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Appendices/Supplementary Information

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Appendix 1: Intravenous Administration of Antimicrobials

Appendix 1: IV Administration of Antimicrobials

Information regarding the Administration of Intravenous Antimicrobials can be found via accessing:

Or

Both links can be found on the Linkopolis app on HSE desktop computers.

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Appendix 2: Clostridioides difficile Infection (CDI)

Appendix 2: Clostridioides difficile Infection (CDI)

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Intracolonic Vancomycin

Intracolonic Vancomycin

  1. Requires Microbiology approval
  2. Adapted from the University of Washington
  3. Adjunctive therapy for failing Vancomycin therapy in severe CDI
  • 500mg of Vancomycin injection is reconstituted and added to 100ml of NaCl 0.9%
  • An 18G Foley catheter is inserted per rectum and the balloon is inflated
  • The Vancomycin solution is instilled into the rectum and retained for 60 minutes by clamping the catheter
  • Once retention time complete, the catheter is unclamped, the balloon deflated and the catheter removed
  • The process is repeated every 6 hours
  • Duration should be discussed with microbiology

Reference:Health Protection Surveillance Centre. Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland June 2014

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Tapered pulsed oral Vancomycin

Tapered Pulsed Oral Vancomycin

Requires Microbiology approval ​

Vancomycin PO

  • 125mg every 6 hours for 1 week, then
  • 125mg every 12 hours for 1 week, then
  • 125mg once daily for 1 week, then
  • 125mg every second day for 1 week, then
  • 125mg every three days for 2 weeks.

Reference:
Health Protection Surveillance Centre. Surveillance, Diagnosis and Management of Clostridium difficile Infection in Ireland June 2014

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Alternative routes of administration and preparation for Vancomycin

For treatment of Clostridioides difficile infection (CDI)

Alternative routes of administration and preparation for Vancomycin:

Administration via oral route (unable to swallow vancomycin capsules but able to swallow liquids):

Vancomycin preparation for injection is licensed for oral use:

  • Reconstitute vancomycin 500mg vial with 10 ml of water for injection to give a concentration of 50 mg/ml
  • Withdraw the required volume (e.g. for 125mg withdraw 2.5 ml and for 500mg withdraw 10 ml) and administer via an oral syringe
  • Dilute further with 20 – 30 ml sterile water before administering
  • Vials are for single use only and any remaining volume should be disposed of immediately in accordance with the safe and secure handling of medicine protocol

NB: Medicines intended for oral administration should not be prepared using intravenous needles and syringes because of the risk of the medicine being given intravenously in error. Enteral devices should be used.

An ENFit needle attached to an enteral ENFit syringe can be used to pierce the vancomycin vial bung to reconstitute and withdraw the solution for oral administration.

Administration via enteral feeding tubes:

This is an unlicensed route of administration and is only recommended under the advice of microbiology

  • Preparation as above for oral

References:

Summary of Product Characteristics: Vancomycin Viatris 500mg & 1000mg powder for solution. Accessed via HPRA website on 16/12/25

Medinfo Galway University Hospital Intravenous Vancomycin monograph . Accessed 16/12/25

NHS Specialist Pharmacy Service - choosing between oral vancomycin options . Accessed 17/12/25

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LUH CDI Practical Treatment Guidance

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Appendix 3: Guidelines for Management of Patients with an Absent or Dysfunctional Spleen (Adults)

Appendix 3: Guidelines for Management of Patients with an Absent or Dysfunctional Spleen (Adults)

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Immunisation

Immunisation

  • Check Chapter 3 and 5a : Immunisation of immunocompromised persons and COVID-19 to ensure you have the most up to date guidance.

  • NB: Ideally give required vaccinations at least two weeks, and preferably 4 weeks or more, before splenectomy.

  • For emergency splenectomy or if prior vaccination is overlooked or incomplete, administration two weeks after splenectomy is recommended.

  • However, if waiting until 2 weeks post surgery (to optimise immune response to vaccine) take care that vaccination is not missed entirely, especially if the patient is being discharged in the interim.

  • If concerned that the patient may not present to the GP for vaccination or for any other reason, vaccination prior to discharge may merit consideration, even if it is before the required 14 day gap.

  • In general, wait at least 3 months after immunosuppressive chemotherapy or radiotherapy (or give two weeks before such treatment).

  • Where a patient has had a splenectomy in the past, and has not received the required vaccines at the time, they should be immunised at the earliest possible opportunity.

  • When the patient is being sent home, make sure the GP is fully informed about any vaccines required, and the date on which they are due.

Recommended additional vaccines for adults with asplenia & hyposplenia.

  • Please check Chapter 3 of the HSE Immunisation Guidelines for Ireland to ensure you have the most up to date guidance on recommended additional vaccines for adults with functional or anatomical asplenia & hyposplenia.

  • Check routine immunisation from birth and boosters have been given.

Additional considerations:

  • Dose: The usual dose is 0.5ml by IM injection. In adults the deltoid is generally the preferred site. Give vaccines at separate injection sites.
  • Ordering vaccines: Vaccines are supplied by the National Immunisation Office. Men B and Men ACWY vaccines are not routinely available - a special order is required. Please liaise with Pharmacy to organise supply.

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Prophylactic Antibiotics for patients with asplenia & hyposplenia

Prophylactic Antibiotics for patients with asplenia & hyposplenia

  • Recommendations regarding the duration of antibiotic prophylaxis for asplenia and hyposplenia vary. The risk for invasive pneumococcal infection is elevated throughout life but highest for those <16 and >50 years of age.
  • All patients should receive prophylactic antibiotics for a minimum of one to two years post splenectomy.
  • Lifelong prophylaxis is recommended for high-risk patients. See risk factors below.
  • Risk assessment is recommended for low risk patients. Such patients should be counselled regarding the risks and benefits of lifelong antibiotics and may choose to discontinue prophylaxis. Prophylaxis should only be discontinued if the patient is fully immunised and education and counselling is given regarding the risks of pneumococcal, meningococcal and Haemophilus B infection and the need for prompt early management of febrile illness.

Risk factors associated with high risk of invasive pneumococcal disease in hyposplenism include:

  • Immediate post-operative period
  • Age less than 16 or greater than 50 years
  • Inadequate serological response to pneumococcal vaccination
  • A history of previous invasive pneumococcal disease
  • Splenectomy for underlying haematological malignancy particularly in the context of on-going immunosuppression
  • Poor clinic attendees
  • Patients with sickle cell disease with surgical splenectomy

Prophylactic Antibiotics for Adult Patients with an Absent or Dysfunctional Spleen

Infection

First line antibiotics

If penicillin allergy

Comment

Prophylaxis for patients with an absent or dysfunctional spleen

Phenoxymethylpenicillin 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 doses of amoxicillin are preferable.

Treatment doses

Amoxicillin PO 500mg to 1g every 8 hours

Erythromycin PO 500mg to 1g every 6 hours

Amoxicillin advantages: absorption not affected by food, broader spectrum

A supply of treatment doses of amoxicillin should be kept at home (and on holidays) and used immediately should infective symptoms of raised temperature or malaise develop. In such a situation, the patient should seek urgent medical attention

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Patient Education & Documentation

Patient Education & Documentation

  • Patients developing infection, despite measures, must be given systemic antibiotics and admitted urgently to hospital.
  • Patients should be given written information and carry a card to alert health professionals to the risk of overwhelming infection. Patients may wish to invest in alert bracelet or pendant. Please see the Public Health Agency website to print out the alert card and patient information leaflet .
  • Patients should be educated as to the potential risks of overseas travel, particularly regarding malaria and unusual infections, for example resulting from animal bites. Co-amoxiclav (or appropriate alternative in penicillin allergy) is recommended after animal bites.
  • The front cover of patient records should be clearly labelled to indicate the underlying risk of infection from absent or dysfunctional spleen.
  • Vaccination and revaccination status should be clearly and adequately documented.
  • It may be appropriate to advise people that they are at risk of infection with the agent associated with red water fever in cattle and that they should take precaution against tick exposure (wear protective clothing in tick infested areas) when walking in the countryside.

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References

References ​

1. Royal College of Physicians of Ireland, National Immunisation Advisory Committee (NIAC) Immunisation Guidelines for Ireland Royal College of Physicians of Ireland Website > Healthcare Leadership > NIAC > Immunisation Guidelines for Ireland (Accessed October 2024)

- Chapter 3 – Immunisation of immunocompromised persons (updated 30 May 2023 )

- Chapter 5a – COVID-19 (updated 30 August 2024)

- Chapter 16 – Pneumococcal infection (updated July 2018 )

- Chapter 13 – Meningococcal infection (updated October 2019 )

2. Davies et al. Review of guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen: Prepared on behalf of the British Committee for Standards in Haematology by a Working party of the Haemato-Oncology Task Force British Journal of Haematology 2011;155:208-317

3. IDSA Clinical Guidelines for Vaccination of the Immunocompromised Host 2013

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Appendix 4: Chemoprophylaxis for Contacts of Meningococcal & Hib Disease

Appendix 4: Chemoprophylaxis for Contacts of Meningococcal & Hib Disease

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Management of Contacts of Meningococcal Disease (Meningitis/Septicaemia)

Management of Contacts of Meningococcal Disease (Meningitis/Septicaemia)

  1. Immediately notify all cases of suspected invasive meningococcal disease to the local Public Health Department 071 - 9852900 (contact out-of-hours through Ambulance control 0818501999), without waiting for microbiological confirmation.
  2. Public Health will advise on the management of contacts and suspected outbreaks.
  3. Close contacts of all cases of invasive meningococcal disease are at increased risk of developing infection. This risk is highest in the first 7 days following onset of symptoms in the index case.
  4. Chemoprophylaxis should be offered to close contacts irrespective of vaccination status and should be given as soon as possible after notification of the index case, preferably within 24 hours of diagnosis but can be given up to one month later if a contact is not immediately identified or traced.
  5. Medical teams are only required to prescribe prophylaxis for direct family contacts of the index case. All other contacts should be referred to the Public Health team.
  6. The following is provided for information in relation to close contacts who should be offered chemoprophylaxis:
    • Household-type contacts are defined as those who in the seven days prior to the onset of illness of the index case e.g.
      • shared living/sleeping accommodation with the index case, pupils in the same domitory, boy/girlfriend, university students sharing kitchen in a hall of residence, child-minders and baby-sitters.
      • Intimiate mouth to mouth kissing contacts with the index case.
      • Nursery/crèche contacts where the nature of contact is similar to that for household contacts, including adult carers.
      • Other siutations with possible close contact (e.g. attendance at a house party, classmates, extended family) may also warrant prophylaxis in certain circumstances as advised by Public Health .
    • Health Care Workers (HCWs) (including those present at autopsy) whose mouth and nose is directly exposed to respiratory droplets or secretions of a probable or confirmed case within 24 hours of commencement of antibiotics i.e. those carrying out high risk procedures and when within one metre of the patient. HCWs should wear masks when in close contact with an infectious case in the first 24 hours after starting antibiotic treatment. Occupational Health should be contacted if necessary.
    • The index case should be given chemoprophylaxis before discharge from hospital UNLESS treated with cefTRIAXone.
  7. Prophylactic antibiotics
    • ​Recipients should be given information on symptoms and signs of disease and the need to seek urgent medical advice should they become unwell, even if they have already received chemoprophylaxis.
      • Ciprofloxacin is the overall antibiotic of choice for chemoprophylaxis in the North West except for the following:
        • If the index case received ceftriaxone treatment in hospital, otherwise chemoprophylaxis should be given to the patient before discharge.
        • For those who have other contra-indications to the use of ciprofloxacin e.g. allergy, please review options.
        • Please refer to the most recent SPC available at The Health Products Regulatory Authority (hpra.ie) for contraindications, allergies or potential drug interactions.
  8. For more comprehensive guidance see the Royal College of Physicans of Ireland Immunisation Guidelines for Ireland - Chapter 13 - Meningococcal Infection.

Dose of Ciprofloxacin for Meningococcal Chemoprophylaxis

Age

Dose

Adults & children >12 years

A single oral dose of 500mg

Children 5-12 years

A single oral dose of 250mg

Children <5 years

A single oral dose of 30mg/kg up to a max of 125mg

Ciprofloxacin is also the preferred chemoprophylaxis agent for:

• women on the contraceptive pill (rifampicin may interfere with efficacy)

• women who are pregnant

Reference:
1. Royal College of Physicans of Ireland: National Immunisation Advisory Committee- Immunisation Guidlines for Ireland Chapter 13 - Meningococcal Infection - Updated October 2019

2. HPSC Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including meningococcal disease) Jan 2012 (revised Nov 2016)

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Management of Contacts of Invasive Haemophilus Influenzae B Disease

Management of Contacts of Invasive Haemophilus Influenzae B Disease

  1. Immediately notify all cases of suspected invasive Hib disease to the local Public Health Department 071 - 9852900 (contact out-of-hours through Ambulance Control 081501999), without waiting for microbiological confirmation.
  2. Public Health will advise on the management of contacts and suspected outbreaks .
  3. The following is provided for information:
    • Chemoprophylaxis: Indicated for all household contacts (irrespective of age, immunisation history, pregnancy or breastfeeding) in the following situations (and for up to four weeks after exposure):
      • If there are any unvaccinated or incompletely vaccinated children under the age of 10 years.
      • If there are any persons at increased risk of invasive Hib disease (asplenia, hyposlenism, immunocompromised etc.).
    • Play-group, crèche or school contacts aged less than 10 years: when 2 or more cases occur within 2 months, chemoprophylaxis should be offered to all room contacts, both adults and children.
    • Index patients aged <10 years with confirmed or probable invasive Hib disease treated with an antibiotic other than cefoTAXime or cefTRIAXone should receive ciprofloxacin prior to hospital discharge.
    • Index cases of any age treated with an antibiotic other than cefoTAXime or cefTRIAXone should receive ciprofloxacin chemoprophylaxis prior to hospital discharge if there is a vulnerable individual in the household.
    • Vaccination: In addition to prophylaxis, unvaccinated or partially vaccinated contacts should complete the age-appropriate vaccination schedule.
  4. For more comprehensive guidance see the RCPI's Immunisation Guidelines for Ireland

References:

1. Immunisation Guidelines for Ireland https://www.rcpi.ie/Healthcare-Leadership/NIAC/Immunisation-Guidelines-for-Ireland . Chapter 7- Haemophilus influenzae type b (updated July 2018)

2. HPSC Guidelines for the Early Clinical and Public Health Management of Bacterial Meningitis (including meningococcal disease) Jan 2012 (revised Nov 2016)

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Appendix 5: Drug Interactions and Warnings with Antimicrobials

Appendix 5: Drug Interactions and Warnings with Antimicrobials

As with all medication, there is potential for interactions and side effects when prescribing antimicrobials. Please review the Prescribing Principles prior to prescribing antimicrobials. The HSE Antibiotic Prescribing website contains useful information on the safe prescribing of antibiotics.

Including the following:

All antimicrobials should be reviewed for interactions with prescribed medicines at the point of prescribing and discuss with Microbiology if necessary. The most important drug-drug interactions occur within the following drug or classes or drugs:

  • Macrolides e.g. Clarithromycin and Erythromycin
  • Fluoroquinolones e.g. Ciprofloxacin
  • Rifamycins e.g. Rifampicin
  • Azole antifungals e.g. Fluconazole
  • Antiretrovirals (ARVs)
  • Hepatitis C direct acting agents (DAAs)
  • Linezolid
  • Paxlovid (Nirmatrelvir/ritonavir)

A list of the patients current medication along with any antimicrobials prescribed can be inputted into the following interactions checker:

or

  • You can access Stockleys interaction checker on any hospital desktop computer via the Linkopolis icon -> Pharmacy Medicine Information -> Prescribing -> Drug Interaction Checkers -> All Medicines- Stockleys

The following interaction checkers can be used for more specific drug-drug interactions and are available online. Please use the linked sources below to cross check prescribed antimicrobials with prescribed medication.

If any queries regarding interactions between drugs not available in the above resources please contact the ward pharmacist or LUH dispensary on extension 8961 or 3551.

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Fluoroquinolone Warning

Systemtic fluoroquinolones (by mouth, injection, or inhalation) e.g. ciprofloxacin and levofloxacin can very rarely cause long-lasting (up to months or years), disabling, and potentially irreversible adverse effects , sometimes affecting multiple systems and organs e.g. tendons, muscles, joints, nerves and aorta.

  • The risk of tendinopathy is increased in elderly patients or those with concomitant steroid use, renal disease, or post-transplant (heart/lung/kidney). Tendon damage can occur within 48hours of commencing treatment or effects can be delayed for several months after stopping.
  • Fluoroquinolone use is also associated with QTc prolongation (which can lead to torsades de pointes and ventricular fibrillation), C. difficile colitis, aortic aneurysm rupture/dissections and heart valve regurgitation /incompetence.
  • Fluoroquinolones can lower the seizure threshold and are not recommended in patients with a history of seizures/epilepsy.
  • Fluoroquinolones can cause an exacerbation of Myasthenia Gravis .
  • See the Summary of Product Characteristics via the HPRA website for full product information.

Patients should be informed to stop treatment with a fluoroquinolone antibiotic at the first sign of a side effect involving muscles, tendons or bones (such as inflamed or torn tendon, muscle pain or weakness, and joint pain or swelling) or the nervous system (such as feeling pins and needles, tiredness, depression, confusion, suicidal thoughts, sleep disorders, vision and hearing problems, and altered taste and smell).

References:

European Medicines Agency 5 October 2021: Fluoroquinolone and quinoloneantibiotics: PRAC recommends new restrictions on use following review of disabling and potentially long-lasting side effect [Accessed June 2024]

Summary of Product Characteristics Ciprofloxacin (Ciproxin) 500mg film coated tablets [Accessed 05/06/24]

Fluoroquinolone Warnings - HSE.ie

Medicines and Healthcare products Regulatory Agency (MHRA) 21 March 2019: Fluoroquinolone antibiotics: new restrictions and precautions for use due to very rare reports of disabling and potentially long-lasting or irreversible side effects [Accessed June 2024]

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Appendix 6 : High Tech Antimicrobials

Appendix 6: High Tech Antimicrobials

The following antimicrobials are classified by the HSE as high tech medicines:

  • Fidaxomicin (oral)
  • Linezolid (oral)
  • Voriconazole (oral)
  • Tobramycin (nebules)

The High Tech drugs scheme is administered by the HSE through the Primary Care Reimbursement Service (PCRS).

If a patient is being discharged on a high tech drug, the team are responsible for ensuring that the patient and the prescription have been registered with the PCRS via the high tech hub before the patient is discharged. The team are also responsible for ensuring that the appropriate section of the high tech prescription is sent to the nominated community pharmacy. This should be done at least 24hrs prior to the patient being discharged (Monday –Friday) or 48hrs at weekends. This is necessary to avoid unnecessary delays in patients accessing high tech medicines and the associated potential for treatment interruptions.

For further information please contact the ward Pharmacist or LUH dispensary on ext 8961 or 3551.