How to contact Microbiology/Pharmacy

Microbiology

Consultants: Dr. Michael Mulhern extn 4090 (or through hospital switch board), Dr. Patricia Roces Alvarez extn 3787 (or through hospital switch board), Dr. Jayanta Sarma extn 5202 (or through hospital switch board).

Pharmacy

Antimicrobial Pharmacists: Ms. Roisin McMenamin and Mrs Caitriona Lange bleep 640 or extn 8960
Pharmacy extn 3551/8961

Out of Hours: A Consultant Microbiologist is on call 24 hours per day 7 days per week and can be contacted through the hospital switch board. In general, out of hours, the Consultant Microbiologist should be contacted by the appropriate Registrar or Consultant.

Guideline Development Group

These guidelines have been adapted from original Galway University Hospitals (GUH) guidelines for use in Letterkenny University Hospital (LUH) by Dr. Michael Mulhern and Ms. Aisling Clancy. Note an update and review has been initiated and is underway by Dr Michael Mulhern, Dr Muna Kayalova, Ms Roisin McMenamin, Ms Helen Duffy and Mrs Caitriona Lange.

Development of these guidelines was led by a group comprised Dr. Ú. Ní Riain, Dr. D. Hogan-Murphy, Ms. M. Tierney, Dr. T. Boo, Prof. M. Cormican, Dr. C. Fleming, Dr. H. Tuite, Dr. D. Gallagher, Dr. D. Keady, Dr. E. McCarthy, Dr. L. Ryan, Dr. D. Nashev, Dr. S. O’Donnell and Dr. R. Waldron. The guidelines initially developed by Prof. M. Cormican in 2004 have been revised and expanded every two years. The guidelines are based on national and international guidelines, local microbiological data and expert opinion.

During the consultation process contributions and suggestions were received from colleagues. Comments or suggestions for improvement for future editions can be sent by email to Dr. Michael Mulhern at michaelf.mulhern@hse.ie or Ms Roisin Mc Menamin at roisin.mcmenamin@hse.ie

The guidelines have been approved by LUH Drug and Therapeutics Committee. See Linkopolis -> Pharmacy Information for the most up-to-date electronic version of these guidelines.

The guidelines are now available as an application for Smartphones (Apple and Android), with built-in dosing calculators for gentamicin, tobramycin and vancomycin. Please contact Pharmacy (extn 8960) for a password for the LAPP (Letterkenny Antimicrobial Prescribing Policy/Guidelines) App. The LAPP App provides automatic updates to ensure access to the most recent version of the guidelines.

Effective from: July 2019 (Phase 1 review complete Feb 2024, Phase 2 review complete June 2024, Phase 3 review June 2025, Phase 4 review March 2026)

Review Date: July 2022

Statement of Purpose and Limitations

This document relates primarily to common conditions or to conditions that are uncommon but associated with serious morbidity or mortality. It is intentional that this empiric guideline document presents minimal background and explanation.

Dosage and dose intervals as specified are for adults with normal renal and hepatic function. Although certain specific adverse effects are referred to, issues of adverse effects, drug interactions and contraindications are not addressed in detail and should be checked in appropriate sources such as the BNF and SPCs.

Prescribers must use their professional judgement to identify circumstances in which there are specific reasons why this general guidance is not appropriate. In such circumstances please discuss treatment with the Departments of Microbiology or Pharmacy.

These empiric guidelines are designed in line with best practice in antimicrobial prescribing and with national and international guidelines on antimicrobial stewardship. As such, they support optimal antimicrobial use in LUH. Optimal antimicrobial use means patients receive the right antimicrobial therapy at the right dose, route and duration, and for the right infection type at the right time, while minimising the risk of development of resistance, adverse drug events (including C. difficile associated disease) and cost.

These guidelines are intended for initial empiric therapy. Empiric treatment is choice of antimicrobial prior to susceptibility results being available.
Regular review of the patient’s progress is essential and treatment should be reviewed in the light of changes in clinical condition.
If a specific pathogen(s) is identified the treatment should be reviewed. The least toxic, narrowest spectrum and least expensive agent or combination of agents that is effective should be used for the treatment of specific pathogens.
Usual recommended duration of therapy is included for many conditions, and assumes there is satisfactory clinical progress and response to therapy – clearly if clinical progress is slow or not satisfactory then individual patient management, including the duration of therapy, should be reviewed and discussed with Microbiology if required.
It may be possible to switch from IV to oral therapy after 24 to 48 hours.
Please discuss duration of therapy and potential for switch from IV to oral therapy with Microbiology if required.

LUH Disclaimer

These guidelines are intended to guide and facilitate the care of patients at Letterkenny University Hospital (LUH) only. The guidance contained therein is not intended to replace individual assessment and personalised treatment of the patient. The authors have made every reasonable effort to base the guidance on best available evidence and to ensure accuracy of content at the time of going to press. However technical and clinical information changes rapidly and it is not possible to guarantee that all items will be accurate at all times. The application of the information in this guideline in clinical situations remains the professional responsibility of the practitioner.

Changes for this Edition

Changes for this edition – Version 2.5 May 2026

(Note this is Phase 4 in the planned review and update of the empiric antimicrobial prescribing guidelines).

Viral

BASHH guidance updated in 2024 - new link created.

Clarified durations of therapy between immunocompromised and not immunocompromised.

Throat

Added FEVERpain tool from community AMRIC guidelines.

Tonsilitis/Acute Pharyngitis: Information on oral switch after 24-48 hours if good response.

Peritonsillar abscess: Change in antibiotic choice in penicillin allergy.

References updated.

CNS

Suspected Bacterial Meningitis: Initial information in chapter updated to include:

-Use of meropenem as an alternative to chloramphencol in penicillin anaphylaxis requires discussion with microbiology, as well as close monitoring for cross-sensitivity.

-On review of the literature, more information added on patients at risk, risk factors for Listeria monocytogenes meningitis and the age at risk changed to over 60.

-Contacts link updated (appendix 4).

Use of vancomycin therapy removed with advice on when to add in, with a link included to the European Centre for Disease Prevention and Control website, for up to date European and worldwide data on resistance.

Frequency of chloramphenicol therapy updated and all durations of therapy updated in line with NICE guidance.

Use of rifamipicin removed.

Information of steroid use updated.

Suspected Herpes Simplex Encephalitis: Information added on dosing in obesity.

Intravascular line

Initial introductory information changed in line with National guidance.

Changes for this edition – Version 2.4 March 2026 (Note this is Phase 4 in the planned review and update of the empiric antimicrobial prescribing guidelines).
A reminder that these Empiric guidelines are intended to be used in conjunction with clinical judgement for patients in Letterkenny Hospital only.	The password requirement for the app has been removed – this is under the strict understanding that these guidelines are used as a support tool for patients under the care of Letterkenny University Hospital only.
New Peritoneal Dialysis section	As per new guideline - available under the renal dosing section and linked within the Abdomen chapter.
Information section	Updated contact information for Dr Patricia Roces Alvarez, Consultant Microbiologist and Ms Caitriona Lange, AMS Pharmacist.
Malaria chapter	Change in choice of antimalarial in pregnancy and for Severe Malaria.
Genital chapter	Changes to choice of quinolone for PID in penicillin allergy and acute prostatitis if not sexually active, dosing of Ceftriaxone in Acute prostatitis as well as duration of treatment.
Cardiovascular chapter	All changes including choice of antimicrobial and dosing for treatment and prophylaxis updated in line with the European Society of Cardiology Guidelines on the Management of Endocarditis 2023.
Eye chapter	Included treatment options for management of bacterial conjunctivitis.
Fungal chapter	Dosing changes in line with summary of product characteristics for Fluconazole as well as durations of treatment of oesophageal candidiasis.
Aminoglycoside and Vancomycin dosing and monitoring chapter	Aminoglycoside chapter – removed multiple daily dosing of gentamicin. As per the Esc 2023 guidelines for treatment of Endocarditis now 3mg/kg OD (as opposed to 1mg/kg BD). Updated Vancomycin section.
Appendix 2	Updated to include information on administration of the injection formulation of vancomycin orally in the treatment of CDI.
Changes for this edition – Version 2.3 June 2025 (Note this is Phase 3 in the planned review and update of the empiric antimicrobial prescribing guidelines).
Surgical Antimicrobial Prophylaxis	Antibiotic use in surgical prophylaxis - Chapter to be updated in line with National AMRIC QIP Principles of Antibiotic Prophylaxis in Surgery Note regarding risk factors for MRSA Classification of surgical procedure Breast Surgery Cardiothoracic Surgery Gastrointestinal Surgery Head and Neck Surgery Obstetric and Gynaecological Surgery Orthopaedic and Trauma Surgery Plastic Surgery Urological Surgery
The following have been removed, as surgeries relating to these disciplines are not performed in LUH: Maxillofacial Surgery Ophthalmic Surgery Vascular Surgery and Limb Amputations Ear, Nose and Throat (ENT) Surgery

Changes for this edition – Version 2.2 2024

(Note this is Phase 2 in the planned review and update of the empiric antimicrobial prescribing guidelines.

Dosing in renal impairment chapter

All drug monographs reviewed against the Renal Drug Database (RDD), information updated as to how you can access the RDD, information added regarding Cefazolin dosing in intermittent haemodialysis as now part of the empiric guidance for penicillin allergic patients (with delayed onset reaction) for moderate to severe skin and soft tissue infections.

Red light and Reserve Antimicrobial Policy

Red light and Reserve antimicrobial list updated as well as process of how to access.

Prescribing Principles chapter

Updated to include information on how to access prescribing guidelines for children i.e. CHI Clinibee application. Additional good practice information included around interaction checkers, general dosing advice, IV administration advice and Start Smart then Focus guidance.

Example of antimicrobial prescription within LUH included.

Urinary chapter:

Cystitis/lower UTI in Non-pregnant women, men, catheter associated UTI (lower UTI/not systemically unwell)
Pyelonephritis/ Complicated UTI (non-pregnancy)
Acute Pyelonephritis in pregnancy
Prophylaxis of Recurrent Urinary Tract Infections

Updated to include more information on male vs female vs catheter associated UTIs. Treatment options and durations changed for the following:

Cystitis/lower UTI in Non-pregnant women, men
Catheter associated UTI (lower UTI/not systemically unwell)
Pyelonephritis/ Complicated UTI (non-pregnancy)

Additional information included about inappropriate use of urine dipsticks in patients over 65 and/or with a urinary catheter.

Information added around prophylaxis of recurrent urinary tract infections i.e. appropriate use, important of review dates.

Information on Acute Pyelonephritis in pregnancy remains the same with recommendations to review Saolta WAC guideline.

Skin and Soft tissue chapter:

Cellulitis/wound infection (mild/moderate/severe)
Incipient Necrotising fasciitis
Necrotising fasciitis/gas gangrene (Group A Streptococcal infection)
Orbital and periorbital cellulitis
Diabetic Soft Tissue Infection (without osteomyelitis)
Bites, Animal and Human, Prophylaxis and Treatment

Additional information included around diagnosis and management of skin and soft tissue infections.

Treatment options reviewed and updated for the following:

Cellulitis/wound infection (mild/moderate/severe)
Incipient Necrotising fasciitis
Orbital and periorbital cellulitis
Diabetic Soft Tissue Infection (without osteomyelitis)

For the Bites, Animal and Human, Prophylaxis and Treatment section included updated practical information and doxycycline dose amended.

Changes for this edition – Version 2.1 2024 (note this is Phase 1 in the planned review and update of the app. The remaining chapters are currently under review.)
Information section	Updated with new contact information: Dr Kayalova – Consultant Microbiologist Roisin McMenamin & Helen Duffy – Antimicrobial Pharmacists.
IV Administration Guide	Removed -- monographs are out of date. Appendix 2 added with links of how to access Saolta monographs and Medusa.
Summary Adult Guidelines	Removed – due to partial duplication and not being as user friendly as the full Adult Guidelines.
Penicillin Hypersensitivity	Updated with additional information around managing patients with Penicillin allergies.
Gastrointestinal system – Clostridioides Difficile Infection (CDI)	Within the chapter included criteria for differentiating non-severe CDI, severe CDI, and severe, complicated / fulminant CDI. Removed PO metronidazole as option for management of non-severe CDI (in line with European guidance). Included fidaxomicin as first line option for patients at risk of recurrence for non-severe CDI (in line with European guidance). Included fidaxomicin as first line option for patients at risk of recurrence for severe CDI (in line with European guidance). Severe complicated/fulminant CDI remains the same in line with National AMRIC guidelines, updated in April 2023 (of note these differ from European consensus documents – will be under review). First recurrence of CDI changed to fidaxomicin as the only treatment option i.e. following an initial course of either vancomycin or fidaxomicin. For second or more recurrence – cases should be discussed with Microbiologist given complexity and importance of history. Information added around the fact fidaxomicin is a high tech medication and how to access in the community. Note it will remain a restricted antimicrobial and any use that is not in line with the empiric guideline must be discussed with Microbiologist.
Gastrointestinal system – Gastroenteritis	Ceftriaxone removed from the empiric guideline. To discuss with Microbiologist if clinical evidence of invasive disease or patient is immunocompromised.
Gastrointestinal system – Helicobacter Pylori	Empiric treatment guidelines have been simplified (following consultation with Gastroenterologists) to include -- 1^st line option of amoxicillin, clarithromycin and PPI -- Alternative 1^st line option of quadruple therapy with bismuth (UL product), metronidazole, doxycycline and PPI, if penicillin allergic or had clarithromycin in the last 12 months. 2^nd line eradication regime if still infected after 1^st line therapy has been changed to recommend a discussion with Gastroenterology. Although evidence stipulates the use of tetracycline over doxycycline, it is not covered by the medical card and is expensive in Ireland. Therefore guideline changed to recommend doxycycline instead.
Respiratory system – Community Acquired Pneumonia	Updated to include more information on risk factors for MRSA and pseudomonas infection. Although already included within version 1.0 guideline included another line highlighting that Nursing home patients presenting with pneumonia should be treated as CAP unless history of MDROs or recent discharge from hospital. For mild and moderate CAP doxycycline dose increased to 100mg 12hourly in line with licensing, IDSA guidance and AMRIC community guidelines. Due to risk of error we will not advocate for a 200mg loading dose. For severe CAP with non-severe penicillin allergy cefuroxime 1.5g 8hourly IV changed to Ceftriaxone 2g 24hourly IV in line with GUH. Doxycycline listed before clarithromycin for atypical cover – less side effects, less interactions, on WHO “green” AWaRe list of antibiotics – this does not mean it is preferential just that either can be used. Information added relating to vaccination status and smoking cessation advice.
Respiratory system – Infective exacerbation of Chronic Obstructive Pulmonary Disease (COPD).	Doxycycline dose increased to 100mg BD in line with licensing, IDSA guidance and AMRIC community guidelines. Doxycycline listed as preferred option in penicillin allergy in line with National community guidelines due to side effects-risk of QT prolongation, interactions (particularly azithromycin) and clarithromycin being on the WHO AWaRe list of “Watch” antibiotics.
Respiratory system – Hospital Acquired Pneumonia (HAP)	Piperacillin/Tazobactam (Tazocin) dosing for Moderate and Severe HAP changed to 6 hourly in line with licencing for a nosocomial respiratory infection. Wording changed around how HAP is classified within LUH i.e. removed “14 days duration after discharge from hospital” should be treated as hospital acquired infection. Instead “if recent hospital admission or multiple admissions over the previous 6 to 12 months please discuss with consultant Microbiologist”.
Respiratory system – Pneumocystis Jirovecii Pneumonia (PJP)	Changed duration of treatment to: Non-HIV infected 14-21 days, HIV infected: 21 days 2^nd line option in severe disease Pentamidine IV 4mg/kg line added to discuss with microbiology. Pentamidine IV preparation difficult to reconstitute safely.
Sepsis - Sepsis Unclear	Link added to HSE Sepsis Programme resources. Piperacillin/Tazobactam (Tazocin) 4.5g IV dosing increased to 6 hourly (from 8 hourly). Link to Saolta guideline on management of sepsis in pregnancy added for information following consultation with Obstetrics.
Neutropenic Sepsis	This has been changed to sit as its own chapter (and not under sepsis as it previously was) – this is in line with GUH.
Appendix 2 – Intravenous Administration of Antimicrobials	New appendix. Contains links to the Saolta IV monographs and Medusa. (Replaces the IV monographs).
Appendix 3 – Clostridioides difficile Infection (CDI)	Formatting changed to include all additional information relating to CDI i.e. Patient Information leaflet, tapered pulsed oral Vancomycin and intracolonic Vancomycin.
Appendix 5 – Chemoprophylaxis for Contacts of Meningococcal & Hib Disease	Contact numbers updated for Public Health. Chapter clearly specifies that Public Health will lead and advise on management of contacts and suspected outbreaks. Additional advice updated in line with GUH and National guidance. Prophylactic antibiotics changed as per Public Health consultant Dr Breslin to ciprofloxacin for Meningococcal and Hib Chemoprophylaxis.
Appendix 6 – Drug Interactions and Warnings with Antimicrobials	New section. Supports prescribers to check for interactions and recognise warnings associated with commonly prescribed antibiotics List of antimicrobials that have potential to interact included.
Appendix 7 – High Tech Antimicrobials	Updated to reflect current antimicrobials that are High Tech.

Document Version

Version 1 App July 2019

App Document History
Version date	Document version	Changes from previous version	Edited by
2019	Version 1	1st version App* (*Version 7 of LUH Antimicrobial Guidelines)	MM/AC
16-12-19	Version 1.1	Malaria guidelines update - Riamet	AC-MM
17-12-19	Version 1.2	New section added re. Global Shortage co-amoxiclav affecting LUH - December 2019	MM
31-01-24	Version 2.1	Sections updated- Gastrointestinal system, Respiratory system, Sepsis, Penicillin allergy, Appendix 2,3,5,6,7	RM,HD,MM,MK
05-06-24	Version 2.2	Sections updated- Urinary system, Skin and Soft tissue, Renal dosing, Reserve and Red light, Prescribing Principles	RM,HD,MM,MK
18-06-25	Version 2.3	Surgical Antimicrobial Prophylaxis section updated	RM, MM, HD
18-03-26	Version 2.4	Sections updated - Peritoneal dialysis, Genital, Malaria, Cardiovascular, Fungal, Eye, Aminoglycoside and Vancomycin Dosing & Monitoring	RM, CL, MM

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