Intra-abdominal

Mild Community Acquired

e.g. cholecystitis/

appendicitis/

diverticulitis

Co-amoxiclav IV

1.2g every 8 hours

CefUROXime IV

1.5g every 8 hours

+

Metronidazole IV 500mg every 8 hours

Ciprofloxacin IV 400mg every 12 hours

+

Metronidazole IV 500mg every 8 hours

Duration

4 to 7 days assuming adequate source control

Intra-abdominal

Moderate to Severe Community &

All Hospital Acquired

including

cholangitis/ intra-abdominal abscess/diverticulitis

Piperacillin/

tazobactam IV

4.5g every 8 hours

Add Gentamicin IV IF haemo-dynamically unstable. Give one dose per LAPP App calculator. See footnote* re further doses and monitoring.

CefTRIAXone IV

2g every 24 hours

+

Metronidazole IV 500mg every 8 hours

Add Gentamicin IV IF haemodynamically unstable. Give one dose per LAPP App calculator. See footnote* re further doses and monitoring.

Ciprofloxacin IV 400mg every 12 hours

+

Gentamicin IV one dose per LAPP App calculator. See footnote* re further doses and monitoring.

+

Vancomycin IV infusion, dose per LAPP App calculator. See footnote* re monitoring.

+

Metronidazole IV 500mg every 8 hours

Discuss with Microbio-logy.

Duration

7 to 10 days assuming adequate source control.

Necrotising Pancreatitis

Patients with acute pancreatitis admitted to ICU or necrotising pancreatitis confirmed by imaging

CefTRIAXone IV 2g every 24 hours

+

Metronidazole IV 500mg every 8 hours

Ciprofloxacin IV 400mg every 12 hours

+

Metronidazole IV

500mg every 8 hours

Review need for antibiotics every 72 hours. See note below.

Discuss with Microbiology if deterioration or requiring antibiotics for more than 5 days

Spontaneous Bacterial Peritonitis

CefTRIAXone IV 2g every 24 hours

Ciprofloxacin IV 400mg every 12 hours

5 days

Peritoneal Dialysis Peritonitis

Please see Peritoneal Dialysis in the Renal Dosing Section.

Cirrhosis with Acute Variceal Haemorrhage, Prophylaxis

CefTRIAXone IV

2g every 24 hours

CefTRIAXone IV 2g every 24 hours

Ciprofloxacin PO

500mg every 12 hours

7 Days

Prophylaxis for patients with an absent or dysfunctional spleen

Phenoxymethyl-penicillin PO

666mg

(Calvepen ^® )

every 12 hours
OR

Amoxicillin PO

500mg every 24 hours

Erythromycin PO

250 to 500mg every 24 hours

Oral absorption of phenoxymethylpenicillin is limited and affected by a number of variables. For emergency self initiated therapy of a suspected systemic infection treatment with amoxicillin is preferable.

See Appendix 3 for guidelines for management of patients with absent or dysfunctional spleen (adults only) including recommended vaccines & antibiotics.

Emergency treatment doses

Amoxicillin PO

500mg to 1g every 8 hours

Erythromycin PO

500mg to 1g every 6 hours

* Review need for ongoing Gentamicin and Vancomycin on a daily basis. Continue with once daily Gentamicin dosing ONLY if C onsultant/Registrar recommended. For advice on monitoring see Aminoglycoside & Vancomycin Dosing & Monitoring section.

Empiric Antibiotics for Bone and Joint Infections

Infection

1 ^st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

The regimens below may NOT cover Multi-drug Resistant Organisms (MRDO) in all cases. See note on MDRO

Septic Arthritis

Flucloxacillin IV

2g every 6 hours

OR

CefTRIAXone IV 2g every 24 hours ( IF high risk of Gram-negative organisms (e.g. elderly; nursing home resident; recurrent UTIs) or risk of gonococcus)

Vancomycin IV infusion, dose per LAPP App calculator. See footnote* re monitoring.

OR

CefTRIAXone IV 2g every 24 hours ( IF high risk of Gram-negative organisms (e.g. elderly; nursing home resident; recurrent UTIs) or risk of gonococcus)

Discuss with Microbiology

Adequate drainage of joint fluid essential. Blood cultures also required. Gram stain may alter antibiotic therapy.

Minimum

2 weeks parenteral therapy.

Discuss with Microbiology.

Osteomyelitis

Discuss with Microbiology; treat according to culture results.

Prosthetic Joint Infection

Discuss with Microbiology; treat according to culture results.

*For advice on monitoring see Vancomycin Dosing & Monitoring section.

Empiric Antibiotics for Bacterial Endocarditis

Infection

1 ^st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

Bacterial Endocarditis

Community Acquired Native Valve Endocarditis  or late Prosthetic Valve Endocarditis ( ≥ 12 months post-surgery)

Amoxicillin IV 2g 4 hourly

+

Flucloxacillin IV 2g 4 hourly

+

Gentamicin IV 3mg/kg/day (maximum 240mg/day). See footnote* re monitoring.

CeFAZOLin IV 2g TDS

+

Gentamicin IV 3mg/kg/day  (maximum 240mg/day). See footnote* re monitoring.

Vancomycin IV infusion, dose per LAPP App calculator .  See footnote** re monitoring.

+

Gentamicin IV 3mg/kg/day (maximum 240mg/day). See footnote* re monitoring.

Once culture and sensitivity results are available direct antibiotic therapy accordingly in discussion with Microbiology .

Rifampicin PO 450mg every 12 hours can be added for prosthetic valve endocarditis, it may be preferrable to delay this for 3-5 days after commencement of other antibiotic therapy.

Duration as advised by Microbiology.

Early Prosthetic Valve Endocarditis (<12 months post-surgery), nosocomial or non-nosocomial healthcare-associated Infective Endocarditis

Vancomycin IV infusion, dose per LAPP App calculator .  See footnote** re monitoring.

+

Gentamicin IV 3mg/kg/day (maximum 240mg/day)
See footnote* re monitoring.

+

Rifampicin PO 450mg 12hrly ¹ [Can be given IV if PO route not available]

( ¹ Consider delaying initiation of Rifampicin for 3 to 5 days after commencement of Vancomycin and Gentamicin, once the bacteraemia has been cleared).

* For advice on monitoring of Gentamicin for the treatment of Infective Endocarditis see the Aminoglycoside Dosing & Monitoring section (table 4 - Once daily low dose Gentamicin in Infective Endocarditis)

** Review need for ongoing Vancomycin on a daily basis. For advice on monitoring see Vancomycin Dosing & Monitoring section.

Prophylaxis of Infective Endocarditis

Box 1: Cardiac conditions requiring endocarditis prophylaxis - for high risk procedures

1. Prosthetic valve or prosthetic material used for cardiac valve repair.
2. Previous infective endocarditis.
3. Cardiac transplantation recipients who develop cardiac valvulopathy.
4. Congenital heart disease (CHD):

• Unrepaired cyanotic CHD, including palliative shunts and conduits
• Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or catheter intervention, during the first 6 months after the procedure
• Repaired CHD with residual defects at or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialisation).

Box 2: Recommendations by procedure - for patients with identified cardiac conditions

A. Dental Procedures

Antibiotic prophylaxis should only be considered for dental procedures requiring manipulation of gingival or periapical region of teeth or perforation of oral mucosa.

Antibiotic prophylaxis is not recommended for local anaesthetic injections in non-infected tissue, removal of sutures, dental X-rays, placement or adjustment of removable prosthodontic or orthodontic appliances or braces, or following shedding of deciduous teeth, or trauma to lips or oral mucosa.

B. Respiratory Tract Procedures

Antibiotic prophylaxis should only be considered for invasive procedures involving incision or biopsy of the respiratory mucosa e.g. tonsillectomy or adenoidectomy, or to treat infection e.g. drainage of abscess or empyema.

Antibiotic prophylaxis is not recommended for respiratory tract procedures, including bronchoscopy or laryngoscopy, transnasal or endotracheal intubation.

C. Gastrointestinal or genitourinary tract procedures

Antibiotic prophylaxis is not recommended for any procedure.

Box 3: Recommended prophylaxis for procedures at risk

Give as a single dose 30 to 60 minutes before procedure

Procedure

1st line antibiotic

Alternative if penicillin allergic

Dental

Adults: Amoxicillin PO/IV 2g

Adults: Doxycycline 100mg PO

Respiratory

As for dental

Empiric Antibiotics for Suspected Bacterial Meningitis

Infection

1 ^st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

Suspected Bacterial Meningitis

CefTRIAXone IV 2g every 12 hours

+

Consider adding Amoxicillin IV 2g every 4 hours if at risk for L. monocytogenes

(See point 5 above)

See footnote ** re Dexamethasone.

CefTRIAXone IV 2g every 12 hours

+

Consider adding

Co-trimoxazole IV 60mg/kg every 12 hours (round dose to nearest multiple of 480mg) if at risk for L. monocytogenes

(See point 5 above)

See footnote ** re Dexamethasone.

Chloramphenicol IV 25mg/kg

• Give this first dose, THEN IMMEDIATELY discuss with Microbiology regarding further therapy.

Consider adding

Co-trimoxazole IV 60mg/kg every 12 hours (round dose to nearest multiple of 480mg) if at risk for L. monocytogenes

Discuss need for nasopharyngeal eradication for the patient with Microbiology

(See point 5 above)

See footnote ** re Dexamethasone.

Minimum duration of treatment:

Meningococcal meningitis:

5 to 7 days

Haemophilus

meningitis:

7 to 10 days

Pneumococcal meningitis:

10 to 14 days

Listeria meningitis:

21 days

If patient has, within the last 6 months, been to a country where penicillin resistant pneumococci are prevalent , IV Vancomycin should be added , dose per LAPP App calculator. See footnote* re review and monitoring. Recommend discussion with Microbiology.

Note: Up to date European and worldwide data on resistance can be found via the European Centre for Disease Prevention and Control website . Or please consider a discussion with Microbiology if recent travel.

* Review need for ongoing vancomycin on a daily basis. For advice on monitoring see Vancomycin Dosing & Monitoring section.

**Dexamethasone

• Consider adjunctive treatment with dexamethasone IV 0.15mg/kg every 6 hours for four days (particularly if Pneumococcal or Haemophilus influenzae meningitis suspected in adults), preferably starting before or with first dose of antibiotic , but no later than 12 hours after starting antibiotic. Discontinue dexamethasone if a diagnosis other than bacterial meningitis is subsequently made. Discontinue dexamethasone if bacterial meningitis with an organism other than Streptococcus pneumoniae or H. Influenzae is confirmed.
• For haemodynamically unstable patients with sepsis, and unresponsive to fluid and inotrope resuscitation, give low dose hydrocortisone - 50mg IV 6 hourly

Antivirals for Suspected Herpes Simplex Encephalitis

Infection

1 ^st Line

Comment

Suspected

Herpes Simplex

Encephalitis

Aciclovir IV 10mg/kg every 8 hours

If obese, consider using ideal or adjusted body weight to calculate dose – See Medinfo GUH IV guideline for more details.

Confirmed HSV encephalitis requires a total of 14 to 21 days IV therapy.

Empiric Treatment of Acute Bacterial Conjunctivitis

Infection

Treatment

Comment

Acute Bacterial Conjunctivitis

Chloramphenicol 0.5% eye drops — apply 2 drops 3 hourly during waking hours or more frequently if required.

Or

Chloramphenicol 1% eye ointment (Unlicensed) — apply every 6 hours or apply at night only if used in conjunction with chloramphenicol drops.

Or

Fusidic acid 1% eye drops — can be used second line. Apply 1 drop every 12 hours.

Duration 48 hours after resolution of symptoms

Note risk of local hypersensitivity reaction to antimicrobial.

Empiric Treatment of Fungal Infections

Infection

Treatment

Comment

Oropharyngeal candidiasis

Mild

Nystatin suspension PO 5ml every 6 hours after food. Swish and swallow, leaving in contact with mouth for at least 30 seconds.

Duration usually for 7 days, continued for 48 hours after lesions have resolved.

Moderate to severe

Fluconazole PO 200mg loading dose on day 1 followed by 100mg every 24 hours

Duration 7 to 14 days

Fluconazole refractory

Contact Microbiology

Denture related

As above plus disinfection of dentures.

Oesophageal candidiasis

Fluconazole PO 400mg loading dose on day 1 followed by 200mg every 24 hours

Duration 14 to 21 days

Acute Vulvovaginal candidiasis (VVC)

Recommended regimen:

Clotrimazole 2% cream topically 2-3 times daily for 7-14 days
+
Clotrimazole pessary 500mg intravaginally as a single dose

Add Fluconazole PO 150mg as a single dose if not responding.

Severe Acute VVC:

Fluconazole PO 150mg every 72 hours for 3 doses

Acute VVC in Pregnancy and breastfeeding:

Clotrimazole pessary 500 mg intravaginally at night for up to 7 consecutive nights

Fluconazole refractory/severe/recurrent PVC

Contact Microbiology

Candida at urinary, respiratory & other sites

Treatment not routinely indicated. Contact Microbiology

Disseminated candidiasis

Contact Microbiology. Choice of antifungal depends on sensitivities.

Fungal skin infection

Contact Microbiology or Dermatology for advice.

Fungal nail infection

Contact Microbiology or Dermatology for advice.

For all other suspected fungal infections e.g. aspergillosis contact Microbiology

Contact Microbiology for advice.

Antibiotics for Clostridium difficile Infection

Infection

1 ^st Line Antibiotics

Comment

Non severe CDI

Mildly symptomatic patients (positive test result but less than 3 episodes of diarrhoea in 24 hours):

Discontinue antibiotic therapy with the inciting antibiotic if possible and closely monitor the patient for 48 hours. C. difficile treatment should be initiated if any signs of clinical deterioration are observed.

General measures advised in the treatment of all patients with CDI:

1. Patients with potentially infectious diarrhoea (i.e. no clear alternative cause) should be isolated with Standard and Contact Precautions as soon as possible.
2. Stop unnecessary antimicrobial therapy (if possible). If an antibiotic is still essential, consider changing to one with a lower risk of causing CDI. It is preferable to use agents with as narrow spectrum as possible.  Almost all antibiotics increase the risk of CDI but clindamycin, cephalosporins, ciprofloxacin (and other fluoroquinolones) and co-amoxiclav are well-documented as having the greatest risk. Please consider discussing with microbiologist.
3. Ensure adequate nutrition and replacement of fluid and electrolytes.
4. Avoid anti-motility medications e.g. loperamide, laxatives.
5. Review proton pump inhibitor use.
6. Ensure a stool chart is commenced and close monitoring of bowel motions.

Non severe CDI

Positive test results and 3 or more episodes of diarrhoea in 24 hours :

1st line

• Vancomycin^ PO/NG 125mg every 6 hours for 10 days

Alternative 1 ^st line treatment option but must have prior approval by Consultant Microbiologist .

• Fidaxomicin* PO 200mg every 12 hours for 10 days

It can be considered as a treatment option for patients at high risk of recurrence supported by age over 65 years plus the presence of one or more of these additional risk factors:

- healthcare associated CDI

- prior hospitalisation in the last 3 months

- use of concomitant antibiotics

- PPI started during/after CDI diagnosis

- prior CDI episode

- immunocompromised or if severe underlying disease and/or renal insufficiency.

Severe CDI

Defined by one of the following:

• fever, rigors i.e. core body temperature greater than 38.5°C,
• marked leucocytosis, i.e. leucocyte count greater than 15 x 10 ⁹ /L,
• rise in serum creatinine, i.e. more than 50% above the baseline.

Additional supporting factors, when available are distension of the large intestine, peri-colonic fat stranding or colonic wall thickening at imaging.

Please discuss with Consultant Microbiologist.

Early surgical opinion for all patients with severe CDI. Patients with severe CDI should be managed by a multidisciplinary team to include a clinical microbiologist, gastroenterologist, surgeon and pharmacist as needed.

1st line

• Vancomycin^ PO/NG 125mg every 6 hours for 10 days

Alternative 1 ^st line treatment option but must have prior approval by Consultant Microbiologist:

• Fidaxomicin* PO 200mg every 12 hours for 10 days

It can be considered as a treatment option for patients at high risk of recurrence supported by age over 65 years plus the presence of one or more of these additional risk factors:

- healthcare associated CDI

- prior hospitalisation in the last 3 months

- use of concomitant antibiotics

- PPI started during/after CDI diagnosis

- prior CDI episode

- immunocompromised or if severe underlying disease and/or renal insufficiency.

Severe complicated/fulminant CDI

Defined by the presence of one of the following attributed to CDI:

• hypotension, septic shock, elevated serum lactate, ileus, toxic megacolon, bowel perforation or any fulminant course of disease (i.e. rapid deterioration of the patient).

Please discuss with Consultant Microbiologist.

• Early surgical opinion for all patients with severe CDI
• Patients with severe CDI should be managed by a multidisciplinary team to include a clinical microbiologist, gastroenterologist, surgeon and pharmacist as needed.

1 ^st line

Vancomycin^ PO/NG 500mg every 6 hours

Plus

Metronidazole IV 500mg every 8 hours

2 ^nd line
Other therapeutic options may be considered on a case-by-case basis and after multidisciplinary discussions. Please discuss with Consultant Microbiologist.

First recurrence of CDI

Recurrence is present when CDI recurs within 8 weeks after a previous episode, provided the symptoms from the previous episode resolved after completion of initial treatment.

Choice depends on first line treatment.

Pulsed Vancomycin^ PO may be an option

Or

Fidaxomicin* PO 200mg every 12 hours

These options must be discussed with a Consultant microbiologist.

Second or more recurrence of CDI

Discuss with a Consultant Microbiologist.

*Prescribing notes: Fidaxomicin requires a High Tech prescription on discharge and is not routinely stocked in community pharmacies. Please contact ward and community pharmacy at least 24 hours prior to discharge to arrange supply if required.

^Vancomycin: If a person has swallowing difficulties or a nasogastric or PEG tube for enteral administration, vials of vancomycin powder for injection may be used to make an extemporaneous oral solution. See package insert or Appendix 2 . Alternatively contact pharmacy for further advice. Vancomycin capsules are not routinely stocked in community pharmacies. Please contact ward and community pharmacy at least 24 hours prior to discharge to arrange supply if required.

Antibiotic regimens for Helicobacter pylori Eradication

1 ^st Line Helicobacter pylori eradication

1 ^st Line Triple Therapy

Penicillin allergy

Comment

Alternative 1 ^st Line Quadruple Therapy if:

• Allergy to first line antibiotic(s)
• Prior exposure to clarithromycin (in the past 12 months)

Amoxicillin PO 1g every 12 hours

+

Clarithromycin PO 500mg every 12 hours

+

Esomeprazole PO 40mg every 12 hours

Metronidazole PO 400mg every 8 hours

+

Doxycycline PO 100mg every 12 hours

+

Bismuth ¹ ( brands include Gastrodenol ^®​ or DeNoltab ^® ) PO 120mg every 6 hours (unlicensed)

+

Esomeprazole PO 40mg every 12 hours

Duration:

14 days

2 ^nd line Helicobacter pylori eradication
- if still infected after 1 ^st line therapy

Discuss with gastroenterology

2 ^nd Line Triple Therapy

Second-line therapy depends on the first-line therapy and should not be the same treatment. Please discuss options with gastroenterology.

Potential options include:

2 ^nd line Therapy

Alternative 2 ^nd line therapy

• IF patient has received Clarithromycin in the past 12 months

NO Penicillin allergy

Penicillin allergy

Clarithromycin PO 500mg every 12 hours

+

Metronidazole PO 400mg every 12 hours

+

Esomeprazole PO 40mg every 12 hours

Levofloxacin PO 250mg every 12 hours

+

Amoxicillin PO 1g every 12hours

+

Esomeprazole PO 40mg every 12 hours

Metronidazole PO 400mg every 8 hours

+

Doxycycline PO 100mg every 12 hours

+

Bismuth ¹ ( brands include Gastrodenol ^® or DeNoltab ^® ) PO 120mg every 6 hours (unlicensed)

+

Esomeprazole PO 40mg every 12 hours

¹ Bismuth is available in Ireland as an unlicensed medicine. As it is unlicensed it will not be routinely stocked in community pharmacies. Please contact the community pharmacy at least 24 hours prior to discharge to arrange supply. Whilst inpatient brand of Bismuth stocked is Gastrodenal ®.

Empiric Antibiotics for Genital System Infections

Infection

1 ^st Line Antibiotics

Penicillin allergy: immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

Pelvic Inflammatory Disease -

Outpatient Treatment

Send a full STI screen including Chlamydia & Gonorrhoea

CefTRIAXone IM 1G single dose

+

Doxycycline PO 100mg every 12 hours

+

Metronidazole PO 400mg every 12 hours

Levofloxacin PO 500mg OD ( see Fluroquinolone warning )

+

Metronidazole PO 400mg every 12 hours

Duration

14 days

Pelvic Inflammatory Disease -

Inpatient Treatment

Send a full STI screen including Chlamydia & Gonorrhoea

CefTRIAXone IV 2g every 24 hours

+

Doxycycline PO 100mg every 12 hours

+

Metronidazole PO 400mg every 12 hours

Clindamycin IV 900mg every 8 hours

+

Gentamicin IV every 24 hours, dose per LAPP App calculator . See footnote* re review and monitoring.

Followed by an oral switch to:

Doxycycline PO 100mg every 12 hours

+

Metronidazole PO 400mg every 12 hours

Note: The initial IV regimen does not cover Chlamydia or Gonorrhoea. It is important to send a full STI screen.

Continue IV treatment for 24 hours after clinical improvement.

Total duration of antibiotic therapy 14 days

Acute Prostatitis/

Epididymo-orchitis

If Sexually active

CefTRIAXone IM 1g single dose (or 2g IV if inpatient)

+

Doxycycline PO 100mg every 12 hours

Send urethral swabs for Chlamydia & Gonorrhoea if sexually active in past six months & refer to Sexually Transmitted Infection (STI) Clinic.

Duration of 14 days for oral doxycycline.

Consider mumps as aetiology.

Acute Prostatitis/

Epididymo-orchitis

If NOT sexually active

Ciprofloxacin PO 500mg every 12 hours (See Fluoroquinolone warning )

IF patient appears septic treat as suspected bloodstream infection:

Add Gentamicin IV one dose per LAPP App calculator. See footnote* re further doses and monitoring.

Duration

14 to 28 days

* Review need for ongoing Gentamicin on a daily basis. Continue with once daily Gentamicin dosing ONLY if Consultant/Registrar recommended. For advice on monitoring see Aminoglycoside Dosing & Monitoring section.

Empiric Antibiotics for Intravascular Line Infections

Infection

1 ^st Line

Comment

Central and Peripheral IV Catheter Exit Site Infection

See notes above

Vancomycin IV infusion, dose per LAPP App calculator. See footnote* re monitoring.

Review at 48 hours, change to pathogen directed therapy based on culture & sensitivity

Duration 7 to 10 days

Peripheral Line-related Infection and/or

Bacteraemia

Vancomycin IV infusion, dose per LAPP App calculator. See footnote* re monitoring.

Review at 48 hours, change to pathogen directed therapy based on culture & sensitivity

Duration minimum 14 days, for exceptions see algorithm for NON-tunnelled CVC bacteraemia .

Central Line-related Infection and/or

Bacteraemia

Remove CVC and send tip to microbiology

Vancomycin IV infusion, dose per LAPP App calculator. See footnote* re monitoring.

+

Gentamicin IV one dose per LAPP App calculator and review . See footnote* re further doses and monitoring.

If blood cultures are positive treat as per Microbiology advice.

Duration varies by type of line, organism and complications.  A prolonged course may be required.

See algorithms for NON-tunnelled CVC bacteraemia and tunnelled CVC/port bacteraemia .

When denoting duration of antimicrobial therapy day 1 is the first day on which negative blood cultures are obtained.

* Review need for ongoing Gentamicin & Vancomycin on a daily basis. Continue with once daily Gentamicin dosing ONLY if Consultant/Registrar recommended. For advice on monitoring see Aminoglycoside & Vancomycin Dosing & Monitoring section.

Indication

Oral Antimalarials

Comment

1 ^st Line

2 ^nd & 3 ^rd line

Non-severe malaria

Non-Pregnant Adult

Riamet ^® PO (over 35kg body weight) 4 tablets PO at 0hrs, 8hrs, 24hrs, 36hrs, 48hrs, 60hours (total 24 tablets over 60 hours)

(Four tablets of Riamet ^® contain 80mg of Artemether & 480mg of Lumefantrine)

Second line:

Malarone ^® PO 4 tablets every 24 hours for 3 days

(Four tablets of Malarone ^® contain 1g of Atovaquone & 400mg of Proguanil)

OR

Third line option - non-pregnant adult only:

Quinine PO 600mg (unlicensed) every 8 hours

+

Doxycycline PO 200mg every 24 hours

Duration 7 days

Avoid quinine if hypersensitive

Non-severe malaria

Pregnant Adult

All Trimesters:

Riamet ^® PO (over 35kg body weight) 4 tablets PO at 0hrs, 8hrs, 24hrs, 36hrs, 48hrs, 60hours (total 24 tablets over 60 hours)

(Four tablets of Riamet ^® contain 80mg of Artemether & 480mg of Lumefantrine)

Second line:

Quinine PO 600mg every 8 hours

+

Clindamycin PO 450mg every 8 hours

Duration 7 days

Severe Malaria

Treat as a medical emergency. See notes above.

Intravenous Antimalarials: If seriously ill or unable to take tablets

Comment

1 ^st Line

2 ^nd line (if artesunate not available). Avoid quinine if hypersensitive.

Artesunate IV 2.4mg/kg at 0hrs, 12hrs, 24hours, then every 24 hours until oral treatment can be substituted (see below).

Quinine IV infusion (Unlicensed)

Loading dose*: 20mg/kg (maximum 1.4g) infused over 4 hours, followed 8 hours after start of the loading dose by Maintenance dose: 10mg/kg (maximum 700mg) IV Infusion (over 4 hours) every 8 hours

Reduce maintenance dose to

5 to 7 mg/kg (maximum 700mg) every 8 hours in severe renal impairment, severe hepatic impairment, or if IV treatment continues for more than 48 hours.

*Do NOT give loading dose if patient has received quinine or mefloquine in previous 12 hours

Oral switch after 24 hours: see below.

Give intravenous antimalarials in the treatment of severe malaria for a minimum of 24 hours - irrespective of the patient’s ability to tolerate oral medication earlier.

Quinine toxicity:

ECG monitoring required in the elderly and patients with cardiac disease during IV quinine administration.

Significant risk of hypoglycaemia with IV quinine. Monitor blood glucose regularly (about every 2 hours) in the acute situation.

A full course of oral treatment should always follow IV artesunate (see below). This applies even if the duration of IV treatment was for 2 days or more.

When the patient has had at least 24 hours of IV artesunate (doses at 0hrs, 12hrs, 24 hours) and the patient is able to swallow and absorb medication, give Riamet® PO, starting at least 4 hours after the final dose of IV artesunate.

Riamet® PO (over 35kg body weight) 4 tablets at 0hrs, 8hrs, 24hrs, 36hrs, 48hrs, 60 hours (total 24 tablets over 60 hours)

(Four tablets of Riamet® contain 80mg of Artemether & 480mg of Lumefantrine)

Switch to oral therapy after the first 24 hours (3 doses) to complete a full oral course when the patient is able to swallow AND retain oral medication by giving a course of:

Riamet® PO (over 35kg body weight) 4 tablets at 0hrs, 8hrs, 24hrs, 36hrs, 48hrs, 60 hours (total 24 tablets over 60 hours)

(Four tablets of Riamet® contain 80mg of Artemether & 480mg of Lumefantrine)

Chorioamnionitis

Discuss considerations around delivery with consultant obstetrician

Or

Endometritis (Post-partum)

If systemically septic follow antibiotic treatment for sepsis

Co-amoxiclav IV 1.2g every 8 hours

+

Gentamicin V one dose per GAPP App calculator (use booking weight). See footnote* re further doses and monitoring

CefTRIAXone IV

2g every 24 hours

+

Gentamicin V one dose per GAPP App calculator (use booking weight). See footnote* re further doses and monitoring

+

Metronidazole IV 500mg every 8 hours

Discuss with Microbiology

Ciprofloxacin IV 400mg every 12 hours. See footnote^ re use in pregnancy

+

Gentamicin IV one dose per LAPP App calculator (use booking weight). See footnote* re further doses and monitoring See footnote^ re use in pregnancy.

+

Vancomycin IV infusion, dose per LAPP App calculator (use booking weight). See footnote* re monitoring

+

Metronidazole IV 500mg every 8 hours

Preterm Prelabour R upture of Membranes

With NO evidence of sepsis/Chorioamnionitis

Duration 10 days

Erythromycin PO 250mg every 6 hours

Mastitis

Page 17 of National Clinical Programme for Obstetrics and Gynaecology Antimicrobial Prescribing Guidelines for infections including sepsis https://rcpi-live-cdn.s3.amazonaws.com/wp-content/uploads/2018/06/Medication-Guidelines_-Vol-1_Antimicrobial-Prescribing_v1.1-1.pdf

Sepsis

Urinary Tract Infection

Page 12 of National Clinical Programme for Obstetrics and Gynaecology Antimicrobial Prescribing Guidelines for infections including sepsis https://rcpi-live-cdn.s3.amazonaws.com/wp-content/uploads/2018/06/Medication-Guidelines_-Vol-1_Antimicrobial-Prescribing_v1.1-1.pdf

^Gentamicin & Ciprofloxacin are recommended in pregnancy when benefit outweighs risk.

* Gentamicin is generally NOT recommended in pregnancy unless benefit outweighs risk. Review need for ongoing Gentamicin on a daily basis. Continue with once daily Gentamicin dosing ONLY if Consultant/Registrar recommended. For advice on monitoring see Aminoglycoside Dosing & Monitoring section.

Antiviral regimens for Influenza

Antiviral treatment

1 ^st line

Alternative therapy

Duration is generally 5 days .

There is limited evidence to support treating for longer duration in those with severe influenza (e.g critically ill in ICU) and in severely immunosuppressed patients. Discussion with Microbiology is recommended.

Oseltamivir PO/NG 75mg every 12 hours

Zanamivir may be indicated for patients if severely immunocompromised – please discuss with Microbiology .

Antiviral prophylaxis

Chemoprophylaxis (generally PO/NG Oseltamivir) may be considered for people at higher risk from influenza complications (as above, 1 to 13) who have had recent close contact with a person with influenza. Details on use of Oseltamivir for prophylaxis of high risk contacts, including dose and duration are to be found in the HPSC/ HSE guidance . For additional information on renal dosing please see the renal dosing section .

Empiric Antibiotics for Community Acquired Pneumonia (CAP)

Infection

1 ^st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

Community Acquired Pneumonia (including nursing home patients unless history of MDRO).

See note on MDRO .

Signs and symptoms of LRTI

AND new consolidation on chest X-ray

Mild CURB-65 Score 0 or 1

Amoxicillin PO 1g every 8 hours

Consider adding atypical cover with either:

Doxycycline PO 100mg every 12 hours

Or

Clarithromycin PO 500mg every 12 hours

Doxycycline PO 100mg every 12 hours

Or

Clarithromycin PO 500mg every 12 hours

Duration

5 days

(provided afebrile and clinically stable for 48 hours. Otherwise 7 days)

Moderate CURB-65 Score 2

Amoxicillin PO/IV 1g every 8 hours

+

Add atypical cover with either:

Doxycycline PO 100mg every 12 hours

Or

Clarithromycin PO (IV if NPO) 500mg every 12 hours

Levofloxacin PO (IV if NPO)

500mg every 12 hours

Duration

5 days

(provided afebrile and clinically stable for 48 hours. Otherwise 7 days )

Most patients can be treated with oral antibiotics.

Severe CURB-65 Score ≥ 3

Co-amoxiclav IV 1.2g every 8 hours

+

Add atypical cover with either:

Doxycycline PO 100mg every 12 hours

Or

Clarithromycin PO (IV if NPO) 500mg every 12 hours

CefTRIAXone IV 2g every 24 hours

+

Add atypical cover with either:

Doxycycline PO 100mg every 12 hours

Or

Clarithromycin PO (IV if NPO) 500mg every 12 hours

Levofloxacin PO

(IV if NPO) 500mg every 12 hours

+

Consider adding

Vancomycin IV infusion, IF at risk of Staph aureus infection. Dose per LAPP App calculator. See footnote* re review and monitoring.

Duration

7 days

Longer courses are indicated according to clinical judgement and after discussion with Microbiologist e.g. if Legionella pneumophila , Staphylococcus aureus or Gram-negative bacilli suspected or confirmed.

Send urine sample for both pneumococcal and legionella urinary antigen testing in severe CAP.

* Review need for ongoing vancomycin on a daily basis. For advice on monitoring see Vancomycin Dosing & Monitoring section.

Empiric Antibiotics for Aspiration Pneumonia

Infection

1st Line Antibiotics

In penicillin allergy

Comment

Aspiration Pneumonia

Note: Antimicrobial therapy for
patients with aspiration without
clinical evidence of pneumonia
(acute aspiration pneumonitis)
does not offer clinical benefit.

Co-amoxiclav IV

1.2g every 8 hours

Discuss with Microbiology

Duration

5 days

(provided afebrile and clinically stable for 48 hours. Otherwise 7 days)

Empiric Antibiotics for COPD

Infection

1st Line Antibiotics

In penicillin allergy

Comment

COPD Exacerbation

without infiltrate

Amoxicillin PO 1g every 8 hours

OR If recent (<2/52) course of amoxicillin:
Co-amoxiclav PO 625mg every 8 hours
( Consider boosted co-amoxiclav PO 625mg every 8 hours AND amoxicillin 500mg every 8hours for severe infection).

Doxycycline PO 100mg every 12 hours
(first choice in penicillin allergy)

OR

Clarithromycin PO 500mg every 12 hours

Duration

5 days

(provided afebrile and clinically stable for 48 hours. Otherwise 7 days)

Empiric Antibiotics for Hospital Acquired Pneumonia

Infection

1 ^st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

In penicillin allergy

Comment

See penicillin hypersensitivity section for further information

The regimens below may NOT cover Multi-drug Resistant Organisms (MDRO) in all cases. See note on MDRO

Hospital Acquired Pneumonia

Contact Microbiology for treatment of Pseudomonal infection.

Moderate

Piperacillin/tazobactam  IV
4.5g every 6 hours

Moderate

CefTRIAXone IV 2g
every 24 hours

Add Gentamicin IV IF haemodynamically unstable. Give one dose per LAPP App calculator. See footnote* re further doses and monitoring.

Note if history of Pseudomonas colonisation/infection discuss alternative treatment with microbiologist.

Moderate

Vancomycin IV infusion, dose per LAPP App calculator. See footnote* re monitoring.

+

Ciprofloxacin ** IV
400mg every 12 hours

If possible aspiration Add

Metronidazole IV
500mg every 8 hours

Add Gentamicin IV IF haemodynamically unstable. Give one dose per LAPP App calculator. See footnote* re further doses and monitoring.

Duration

7 days

May need to be extended according to clinical judgement in discussion with microbiology e.g. if Legionella pneumophila , Staphylococcus aureus or Gram-negative bacilli suspected or confirmed.

Severe (ICU assessment required)

Piperacillin/tazobactam IV

4.5g every 6 hours

+

Vancomycin IV infusion, dose per LAPP App calculator. See footnote* re review and monitoring. Review at 24 - 48 hours and stop if MRSA not detected from clinical samples or MRSA screen.

Add Gentamicin IV IF haemodynamically unstable. Give one dose per LAPP App calculator. See footnote* re further doses and monitoring

Severe (ICU assessment required)

Vancomycin IV infusion, dose per LAPP App calculator. See footnote* re monitoring.

+

Ciprofloxacin ** IV
400mg every 12 hours

If possible aspiration add

Metronidazole IV
500mg every 8 hours

Add Gentamicin IV IF haemodynamically unstable. Give one dose per LAPP App calculator. See footnote* re further doses and monitoring.

* Review need for ongoing Gentamicin and Vancomycin on a daily basis. Continue with once daily Gentamicin dosing ONLY if recommended by the patient's Consultant/Registrar . For advice on monitoring see Aminoglycoside & Vancomycin Dosing & Monitoring section.

**Switch from IV to oral Ciprofloxacin (500mg PO every 12 hours) as soon as possible.

PJP Treatment

Infection

1 ^st Line

2 ^nd line

Comment

PJP

Co-trimoxazole * IV/PO 120mg/kg/ day divided into a 6 to 8 hourly dosing regimen

e.g. 30mg/kg every 6 hours *

e.g. 70kg patient: 70x120mg = 8,400mg daily, dosing regimen would be 2,100mg every 6 hours (round dose to nearest 480mg vial=1920mg)

In severe disease consider oral switch at same dose when clinically improving.

In mild to moderate disease consider oral route from outset.

Severe disease:

Pentamidine IV 4mg/kg once daily

Please discuss with Microbiology.  Only to be used if intolerant or unresponsive to co- trimoxazole.  Risk of significant adverse events including severe hypotension and hypoglycaemia with administration.

Non-severe disease:

Atovaquone

OR

Dapsone + Trimethoprim

OR

Clindamycin + Primaquine

Contact Microbiology or Pharmacy for advice and dosing.

Duration (Micro consult recommended):

Non-HIV infected: 14 to 21 days

HIV infected: 21 days

* Please note the co-trimoxazole dose is a combined trimethoprim/sulfamethoxazole dose.

Caution with dose calculation as errors have occurred when dosing is based on the trimethoprim component (as recommended in US literature).

Infection

1 ^st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

See penicillin hypersensitivity section for further information

The regimens below may NOT cover Multi-drug Resistant Organisms (MDRO) in all cases. See note on MDRO .

If haemodynamically unstable

Antibiotics must be given as soon as possible, then discuss with Microbiology.

Meropenem should be considered in patients who are critically ill with sepsis or have a history of a Gram-negative Multi-drug Resistant Organism (MDRO). Discuss use of Meropenem with Microbiology. If meropenem is essential in a patient with a history of severe penicillin allergy e.g. anaphylaxis, close monitoring is required for cross sensitivity.

Sepsis – Source Unclear

No risk factors for MRSA e.g.

No CVC/

No IV Drug Use

Give antibiotics immediately

Piperacillin/tazobactam IV
4.5g every 6 hours

+

Gentamicin IV one dose per LAPP App calculator.

See footnote ¹ re further doses and monitoring.

See footnote ² re use in pregnancy.

See footnote ³ re sepsis in pregnancy.

CefTRIAXone IV
2g every 24 hours

+

Gentamicin IV one dose per LAPP App calculator.

See footnote ¹ re further doses and monitoring.

See footnote ² re use in pregnancy.

If pregnant or suspected intra-abdominal source:

Add

Metronidazole IV
500mg every 8 hours

See footnote ³ re sepsis in pregnancy.

Discuss with Microbiology

Ciprofloxacin IV
400mg every 12 hours.

See footnote ² re use in pregnancy.

+

Gentamicin IV one dose per LAPP App calculator.

See footnote ¹ re further doses and monitoring.

See footnote ² re use in pregnancy.

+

Vancomycin IV infusion, dose per LAPP App calculator.

See footnote ¹ re monitoring.

If pregnant or suspected intra-abdominal source:

Add

Metronidazole IV
500mg every 8 hours

See footnote ³ re sepsis in pregnancy.

Sepsis – Source Unclear

CVC in situ/

Inflammation at intravascular catheter insertion site/IV Drug Use/

Risk factors for MRSA

Give antibiotics immediately

Piperacillin/tazobactam IV
4.5g every 6 hours

+

Gentamicin IV one dose per LAPP App calculator.

See footnote ¹ re further doses and monitoring.

See footnote ² re use in pregnancy.

+

Vancomycin IV infusion, dose per LAPP App calculator.

See footnote ¹ re monitoring.

See footnote ³ re sepsis in pregnancy.

CefTRIAXone IV
2g every 24 hours

+

Gentamicin IV one dose per LAPP App calculator.

See footnote ¹ re further doses and monitoring.

See footnote ² re use in pregnancy.

+

Vancomycin IV infusion, dose per LAPP App calculator.

See footnote ¹ re monitoring.

If pregnant or suspected intra-abdominal source:

Add
Metronidazole IV
500mg every 8 hours

See footnote ³ re sepsis in pregnancy.

¹ Review need for ongoing Gentamicin and Vancomycin on a daily basis. Continue with once daily Gentamicin dosing ONLY if recommended by patient's Consultant/Registrar . For advice on monitoring see Aminoglycoside & Vancomycin Dosing & Monitoring section.

² Gentamicin & Ciprofloxacin are recommended in pregnancy when benefit outweighs risk.

³ For full detailed guidance on the management of sepsis in a pregnant patient, see WAC Directorate Guideline on the Management of Suspected Sepsis and Sepsis in Obstetric Care (Available via QPulse Knowledge base CLN-OGCP-218 on Linkopolis). Discuss with Obstetrics.

Empiric Antibiotics for Suspected Meningococcaemia

Infection

1 ^st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

Suspected Meningoccaemia (without features of meningitis)

CefTRIAXone IV 2g every 12 hours

CefTRIAXone IV 2g every 12 hours

Give first dose Chloramphenicol IV 25mg/kg and IMMEDIATELY discuss with Microbiology to discuss options.

Meropenem 2g every 8 hours may be an alternative to chloramphenicol in patients with a history of penicillin anaphylaxis, as recommended in Irish guidelines, with close monitoring for cross-sensitivity. Please discuss with microbiology.

Discuss need for nasopharyngeal eradication for the patient with Microbiology.

Duration

7 days

Empiric Antibiotics for Skin and Soft Tissue Infections

The regimens below may NOT cover Multi-drug Resistant Organisms (MDRO) in all cases. Vancomycin may be required in addition to cover MRSA. See note on MDRO .

Cellulitis/Wound Infection

1 ^st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

Immediate or severe delayed reaction

Comment

Mild

Flucloxacillin PO ¹ 1g every 6 hours

CefALEXin PO 500mg every 6 hours

Clarithromycin
PO 500mg every 12 hours

Duration

5-7 days

If a patient requires an extended course please discuss with Microbiology

Moderate - Severe

Flucloxacillin IV
2g every 6 hours

Clindamycin IV 900mg every 8 hours

Duration

7-10 days

If a patient requires an extended course please discuss with Microbiology

Incipient necrotising fasciitis

Discuss urgently with Consultant Microbiologist

Flucloxacillin IV 2g every 6 hours

+

Clindamycin IV 900mg every 8 hours

Vancomycin ² IV infusion, dose per LAPP App calculator. See footnote ² re monitoring.

+

Clindamycin IV 900mg every 8 hours

Duration

7-10 days

If a patient requires an extended course please discuss with Microbiology

For severe cellulitis and incipient necrotising fasciitis , if involving abdominal wall or groin or water exposure, consider adding Ciprofloxacin IV 400mg every 12 hours

Necrotising fasciitis/gas gangrene (Group A Streptococcal infection)

Immediate surgical debridement is essential

Discuss immediately with Consultant Microbiologist

Piperacillin/tazobactam IV 4.5g every 6 hours

+

Clindamycin IV 1.2g every 6 hours

For MRSA Add

Vancomycin ² IV infusion, dose per LAPP App calculator. See footnote ² re monitoring.

Discuss with Microbiology

Consider

Vancomycin ² IV infusion, dose per LAPP App calculator. See footnote ² re monitoring.

+

Clindamycin IV 1.2g every 6 hours

+

Ciprofloxacin IV 400mg every 8 hours

Monitor for diarrhoea

Duration

Usual duration 14 days

Orbital and Periorbital Cellulitis ( Seek Specialist ENT or Ophthalmology advice urgently )

Treat non-orbital facial cellulitis as cellulitis.

1 ^st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

Immediate or severe delayed reaction

Comment

Mild

Co-amoxiclav PO 625mg every 8 hours

+

Amoxicillin PO 500mg every 8 hours

CefALEXin PO 500mg every 6 hours

+

Metronidazole PO 400mg every 8 hours

Clarithromycin PO 500mg every 12 hours

+

Metronidazole PO 400mg every 8 hours

Duration

7 days

Moderate-Severe

Please consider discussing with Microbiology

CefTRIAXone IV 2g every 24 hours

+

Metronidazole IV 500mg every 8 hours

+

Flucloxacillin IV 2g every 6 hours

CefTRIAXone IV 2g every
24 hours

+

Metronidazole IV 500mg every 8 hours

+

Vancomycin ² IV infusion, dose per LAPP App calculator. See footnote ² re monitoring.

Vancomycin ² IV infusion, dose per LAPP App calculator. See footnote ² re monitoring.

+

Clindamycin IV 900mg every
8 hours

+

Ciprofloxacin IV 400mg every
12 hours

Monitor for diarrhoea.

Duration

10 to 14 days

Diabetic Soft Tissue Infection (without osteomyelitis)

1 ^st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

Immediate or severe delayed reaction

Comment

Mild

Co-amoxiclav PO 625mg every 8 hours

+

Amoxicillin PO 500mg every 8 hours

CefUROXime PO 500mg every 12 hours

+

Metronidazole PO 400mg every 8 hours

Clindamycin PO 450mg every 6 hours

+

Ciprofloxacin PO 500mg every 12 hours

Monitor for diarrhoea

Duration:

Minimum 7 days

Moderate

Co-amoxiclav IV 1.2g every 8 hours

CefUROXime IV 1.5g every 8 hours

+

Metronidazole IV 500mg every 8 hours

Clindamycin IV
900mg every 8 hours

+

Ciprofloxacin IV
400mg every 12 hours

Monitor for diarrhoea

Duration:

10-14 days in Moderate to Severe infection.

May require up to 3 weeks for severe infection.

Severe

Discuss with Consultant Microbiologist.

Higher doses may be indicated

Piperacillin/tazobactam IV 4.5g every 6 hours

Vancomycin ² IV infusion, dose per LAPP App calculator. See footnote ² re monitoring.

+

Clindamycin IV 900mg every 8 hours

+

Ciprofloxacin IV 400mg every 12 hours

Monitor for diarrhoea

Discuss with Microbiology

1.  The upper dose of Flucloxacillin PO 1g four times a day is unlicensed.

2. Review need for ongoing vancomycin on a daily basis. For advice on monitoring see Vancomycin Dosing & Monitoring section.

Empiric Antibiotics for Animal and Human Bites

Infection

1 ^st line Antibiotics

In penicillin allergy

Comment

Animal & human bites, prophylaxis and treatment

Co-amoxiclav PO 625mg every 8 hours

Metronidazole PO 400mg every 8 hours

+

Doxycycline PO 100mg every 12 hours

Duration:

Prophylaxis - 3 days

Treatment* - 5 days

*Treatment duration can be increased to 7 days if there was significant tissue destruction or the wound has penetrated bone, joint, tendon or vascular structures. Such wounds would require surgical management

Consider need for IV therapy or longer duration if severe infection

Empiric Antibiotics for Throat Infections

Infection

1 ^st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

Acute Pharyngitis/

Tonsillitis

Benzylpenicillin IV 1.2g every 4 hours

If there is a good response to initial IV therapy consider switch to oral therapy with: Phenoxymethylpenicillin PO 666mg every 6 hours

OR

Amoxicillin PO 500mg every 8 hours

Clarithromycin IV 500mg every 12 hours

Consider switch to oral therapy if good response to initial IV therapy

Duration 10 days.

Consider switch to oral agents after 24-48 hours.

If failure to respond to initial therapy consider:

Co-amoxiclav IV 1.2g every 8 hours (if no allergy to penicillin).

Peritonsillar abscess

Discuss with ENT re early surgical drainage of abscess

Co-amoxiclav IV 1.2g  every 8 hours

CefTRIAXone 2g every 24 hours

+

Metronidazole IV 500mg every 8 hours

Clindamycin IV 900mg every 8 hours

Duration usually 7 days.

Consider oral switch when appropriate -discuss with Micro.

Severe Acute Epiglottitis

Discuss with Microbiology

CefTRIAXone IV

2g every 24 hours

CefTRIAXone IV

2g every 24 hours

Vancomycin IV infusion, dose per LAPP App calculator. See footnote* re monitoring.

+

Ciprofloxacin IV 400mg every 12 hours

Optimal duration of treatment not established.

Generally treat for 7-10 days.

Longer duration may be indicated in selected patients.

Consider oral switch when appropriate - discuss with Microbiology.

* For advice on monitoring see Vancomycin Dosing & Monitoring section.

Non-pregnant Females & Males

Cystitis/Lower UTI

(i.e. uncomplicated UTI)

Nitrofurantoin PO (immediate release preparation)
50mg every 6 hours

Avoid nitrofurantoin if eGFR <45ml/min/1.73m ² .
(May be used with caution if eGFR 30–44 mL/ minute/1.73 m ² as a short-course only for suspected or proven multidrug resistant organisms and only if potential benefit outweighs risk ).

Alternative 1 st choice option ( only if nitrofurantoin unsuitable) :

CeFALexin PO 500mg every 8 to 12 hours

OR

Trimethoprim PO 200mg every 12 hours
(Use only when risk of resistance is low i.e. where previous culture suggests susceptibility (and trimethoprim was not used) or in younger patients without a significant antibiotic exposure history. Risk of resistance is more likely in older people in residential facilities.)

Adjust initial treatment based on culture & sensitivity results. Please ensure pre-treatment MSU in males sent .

If eGFR <45ml/min/1.73m ² and penicillin allergic please discuss patients with Microbiology.

If pregnant , see Saolta full detailed guideline WAC Group Management of Urinary Tract Infections (UTIs) in Pregnancy (available via Linkopolis > HCI-QPulse Knowledgebase > PPG Library > Women’s & Children’s Directorate and search CLN-OGCP-227) or please discuss with microbiology.

Important to note for men:

• Consider Sexually Transmitted Infections particularly in young people presenting with lower urinary tract symptoms.
• Consider acute prostatitis in males >50 years with lower urinary tract symptoms.
• Nitrofurantoin should NOT be given if there is any suspicion of prostatitis.
• Consider prostatitis as a diagnosis in males if symptoms persist. See section on prostatitis treatment for more information.
• It is advisable to refer men with recurrent UTI to a Urology consultant. Antimicrobial prophylaxis should only be considered following discussion with a Microbiologist.

Duration for non-pregnant women : 3 days *

Duration for males :
7 days

*Note: If history of recurrent infection or inadequate treatment response, consider extending treatment to 5 days.

Catheter associated UTI (Lower UTI/not systemically unwell)

Refers to patients (male/female) whose urinary tract is currently catheterised or has been catheterised within the past 48hours.

For Upper catheter associated UTI / systemically unwell please see below under “Complicated UTI”.

Nitrofurantoin PO (immediate release preparation)
50mg every 6 hours

Avoid nitrofurantoin if eGFR <45ml/min/1.73m ² .
(May be used with caution if eGFR 30-44ml/minute/1.73m2 as a short-course only for suspected or proven multidrug resistant organisms and only if potential benefit outweighs risk ).

Alternative 1 ^st choice option ( only if nitrofurantoin is unsuitable):

CeFALexin PO 500mg every 8 to 12 hours

OR

Trimethoprim PO 200mg every 12 hours
Use only when risk of resistance is low i.e. where previous culture suggests susceptibility (and trimethoprim was not used) or in younger patients without a significant antibiotic exposure history. Risk of resistance is more likely in older people in residential facilities.)

Adjust initial treatment based on culture & sensitivity results.

If eGFR <45ml/min/1.73m ² and penicillin allergic please discuss patients with Microbiology.

Note indwelling urethral or suprapubic catheters often become colonised with bacteria without signs of symptoms of infection in the patient. Antibiotic treatment is of no benefit in these patients.

• Consider removing or, if this cannot be done, changing the catheter as soon as possible in people with a catheter-associated UTI if it has been in place for more than 7 days.
• Discuss with Urology where appropriate.
• Do not allow catheter removal or change to delay antibiotic treatment.

Antibiotic prophylaxis for urinary catheter changes is NOT appropriate unless there is a definite history of UTI due to catheter change.

7 days

Infection

1 ^st Line Antibiotics

Penicillin allergy:

delayed onset non-severe reaction

Penicillin allergy:

immediate or severe delayed reaction

Comment

See penicillin hypersensitivity section for further information

Pyelonephritis or

Complicated UTI

Non-pregnancy

Consider acute pyelonephritis/upper UTI when:

• Flank pain which radiates to the iliac fossa and suprapubic area.
• Sudden onset general systemic disturbance with fever, rigors, vomiting.
• Tenderness and guarding over the kidney.
• Nausea and/or vomiting.

< 50 years with minimal previous exposure to
antibiotics:

Co-amoxiclav IV 1.2g every 8 hours

+

Gentamicin IV one dose per LAPP App calculator. See footnote* re further doses and monitoring. If a patient continues to be haemodynamically unstable continue gentamicin guided by trough levels. Please consult the gentamicin calculator , microbiologist or pharmacy for dosing information as needed.

>50 years and/or extensive previous exposure to antibitoics:

Piperacillin/tazobactam IV 4.5g every 8 hours

+

Gentamicin IV one dose per LAPP App calculator. See footnote* re further doses and monitoring. If a patient continues to be haemodynamically unstable continue gentamicin guided by trough levels. Please consult the gentamicin calculator , microbiologist or pharmacy for dosing information as needed.

If patient is septic and/or acutely unwell discuss with Microbiology.

CefTRIAXone IV 2g every 24 hours

Add Gentamicin IV IF
haemodynamically unstable. Give one dose per LAPP App calculator. See footnote* re further doses and monitoring. If a patient continues to be haemodynamically unstable continue gentamicin guided by trough levels. Please consult the gentamicin calculator, microbiologist or pharmacy for dosing information as needed.

Ciprofloxacin IV 400mg (or PO 500mg) every 12 hours (consider oral route from outset)

(See Fluroquinolone warning)

Add Gentamicin IV
IF haemodynamically unstable. Give one dose per LAPP App calculator. See footnote* re further doses and monitoring. If a patient continues to be haemodynamically unstable continue gentamicin guided by trough levels. Please consult the gentamicin calculator , microbiologist or pharmacy for dosing information as needed.

Minimum duration of treatment is 10 days.

Consider switch to oral therapy if good early clinical response to IV therapy. Please see chapter on IV to PO switch for more information.

Review need for continuing Gentamicin after 24 hours.

Acute Pyelonephritis In pregnancy

If pregnant, see Saolta full detailed guideline WAC Group Management of Urinary Tract Infections (UTIs) in Pregnancy (available via Linkopolis > HCI-QPulse Knowledgebase > PPG Library > Women’s & Children’s Directorate and search CLN-OGCP-227).

CefTRIAXone IV 2g every 24 hours

Add Gentamicin IV IF
haemodynamically unstable. Give one dose per LAPP App calculator (use booking weight). See footnote* re further doses and monitoring. See footnote^ re use in pregnancy.

Gentamicin IV every 24 hours, dose per LAPP App calculator (use booking weight).

See footnote* re review and monitoring. See footnote^ re use in pregnancy.

+

Either (depending on Group B Streptococcus susceptibility result if available)

Vancomycin IV infusion, dose per LAPP App calculator (use booking weight). See footnote*
re review and monitoring.

OR

Clindamycin IV 900mg every 8 hours

Give first doses, THEN IMMEDIATELY discuss with Microbiology to discuss further therapy.

^ Gentamicin is recommended in pregnancy when benefit outweighs risk.

* Review need for ongoing Gentamicin and Vancomycin on a daily basis. Continue with once daily Gentamicin dosing ONLY if Consultant/Registrar recommended. For advice on monitoring see Aminoglycoside & Vancomycin Dosing & Monitoring section.

Treatment of Viral Infections

Infection

Treatment

Comment

Herpes simplex - Cold sores

Aciclovir 5% cream every 4 hours
(5 times daily) for 5 to 10 days, starting at onset of symptoms

Most effective when applied at the earliest possible stage - at prodromal stage before vesicles appear.

Systemic treatment is necessary if frequent recurrences or for extensive infections.

Herpes simplex –

Including

Mouth/lips

and

Genital herpes

Treatment:

ValACIclovir PO 500mg every 12 hours (1g every 12 hours in immunocompromised)

Initial duration: Treat for 5 to 10 days (10 days duration in immunocompromised)

If Recurrent: Treat for 3 to 5 days (5 to 10 days in immunocompromised)

Suppression:

ValACIclovir PO 500mg every 24 hours (500mg every 12 hours in immunocompromised), therapy to be interrupted every 6 to 12 months to reassess recurrence frequency.

If IV treatment needed

e.g. herpes simplex in immunocompromised, severe genital herpes or prophylaxis in immunocompromised:

Aciclovir IV 5mg/kg every 8 hours.

Higher dose may be required in severe infection/immunocompromised. Discuss with Microbiology.

Herpes zoster (shingles)

ValACIclovir PO 1g every 8 hours for 7 days (in immunocompromised continue for 2 days after crusting of lesions)

If IV treatment needed:

Aciclovir IV 5mg/kg every 8 hours (10mg/kg every 8 hours in immunocompromised).

If disease is severe i.e. ocular, neurologic, disseminated disease or immunocompromised discuss with Microbiology.

Herpes simplex encephalitis

See Herpes Simplex Encephalitis Section