How do we ensure that the calculators are correct?

We apply a system of multiple verification and validation checks to ensure that the calculators are correct.

• The algorithms for the calculators are sourced from the original policy document, which has been produced and reviewed by clinicians in the Trust. This ensures the original algorithms are appropriate.

• Trust clinicians have independently written test data and a verification implementation of the algorithms in a completely separate system. This ensures our interpretation of the policy is the same as the clinicians.

• A large number of randomly generated test cases are also run against this verification implementation. This ensures that corner cases are explored.

• Each time an app runs the same two sets of test data are run by the app itself and the app is not run if there is any discrepancy. This ensures that the implementation of that app matches the verification implementation, and that the web browser and underlying software and hardware is correctly executing the code.

Version 2

Consultation, Communication

Implementation Plan

Performance Management of Policy KPIs (expected outcomes)

Performance Management of minimum NHSLA process for this policy

Learning from experience

Document Version History

Policy Aim

This policy aims to ensure appropriate antimicrobial use in patients with commonly encountered infections primarily relating to appropriate empirical antimicrobial treatment.

Policy Description

This policy describes appropriate empirical antimicrobial treatment of patients with commonly encountered infections as well as the use of antimicrobial prophylaxis where relevant.

Staff

It is the responsibility of all staff to:

• be aware of the current policy
• put these policy into practice.
• bring to the attention of the Unit Manager/Clinical Lead or Antimicrobial Management Team any problems in applying this policy.

Medical staff and non-medical prescribers

• All prescribers must review previous positive microbiology results (e.g. on OCS/Maxims or the Clinical Portal, when this is implemented) prior to prescribing any antibiotic to ensure that the antibiotic(s) prescribed cover(s) potential likely pathogens (including any multi-resistant organisms isolated from the patient in the past).
• Consultants should review antibiotic prescribing on all their ward rounds, stopping unnecessary prescriptions and changing those that do not comply with guidelines, as should junior medical staff (and any non- medical prescribers) on their own ward rounds.

Breaches of this policy may lead to disciplinary action being taken against the individual.

Unit managers (person in charge of a ward or department) must ensure that

• The policy is readily accessible to all staff.
• The required facilities and equipment are available to enable compliance with the policies.
• All staff within their area of responsibility have received training in the appropriate procedures with respect to antimicrobial prescribing.

General Points

The purpose of this policy is to provide recommendations on the initial empirical or ‘blind’ therapy based on the likely pathogens and local antimicrobial susceptibility data. Doses given are generally those for adults with normal renal and hepatic function. Further details of side effects and contra-indications etc. can be obtained in the British National Formulary or from Whiston Hospital Medicines Information ext. 1565

In addition, the Medicines Resources page on the Trust intranet contains useful information on all aspects of prescribing and administration of medicines including antimicrobials (e.g. policies, procedures and guidance on medicines, prescribing, administration including injectable medicines guide, storage and adverse drug reactions). The content of this policy as well as calculators for gentamicin (once daily) and vancomycin dosing and creatinine clearance, are also available on the Mersey Micro app for smart phones/tablet devices at http://ab.shk.nhs.uk which is available free of charge to all Trust staff.

ANTIFUNGAL ASSAYS

Duration of Treatment

Most infections e.g. pneumonia, septicaemia respond to 5-7 days of antibiotics.

IV to Oral Switch

Serious infections require intravenous antibiotics initially. Unless the patient is suffering from a deep-seated/high risk infection (see below), the treatment should usually be changed to oral after 1-2 days, as long as the patient has shown signs of clinical improvement, is able tolerate oral medication and is medically stable. It is acceptable to change to a different antibiotic if the infecting organism is sensitive e.g. IV CefUROXime may be changed to oral trimethoprim, IV CefTAZidime may be changed to oral ciprofloxacin.

Penicillin Allergy

Ten per cent of patients who are allergic to penicillin will also be allergic to cephalosporins. If the allergic reaction to penicillin is non-severe e.g. minor rash or delayed rash (>72 hours after administration), cephalosporins or meropenem can be given. If the allergic reaction is severe e.g. anaphylaxis, urticaria, or rash immediately after penicillin administration, cephalosporins and meropenem must be avoided.

Note that co-amoxiclav (Augmentin®) and piperacillin-tazobactam (Tazocin®) are penicillin-based.

Approximately 10% of patients allergic to penicillin will also be allergic to The guidelines do not cover every eventuality. Advice on antibiotic therapy can be meropenem. If the patient has a history of anaphylactic reaction to penicillin, but no alternative antibiotics are available, meropenem can be used with caution (patient under careful observation with team ready to treat anaphylaxis, should it occur). If an allergic reaction to meropenem occurs, the drug should be discontinued and an alternative discussed with microbiology. Click here for a summary penicillin/beta-lactam allergy chart.

Antibiotics and Clostridium Difficile Infection (CDI)

ALL antibiotics and proton pump inhibitors predispose the patient to CDI.

Intravenous Additive Service

Wherever possible, use IV antibiotics which have been prepared by the Pharmacy Department.

Drugs currently being prepared for all wards are listed below:

For any drugs not listed in the above table please check with Pharmacy. If you require any of the above drugs to be prepared for a patient on your ward please ask your ward pharmacist when they visit in the morning or telephone extension 1514.

National Patient Safety Agency (NPSA) guidance advises that ready-to administer injectable medicines should be used whenever possible to reduce the risk of errors in preparation and administration. The Ecoflac connect adapter port system is suitable for conveniently and safely preparing many commonly used injectable antibiotics which are supplied in vials by attaching them on to infusion bottles as an alternative to products that cannot be obtained from the pharmacy aseptic unit. For further information consult your ward pharmacist/technician or the Pharmacy Aseptic Dispensing Unit for advice.

Outpatient Parenteral Antibiotic Therapy (OPAT)

A multidisciplinary team approach for the management of medically stable patients under OPAT continues provides both an efficacious and cost effective treatment option for patients needing long and short term IV antibiotics.

An effective community intravenous antibiotic therapy service will promote:

• better quality of life for patients
• reduce the length of hospital stay
• potentially reduce health care related infections

There are a number of community IV antibiotics/OPAT teams working in this locality namely, Liverpool, Sefton, Knowsley, Halton and St. Helens and Warrington.

There teams have specific referral criteria (which can be different according to the team) including drug dosing regime and IV access available for administering antibiotics in the community. Due to this, all patients must be individually discussed with either District Nurse Liaison or the community team looking after the patients prior to discharge.

Antibiotic Assays

Reserved Antimicrobials

The following antimicrobials are not recommended for routine use other than as described in this policy. They should be prescribed only after consultation with a microbiologist or if the sensitivity is reported on the microbiology report and antibiotic treatment if clinically indicated.

• Ambisome (Liposomal amphotericin)
• Amikacin
• Azithromycin
• Caspofungin
• Co-amoxiclav/Augmentin® (exceptions: empirical treatment of pneumonia and bites)
• Cefixime
• CefOTAXime (exception: neonatal infections)
• CefTAZidime
• CefTRIAXone
• Chloramphenicol (exceptions: eye ointment/drops, IV preparation – meningitis/epiglottitis in severely penicillin allergic patients)
• Ciprofloxacin
• Daptomycin
• Ertapenem
• Fidaxomicin
• Fosfomycin
• Fusidic acid/sodium fusidate (topical preparations) – unless advised by Dermatology
• Imipenem/cilastatin
• Levofloxacin
• Linezolid
• Meropenem
• Moxifloxacin (Respiratory and Ophthalmology consultant use only)
• Netilmicin
• Norfloxacin
• Ofloxacin (exception: pelvic inflammatory disease)
• Pivmecillinam
• Streptomycin
• Teicoplanin
• Telithromycin
• Tigecycline
• Tinidazole (use metronidazole instead)
• Tobramycin
• Voriconazole

Antibiotic Anaphylaxis

Antibiotics are associated with anaphylaxis. This can be a life threatening event.

Parental administration and atopic status are more frequently associated with clinically significant events. Rapid intravenous administration is the most likely to produce such a reaction.

Calculation of Creatinine Clearance: Where F = 1.04 (females) or 1.23 (males) GFR (mL/min) = (F x (140 – age) x Ideal Body Weight (Kg)) ÷ Serum creatinine (mcmol/L)

Septic Arthritis: General Information

Specimens:

• Joint aspirate and blood cultures.
• Urethral, cervical, pharyngeal and/or rectal swabs if gonococcal infection is suspected.

Septic Arthritis: Empirical Therapy (Pending Joint Fluid Gram Stain Results)

Septic Arthritis: Initial Therapy If Joint Aspirate Shows Organisms On Gram Stain

• Staphylococci (Gram positive cocci):
  Not penicillin allergic and no history of MRSA:
  Flucloxacillin 2g IV 6 hourly

  Non-severe penicillin allergy and no history of MRSA
  CefUROXime 1.5g IV 8 hourly

  Severe penicillin allergy or history of MRSA
  Vancomycin IV

  A second agent should be added when antibiotic susceptibility tests are available e.g. sodium fusidate 500mg oral 8 hourly.

• Gonococci (Gram negative cocci):
  CefTRIAXone 2g IV once daily followed by Ciprofloxacin 500mg orally 12 hourly if organism is sensitive

• Haemophilus (Gram negative cocobacilli) usually affecting children:
  CefUROXime (see BNF for Children for dosing).

• Coliform (Gram negative bacilli)
  CefUROXime 1.5g IV 8 hourly

Please note:

Review treatment with culture results. If Gram stain and culture are negative please contact Rheumatology to arrange review prior to discharge: fax referral to ext. 6331 and telephone ext. 6612 to ensure fax has been received.

Injection of antibiotics into the joint is not usually necessary, may cause chemical synovitis and should only be performed on the advice of a consultant.

Erythromycin and clarithromycin do not cross into synovial fluid in adequate amounts and should not be used.

Septic Arthritis: Duration of treatment

These are broad guidelines only. More prolonged therapy will be required when treatment has been delayed for more than a week after the onset of symptoms or if the patient is immunocompromised or when signs of joint inflammation have been slow to abate. Intravenous treatment should be given for at least 7-14 days (or until inflammatory signs have substantially diminished). The total course of antibiotics (intravenous plus oral) is shown below.

Duration of Antibiotic therapy

Continue antibiotic therapy until there is evidence that the infection has resolved but not necessarily until the wound has healed. Suggested course lengths:

• Mild infections: 1 to 2 weeks
• Moderate/severe infections: 2 to 4 weeks
• Osteomyelitis: at least 6 weeks is generally required.

Furunculosis

Specimen: ear swab
Pain relief e.g. paracetamol and local heat
If severe: flucloxacillin 500mg-1g PO 6 hourly or clarithromycin 500mg PO 12 hourly (if pregnant patient use erythromycin 500mg 6 hourly instead)

Diffuse otitis externa

Specimen: ear swab
Keep ears dry. Do not pick.
Pain relief if required.
First Line: Avoid antibiotics wherever possible and use 2% acetic acid (e.g. EarCalm spray)
Second line: topical gentamicin 0.3% (contraindicated in perforated tympanic membrane).

Malignant otitis externa

Specimens: ensure specimens for culture including tissue/pus are sent (if possible before starting antibiotic therapy)

CefTAZidime 2g IV 8 hourly
If severe penicillin allergy – discuss with Microbiology.

Likely Pathogens and Specimens

Likely pathogens:

• Chlamydia trachomatis
• Neisseria gonorrhoeae
• Anaerobes
• Enterobacteriaceae
• Streptococci
• Mycoplasma

Specimens:

• Cervical swab for gonococcal culture (plain transport medium).
• Urethral/vaginal swabs in Aptima transport medium for chlamydia and Neisseria gonorrhoeae PCR. NB: In women, PCR for chlamydia and Neisseria gonorrhoeae on first void urine is less sensitive compared with genital swabs.
• Culdocentesis fluid if available.
• Blood cultures if systemic illness.
• Consider testing for HIV and syphilis if risk factors are present.

Mild/moderate PID or outpatient treatment

CefTRIAXone 500mg stat intramuscularly
AND
Doxycycline 100mg PO 12 hourly for 14 days
AND
Metronidazole 400mg PO 12 hourly for 14 days.

If pregnant patient use erythromycin 500mg 6 hourly for 14 days instead of doxycycline.

Severe PID or inpatient treatment

CefTRIAXone 2 g IV once daily to be continued until 24 hours after clinical improvement
AND
Metronidazole IV* 500 mg 8 hourly AND oral doxycycline 100 mg 12 hourly for a total of 14 days.

* Change to oral metronidazole 400mg 12 hourly 24 hours after clinical improvement.

If patient unable to tolerate oral treatment, use clarithromycin 500mg IV 12 hourly.

If pregnant patient, substitute erythromycin 500mg 6 hourly for doxycycline in the above regime.

If severe penicillin allergy discuss with Microbiology.

Sexually transmitted infection suspected
CefTRIAXone 500mg stat intramuscularly
AND
Doxycycline 100mg oral 12 hourly for 14 days

If gonococcal infection is unlikely as microscopy is negative for Gram-negative intracellular diplococci AND patient has no risk factors (i.e. previous N. gonorrhoeae infection, known contact of gonorrhoea, presence of purulent urethral discharge, men who have sex with men or black ethnicity):

Doxycycline 100mg oral twice daily for 14 days
OR
Ofloxacin 200mg oral twice daily for 14 days

Refer to Sexual Health Clinic for diagnosis, treatment and contact tracing.

Sexually transmitted infection NOT suspected
Ciprofloxacin 500mg orally 12 hourly for 2-4 weeks

If patient is to be admitted give:
CefUROXime 1.5g IV 8 hourly
OR
Ciprofloxacin 400mg IV 12 hourly

Appendix 3: Treatment of first episode of Clostridium difficile infection

Appendix 4: Treatment of patients with recurrent Clostridium difficile infection

Treatment should be offered to all positive patients with known duodenal or gastric ulcer or low grade MALToma.
Duration of treatment for all regimes is 7 days (except for in MALToma where the treatment should be given for 14 days).
Do not offer eradication for gastro-oesophageal reflux disease. Do not use clarithromycin, metronidazole or quinolone (e.g. levofloxacin) if used in the past year for ANY infection.

First line Regime

Lansoprazole 30mg orally 12 hourly
ANDAmoxicillin 1g orally 12 hourly

AND
Clarithromycin 500mg orally 12 hourly OR Metronidazole 400mg orally 12 hourly

If patient is allergic to penicillin:
Lansoprazole 30mg orally 12 hourly
AND
Metronidazole 400mg orally 12 hourly
AND
Clarithromycin 250mg orally 12 hourly

If patient is penicillin allergic and has had previous exposure to clarithromycin:
Lansoprazole 30mg orally 12 hourly
AND
Tripotassium dicitratobismuthate 240mg 12 hourly
AND
Metronidazole 400mg 12 hourly
AND
Tetracycline hydrochloride 500mg 6 hourly

Second line Regime

Second line regime

Treatment should be offered to all positive patients with known duodenal or gastric ulcer or low grade MALToma.
Duration of treatment for all regimes is 7 days (except for in MALToma where the treatment should be given for 14 days).
Do not offer eradication for gastro-oesophageal reflux disease. Do not use clarithromycin, metronidazole or quinolone (e.g. levofloxacin) if used in the past year for ANY infection.

If patient fails to respond to first line treatment use quadruple therapy for 14 days:
Lansoprazole 30mg orally 12 hourly
Tripotassium dicitratobismuthate 240mg 12 hourly
AND TWO antibiotics not previously used. Pick from:
Amoxicillin 1g 12 hourly
Clarithromycin 500mg 12 hourly
Metronidazole 400mg 12 hourly
Tetracycline hydrochloride 500mg 6 hourly
NB. Do not use clarithromycin or metronidazole if used in the past year for ANY
infection.

Unknown organism i.e. empirical treatment

CefTRIAXone 2g 12 hourly IV
AND if patient is immunocompromised, pregnant or aged >55 years
ADD Amoxicillin 2g IV 4 hourly to cover listeria.

If patient has severe penicillin allergy:
Chloramphenicol 1g IV 6 hourly

Meningococcal (Gram negative coccus)

CefTRIAXone 2g 12 hourly IV
OR
Chloramphenicol 1g IV 6 hourly if severe penicillin allergy
Duration 5-7 days
If patient did not receive treatment with CefTRIAXone, give 2 days oral rifampicin 600mg 12 hourly to clear nasopharyngeal carriage prior to discharge from hospital.

Pneumococcus (Gram positive diplococcus)

CefTRIAXone 2g 12 hourly IV
OR
Chloramphenicol 1g IV 6 hourly (if severe penicillin allergy)
Duration 10-14 days

Haemophilus influenzae type B or HiB (Gram negative coco-bacillus)

CefTRIAXone 2g 12 hourly IV
OR
Chloramphenicol 1g IV 6 hourly (if severe penicillin allergy)
Duration 7-10 days
In addition, also give 4 days oral rifampicin 600mg 12 hourly to clear nasopharyngeal carriage prior to discharge from hospital.

Listeria monocytogenes (Gram positive bacillus)

Amoxicillin 2g IV 4 hourly
AND
Gentamicin IV

If non-severe penicillin allergy:
Meropenem 2g IV 8 hourly

If severe penicillin allergy:
Co-trimoxazole 1.44g IV 12 hourly
Duration: 2-3 weeks

Treatment of confirmed MRSA infections

Definition of community-acquired:

Onset of infection within less than 48 hours of hospital admission and not within 10 days of hospital discharge.

Definition of hospital-acquired:

Onset of infection 48 hours or more after hospital admission or infection present on admission but patient is within 10 days of previous in-patient stay.

Community Acquired Pneumonia

Pneumonia that develops in a patient before admission to hospital, within 48 hours of admission or more than 10 days after the last discharge from hospital. Pneumonia that develops in a nursing home resident is included in this definition.

Severity assessment for community acquired pneumonia

“Pneumonia” is assumed to include radiological evidence of consolidation
Investigation and management should be guided by the CURB-65 severity score (1 point for each):

C = confusion (mental test score 8 or less)
U = urea > 7mmol/L
R = respiratory rate ≥ 30 per minute
B = systolic BP < 90 or diastolic BP ≤ 60
65: age ≥ 65 years
Note: the CURB-65 score alone can be misleading in terms of severity assessment for patients younger than 65 years of age.
If the patient is likely to have post influenza pneumonia, follow the severe pneumonia treatment guidance. The choice of route of administration should be reviewed initially on the post take round and then daily.

Low Severity (CURB-65 score = 0 – 1)

Probably suitable for treatment at home.

First line:
Amoxicillin 500mg-1g 8 hourly orally

If penicillin allergic:
Clarithromycin 500mg 12 hourly orally (If pregnant patient use erythromycin 500mg 6 hourly instead).

If history of MRSA:

Doxycycline 200mg PO once daily on day one, followed by 100mg once daily.

Moderate Severity (CURB-65 score = 2)

Consider admission to hospital.
Amoxicillin 1g 8 hourly orally AND clarithromycin 500mg 12 hourly orally (If pregnant patient use erythromycin 500mg 6 hourly).

If penicillin allergy or history of MRSA - Doxycycline 200mg PO once daily on day one, followed by 100mg once daily.

If IV therapy needed:
Amoxicillin 500mg-1g 8 hourly AND clarithromycin 500mg 12 hourly. If pregnant patient requires IV therapy, discuss with Microbiology

If non-severe penicillin allergy - substitute IV CefUROXime 1.5g 8 hourly for IV amoxicillin

If severe penicillin allergy OR patient with history of MRSA requiring IV therapy: discuss with Microbiology.

If there is any reason why a patient cannot have IV therapy and oral therapy options are chosen please document reason in the patient notes.

High severity (CURB-65 score ≥3)

Initial management must be with IV antibiotics in hospital. If pregnant patient requires IV therapy, discuss with Microbiology

First Line:
Co-amoxiclav 1.2g 8 hourly AND clarithromycin 500mg 12 hourly

If non-severe penicillin allergy:
CefUROXime 1.5g 8 hourly AND clarithromycin 500mg 12 hourly

If history of MRSA:
ADD Vancomycin IV to above regimes.

If severe penicillin allergy:
Ciprofloxacin 400mg IV 12 hourly
AND
Vancomycin IV

If there is any reason why a patient cannot have IV therapy and oral therapy options are chosen please document reason in the patient notes.

Rationalisation of therapy and oral switch

Rationalise initial treatment regime with results of sputum cultures (aim for narrow spectrum of activity). Route of administration should be reviewed every 24 hours and documented in medical notes. Switch to oral route when the patient has been afebrile for 24 hours, shows signs of clinical improvement and oral intake is satisfactory. Base the choice of oral antibiotic on culture results, if available.

If no positive culture results, change to the oral formulation. For IV CefUROXime, switch to oral doxycycline. Note: CefaCLOR must not be used unless an organism which is sensitive to this has been isolated as CefaCLOR has poor activity against Haemophilus influenzae.

Treatment duration

5-7 days but 2-3 weeks may be necessary for patients with staphylococcal/
Gram negative or legionella pneumonia.

Microbiological Investigations

• Non-severe hospital acquired pneumonia

  First line (including patients known to be colonised with MRSA):

  Doxycycline 200mg PO once daily on day 1 then 100mg once daily
  NB. Review treatment with culture results and rationalise if possible.
  
  If patient is unable to take oral medications (and patient does not have severe penicillin allergy):
  CefUROXime 1.5g 8 hourly IV (if history of MRSA, ADD vancomycin.
  If patient is unable to take oral medications (and patient has severe penicillin allergy): discuss with Microbiology.
  

• Severe hospital acquired pneumonia

  First line:
  CefUROXime* 1.5g 8 hourly IV (if history of MRSA, ADD vancomycin).
  *If recent therapy with CefUROXime, use piperacillin-tazobactam 4.5g IV 8 hourly if not penicillin allergic
  
  Please note piperacillin-tazobactam is NOT the first line treatment for HAP in a patient who has not had recent therapy with cefuroxime.
  
  In the event of piperacillin-tazobactam being not available:
  Discuss with Microbiology.
  
  If severe penicillin allergy:
  Ciprofloxacin 400mg IV 12 hourly
  AND
  Vancomycin IV

Patients with hospital acquired pneumonia on ICU: For ICU patients who develop pneumonia prior to ventilation, please refer to the community or hospital acquired pneumonia guidance as appropriate. For patients with ventilator acquired pneumonia, treat as according to ventilator associated pneumonia guidance.

Ventilator Associated Pneumonia

• In patient ≤ 4 days:

  Check recent laboratory reports. If none, first line:
  CefUROXime* 1.5g 8 hourly IV,
  If patient has recently been treated with CefUROXime use:
  Piperacillin-tazobactam* 4.5g 8 hourly.

  If patient has been recently treated with piperacillin-tazobactam OR in the event of piperacillin-tazobactam being not available use:
  Meropenem* 1g IV 8 hourly

  *If history of MRSA ADD vancomycin to above.

  Contact Microbiologist if patient is allergic to penicillin.

• Inpatient >4 days:

  Check recent laboratory reports.
  If no reistant organisms, first line: Piperacillin-tazobactam* 4.5g 8 hourly.
  If patient has been recently treated with piperacillin-tazobactam, has resistant organisms OR in the event of piperacillin-tazobactam being not available use:
  Meropenem* 1g IV 8 hourly

  **If history of MRSA ADD vancomycin to above.
  ***See notes on specific anti-biotics

  Contact Microbiologist if patient is allergic to penicillin.

Pneumocystis jirovecii (carinii)

Risk factors: immunocompromise e.g. HIV/chemotherapy

Specimens: PCR on induced sputum or BAL fluid (ordinary sputum is a less optimal specimen).
No serological test available. PCR on EDTA blood can be considered if unable to obtain any respiratory specimens.

Treatment:
Co-trimoxazole (high dose) IV or orally, depending on condition, 30mg/kg 6 hourly for at least 3 weeks.
If signs of bone marrow depression occur, give calcium folinate 15mg/day supplementation
Adjunctive corticosteroid therapy can be life-saving in severe cases.

Prophylaxis:
Co-trimoxazole 960mg orally once daily.

Legionella

Specimens:
Urine (in white top sterile universal container) for legionella antigen (rapid test)
Sputum for legionella culture (NB. this must be specifically stated on the request card)
Serological testing is no longer recommended.

Treatment:
First line for patient with non-severe pneumonia
Clarithromycin 500mg IV 12 hourly.

Seriously ill patient or fails to respond:
Ciprofloxacin IV 400mg 12 hourly

Switch to oral clarithromycin (500mg 12 hourly) when response to treatment.

Duration:
14 days (immunocompetent)
14 – 21 days (immunocompromised)

Mycoplasma

Specimens:
Serology (send paired acute serum and convalescent serum 2 weeks later)

Treatment:
Clarithromycin 500mg IV 12 hourly if ill
OR
Clarithromycin 500mg oral 12 hourly if clinical condition permits.

Duration: 10-14 days

Please see BNF for Children for Paediatric doses.

Chlamydia psittaci (psittacosis)/Chlamydia pneumoniae

Specimens:
Serology

Treatment:
Doxycycline 200mg orally on first day then 100mg daily
OR
Clarithromycin 500mg IV 12 hourly
Duration: 14-21 days

Whooping cough:

Treatment: Clarithromycin orally for 7 days
Prophylaxis: Household contacts where there are vulnerable children
(e.g. unimmunised children, newborn, chronic illness, immunocompromised)
This must be given within 21 days of onset of the primary case.
Duration: 7 days

Clarithromycin 500mg oral 12 hourly for adults.
Please see BNF for Children for paediatric doses.

Animal bites

Topical cleansing, irrigation and debridement as indicated
If infected and patient able to have oral treatment:
Co-amoxiclav 625mg 8 hourly for 5 days
If penicillin allergic:
Doxycycline 100mg 12 hourly and metronidazole 400mg 8 hourly
N.B. Doxycycline must not be used in children under 12y or in pregnant/breast feeding women

If IV treatment indicated:
Co-amoxiclav 1.2g IV 8 hourly

If IV treatment indicated and patient has non-severe penicillin allergy:
CefUROXime 1.5g IV 8 hourly
AND
Metronidazole 500mg IV 8 hourly

If IV treatment indicated and patient has severe penicillin allergy, discuss with Microbiology.

If not infected and presenting within 48 hours of injury give antibiotics as for infected bites ONLY IF high risk of infection as below

• All cat bites
• Animal bites to the hand, foot, face or genitalia
• Puncture wounds
• Bites requiring surgical debridement
• Bites involving joints, tendons, ligaments or suspected fractures
• Wounds that have undergoneprimary closure
• Patients with Diabetes, liver cirrhosis, asplenia or immunosuppression
• Patients with a prosthetic valve or a prosthetic joint

In addition, review if:
Tetanus immunisation is up to date?
Is there a risk of rabies?
Consult Microbiologist if advice is required.

Human bites

Topical cleansing, irrigation and debridement as indicated: fight bites involving hands should have surgical washout/debridement.

Prescribe antibiotics for all human bites under 72 hours old, even if there is no sign of infection. If a bite is ≥72 hours old and there are no signs of infection, risk of infection is likely to be low and antibiotics are not indicated. If the bite is ≥72 hours old and there are clinical signs of infection, treat as below.

First line (if patient able to have oral treatment):
Co-amoxiclav 625mg 8 hourly for 5 days

If penicillin allergic:
Doxycycline 100mg 12 hourly and metronidazole 400mg 8 hourly
N.B. Doxycycline must not be used in children under 12y or in pregnant /breast feeding women

If IV treatment indicated:
Co-amoxiclav 1.2g IV 8 hourly

If IV treatment indicated and patient has non-severe penicillin allergy:
CefUROXime 1.5g IV 8 hourly
AND
Metronidazole 500mg IV 8 hourly

If IV treatment indicated and patient has severe penicillin allergy, discuss with Microbiology.

Is tetanus immunisation up-to-date?
Is Hepatitis B immunoglobulin/vaccine required?
Consult Microbiologist if advice is required

Preseptal cellulitis

• No chemosis
• No proptosis
• No ophthalmoplegia
• No visual loss

Mild:
Co-amoxiclav 625mg PO 8 hourly

Severe (or if no response to amoxicillin and flucloxacillin in 24 hours):
IV CefTRIAXone 2g 12 hourly for 24 hours then reduce to 2g once daily

Add in IV Metronidazole 500mg 8 hourly if no improvement in 12-18 hours.

If severe penicillin allergic:
IV ciprofloxacin 400mg 12 hourly and Clindamycin 600mg 6 hourly.

If history of MRSA:
Consult with microbiology

Refer to Ophthalmology and ENT if no response within 24 hours.

Orbital cellulitis

• Painful eye movements
• +/- chemosis
• +/- proptosis
• +/- restricted eye movements
• +/- visual loss

Refer to Ophthalmology and ENT
IV CefTRIAXone 2g 12 hourly for 24 hours then reduce to 2g once daily

Add in IV Metronidazole if no improvement in 12-18 hours.

If severe penicillin allergic:
IV ciprofloxacin 400mg 12 hourly and Clindamycin 600mg 6 hourly.
IV antibiotics for 24-48 hours, followed by oral antibiotics for 7-14 days if satisfactory response.

If history of MRSA
Consult with microbiology

Scalp (Tinea Capitis)

In urban areas in UK, tinea capitis is largely caused by Trichophyton tonsurans which is sensitive to terbinafine. In Europe and rural parts of the UK, it is largely caused by Microsporum canis (a zoophilic fungus that normally affects household pets) which is sensitive to griseofulvin.

Treatment in adults:
Positive microscopy or fungal culture is recommended before starting treatment. If test results are negative, but the clinical appearance is very suggestive of fungal infection, repeat sampling and start treatment. To reduce the risk of cross transmission to others, also prescribe a topical antifungal treatment to be used at least twice weekly during first two weeks of treatment with the oral antifungal (e.g. selenium sulphide shampoo, ketoconazole shampoo or terbinafine cream).

Patient living in urban area:
Terbinafine (off-label use) 250mg PO once daily for 4 weeks

Patient living in rural area: Griseofulvin 1g PO once daily for 4-8 weeks (8-12 weeks in refractory cases) and continued for 2 weeks after all signs of infection have resolved.
Review empirical treatment with mycology culture results

Treatment in children:
If oral antifungal treatment is being considered in children, seek Dermatology and Microbiology advice.

Body and groin infections

Adult:

• Localised infection - topical clotrimazole cream 1% 2-3 times daily for 4 weeks
• Widespread infection - Positive microscopy or fungal culture is recommended before starting treatment. If test results are negative, but the clinical appearance is very suggestive of fungal infection, repeat sampling and start treatment.
  Terbinafine 250mg PO once daily for 2-6 weeks
  OR
  Griseofulvin 1g PO once daily for 4-8 weeks and continued for 2 weeks after all signs of infection have resolved
  OR
  Itraconazole 100 mg PO once daily for 30 days or 200 mg twice a day for 7 days.

Child:

• Localised infection – topical clotrimazole cream 1% 2-3 times daily for 4 weeks
• Widespread infection - seek Dermatology and Microbiology advice.

Athlete’s foot

Keep feet cool and dry. Wear cotton socks and non-synthetic footwear.
For mild, non-extensive disease:
Topical clotrimazole 1% cream 2-3 times daily for 4 weeks
Adult with severe or extensive disease, or when topical treatment has failed:
Positive microscopy or fungal culture is recommended before starting treatment. If test results are negative, but the clinical appearance is very suggestive of fungal infection, repeat sampling and start treatment.
Terbinafine 250mg PO once daily for 2-6 weeks
OR
Griseofulvin 1g PO once daily for 4-8 weeks and continued for 2 weeks after all signs of infection have resolved
OR
Itraconazole 100 mg PO once daily for 30 days or 200 mg twice a day for 7 days.
Child with severe or extensive disease, or when topical treatment has failed:
Seek Dermatology and Microbiology advice

Fungal nail infection

Terbinafine 250mg PO once daily for 6 weeks to 3 months for finger nails and 3 to 6 months for toe nails (not for children)
OR
Itraconazole 200 mg twice a day for 1 week, with one subsequent course repeated after 21 days for finger nail infection and two further pulsed courses for toe nail infection.

Other nail infections
Scopulariopsis brevicaulis:
This is one of the 10 most common fungal contaminants. It is omnipresent and rarely pathogenic but can cause nail infections which usually respond to terbinafine or griseofulvin.
Candida sp:
Topical 1% clotrimazole cream 3 times daily
Keep hands dry

Prophylaxis For Implants

CefUROXime 1.5g IV at induction

Prophylaxis For Head and Neck Surgery

Prophylaxis is needed only for major procedures involving oral/pharyngeal mucosa.
Clean surgery, surgery on benign lesions does not require prophylaxis.

The following types of head and neck surgery require prophylaxis:

• Contaminated surgery
• Malignant lesions
• Neck dissection

Co-amoxiclav* 1.2g IV at induction

If non severe penicillin allergy:
CefUROXime* 1.5g IV at induction
AND
Metronidazole 500mg IV at induction

*If history of MRSA: add teicoplanin 400mg IV at induction.

If severe penicillin allergy:
Teicoplanin 400mg IV
AND
Metronidazole 500mg IV
AND
Ciprofloxacin 400mg IV (infuse over 60 minutes, finish within 60 minutes of surgery commencement)

Prophylaxis for Surgery on Infected Sites

Be guided by recent culture results.

Prophylaxis for Hand Surgery

• Elective
  Antibiotics (see below) should be given for:
  Implants/percutaneous K-wires/operations over 2 hours long

• Emergency
  Prophylaxis is not necessary for simple lacerations.
  Prompt, meticulous wound management is crucial in all cases.
  Antibiotics (see below) should be given for:

  • Implants/percutaneous K-wires/operations over 2 hours long
  • Dirty wounds
  • Clean wounds with more than 12 hour delay before surgery
  • Compound fractures

Choice of antibiotics for hand surgery:
Flucloxacillin 1g IV at induction (before tourniquet inflation)
Repeat doses every 6 hours until surgery is completed

If penicillin allergic or if patient has received oral flucloxacillin for more than 48 hours while awaiting surgery or history of MRSA:

Teicoplanin 400mg IV at induction (before tourniquet inflation)
Repeat doses are not required for teicoplanin).

If gross contamination e.g. soil, manure, raw meat/fish etc. ADD the following antibiotics to the above regime:

Metronidazole 500mg IV AND CefUROXime 1.5g IV on induction

Prophylaxis for Compound Lower Limb Injuries

• Lower limb open fracture (Gustilo type I)

  CefUROXime 1.5g IV as soon as possible after injury.

  Then 750mg 8 hourly until 24 hours after wound closure or for a maximum of 72 hours (whichever is sooner).

  If patient has severe penicillin allergy:

  Clindamycin 600mg IV 6 hourly in place of CefUROXime.

• Lower limb open fracture (Gustilo types II and III)

  CefUROXime 1.5g IV as soon as possible after injury until soft tissue closure or for a maximum of 72 hours.

  In addition, at time of first debridement give:

  Gentamicin 2mg/kg (single dose)

  In addition, at time of skeletal stabilisation and definitive soft tissue closure give:

  Gentamicin 2mg/kg

  AND

  Teicoplanin 400mg IV at time of induction.

  If patient has severe penicillin allergy:

  Clindamycin 600mg IV 6 hourly in place of CefUROXime.

Prophylaxis for Breast Surgery

Only required for implants or wounds near/in axillae (mastectomy, wide local excision, axillary clearance)
CefUROXime 1.5g IV at induction
A second dose should be given for prolonged procedures (>4 hours) or if there is substantial blood loss (>1500ml).

If severe penicillin allergy or history of MRSA:
Teicoplanin 400mg IV at induction (repeat doses are not required).

Prophylaxis for leech therapy

To prevent Aeromonas wound infection:
Ciprofloxacin 500mg orally 12 hourly for duration of leech treatment.
Do not re-use leeches.

Prophylaxis for abdominoplasty

CefUROXime 1.5g IV at induction
If history of MRSA add teicoplanin 400mg IV at induction to above.

Likely pathogens and specimens for neonatal sepsis

Most common pathogens are:

• Group B streptococci
• E. coli

Less commonly:

• Klebsiella
• Enterobacter
• Listeria monocytogenes

Specimens:

• Blood cultures
• Urine
• CSF

Empirical treatment of neonatal sepsis

Antibiotics:

See neonatal meningitis if meningitis suspected

Benzylpenicillin
AND
Gentamicin* (in the event gentamicin is not available use CefUROXime)

N.B. Amoxicillin should be substituted for penicillin if listeria is suspected in neonates e.g. if mother is febrile/unwell.

*Refer to SCBU Neonatal Antibiotic Policy for further information including dosing and monitoring of gentamicin.

Discontinue antibiotics after 36 hours if cultures and clinical course do not support diagnosis of infection.

Also see neonatal meningitis.

Neutropenic Sepsis: Risk Stratification

The Multinational Association for Supportive Care in Cancer (MASCC) risk index (see Table 1) accurately identifies patients at low risk for complications and presents the opportunity to use less broad spectrum antibiotics and reduce length of stay. All patients should be assigned to a risk index to determine optimum treatment.

Table 1:  Scoring index for identification of low-risk febrile neutropenic patients at time of presentation with fever. (MASCC INDEX - Multinational association for Supportive Care in Cancer Scoring system for the proposed risk index for identifying low-risk febrile neutropenic patients)

Notes:

Points attributable to burden of illness are not cumulative. The maximum theoretical score is therefore 26. The authors used a threshold of ≥21 points to define ‘low-risk’.

Burden of illness is defined according to a 9 point visual analogue scale in response to ‘how sick is the patient now?’ Ratings of 1 or 2 form not ill, 3 or 4 mildly ill, 5 moderately ill, 6 or 7 severely ill and 9 moribund.

NB. Where any doubt exists, it is preferable to manage patients as high risk in the first instance.

Risk factors for GBS

GBS is found as part of the normal vaginal flora of approximately 10-30% of pregnant women. The vast majority of these women and their babies will not develop symptomatic infections although GBS can cause a symptomatic urinary tract infection in pregnancy. In a small proportion, about 1-2%, intra-partum transmission of GBS to a new-born infant occurs and can result in early onset neonatal sepsis (i.e. within 7 days of birth) with a mortality of approximately 10%.

Risk factors for early onset GBS Infection:

­* Previous baby INFECTED with GBS (not previous carriage but baby not affected)
­* GBS bacteriuria in this pregnancy
­* GBS on HVS in this pregnancy, any gestation
­* Preterm labour < 37 weeks
­* Prolonged rupture of membranes at term (18 or more hours)
­* Intrapartum pyrexia >38ºC

Group B streptococcal colonisation can be identified by culture of GBS isolated from a genital tract swab (which does not require antibiotics to be given antenatally to eradicate colonisation but prophylaxis is required in labour) or urine culture (treat with antibiotics for UTI plus requires prophylaxis in labour). Refer to the Trust Guidance on the Management of Colonisation/Infection with Group B Streptococcus for further information.

Antenatal patient with GBS

• GBS isolated from genital tract swab

  Antibiotic treatment to eradicate colonisation is NOT indicated antenatally but intrapartum antibiotic prophylaxis (IAP) is required as below.

• GBS isolated from urine

  Treat with antibiotics for UTI based on sensitivities plus requires IAP as below.

• Pre-labour rupture of membranes at term

  Women colonised with GBS with pre-labour rupture of the membranes at term should be offered immediate induction of labour and should receive IAP as below.

  Women without GBS colonisation with term prelabour rupture of membranes only require IAP if they have other risk factors for early onset GBS infection as stated above and should be offered induction after 24 hours.

• Preterm pre-labour rupture of membranes (PPROM)

  In the absence of chorioamnionitis, PPROM should be managed conservatively to allow administration of corticosteroids and prolong gestation. Erythromycin 250mg PO 6 hourly for 10 days or until delivery (whichever is earlier) should be given as per the Trust PPROM guidelines. Antibiotic administration specifically for GBS colonisation is not necessary prior to labour.

  There is currently no evidence to recommend earlier induction of labour for women with PPROM and GBS carriage. Decisions should be made on an individual basis and in conjunction with PPROM guidelines.

  Induction of labour should be considered if there is suspicion of chorioamnionitis.

  If these women are known to be colonised with GBS, IAP should be offered.

• Preterm labour

  Women presenting in established preterm labour (<37 weeks) with intact membranes with no other risk factors for GBS infection should not routinely be offered IAP unless they are known to be colonised with GBS.

• GBS carriage in previous pregnancy

  Intrapartum prophylactic antibiotics should be offered to women with a previous baby infected with GBS (even if GBS has not been isolated during the current pregnancy. Women who have had GBS isolated in previous pregnancies but have not had a baby infected with GBS do not require IAP.

Intrapartum management of GBS

• Intrapartum prophylaxis (IAP) for GBS

  Intrapartum prophylaxis is indicated (see above), it should be started as soon as possible after the onset of labour and at least 2 hours prior to delivery.

  First line antibiotic:

  Benzylpenicillin 3g (5MU) IV followed by 1.5g (2.5MU) 4 hourly until delivery.

  If allergic to penicillin:

  Clindamycin 900mg IV 8 hourly until delivery. NB: check sensitivity of the GBS on microbiology reports first. If the isolate of GBS is resistant to erythromycin/clarithromycin, the organism should be assumed to be resistant to clindamycin. If this is the case and the patient has a non-severe pencillin allergy, intravenous CefUROXime 1.5g 8 hourly should be used until delivery. If the patient has a severe penicillin allergy and has a GBS isolate resistant to clindamycin, discuss with Microbiology.

• Elective Caesarean section

  Intrapartum prophylaxis is NOT indicated for GBS positive patients in addition to routine surgical antibiotic prophylaxis, who are to undergo planned Caesarean section with intact membranes and patient not in labour.

• Chorioamnionitis and/or pyrexia in labour >38ºC

  CefUROXime 1.5kg IV 8 hourly
  AND
  *Metronidazole 500mg IV 8 hourly
  This regime covers GBS as well as other relevant pathogens.
  If severe penicillin allergy, discuss with Microbiology.

  * see metronidazole for prescribing information.

Post-Natal management of GBS

Inform Paediatrician. Isolate mother and baby.

• Septic/unwell baby

  Take blood cultures.
  Send urine and consider lumbar puncture, if appropriate.
  Give benzyl penicillin/amoxicillin AND gentamicin to cover GBS and other neonatal pathogens (refer to neonatal guideline neonates).

• Neonates positive for GBS

  Baby clinically well and GBS isolated only from superficial site (e.g. surface swabs)
  Observe for 12 hours.
  90% of cases of GBS sepsis will present clinically before 12 hours of birth.

  Baby clinically unwell and/or GBS isolated from sterile site (e.g. blood culture/CSF)
  Antibiotic treatment required.
  Blood culture positive (and NO clinical evidence of meningitis):
  Benzyl penicillin IV 7 days

  Meningitis:
  CefOTAXime IV minimum 14 days
  OR
  Benzyl penicillin IV minimum 14 days AND gentamicin for 5 days.

  Any babies born to women who should have received intrapartum prophylaxis but did not or those delivered within 2 hours of starting prophylaxis:
  Observe for 12 hours, starting antibiotics if baby becomes unwell after sending appropriate samples for culture.

• Multiple birth, one baby has GBS sepsis

  Treat ALL babies with benzyl penicillin, even if clinically well.

Management of Patients With an Absent or Poorly Functioning Spleen

Principles of Antibiotic Prophylaxis

Duration of prophylaxis

Where single dose regimes are recommended these have been shown to be as effective as multiple dose regimes.

The recommended number of doses must NOT be exceeded as this confers absolutely no advantage whatsoever and is associated with greater toxicity, more adverse effects, more bacterial resistance and increased costs.

Prophylaxis must be given within 1 hour before the procedure or surgical incision.

The exceptions to single dose prophylaxis are stated below.

In addition, if the operation lasts more than 4 hours and/or the total blood loss is >1500ml, further doses may be required.

Risk of C difficile infection

Remember: the higher the number of doses of antibiotics given, the higher the risk of morbidity and mortality from C difficile infection.

Allergy to penicillin/cephalosporins

Patients who are allergic to penicillin may safely be given cephalosporins unless there is a history of serious reaction e.g. anaphylaxis, urticaria, or rash immediately after penicillin administration. If there is a history of anaphylaxis or the patient is allergic to cephalosporins give ciprofloxacin 400mg IV in place of each dose of cefUROXime.

Use of gentamicin for prophylaxis

A single dose of gentamicin does not require monitoring of levels.

Patients colonised with MRSA

Prophylaxis regimes including CefUROXime, metronidazole, co-amoxiclav, penicillin and ciprofloxacin will NOT cover for MRSA.

Regimes containing gentamicin WILL cover most of the MRSA strains isolated from our patient population and need not be altered, unless the MRSA is, unusually, resistant to this antibiotic.

If MRSA cover is required (i.e. risk of post-op MRSA infection in patient known to be colonised with MRSA), and the normal prophylaxis regime does NOT cover MRSA (see above) then teicoplanin 400mg IV (given at induction) should be added.

Patients colonised with glycopeptide resistant enterococci (GRE)

Prophylaxis regimes including CefUROXime, metronidazole, co-amoxiclav, penicillin, ciprofloxacin and vancomycin will NOT cover for GRE.
If GRE cover is required (contact Microbiologist if in doubt), linezolid 600mg IV should be added to the regime. A second dose can be given 12 hours later (orally or IV) if 24 hours prophylactic antibiotics are normally given for this procedure e.g. orthopaedic procedures.

Antibiotic prophylaxis for surgical/endoscopic procedures

Cardiology/vascular procedures


• High leg amputation (for ischaemia)

  Metronidazole 500mg IV at induction then 8 hourly for 5 days
  OR
  Benzylpenicillin 600mg IV at induction then 6 hourly for 5 days

• Central venous catheter insertion

  Antibiotic prophylaxis NOT required

• Insertion of permanent pacemaker

  
  Teicoplanin 400mg IV as a single dose

  Flucloxacillin 1g IV at induction then second dose 6 hours later

  If penicillin allergic or history of MRSA:
  Teicoplanin 400mg IV as a single dose.

ENT Surgery/Procedures

Antibiotic prophylaxis is NOT recommended for ear surgery (clean/clean-contaminated); routine nose, sinus and endoscopic sinus surgery; tonsillectomy or adenoidectomy.

• Complex septorhinoplasty

  First line:
  Co-amoxiclav 1.2g IV at induction

  If non-severe penicillin allergy:
  CefUROXime 1.5g AND metronidazole 400mg at induction

  If severe penicillin allergy discuss with Microbiology.

Eye Surgery

• Phacoemulsification/cataract surgery

  First line:
  CefUROXime (1mg in 0.1ml) into anterior chamber at end of surgery.

  If history of MRSA:
  Vancomycin 1mg in 0.1ml into anterior chamber at end of surgery.

Gastric, Biliary And Colonic Surgery/Procedures

Obstetric/Gynaecological Procedures (Antibiotic Prophylaxis)

• Caesarean section (emergency or elective): antibiotic prophylaxis must be given in the 60 minutes BEFORE skin incision is made.

  First line:

  CefUROXime 1.5g IV
  AND
  Metronidazole 500mg IV

  If history of MRSA ADD teicoplanin 400mg IV to above.

  If severe penicillin allergy:

  Teicoplanin 400mg IV
  AND
  Metronidazole 500mg IV
  AND
  Gentamicin 2mg/kg IV (if gentamicin is not available use tobramycin 2mg/kg)




• Insertion of IUCD

  Screen for sexually transmitted infections and treat if necessary prior to insertion. No other prophylaxis is indicated.




• Hysterectomy

  CefUROXime 1.5g IV at induction
  AND
  Metronidazole 500mg IV


If severe penicillin allergy:
Ciprofloxacin 400mg IV at induction (infuse over 60 minutes, finish within 60 minutes of surgery commencement)
AND
Metronidazole 500mg IV at induction

If history of MRSA ADD teicoplanin 400mg IV to above.



• Cervical cerclage

  Elective cervical cerclage:
  CefUROXime 1.5g IV
  AND
  Metronidazole 500mg IV at induction.
  No repeat doses are required.

  Emergency/rescue cervical cerclage:
  CefUROXime 1.5g IV
  AND
  Metronidazole 500mg IV at induction
  Then further 2 doses of both CefUROXime AND metronidazole are given IV at 8 hourly intervals and then change to CefaCLOR 500mg PO 8 hourly plus metronidazole 400mg PO for a total of 5 days.




• Termination of pregnancy

  Metronidazole 1g PR one hour prior to procedure.
  Screen for sexual transmitted infections and treat if positive prior to surgery.
  If this is not possible ADD to the above:
  Doxycycline 100mg 12 hourly for 7 days post-operatively to cover for chlamydia.

Orthopaedic Surgery/Procedures

Dental treatment for patients with joint prostheses:
Antibiotic prophylaxis NOT required.

• Repair of hip fracture

  CefUROXime 1.5g IV at induction (single dose)*
  Additional doses of CefUROXime 750mg at 8 and 16 hours only for prolonged procedures (>4 hours) or if there is major blood loss (>1500ml).

  *If history of MRSA ADD teicoplanin 400mg IV at induction.

  If severe penicillin allergy or history of C difficile infection:
  Teicoplanin 400mg IV
  AND
  Gentamicin 2mg/kg IV both given at induction (if gentamicin is not available use tobramycin 2mg/kg).




• Lower limb open fracture (Gustilo type I)

  CefUROXime 1.5g IV as soon as possible after injury.
  then 750mg 8 hourly until 24 hours after wound closure or for a maximum of 72 hours.
  
  In addition, at time of first debridement give:
  CefUROXime* 1.5g IV
  
  In addition, at time of skeletal stabilisation and definitive soft tissue closure give:
  CefUROXime* 1.5g IV
  AND
  Teicoplanin 400mg IV at time of induction.
  

  If patient has severe penicillin allergy:
  Clindamycin 600mg IV 6 hourly in place of CefUROXime.

• Lower limb open fracture (Gustilo types II and III)

  CefUROXime 1.5g IV as soon as possible after injury until soft tissue closure or for a maximum of 72 hours.
  In addition, at time of first debridement give:
  Gentamicin 2mg/kg (single dose)
  In addition, at time of skeletal stabilisation and definitive soft tissue closure give:
  Gentamicin 2mg/kg
  AND
  Teicoplanin 400mg IV at time of induction.

  If patient has severe penicillin allergy:
  Clindamycin 600mg IV 6 hourly in place of CefUROXime.

• Open reduction of closed fracture with internal fixation

  CefUROXime 1.5g IV at induction (single dose).
  If history of MRSA ADD teicoplanin 400mg IV induction to above.

  Additional doses of CefUROXime 750mg at 8 and 16 hours only for prolonged procedures (lasting >4 hours) or if there is major blood loss (>1500ml).

• Total joint replacement

  CefUROXime 1.5g IV at induction (single dose)
  Additional doses of CefUROXime 750mg at 8 and 16 hours only for prolonged procedures (>4 hours) or if there is major blood loss (>1500ml).

If severe penicillin allergy or history of C difficile infection:
Teicoplanin 400mg IV
AND
Gentamicin 2mg/kg IV both given at induction (If gentamicin is not available use tobramycin 2mg/kg).


• Total joint replacement in a patient with a history of MRSA

  One to 2 days prior to surgery start:

  • Nasal mupirocin ointment applied to anterior nares 8 hourly.
  • Daily total body washing in Hibiscrub (or Octenisan).
  • 1% chlorhexidine powder applied daily after washing and drying to axillae, perineum and groins.
    If the patient has already been given a supply of the above topical agents from Pre-Op Clinic, the ward medical staff must ensure that these agents are prescribed on the medication chart on admission.

  Replace disposable items e.g. toothbrushes, loofahs, make-up brushes/sponges etc. Hot wash bed linen, towels and clothes.

  At operation give:
  CefUROXime 1.5g IV at induction
  AND
  Teicoplanin 400mg IV at induction

  Additional doses of CefUROXime 750mg at 8 and 16 hours only for prolonged procedures (>4 hours) or if there is major blood loss (>1500ml).
  If severe penicillin allergy or history of C difficile infection:
  Teicoplanin 400mg IV
  AND
  Gentamicin 2mg/kg IV both given at induction (If gentamicin is not available use tobramycin 2mg/kg).

Urological Surgery/Procedures

• Transrectal prostate biopsy

  Ciprofloxacin 500mg PO first dose 60 minutes prior to the procedure then continued 12 hourly for up to 3 days
  AND
  A single dose of metronidazole 1g suppository PR at induction.
  (NB. check previous urine microbiology results for organisms resistant to ciprofloxacin and discuss with Microbiology if required).

• Extracorporeal shock wave lithotripsy

  Prophylaxis is only required for the following groups:
  - All immunocompromised patients;
  - Patients with pre-existing stents, nephrostomies or urethral catheters;
  - Patients with history of recurrent urinary tract infections;
  - Patients suspected or confirmed as having infective based stones (e.g. struvite);
  
  CefUROXime 1.5g IV at induction
  
  If severe penicillin allergy:
  Ciprofloxacin 400mg IV at induction (infuse over 60 minutes, finish within 60 minutes of commencement)
  (NB. check previous urine microbiology results for organisms resistant to cefuroxime/ciprofloxacin and discuss with Microbiology if required).
  
  

• Other urological procedures (e.g. TURT, TURP, open prostatectomy, shock wave lithotripsy)

  CefUROXime 1.5g IV at induction.

If severe penicillin allergy:
Ciprofloxacin 400mg IV at induction (infuse over 60 minutes, finish within 60 minutes of commencement)
(NB. check previous urine microbiology results for organisms resistant to cefuroxime/ciprofloxacin and discuss with Microbiology if required).




• Urinary catheter insertion/change:

  Prophylaxis NOT required UNLESS patient has had a history of sepsis after previous catheter insertion/change or known history of difficult/traumatic catheterisation in the past. single dose of CefUROXime* 1.5g IV just prior to the procedure will be appropriate in most cases. In patients with a history of MRSA ADD single dose of teicoplanin 400mg IV. However, results of recent culture results must be reviewed to ensure that previous isolates are sensitive to this.

  If a patient has a traumatic catheterisation procedure and there is clinical concern about infection, ensure appropriate specimens are sent, including catheter specimen urine (CSU) and commence treatment according to UTI treatment guidance. Ensure previous isolates are sensitive to the empirical regimes. If further advice required, discuss with Microbiology.

  Antibiotic choice should be according to recent sensitivity of urine isolate(s).

Head injury

Antibiotics must NOT be given prophylactically even if there is CSF leak.

Antibiotic Prophylaxis In Patients At Risk Of Endocarditis

NICE guidelines 2016 state that antibiotic prophylaxis against infective endocarditis is no longer indicated routinely for patients at risk of endocarditis who are undergoing procedures at the following sites:

• Dental procedures

• Non-dental procedures involving:

  • Upper and lower gastrointestinal tract
  • Genitourinary tract (this includes urological, gynaecological and obstetric procedures and childbirth)
  • Upper and lower respiratory tract (this includes ear, nose and throat) procedures and bronchoscopy.

Meningitis contacts: notifications

Prophylaxis (antibiotics and vaccination) is organised by the Consultant in Communicable Disease Control (CCDC) as soon as the case has been notified. All cases of meningitis must be notified by telephone to the appropriate CCDC by the treating clinician (see Notification of Infectious Diseases Policy in the Infection Control Manual). Contact details for CCDC/Cheshire and Merseyside Health Protection Unit are as follows:
Monday to Friday 0900-1700: 0344 225 0562 (then press option 1 twice) Out of hours: Call 0151 706 3134 (or 2000) - Royal Liverpool and Broadgreen University Hospital switchboard, ask for On-call Public Health.
There is no indication to take nasopharyngeal swabs from contacts before or after prophylaxis.
Meningococcal meningitis/septicaemia
Who requires prophylaxis?
The patient with meningitis/septicaemia treated with cefotaxime (which may not eradicate carriage) prior to discharge from hospital. Patients treated with ceftriaxone do not required prophylaxis.
Household contacts within 7 days before onset, including frequent visitors.
Boyfriend/girlfriend (mouth kissing contacts).
Staff who have given mouth to mouth resuscitation to the patient before the patient has completed 24 hours of systemic antibiotics.
Prophylaxis for health care workers is NOT recommended unless the patient is within 24 hours of starting antibiotics and staff have given mouth-to-mouth resuscitation or have splashed the patient’s nasopharyngeal secretions into their unprotected face e.g. during suction or intubation. N.B. face masks and eye protection should always be worn when there is a risk of splashing secretions into face and eyes.
School contacts of single cases do not require prophylaxis.

Meningococcal meningitis/septicaemia

Who requires prophylaxis?

The patient with meningitis/septicaemia treated with CefOTAXime (which may not eradicate carriage) prior to discharge from hospital. Patients treated with CefTRIAXone do not required prophylaxis.

Household contacts within 7 days before onset, including frequent visitors.

Boyfriend/girlfriend (mouth kissing contacts).

Staff who have given mouth to mouth resuscitation to the patient before the patient has completed 24 hours of systemic antibiotics.
Prophylaxis for health care workers is NOT recommended unless the patient is within 24 hours of starting antibiotics and staff have given mouth-to-mouth resuscitation or have splashed the patient’s nasopharyngeal secretions into their unprotected face e.g. during suction or intubation. N.B. face masks and eye protection should always be worn when there is a risk of splashing secretions into face and eyes.
School contacts of single cases do not require prophylaxis.

Antibiotic prophylaxis

First line agent recommended for all age groups and in pregnancy is ciprofloxacin (note: this is an unlicensed indication).

Dosage:

• Adults and children over 12 years: 500mg PO stat
• Children aged 5–12 years: 250mg PO stat
• Children aged 1 month to 5 years: 125 mg PO stat

If patient aged <1 month or ciprofloxacin contraindicated, rifampicin is the drug of choice:

Dosage:

• Adults/child >12 years: 600mg PO 12 hourly for 2 days
• Child (1-12 years): 10mg/kg PO 12 hourly for 2 days
• Infants under 1 year: 5mg/kg PO 12 hourly for 2 days

The following side-effects of rifampicin must be explained to the patient.

• This antibiotic colours urine orange.
• Patients on the oral contraceptive pill should be warned to use alternative contraceptive measures for 1 month.
• Patients should avoid alcohol.
• Rifampicin increases the rate of clearance of warfarin and therefore reduces its effect.
• Soft contact lenses may be discoloured permanently (do not wear them while on rifampicin).

Meningococcal vaccine

This vaccine should be given in addition to chemoprophylaxis to contacts of meningitis, according to the strain infecting the index case:
Quadrivalent vaccine (ACYW135)
Vaccine not indicated, but may be given opportunistically to those under 25 years if not already vaccinated
Men C conjugate vaccine (even if previously given)
Quadrivalent vaccine (ACYW135)
W135: Quadrivalent vaccine (ACYW135)
The Men B vaccine is currently not recommended for household contacts of an index case or for contacts in an educational setting.

Although there is no information to suggest that meningococcal vaccine is unsafe during pregnancy, it should only be given when this is unavoidable.

Haemophilus influenzae type B (HiB) meningitis

Prophylaxis is intended for protection of children under 10 years and vulnerable household contacts where there has been close, prolonged contact in a household type setting within 7 days of the index case developing invasive HiB disease.

Who requires prophylaxis?

1. Household contacts: If vulnerable person in household e.g. any child under 10 years of age or immunosuppressed or asplenic person of any age, give to all household members (irrespective of age).
2. All room contacts, both staff and children, where 2 or more cases of HiB disease have occurred in a play group, nursery, day care, crèche or primary school within 120 days.
3. Index case of HiB disease prior to discharge from hospital, to avoid second episodes and further transmission. Index case should also have HiB antibody levels measured around 4 weeks after infection.

Antibiotic prophylaxis

First line
Adults (including pregnant and breast feeding women) and children older than 3 months:
Rifampicin 20 mg/kg (maximum 600 mg) orally once a day for 4 days

Children younger than 3 months:
Rifampicin 10 mg/kg orally once a day for 4 days

Patients should be made aware of interactions with other medications such as anticoagulants, anticonvulsants and particularly oral contraceptives and possible staining of secretions, including urine.

If patient unable to tolerate rifampicin or rifampicin is contraindicated:
Use a 5 day course of ciprofloxacin:
Adults and children over 12 years: 500mg orally 12 hourly
Children aged 5–12 years: 250mg orally 12 hourly
Children aged 2 to 4 years: 125 mg orally 12 hourly
OR
Azithromycin 10 mg/kg (maximum dose 500 mg) orally once daily 3 days

HiB vaccine

All unimmunised and partially immunised index cases as well as contacts under 10 years of age should complete their primary course of HiB immunisation. In addition:

Index cases aged 5-10 months who have been appropriately vaccinated at 2, 3 and 4 months should receive one dose of a HiB- containing vaccine prior to discharge from hospital to provide adequate protection until they receive their routine 12-month booster dose.

Fully vaccinated index cases younger than 10 years should have anti-HiB antibodies measured four weeks after infection and an additional dose of a HiB-containing vaccine given if antibody levels are below 1 mg/ml and antibody levels rechecked following this additional dose. These children should also have total immunoglobulin levels and sub-classes measured and assessed for evidence of an immune deficiency. If it is not possible to measure anti-HiB antibody levels or if there are concerns that the child might be lost to follow-up, then index cases older than twelve months and younger than ten years (irrespective of their HiB vaccination status) should receive an extra dose of a HiB-containing vaccine prior to hospital discharge.

Index cases of any age with asplenia or splenic dysfunction who have previously completed vaccination against HiB with the final dose more than one year previously should receive an extra dose of the vaccine after recovering from their infection.

Pneumococcal meningitis

No prophylaxis is indicated for contacts.

Post Splenectomy Prophylaxis Antibiotics

Splenectomised patients and those with asplenia, splenic dysfunction or complement disorders (including those receiving complement inhibitor therapy) are at increased risk of infection.In splenectomised patients, this is highest during the first 2 years after splenectomy. To reduce the risks of infection the following precautions should be taken. A patient information leaflet is available.

First line:
Phenoxymethylpenicillin (Penicillin V) 500mg orally once daily
If penicillin allergic:
Erythromycin 500mg orally 12 hourly

Life long prophylactic antibiotics should be offered to patients considered at continued high risk of pneumococcal infection. Post splenectomy patients must start prophylactic antibiotics immediately.

Factors associated with high risk of invasive pneumococcal disease in hyposplenism include: aged less than 16 years or greater than 50 years, inadequate serological response to pneumococcal vaccination, a history of previous invasive pneumococcal disease, and splenectomy for underlying haematological malignancy particularly in the context of on-going immunosuppression. Life long compliance with prophylactic antibiotics is problematic. If the patient does not continue to be at high risk as per the criteria above, the patient must have antibiotic prophylaxis until at least 2 years after splenectomy. If compliance is a problem, patient must be advised to have an emergency supply of amoxicillin or erythromycin to take in the event of fever as well plus be advised to seek medical attention urgently.

Post Splenectomy Prophylaxis

The schedule for immunising patients with asplenia, splenic dysfunction or complement disorders (including those receiving complement inhibitor therapy) depending on the age at which their at-risk condition is diagnosed is given below.

Note: patient receiving complement inhibitory therapy (Eculizumab, trade name Soliris®, which acts by down regulating the terminal complement components) are not at increased risk of pneumococcal disease and do not require 23 valent pneumococcal polysaccharide vaccine (PPV23) but should receive the other vaccines as stated below.

The following vaccines should be given at least 2 weeks before elective splenectomy. If this is not possible (or emergency splenectomy) they should be given 2 weeks after surgery or as soon as patient is clinically well prior to discharge. NB. Refer to Department of Health Immunisation Against Infectious Disease: The Green Book for latest updates on vaccine schedules

First diagnosed under six months
 Give the MenB vaccine at 2, 3 and 4 months along with the routine infant immunisations (if the routine schedule has already been initiated, then give 3 doses of MenB with an interval at least one month apart)
 If MenC has not yet been given as part of routine schedule, give one dose of MenACWY conjugate vaccine followed by a second dose at least one month apart. If MenC has already been given as part of routine schedule, then give one additional dose of MenACWY at least one month later
 Give the routine 12-month boosters: Hib/MenC, 13 valent pneumococcal conjugate vaccine (PCV13) and MMR
 Give a MenB booster, an extra dose of 13 valent pneumococcal conjugate vaccine (PCV13) and one dose of MenACWY conjugate vaccine two months after the 12-month boosters
 After the second birthday, an additional dose of Hib/MenC should be given, along with the 23 valent pneumococcal polysaccharide vaccine (PPV23).
First diagnosed at 6-11 months
 Give 2 doses of MenB vaccine at least two months apart (the second dose may be given with the routine 12-month boosters)
 If MenC has not yet been given as part of routine schedule, give one dose of MenACWY conjugate vaccine followed by a second dose at least one month apart. If MenC has already been given as part of routine schedule, then give one additional dose of MenACWY at least one month after any MenC dose.
 Give the routine 12-month boosters: Hib/MenC, 13 valent pneumococcal conjugate vaccine (PCV13) and MMR
 Give a dose of MenACWY conjugate vaccine and an extra dose of PCV13 two months after the Hib/MenC booster
 After the second birthday, an additional dose of Hib/MenC and the MenB booster should be given, along with the 23 valent pneumococcal polysaccharide vaccine (PPV23).

First diagnosed at 12-23 months
 If not yet administered, give the routine 12-month boosters: Hib/ MenC, 13 valent pneumococcal conjugate vaccine (PCV13) and MMR
 Give a dose of MenACWY conjugate vaccine and an extra dose of 13 valent pneumococcal conjugate vaccine (PCV13) two months after the Hib/MenC and PCV13 boosters
 Give 2 doses of MenB vaccine at least two months apart (either of these doses can be given at the same time as the other vaccine visits)
 After the second birthday, an additional dose of Hib/MenC should be given, along with the 23 valent pneumococcal polysaccharide vaccine (PPV23)
 This age group should also receive an additional dose of MenB vaccine with an interval of 12 to 23 months after the primary course.

First diagnosed from two years onwards
 Ensure that the child has been immunised according to national schedule, including the 12-month boosters
 Give an additional dose of Hib/MenC and the first dose of MenB vaccine, along with the 23 valent pneumococcal polysaccharide vaccine (PPV23)
 Give a dose of MenACWY conjugate vaccine and the second dose of MenB two months after the Hib/MenC booster. In adolescents (from 11 years of age) and adults, this interval can be reduced to one month.

In addition to above:

• Pneumococcal polysaccharide vaccine booster every 5 years. No need to check antibody levels before revaccination.
• Influenza vaccine – annually to prevent risk of secondary bacterial infection.
• Carry card/Medic alert bracelet/locket.
• Warn patient to contact doctor if he/she develops high temperature.
• Contact Consultant Microbiologist for advice prior to travel abroad.
• If bitten by an animal e.g. dog a 5 day course of co-amoxiclav (or clarithromycin (use erythromycin in pregnancy) if penicillin allergy) should be prescribed because of the increased risk of infection due to Capnocytophaga canimorsis (DF-2 bacillus)

Chickenpox (Varicella)

Neonate or immunocompromised patient or if pneumonitis/encephalitis is present:

Adult:

• Aciclovir IV 10mg/kg every 8 hours IV for 5-10 days

Use ideal body weight (IBW) for obese patients to avoid excessive dosing.

• IBW (kg) in males = 50.0 + (2.3 x every inch over 5ft)
• IBW (kg) in females = 45.5 + (2.3 x every inch over 5ft)

Child:
Please see BNF for Children for Paediatric doses.

Immunocompetent adult or adolescent (older than 14 years):

Aciclovir 800mg oral five times daily for 7 days.
OR
Valaciclovir PO 1g 8 hourly for 7 days (use if compliance may be a problem)
The oral form is only effective if started within 24 hours of a rash onset

Immunocompetent children aged 1 month to 14 years:
Aciclovir is NOT indicated

Herpes simplex encephalitis

Give IV aciclovir for 21 days.
Adult: 10mg/kg every 8 hours

Use ideal body weight (IBW) for obese patients to avoid excessive dosing (see chickenpox for IBW calculation)

Child: Please see BNF for Children for Paediatric doses.

HIV

Patient must be referred to an Infectious Diseases Physician or the Sexual Health Clinic.

Influenza treatment

Oseltamivir and zanamivir are the two currently available agents for the treatment of influenza. Specific criteria on those eligible for treatment and antiviral agents recommended are updated each influenza season. Refer to the Department fo Health website for the latest guidance https://www.gov.uk/government/collections/seasonal-influenza-guidance-data-and-analysis

Shingles (Herpes Zoster)

For immunocompetent children, antiviral treatment is not usually recommended.

Non-immunocompromised patients:
Start oral treatment within 72 hours of rash onset for the patient groups below. If not possible to initiate treatment within 72 hours, consider starting treatment up to one week after rash onset if severe shingles, continued vesicle formation, older age or patient has severe pain.

 Patients aged 50 years and above
 Adults aged less than 50 years with any of the following criteria:
Ophthalmic involvement (seek immediate Ophthalmology advice)
Ramsay Hunt syndrome
Non-truncal involvement (such as shingles affecting the neck, limbs, or perineum).
Moderate or severe pain
Moderate or severe rash
Eczema herpeticum

Aciclovir PO 800mg 5 times daily for 7 days
OR
Valaciclovir PO 1g 8 hourly for 7 days (use if compliance may be a problem)

Immunocompromised patients*:
Treatment may be started at any time before full crusting of lesions in immunocompromised adults.

Adult: Aciclovir IV 10mg/kg every 8 hours IV for 5-10 days
Use ideal body weight (IBW) for obese patients to avoid excessive dosing.
IBW (kg) in males = 50.0 + (2.3 x every inch over 5ft)
IBW (kg) in females = 45.5 + (2.3 x every inch over 5ft)