxiclav 1.2g IV TDS + Clarithromycin 500mg PO/IV BD Mild Penicillin allergy: Ertapenem 1g IV OD + Clarithromycin 500mg PO/IV BD Penicillin allergy: Teicoplanin 400mg IV BD for 3 doses then 400mg OD + Clarithromycin 500mg IV/PO BD Switch to oral when appropriate: Discuss with Microbiology Total duration: days Hospital acquired pneumonia (HAP) 1st line: Piperacillin/ tazobactam 4.5g IV TDS Mild Penicillin allergy: Meropenem 1g IV TDS Test for legionella antigen (urine) in moderate and severe CAP Penicillin allergy: Teicoplanin 400mg IV BD for 3 doses, then 400mg IV OD Switch to oral when appropriate: Total duration: 5-7 days Legionella Pneumonia Consider in HAP; - Inpatient - Living in an institution - Recent hospital admission - Travel History 1st line: Clarithromycin 500mg IV BD NB check urinary antigen (rapid diagnostic test). Positive contact microbiology Negative stop clarithromycin Community Acquired Aspiration pneumonia Review diagnosis after 5 days. Many do NOT require further antibiotics. 1st line: Amoxicillin 500mg PO/IV TDS + Metronidazole 400mg PO TDS or 500mg IV TDS Penicillin allergy: Clarithromycin 500mg IV/PO BD + Metronidazole 400mg PO TDS or 500mg IV TDS Hospital Acquired Aspiration pneumonia Review diagnosis after 5 days. Many do NOT require further antibiotics. 1st line: Piperacillin/tazobactam 4.5g IV TDS Mild Penicillin allergy: Meropenem 1g IV TDS Penicillin allergy: Teicoplanin 400mg IV BD for 3 doses, then 400mg IV OD + Metronidazole 400mg PO TDS or 500mg IV TDS Infective exacerbation of COPD 1st line: Doxycycline 100mg PO BD for 7 days If intolerant to tetracyclines, amoxicillin can be used. URINARY TRACT Uncomplicated, Lower UTI See UTI care pathway 1st Line: Nitrofurantoin 100mg PO QDS for 3 days for women, 7 days for men (ineffective if egfr <60ml/min)

4 If egfr <60ml/min then use Trimethoprim 200mg BD for 3 days (men 7 days) 2nd Line: Gentamicin 5mg/kg IV OD Complicated UTI & Pyelonephritis 1st Line: Gentamicin 5mg/kg IV OD Do NOT delay treatment Start treatment as soon as blood cultures have been taken 1st Line: Ceftriaxone 2g IV BD (Give IM if no venous access) for 7-14 days Severe Penicillin allergy: Chloramphenicol 1g IV QDS for 7-14 days If Listeria suspected (e.g. patient pregnant or immunosuppressed or age>55 years): Add Amoxicillin 2g IV 4 hourly If Listeria suspected and penicillin allergic speak to microbiology If gram positive cocci seen/cultured or if pneumococcal aetiology is likely (e.g. age>50yrs; sinus infection /otitis media / mastoiditis; csf leak; EtOH; immunocompromised): Add Dexamethasone 0.15mg/kg IV QDS for 4 days. Must start either before, or with the first dose of antibiotic. If GCS <15, recent seizures or suspected viral encephalitis: Add Aciclovir 10mg/kg IV TDS for days Review treatment in light of CSF cultures and PCR results Cellulitis 1st Line: Benzylpenicillin 1.2g IV QDS + Flucloxacillin 1g IV QDS Switch to oral when appropriate Amoxicillin 500mg-1g PO TDS + Flucloxacillin 500mg-1g PO QDS Penicillin Allergy: Clindamycin 600mg IV QDS - Discontinue if diarrhoea develops - Discuss with microbiology If patient >65 years Switch to oral when appropriate MENINGITIS (Contact Microbiology) SKIN & WOUND MRSA: Teicoplanin 400mg IV BD for 3 doses then 400mg OD + Sodium fusidate 500mg PO TDS BONE & JOINT (Contact Microbiology) Discuss with Microbiology if MRSA suspected and in all cases of suspected prosthetic joint infection Osteomyelitis 1st Line: Flucloxacillin 1-2g IV QDS + Sodium Fusidate 500mg PO TDS Pen allergy: Teicoplanin 400mg IV BD for 3 doses then 400mg IV OD + Sodium Fusidate 500mg PO TDS Add Gentamicin 5mg/kg IV OD if Systemically Unwell Duration if acute 42 days Duration if chronic 90 days Septic Arthritis 1st Line: Benzylpenicillin 1.2g IV QDS + Flucloxacillin 1g IV QDS 2nd Line: Teicoplanin 400mg IV BD for 3 doses the 400mg OD

5 + Clindamycin 600mg QDS IV (contact microbiology if patient >65 yrs) NB discontinue clindamycin if diarrhoea develops Biliary tract infection / Liver abscess / Peritonitis 1st Line: Co-amoxiclav 1.2g IV TDS +/- Gentamicin 5mg/kg IV stat Penicillin allergy: Metronidazole 500mg IV TDS + Ciprofloxacin 400mg IV BD Total duration: 7-14 days Post-operative Gastrointestinal Sepsis (including recent instrumentation e.g. ERCP) 1st Line: Tazocin 4.5g IV TDS +/- Gentamicin 5mg/kg IV stat Penicillin allergy: Metronidazole 500mg IV TDS + Teicoplanin 400mg IV BD for 3 doses then 400mg IV OD NB not for simple post-surgical wound infections Acute Gastroenteritis Isolate the patient Avoid laxatives and anti-motility agents Correct fluid and electrolytes Mild symptoms No antibiotic therapy required GASTROINTESTINAL Moderate to severe symptoms (i.e. dehydration, bloody stools, abdominal pain, fever) Send stool sample and await cultures. If antibiotics required discuss with Microbiology CLOSTRIDIUM DIFFICILE COLITIS Isolate the patient Stop precipitating antibiotics if possible Avoid laxatives and anti-motility agents Review use of proton pump inhibitors (PPIs) Review response to therapy daily 1st Line: Metronidazole 400mg PO TDS (if strict NBM or paralytic ileus use Metronidazole 500mg IV TDS) If poor response to 1st line after one week switch to; 2nd Line: Vancomycin 125mg PO QDS (Do not give vancomycin intravenously it is not effective) PELVIC INFLAMMATORY DISEASE 1st Line: Ceftriaxone 2g IV stat + Doxycycline 100mg PO BD + Metronidazole 400mg PO TDS Penicillin allergy: If severe allergy then discuss with Microbiology Total duration: 14 days NB Gonococcal resistance is an increasing clinical problem. Please discuss outpatient treatment with either Microbiology or GU Medicine. Please discuss all cases of tubo-ovarian abscesses with microbiology.

6 MRSA SUPPRESSION THERAPY Refer to MRSA screening policy on HUB for further information. Treatment for 5 days 1st line: Mupirocin (Bactroban ) nasal ointment TDS to both nostrils Octenisan body wash OD Octenisan shampoo hair on days 2 and 4 For alternative agents in case of adverse effects or resistance contact Infection Prevention & Control IV to ORAL SWITCH CRITERIA IV reviewed daily with a view to switch to oral therapy as soon as possible, according to the following criteria: C Clinical Improvement observed: signs & symptoms of infection improving & haemodynamically stable. O Oral route not compromised (vomiting, malabsorption disorder, NBM, Swallowing difficulties, unconscious, Severe diarrhoea) N.B if fed via NG, PEG, RIG, NJ etc. consult ward Pharmacist M Markers showing a trend towards normal Apyrexial: Temp >36 C + <38 C for at least 24 hours BP stable Plus NOT more than one of: Heart rate >90bpm Respiratory Rate >20 breaths/min WCC <4 or >12 S Specific/deep seated infection (see exclusion criteria below) Exclusion Criteria Certain infections require persistent IV therapy to ensure sufficient drug levels are attained at the site of infection to optimise response: Deep abscess: Liver abscess, Cavitating pneumonia, intracranial abscess Bone & Joint infections: Septic arthritis & Osteomyelitis Emphysema Staphylococcus aureus bacteraemia Severe soft tissue infections: necrotising fasciitis, cellulitis Cystic Fibrosis/Bronchiectasis Infected implants/prosthesis Meningitis/Encephalitis Endocarditis/mediastinitis Sepsis & Neutropenic sepsis GENTAMICIN DOSING For <75 years 1st dose: 5mg/kg (max 500mg. Round up or down to nearest 20mg) Dose is calculated using a dosing weight in obese patients Dosing Weight = Ideal Body Weight X [actual Weight ideal weight] Subsequent doses: Check pre-dose level before further doses are given Pre-dose levels must be taken hours after a dose Daily U+E s If <1mg/L give the same dose at 24 hour intervals If 1-2mg/L Reduce dose to 75% of initial dose 24 hourly (Reduce dose once only. If levels still 1mg/L discuss with microbiology) If >2mg/L No further doses until level is <1 (discuss with microbiology)

7 Dose Adjustment in Renal Impairment Estimate GFR using creatinine clearance calculator Creatinine Clearance (ml/min) = [140 age (years) x ideal body weight (kg) x F] /Serum creatinine (F = 1.04 in females and 1.23 in males) egfr (ml/min) Dose 3mg/kg (max 300mg dose rounded to nearest 20mg) <10 Dose 2mg/kg (max 200mg dose rounded to nearest 20mg) Check Levels hours after 1st dose. Re-dose only when levels <1mg/L Dose Adjustment in >75 years 1st Dose: 3mg/kg (max 300mg. Dose rounded to nearest 20mg) Check Levels hours after 1st dose. Redose only when levels <1mg/L PENICILLIN ALLERGIES Not all penicillin s sound like they contain a penicillin PENICILLINS CAN KILL IF GIVEN TO A PATIENT WITH PENICILLIN ALLERGY For any antibiotics NOT listed below please contact your ward Pharmacist or Medicines Information STOP! Contraindicated in Penicillin Allergy Amoxicillin Benzylpenicillin Co-Amoxiclav (Augmentin = Amoxicillin + Clavulanic acid) Flucloxacillin Penicillin V (Phenoxymethylpenicillin) Piperacillin / Tazobactam (Tazocin ) Temocillin Ticarcillin + clavulanic acid (Timentin) CAUTION! Use with caution in Penicillin Allergy Consult Microbiology before prescribing AVOID if history of severe allergy. CAUTION if non-severe allergy Cefalexin Ceftriaxone Meropenem Cefixime Cefuroxime Aztreonam Cefotaxime Ertapenem Ceftazidime Imipenem Approximately 10% of penicillin sensitive patients may be sensitive to a drug in this group. SAFE! Considered Safe in Penicillin Allergy Amikacin Fosfomycin Sodium Fusidate Azithromycin Gentamicin Teicoplanin Chloramphenicol Levofloxacin Tetracycline Clarithromycin Linezolid Trimethoprim Clindamycin Lymecycline Tobramycin Colistin Metronidazole Vancomycin Co-Trimoxazole Minocycline Daptomycin Nitrofurantoin Doxycycline Oxytetracycline Erythromycin Rifampicin