empiric use of
antimicrobials
in adults
HSE South East Hospital Network
June 2012
Issued by:
Revised by:
Revised by:
Revised by:
Revised by:
Revised by:
Revised by:
Table of Contents
Page No.
General Guidance
2-3
MRSA
7-12
12
Gastro-intestinal Infection
13
14
15
15
16
ENT infections
16
17
Gentamicin
18-19
20-21
Switch from IV to PO
Oral Bioavailability and Relative Costs
22
23-24
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Where possible indicate intended duration of therapy at point of initial prescribing. Review IV antimicrobial
therapy daily.
Document indication for therapy and intended duration in medical record. Note these guidelines are intended
for empiric therapy. Rationalise when microbiology results become available.
Some antibiotics e.g. ciprofloxacin, fusidic acid and metronidazole have excellent oral
bioavailability and the oral route should be used where possible. IV formulations of these should only be
used if the patient is not absorbing or unable to have oral medications.
2.
3.
4.
5.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
NB: The prescriber should always check prescribing information such as cautions,
contraindications, interactions and side effects when considering antimicrobial therapy. Ensure
information on antimicrobial prescribing, including risks and side effects associated with
antimicrobial treatment, is available to patients or their legal guardians.
1.
GENERAL GUIDANCE
For oral switch guidelines see pg 22. Oral switch is usually to PO formulation of same antibiotic where
available, except IV penicillin to PO amoxicillin as oral absorption of penicillin is very poor.
Penicillin allergy: obtain & document proper history. If IgE mediated allergic reaction (e.g.
anaphylaxis, angioneurotic oedema, immediate urticaria) avoid all beta-lactams. If rash only, a cephalosporin
may be considered. Erythromycin is often NOT a good substitute.
Risk of Clostridium difficile associated with all antibiotic use. Particular risk with all fluroquinolones (e.g.
levofloxacin and ciprofloxacin), clindamycin and cephalosporins.
7.
8.
9.
10.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Oral switch consider when patient is afebrile and infection parameters are settling for 48 hours and normal
oral absorption. Generally NOT appropriate in meningitis, endocarditis, febrile neutropenia or acute
osteomyelitis/septic arthritis.
6.
Restricted/Reserve Antimicrobials:
A Cochrane review has found that reserving access to selected antimicrobials is the most effective
10
component of any Antimicrobial Stewardship Programme.
Below is the list of Restricted and Reserve antimicrobials for the SE Acute Hospital Network.
These antimicrobials should only be prescribed when this is in line with the recommendations of this
guideline or following discussion with the Clinical Microbiologist.
Indication for therapy and any discussions/advice from the Clinical Microbiologist should be
documented accurately in patients medical record.
Restrictions are in place which limit access to these Antimicrobials. Please refer to South East Acute
Hospital Network Guidelines for use of Reserve and Restricted Antimicrobials for details.
Restricted Antimicrobials
IV Piperacillin/Tazobactam
IV Ceftriaxone
IV Ciprofloxacin
IV/PO Levofloxacin
IV Chloramphenicol
IV/PO Clindamycin
IV Teicoplanin
IV Vancomycin
IV/PO Linezolid
IV Meropenem
*Reserve Antimicrobials
IV Cefotaxime
IV Ceftazidime
IV Erythromycin
IV Ofloxacin
IV Colistin
IV Daptomycin
IV Tigecycline
Antifungals
Liposomal Amphotericin B
Anidulafungin
Caspofungin
Voriconazole
Posaconazole
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
MRSA
Urinary Tract
Infections
Condition
Antibiotic
Comments
Catheter associated
UTI
Pyelonephritis
Prostatitis
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Hospital acquired or
recurrent UTI or
complicated UTI
Condition
Antibiotic
Comments
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Community
Acquired
Pneumonia
Legionellosis
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
High severity
(CURB65 = 3-5)
15 - 40% mortality
Comments
No microbiological tests required. 7
days appropriate antibiotic therapy is
recommended.
Moderate Severity
(CURB65 = 2)
9% mortality
Antibiotic
Amoxicillin 500mg tds PO. (IV if PO
administration not possible.)
Penicillin allergy: clarithromycin 500mg BD
or doxycycline 200mg OD PO loading dose
then 100mg OD PO.
Condition
Low severity
(CURB65 = 0-1)
<3% mortality
Intravenous co-amoxiclav
and macrolide
Oral amoxicillin
and macrolide
Oral amoxicillin
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
CURB-65 score should be used with caution in younger patients as it may underestimate severity in these patients
Inpatient
management
Inpatient
management
Outpatient
management
High risk
3-5 points
Intermediate risk
2 points
Low risk
0 or 1 point
CURB65 score
New onset mental confusion
Urea>7 mmol/L
Respiratory rate 30/min
Systolic blood pressure <90mmHg and/or
diastolic blood pressure 60mmHg
Age 65 years
10
Respiratory
Tract
Infections
Comments
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Hospital acquired
pneumonia 6
Antibiotic
Patients from nursing home/chronic care
nursing facility/recent hospitalisation refer to
algorithm page 11.
Condition
Health care
associated
pneumonia5
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Patients with HCAP should be identified and then divided on the basis of severity of illness to guide initial therapy. Patients in each group are then further divided based on whether
they have risk factors for drug-resistant (MDR) pathogens that include: recent antibiotic therapy in the past 6 months, recent hospitalization in the past 3 months, the presence of immune
suppression, and poor functional status as defined by activities of daily living. CAP, community-acquired pneumonia; HAP, hospital-acquired pneumonia.
*Adapted from Brito V, et al. Current Opinion in Infectious Diseases 2009, 22:316-325
AND
HCAP present: Patient from nursing home/chronic care facility, recent hospitalization
11
12
Examples: Peritonitis,
Diverticulitis, Biliary tract
infections
Pancreatitis
Severe acute
necrotising Pancreatitis
Intra-abdominal
infections
Comments
Severe hypersensitivity
reaction/anaphylaxis to penicillins:
metronidazole + gentamicin
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Antibiotic
Endocarditis
Condition
Antibiotics may not be required
See Comments
Co-amoxiclav oral or IV depending on
severity for 5-7 days. Review need
for IV therapy on a daily basis.
Penicillin allergy : Clarithromycin 500mg BD
daily PO for 5-7 days
13
Condition
Antibiotic
Non-severe CDAD:
Metronidazole 400mg TDS PO for 10
days
Severe CDAD:
Early surgical review recommended
Vancomycin 125mg PO QDS
for 10 days
Inability to take oral medications:
Metronidazole 500 mg IV TDS/QDS for 10
days
Comments
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Clostridium difficile
Associated Disease
(CDAD)
14
Condition
Antibiotic
Comments
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Assess patient re possible focus Ensure blood cultures taken. See individual
of infection e.g. urinary tract, infection treatment guidelines for appropriate
skin/soft tissue, abdominal, therapy.
chest, neurological., community Initial empirical therapy if no obvious
or hospital acquired, travel
source: Piperacillin-tazobactam 4.5g
history, recent antibiotic
IV TDS. Consider adding gentamicin if
therapy, presence of prosthetic haemodynamically unstable / severe infection.
devices, intravascular catheters, Consider need for additional gram positive
etc.
cover e.g vancomycin(or teicoplanin if patient
is already on gentamicin)
Neutropenic sepsis 9
Initial Empiric therapy: Piperacillintazobactam 4.5g QDS IV. Add gentamicin
if complications (e.g. hypotension, pneumonia
or antimicrobial resistance suspected).
Consider adding vancomycin or teicoplanin
for specific clinical indications e.g. suspected
CVC-related infection or complications as above.
Penicillin allergy (Not IgE mediated
reaction/anaphylaxis): Ceftazidime 2g TDS IV
plus vancomycin or teicoplanin.
Severe IgE mediated reaction/anaphylaxis to
penicillin: Ciprofloxacin plus gentamicin plus
teicoplanin
Septicaemia
15
Antibiotic
Flucloxacillin 2g QDS IV plus sodium
fusidate 500mg tabs TDS PO (or fusidic
acid susp. 750mg TDS PO)
Penicillin allergy (NOT IgE mediated
reaction/anaphylaxis): Cefuroxime 1.5g TDS
IV plus fusidic acid as above.
Severe IgE mediated reaction/anaphylaxis
to penicillin: Vancomycin plus fusidic acid as
above.
Benzylpenicillin (penicillin G) 1.2g-2.4g
QDS IV plus flucloxacillin 1-2g QDS IV
Penicillin allergy (NOT IgE mediated
reaction/anaphylaxis): Cefuroxime 750mg1.5g TDS
Severe IgE mediated reaction/anaphylaxis
to penicillin: Clindamycin 1.2g QDS IV.
Condition
Osteomyelitis / Septic
arthritis
Comments
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
16
ENT Infections
Central Nervous
System
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Comments
Seek Microbiology advice.
Consider Dexamethasone phosphate
for bacterial meningitis.(10mg IV 6
hourly for 2 to 4 days. Must commence
before or at same time as antibiotic).
Send Blood cultures, throat swab,
EDTA blood for PCR +/- CSF. Isolate
patient. Notify Public Health.
Acute epiglottitis
Encephalitis
Antibiotic
Ceftriaxone 2g BD IV If Listeria risk add
amoxicillin 2g 4 hrly IV. If Strep pneumoniae
(pneumococcus) suspected add vancomycin
until sensitivities confirmed.
Treat for 14 days if pneumococcus. Treat for 7 days
if meningococcus. Severe IgE mediated reaction/
anaphylaxis to penicillin: chloramphenicol 1g IV
QDS. If immunocompromised add vancomycin and
co-trimoxazole.
Condition
Meningitis
17
Infection
Genital Tract
Condition
Antibiotic
Comments
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Pelvic Inflammatory
Outpatient Rx: Ceftriaxone 250mg IM or IV as
Disease (PID), Salpingitis, single dose, then doxycycline PO 100 mg BD +
Tubo-ovarian abscess
metronidazole PO 400mg TDS
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Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Dose Adjustment
Levels
Comments
Endocarditis: 1mg/kg IV 12 hourly.
Serum levels:
pre-dose level <1g/ml
1 hour post dose level of 3-5g/ml
(not always necessary).
Normal renal function: twice-weekly
serum monitoring may be sufficient.
Abnormal renal function: dosage should
be adjusted according to creatinine
clearance and daily serum assay
results.
Take pre-dose level before the 3rd
dose.
NB Antibiotic assays are done at 12:00 Noon and 4.00 pm Monday to Friday and
12:00 Noon on Saturdays and Sundays. Samples must reach the laboratory in
Waterford Regional Hospital one hour before these above times.
No
CrCl(ml/min)
50-80
30-50
10-30
<10
Yes
Dose
4mg/kg
3mg/kg*
2mg/kg*
1-2mg/kg*
redose
when level
<1g/ml
No
Yes
Is trough level
>1(g/ml) but
<2(g/ml) and
treatment still
Indicated?
No
Seek advice
from Pharmacy
or Clinical
Microbiology
Yes
Reduce once daily
dose by 1mg/kg*
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
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Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
Levels
6 mg/kg 12 hourly for 3 doses and May be required in certain circumstances eg.
thereafter once daily. Higher doses,
endocarditis.
10- 12mg/kg, in similar dosing schedule Discuss with Microbiology team.
is indicated in serious infections e.g.
MRSA infections and endocarditis. Such
patients should be discussed with the
clinical microbiology team.
Levels
Collect predose level before 4th dose of
vancomycin. Give the dose. Any adjustments
necessary can be made to the 5th dose onwards.
Predose level should be between 1015g/ml. (In severe/complicated
infection 15-20 g/ml). If continuing
vancomycin and renal function is stable, repeat
level twice weekly. Daily levels may be required
if renal function is unstable. Note that 1- hour
post dose levels are not necessary.
Clearly state dose, time of dose and time of blood
sample collection on the request form.
At weekends routine assays are carried out at
midday on Saturdays and Sundays.
Comments
Renal impairment:
If teicoplanin is to be used, the full dose
is given for the first 4 days. Thereafter
extended dosing intervals are required.
Comments
Yes
No
No
CrCl
Dose
Check 1st level
(ml/min)
40-60
15mg/kg od
Before 3rd dose**
20-40
15mg/kg
Before 2nd dose**
every 36-48 hrs.
<20
15mg/kg
Before 2nd dose.
every 72-96 hrs. Hold dose until
level available
Once daily doses should preferably be given at
10am to facilitate checking of levels
Yes
Recheck pre-dose
level
After adjusted dose
given and before
following morning dose**
Twice weekly
providing renal
function is stable**
After adjusted dose
given and before
following morning dose**
After adjusted dose
given and
before following
morning dose**
**Unless renal
function is
deteriorating or
specifically
advised DOSES
SHOULD NOT
BE HELD WHILST
AWAITING
LEVELS
Seek advice
from Pharmacy
or Clinical
Microbiology if
in doubt
Recheck
pre-dose level
After adjusted
dose given and
before following
morning dose**
After adjusted
dose given and
before following
morning dose**
Twice weekly
providing renal
function is stable**
After adjusted
dose given and
before following
morning dose**
After adjusted
dose given and
before following
morning dose**
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
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Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
ORAL
Amoxicillin 500mg 8 hr
Co-amoxiclav 625mg 8 hr
Clindamycin 300mg 6 hr
Clindamycin 450mg 6 hr
Flucloxacillin 500mg -1g 6 hr
30 minutes before food
Clarithromycin 500mg 12 hr
Metronidazole 400mg 8 hr
Ciprofloxacin 500 - 750 mg 12 hr
IV
Co-amoxiclav 1.2g 8 hr
Clindamycin 600mg 6 hr
Clindamycin 1.2g 6 hr
Flucloxacillin 1 - 2 g 6 hr
Clarithromycin 500mg 12 hr
Metronidazole 500mg 8 hr
Ciprofloxacin 400mg 12 hr
Antimicrobial
Ciprofloxacin
Clindamycin
Fusidic Acid
Fluconazole
Levofloxacin
Linezolid
Metronidazole
Oral Bioavailability
70%***
90%*
91%(tablets)*
90%*
98%*
100%*
99%**
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
23
0-10
10-40
40-60
150-300
300-500
24
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
REFERENCES:
1. Guidelines for Antimicrobial Stewardship in Hospitals in Ireland. SARI
Hospital Antimicrobial Stewardship Working Group. December 2009.
2. Policy on Control and Prevention of Meticillin Resistant Staphylococcus
aureus (MRSA) in Acute Hospitals in the HSE/SE. November 2009.
3. Gupta K et al International Clinical Practice Guideline for the treatment of
acute uncomplicated cystitis and pylenephritis in women. 2010 update by
IDSA and ESCMID. CID 2011; 52: 103-120.
4. Lim WS, Baudouin SV, George RC et al. BTS Guidelines for the
management of community acquired pneumonia in adults: update 2009.
Thorax 2009; 64 Suppl 3: iii1-55.
5. Brito V et al. Healthcare - associated pneumonia is a heterogenous
disease, and all patients do not need the same broad-spectrum antibiotic
therapy as complex nosocomial pneumonia. Current Opinion in Infectious
Diseases 2009; 22: 316-325.
6. Masterton. RG et al. Guidelines for the management of hospital acquired
pneumonia in the UK. JAC 2008; 62: 5-34.
7. James D. Chalmers, Mudher Al-Khairalla, Philip M. Short, Tom C.
Fardon and John H. Winter. Proposed changes to management of
lower respiratory tract infections in response to the Clostridium difficile
epidemic. J Antimicrob Chemother 2010; 65: 608-618.
8. Policy on Prevention and Control of Clostridium difficile associated
disease In Acute Hospitals HSE/South East. January 2010.
9. Clinical Practice Guideline for the Use of Antimicrobial Agents in
Neutropenic Patients with Cancer, 2010 update by the IDSA. CID 2011;
52(4): e56-e93.
10. Davey et al. Interventions to improve antibiotic prescribing practices for
hospital inpatients (review). The Cochrane Library Oct 2008.
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6
25
Ext. 2490/8053
Dr. M. Hickey
Ext.
Dr. M. Doyle
Ext. 2621.2097
Dr. B. Carey
Ext.
Ext. 2488/2489
Pharmacy Departments.:
WRH Antimicrobial Pharmacist
Ext. 2530/2453
Ext. 3261
26
Ext. 7119
Guidelines for the empiric use of antimicrobials in adults HSE SE Hospital Network June 2012
Index no ASG 001 Date of Approval June 2012 Revision Date June 2013 Revision no 6