Guidance for initial hospital therapy in adults.

Infection Management Guideline: Empirical Antibiotic Therapy Specialist units may have separate policies.
STOP AND THINK BEFORE YOU GIVE ANTIBIOTIC THERAPY! Antibiotics are overused particulary in the elderly, patients with urinary catheters or suspected UTIs and in patients with viral or non-infective exacerbations of COPD. Always
obtain cultures and consider delay in therapy unless there is a clear anatomical site of infection with high probability of bacterial aetiology, if sepsis syndrome is present or if there is clinical deterioration. Record indication and SIRS score in case notes.
INDICATIONS FOR IV ROUTE (see IVOST guidelines) SIMPLIFY, SWITCH, STOP and STATE Duration! DEFINITION OF SEPSIS (Systemic Inflammatory Response Syndrome (SIRS)) - PLEASE RECORD IN CASE NOTES
IV antibiotic therapy should be commenced within 1 hour of recognition of sepsis or severe Clinical symptoms of infection (sweats, chills, malaise, rigors etc) PLUS 2 or more of the following:
infection in the clinical area where the diagnosis has been made. SIMPLIFY Use narrow spectrum agents whenever possible.
Temp <36C or >38C, HR >90bpm, RR >20/min and WCC <4 or >12 x109/L
1. Sepsis or severe sepsis or deteriorating clinical condition
SWITCH In the absence of +ve microbiology and specific situations (see indications for IV route) Severe sepsis: Sepsis + Organ dysfunction/ hypoperfusion eg. oliguria or urine <40ml/hr, confusion, lactic acidosis or hypotension (eg. systolic BP
2. Febrile with neutropenia/ immunosuppression
switch to oral therapy when signs of sepsis are resolving and oral route is not compromised. <90mmHg or reduction of 40mmHg from baseline)
3. Specific indications: endocarditis, deep abscess, bronchiestasis,
meningitis, CNS infection, bone/joint infection, S.aureus bacteraemia, CF, STOP Observe indicated duration of therapy and stop if alternative non-infectious diagnosis is made. NB. Signs of sepsis may be masked in immunosuppression, the elderly and in the presence of anti-inflammatory drugs or beta-blockers.
intra-abdominal / biliary sepsis infection. RECORD INDICATION, SEPSIS CRITERIA AND DURATION FOR ANTIBIOTIC IN NOTES Culture Blood Collect 2 or more (8-10mls each bottle) and appropriate area ie. Urine, sputum, CSF, wound or venous access site
4. Skin and soft tissue infection: IV therapy if sepsis or 2 of heat, erythema, ORAL DURATION SHOULD ALSO BE RECORDED IN KARDEX
induration/ swelling (usually IV for 48-96 hours)
5. Oral route compromised: nil by mouth, reduced GI absorption, mechanical
NB. Recomended doses are based on normal renal / liver function, Clostridium difficile infection is associated with prescribing of; Cephalosporins, Co-amoxiclav, Clindamycin, Quinolones (Ciprofloxacin,
swallowing disorder, unconscious, no oral formulation, vomiting see BNF for dose adjustments in renal / liver impairment. Levofloxacin, Moxifloxacin, Ofloxacin) and Piperacillin + Tazobactam. These agents must be restricted to reduce selection pressure.
Gastric acid suppression may predispose the patient to Clostridium difficile. Stop gastric acid suppressive therapy if possible.
m Immunocompromised
Lower respiratory tract Skin / soft tissue Gastro-intestinal Urinary tract Bone / joint infection CNS infection Severe systemic infection
patient ? source

Pneumonia
CURB 65 score:
Confusion (new onset),
Urea >7mmol/L,
RR30/min,
BP diast 60 or syst BP<90 mmHg
Age 65 yrs
Non-severe community-
acquired pneumonia (CAP)
CURB 65 score: 0-1
Amoxicillin 500mg 8hrly
or Doxycycline 200mg stat then
100mg daily
or *Clarithromycin 500mg 12hrly
Duration 7 days
CURB 65 score: 2 (and no sepsis)
Amoxicillin 500mg 8hrly and either
Doxycycline 200mg stat then
100mg daily
or *Clarithromycin 500mg 12hrly
or if true penicillin allergy
*Clarithromycin 500mg 12hrly
(single therapy)
Duration 7 days
Severe CAP
CURB 65 score: 3 or
CAP PLUS sepsis syndrome:
IV or oral *Clarithromycin 500mg
12hrly and either
IV Amoxicillin 1g 8hrly or
IV Co-amoxiclav 1.2g 8hrly (if previous
treatment in the community)
or if true penicillin allergy
IV or oral Levofloxacin 500mg 12hrly
NB. oral bioavailability 99-100%
Duration 7-10 days (IV/oral) or up to 14
days if atypical suspected or bacteraemia
Hospital-acquired pneumonia
4 days of admission
Treat as for CAP (see above)
Duration 7 days (IV/oral)
5 days admission or within 7 days
discharge from hospital
CURB 65 score: 2 and no sepsis
Oral Co-amoxiclav 625mgs 8 hrly or oral
Doxycycline 200mg stat then 100mg 12 hrly
Duration 7 days
5 days admission or within 7 days
discharge from hospital
CURB 65 score: 3 or sepsis syndrome
IV Amoxicillin 1g 8hrly
+ IV Aztreonam 2g 8hrly
or if true penicillin allergy
IV or oral Levofloxacin 500mg 12hrly
NB. oral bioavailability 99-100%
Duration 7 -10 days (IV/oral) or up to 14
days if atypical suspected or bacteraemia
EXAC of COPD / LRTI
Antibiotics only if purulent sputum.
Oral therapy usually. Dual therapy
not recommended
Amoxicillin 500mg 8hrly or
Doxycyline 200mg stat then
100mg daily or
*Clarithromycin 500mg 12hrly
Duration 5 days
? LRTI / UTI
Non severe
Doxycyline 200mg stat then 100mg daily
or Amoxicillin 500mg 8hrly
Duration 5 days
PLUS Trimethoprim 200mg 12hrly
Duration females 3 days or males 7 days
Severe / sepsis
see Severe systemic infection ? source
ORAL THERAPY USUALLY RECOMMENDED
* Clarithromycin is known to have serious drug interactions and may
prolong the QTc interval. Avoid in patients with other risk factors for QTc
prolongation.See BNF (appendix 1) or contact pharmacy for details
Severe / complicated
infective EXAC of COPD
Use IV therapy if indication for IV
route (see above) or ventilation
required or sepsis.
IV Amoxicillin 1g 8hrly or
IV *Clarithromycin 500mg 12hrly
Duration 7 days (IV/oral)
NB. Doxycycline not available IV.
Aspiration pneumonia
IV Metronidazole 500mg 8hrly
and either
IV Amoxicillin 1g 8hrly or
IV *Clarithromycin 500mg 12hrly
Duration 7 days (IV/oral)
Suspected necrotising fasciitis or any rapidly spreading
infection / severe soft tissue infection in IVDU
IV Flucloxacillin 2 g 4 - 6 hrly + IV Benzylpenicillin 2.4g 6 hrly
+ IV Gentamicin** + IV Clindamycin 600mg 6hrly (up to 1200mg 6hrly)
+ IV Metronidazole 500mg 8hrly AND CONSIDER EARLY DEBRIDEMENT/
EXPLORATION / SURGICAL REFERAL
If MRSA suspected or if true penicillin allergy REPLACE Flucloxacillin
+ Benzylpenicillin with IV Vancomycin**
At 48 hours discuss with microbiology / ID before changing to oral
Duration as per microbiology / ID advice
Mild soft tissue
infection
Flucloxacillin 1g 6hrly
or if true penicillin allergy
Doxycycline 100mg 12hrly or
*Clarithromycin 500mg 12hrly
Duration 7 days seizures, reduced GCS, CNS
Mild human or animal bite
or peri-anal soft tissue
infection
Co-amoxiclav 625mg 8hrly
or if true penicillin allergy
Doxycycline 100mg 12hrly
+ Metronidazole 400mg 8hrly
Duration 7 days
Moderate cellulitis
IV Flucloxacillin 1-2g 6hrly
or if true penicillin allergy
IV Vancomycin**
Total duration 10 days (IV/oral)
Severe or rapidly progressing
Cellulitis (non drug user)
IV Flucloxacillin 2g 4 - 6hrly
+ IV Gentamicin** (max 3-4 days)
+ IV Clindamycin 600mg 6hrly
or if true penicillin allergy REPLACE
Flucloxacillin with IV Vancomycin**
Duration 10 days (IV/oral)
Severe human or animal
infected bite or peri-anal
infection
IV Co-amoxiclav 1.2g 8hrly
or if true penicillin allergy
IV Metronidazole 500mg 8hrly
+ IV *Clarithromycin 500mg 12hrly
+ IV Gentamicin** (max 3-4 days)
Duration 10 days (IV/oral)
Gastroenteritis
Antibiotic not usually required
Clostridium difficile Infection (CDI)
Treat before laboratory confirmation
if suspected CDI (loose stools plus
recent antibiotics or hospitalisation).
Discontinue if toxin negative.
Stop / simplify concomitant antibiot-
ics and gastric acid suppressive
therapy if possible. Ensure adequate
hydration
1st episode / 1st relapse
Severity markers; colonic dilatation
>6cm, WCC >15 x109/L, Creatinine
>1.5 x baseline, temp > 38.5C or
immunosuppression
Severity markers = 0;
oral Metronidazole 400mg 8hrly
Severity markers 1 or no
improvement after 5 days of
metronidazole
oral Vancomycin 125mg 6 hrly
Duration 10 days
2nd episode / or subsequent relaps-
es discuss mith microbiology / ID
Intra abdominal sepsis
IV Amoxicillin 1g 8hrly
+ IV Metronidazole 500mg 8hrly
+ IV Gentamicin** (max 3-4 days)
or if true penicillin allergy
IV Vancomycin**
+ IV Metronidazole 500mg 8hrly
+ IV Gentamicin** (max 3-4 days)
If frail elderly patients or eGFR < 50ml/
2 renal impairment)
min/1.73m prescribe the above but
REPLACE Gentamicin with
IV Aztreonam 2g 8-12 hrly depending on
serverity of infection
Biliary tract infection as above,
Pancreatitis does not require anti-
biotic therapy unless complicated by
gallstones
Duration up to 7 days (IV/oral),
but dependent on clinical review
Spontaneous bacterial
peritonitis
Chronic liver disease with ascites
and peritoneal white cell count >
500/mm3 or >250 neutrophils/mm3
IV Co- amoxiclav 1.2g 8hrly
or if true penicillin allergy
IV or Oral Ciprofloxacin 12hrly
+ IV Vancomycin**
Duration 7 -10 days (IV/oral),
but dependent on clinical review
Lower UTI / cystitis in non
pregnant women
Antibiotics if; urinary symptoms,
frequency, dysuria. Obtain urine
culture.
Trimethoprim 200mg 12hrly
or Nitrofurantoin 50mg 6hrly
Duration 3 days
Lower UTI in men (without sepsis)
Send urine for culture and consider
prostatitis (see therapeutics handbook)
Trimethoprim 200mg 12hrly
or Nitrofurantoin 50mg 6hrly
Duration 7 days
Upper UTI in non pregnant
women and men (without sepsis)
Trimethoprim 200mg 12hrly
or if resistant organisims suspected
Co-amoxiclav 625mg 8hrly
or if true penicillin allergy
Ciprofloxacin 500mg 12hrly
Duration 7 days
Pyelonephritis with sepsis
or oral route compromised in
non pregnant women and men
IV Amoxicillin 1g 8hrly
+ IV Gentamicin** (max 3-4 days)
IVOST to oral Co- amoxiclav 625mg
8 hrly
or if true penicillin allergy
IV Gentamicin** monotherapy
(max 3-4 days)
Discuss IVOST option with
microbiology / ID
Duration 7 days (IV/oral)
Catheter-related UTI
Remove / replace catheter and culture
urine.
Symptomatic bacteriuria without
sepsis
Give single dose of IV Gentamicin**
prior to catheter removal or if IV route
not available give single dose of Oral
Ciprofloxacin 500mg 30 minutes prior to
catheter removal
Symptomatic bacteriuria with sepsis
As above and treat as per Pyelonephritis
/ culture results
Septic arthritis / osteomyelitis
Urgent IV therapy
Consider underlying metal work,
recent surgery, risk factors for
IV therapy to be administered Which patient? Review all anatomical systems
MRSA
URGENTLY on arrival at Chemotherapy within 3 weeks, high dose Hospital vs community-acquired
Consider orthopaedic referral steroids (prednisolone>15mg/day for >2
hospital and after blood cultures. infection? E.coli, S. aureus and
weeks), other immunosuppressive agents
CT scan before LP if age >60, (e.g. anti-TNF, cyclophosphamide), transplant Pneumococcus are commonest
Diabetic foot sepsis patients ( solid organ or bone marrow) or community blood culture isolates
primary immunodeficiency. Please discuss
Assess ulcer, probes to bone, signs or immunosuppression. patients with HIV infection with the ID Brown-
neuropathy, peripheral vascular Seek ID / microbiology advice.
lee Centre.
Consider MRSA infection
disease, MRSA risk? healthcare associated sepsis,
Sepsis syndrome
For outpatient therapy consult recent hospital discharge, post-
Bacterial Meningitis Neutropenic sepsis : Neutrophil <0.5 or < 1.0
diabetic clinic guidelines and falling AND temp > 38C or < 36C on 2 operative wound or line-related
Always refer to senior staff occasions 30mins apart. sepsis or sepsis in previous or
Obtain synovial fluid / deep tissue IV Ceftriaxone 2g 12hrly + Patients on high dose steroids or severely current MRSA carrier.
immunocompromised may not have an in-
IV Dexamethasone 10mg 6hrly (for
as appropriate when possible creased temperature but present with low BP,
Consider severe Streptococcal
4 days) hypothermia and / or rigors.
or if true penicillin allergy sepsis e.g. pharyngitis, erythro-
Septic arthritis / osteomyelitis Neutropenic plus sepsis derma, hypotension.
IV Choramphenicol 1g 6hrly +
IV Dexamethasone 10mg 6hrly (for
Native joint IV Piperacillin / Tazobactam 4.5g 6hrly Source unknown
4 days)
IV Flucloxacillin 2g 6hrly If SIRS 2 or NEWS 5 IV Benzylpenicillin 1.2g- 2.4g 6hrly + IV
then seek ID / microbiology advice.
+ IV Gentamicin** (max 3-4 days) ADD IV Gentamicin** (review duration) Flucloxacillin 2g 4 - 6hrly
or if true penicillin allergy If age 50 years, immunosup- If suspected Staphylococcal infection (e.g. + IV Gentamicin** (max 3-4 days)
IV Vancomycin** pressed, pregnant, alcohol excess, line-related sepsis or soft tissue infection)
or if true penicillin allergy or MRSA
+ IV Gentamicin** (max 3-4 days) liver disease or if listeria meningitis ADD IV Vancomycin** suspected
suspected or If true penicillin allergy (anaphylaxis) IV Vancomycin**
Prosthetic joint ADD IV Amoxicillin 2g 4hrly to above IV Vancomycin** + IV Gentamicin** (max 3-4 days)
IV Vancomycin**
or if true penicillin allergy + IV Gentamicin** (review duration)
+ IV Gentamicin** (max 3-4 days)
ADD IV Vancomycin** to above + IV Ciprofloxacin 400mg 12hrly if severe Streptococcal infection sus-
pected ADD IV Clindamycin 600mg 6hrly
or If true penicillin allergy (not anaphylaxis)
(up to 1200mg 6hrly)
Diabetic foot osteomyelitis Duration 7 days (meningococcal), IV Vancomycin**
14 days (pneumococcal), 21 days Seek ID/ microbiology advice
as above PLUS oral metronidozle + IV Aztreonam 2g 8 hrly
400mg 8hrly (listeria).
If haematology/oncology patient discuss Possible infective endocarditis
with appropriate specialist and seek ID /
Duration (IV/oral) dependent on surgi- Possible viral encephalitis microbiology advice. If stem cell / solid organ
cal intervention. Usually 4 - 6 weeks. Consider if IVDU, line related sepsis, or
IV Aciclovir 10mg/kg 8hrly (see therapeu- transplant or acute leukaemia and associ-
recent dental extraction. Always seek
tics handbook for dosage alteration in
ated severe shock give IV Meropenm + IV
senior specialist advice.
Amikacin (see Neutropenic Sepsis in poster
for details)
Discuss management with ID. May require Immunocompromised patients with fever Native Heart valve
repeat LP or neuro-imaging to establish and no neutropenia IV Amoxicillin 2g 4hrly
diagnosis. If HSV/VSV confirmed continue Manage as per infection management
+ IV Flucloxacillin 2g 4hrly
therapy for 14-21 days IV (no oral switch) guidelines based on anatomical source + IV Gentamicin synergistic dosing
or if true penicillin allergy / penicillin
resistance / MRSA suspected
Avoid Gentamicin in patients with decompensated liver disease, contact microbiology or ID for advice IV Vancomycin**
**Gentamicin/ Vancomycin**
7. If Creatinine not available give gentamicin as follows, + IV Gentamicin synergistic dosing
1. To access dose calculator click on the clinical info Actual weight Gentamicin Dose
icon on staff intranet page. Prosthetic Heart valve
< 40Kg 5mg / kg,
2. Check creatinine / renal function daily. IV Vancomycin**
40-49kg 240mg,
3. Record accurate times of dose administration and + IV Gentamicin synergistic dosing
50-59kg 280mg,
concentration measurement. + oral Rifampicin t 70kg 450mg
60-69kg 320mg, 12hrly, > 70kg 600mg 12 hrly (oral so-
4. Contact pharmacy if advice required.
70-79kg 360mg, dium fusidate if rifampicin not suitable)
5. Do not use Gentamicin beyond 3 or 4 days unless on
80kg 400mg.
advice of mircobiology or ID.
6. Ototoxicity is associated with prolonged use of 8. If CKD5 give 2.5mg/kg (maximum 180mg)
NB discuss synergistic gentamicin dosing
with pharmacy. Duration as per micro/ ID
gentamicin. If the patient reports tinnitus, dizziness, poor 9. For gentamicin take a sample 6 -14 hrs after the start of advice. See therapeutics handbook.
balance, hearing loss, seeing objects oscillating, STOP the first infusion and review frequency once creatinine and
t Rifampicin is known to have serious drug
Gentamicin and contact Micro / ID. concentration are known.
interactions. See BNF (appendix1)
or contact pharmacy for details.
SEVERE INFECTIONS or INFECTIONS WHERE IV THERAPY IS USUALLY RECOMMENDED
Review Antibiotic therapy DAILY: Stop? Simplify? Switch?

RATIONALISE ANTIBIOTIC THERAPY when microbiology results become available or clinical condition changes.
Review IV therapy daily and remember IV-ORAL SWITCH
CRP- does not reflect the severity of infection and may remain elevated when the infection is resolving.
It cannot be used, in isolation, to assess the severity of infection and hence the need for IV therapy.
FURTHER ADVICE Can be obtained from the Duty Microbiologist or Clinical Pharmacist or the ID Unit (Brownlee Centre), Gartnavel General Hospital,
or your local Respiratory Unit (for pneumonia) or Therapeutics handbook. Infection Control advice may be given by the duty microbiologist.
Greater Glasgow & Cyde Antimicrobial Utilisation Committee, ADTC. August 2014 expires Aug 2017. Review updates on .www.ggcformulary.scot.nhs.uk/Guidelines MIS 165760/a.