Professional Documents
Culture Documents
Prescribing Guidelines
Classification: Clinical Guideline
Lead Author: Antibiotic Steering Committee
Additional author(s): Kelly Alexander / Frances Garraghan /
Dr Ahmed Qamruddin / Dr Melissa Whitworth / Dr Teresa Kelly
from Central Manchester Foundation Trust Hospitals.
Authors Division: DCSS & Tertiary Medicine
Unique ID: 144TD(C)25(J2)
Issue number: 1
Date approved: Medicines Management Group - May 2014
Contents
Intro
Section
Page
2
2
2
4
5
6
Standards
Roles and Responsibilities
11
11
Appendix
12
14
Guideline
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6
7
8
9
11
11
Page 1 of 13
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Page 2 of 13
Background
Antimicrobial agents are among the most commonly prescribed drugs and account
for 20% of the hospital pharmacy budget. Unfortunately, the benefits of antibiotics to
individual patients are compromised by the development of bacterial drug resistance.
Resistance is a natural and inevitable result of exposing bacteria to antimicrobials.
Good antimicrobial prescribing will help to reduce the rate at which antibiotic
resistance emerges and spreads. It will also minimise the many side effects
associated with antibiotic prescribing, such as Clostridium difficile infection. It should
be borne in mind that antibiotics are not needed for simple coughs and colds. In
some clinical situations, where infection is one of several possibilities and the patient
is not showing signs of systemic sepsis, a wait and see approach to antibiotic
prescribing is often justified while relevant cultures are performed.
This document provides treatment guidelines for the most common situations in
which antibiotic treatment is required. The products and regimens listed here have
been selected by the Trust's Medicines Management Group on the basis of
published evidence. Doses assume a weight of 60-80kg with normal renal and
hepatic function. Adjustments may be needed for the treatment of some patients.
This document provides treatment guidelines for the appropriate use of antibiotics.
The recommendations that follow are for empirical therapy and do not cover all
clinical circumstances. Alternative antimicrobial therapy may be needed in up to 20%
of cases. Alternative recommendations will be made by the microbiologist in
consultation with the clinical team.
This document refers to the treatment of adult patients (unless otherwise stated).
Please refer to up to date BNF/SPC for a full list of cautions, contra-indications,
interactions and adverse effects of individual drugs.
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Page 3 of 13
Guideline
Empiric treatment for unknown source of maternal infection / sepsis
Infection
Maternal
sepsis
(unknown
origin)
Clinically
stable
Maternal
sepsis
Severe
sepsis, septic
shock
IV treatment
Oral treatment
First line
Penicillin allergy
First line
Penicillin allergy
Non-severe delayed:
Co-amoxiclav 1.2g tds
Co-amoxiclav 625mg tds No ideal oral options
plus
plus
Cefuroxime 1.5g tds
consider completion
plus
metronidazole 500mg tds if
metronidazole 400mg tds of IV antibiotic
intra-abdominal collection
Metronidazole 500mg tds
if intra-abdominal
course.
suspected
collection suspected
Clindamycin 450mg
Likely IgE / severe delayed:
IV/po qds plus
Clindamycin 600mg qds
ciprofloxacin 500mg
plus
orally bd may be used
metronidazole 500mg tds
where benefit
plus
outweighs risk.
Gentamicin stat
Choose appropriate route based on clinical condition
Non-severe delayed:
Piperacillin/tazobactam 4.5g
Step down based on
tds
Meropenem 1g tds
culture and sensitivity
plus
Likely IgE / severe delayed: results
metronidazole 500mg tds if
intra-abdominal collections
Clindamycin 600mg qds
suspected
PLUS
metronidazole 500mg tds.
Plus gentamicin IV
First dose of antibiotics should be given within 1 hour.
Consider risk of MRSA and consult microbiology if needed.
Consider a stat dose of gentamicin IV review at 24 hours
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Total duration
Review at 24 hours.
If no improvement
discuss with micro
Total course length
7 - 10 days
Review at 24 hours.
If no improvement at
24 hours discuss with
microbiology.
Pyrexia in labour
Procedure
Pyrexia in
labour
defined as:
38.0 C once
or 37.5 C on
two
occasions 2
hours apart
Penicillin allergy
Previous / current Post delivery doses
Non-severe
Likely IgE / severe MRSA colonised
delayed:
delayed:
Intrapartum fever (>38C) carries a 1 in 167 risk of early onset group B streptococcus infection in the newborn. It may also indicate
intrauterine infection / chorioamnionitis. Therefore therapy is targeted to cover all of these possibilities. Less common causes include
UTIs symptoms should be investigated.
Temperature should be checked every 4 hours during labour. Once pyrexia has been detected, temperature should be checked hourly.
Investigations: FBC, CRP, blood cultures, urine for culture and sensitivity and a vaginal swab as a minimum. Other investigations e.g,
swabs/pus as directed by Obstetrician. Monitor for other signs of infection; maternal or fetal tachycardia, uterine tenderness and
offensive smelling amniotic fluid
General management: to reduce pyrexia, anti-pyretic (paracetamol), hydration with cold fluids, tepid sponging, reduce ambient
temperature.
Non-infective causes of raised temperature (e.g. misoprostol) are common during labour but usually resolve within 6 hours of delivery
Co-amoxiclav 1.2g IV tds
Cefuroxime 1.5g IV
Clindamycin 600mg Discuss with
Continue antibiotics for 24 hours post
microbiology
(+ metronidazole
IV stat then qds
delivery. If no further episodes of
500mg IV if cplus
pyrexia have occurred and there are
section) tds
IV gentamicin
no other signs of infection stop
antibiotics.
For patients with ongoing signs of infection (raised temperature, CRP, WCC, tachycardia etc.) post delivery antibiotics should be
continued for a minimum of 5 days and investigations performed to identify the source of infection.
For patients with pyrexia in labour associated with a surgical intervention e.g. caesarean section, continue recommended prophylactic
antibiotics for 24 hours post delivery. If no further episodes of pyrexia have occurred and there are no other signs of infection stop
antibiotics.
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Group B Haemolytic
Streptococcus
prophylaxis
Benzylpenicillin 3g
IV stat. Then
Benzylpenicillin
1.5g four hourly
until delivery
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Penicillin allergy
Non-severe
Likely IgE / severe
delayed:
delayed:
Clindamicin 900mg IV stat then Clindamycin
900mg eight hourly until delivery
Previous / current
MRSA colonised
Page 6 of 13
Intra-abdominal infections
***NB*** Please note that the following treatment guideline for intra-abdominal infections refer to treatment in pregnant women ONLY. For the
Trust policy on intra-abdominal sepsis in other patient groups, click here.
Intra-abdominal sepsis
1st line
Antibiotics
Co-amoxiclav
Route
IV
Dose
1.2g
Frequency
tds
IV
500mg
tds
IV
4.5g
tds
IV
1g
tds
Non-severe delayed:
Meropenem 1g TDS
Likely IgE / severe delayed: Discuss with micro
Add
2nd line
Non- response to first line
Recent ITU admission
Likely pseudomonas
infection
3rd line
Oral continuation
Metronidazole if
collection present
Piperacillin /
tazobactam
Meropenem
Only after
discussion with
microbiology
Co-amoxiclav
Add
Metronidazole if
collection present
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Duration
5-10 days
therapy, but
may be
longer (e.g
liver abscess,
4-6 weeks)
Consider adding gentamicin IV stat if >2 signs and symptoms of sepsis (SIRS)
Review at 24 hours
po
625mg
tds
No ideal oral options consider completion of IV antibiotic
course.
po
400mg
tds
Clindamycin 450mg IV/po qds plus ciprofloxacin 500mg
orally bd may be used where benefit outweighs risk.
Page 7 of 13
Route
Dose
Frequency
Duration
Cefalexin
po
500mg
tds
7 days
Trimethoprim
Nitrofurantoin
po
po
200mg
50mg
bd
qds
7 days
Alternative in
penicillin allergy
See below (if
anaphylaxis)
Comments
NA
Clindamycin and macrolides (erythromycin, clarithromycin) are not excreted in the urine therefore are not suitable treatment
Amoxicillin may be used where sensitivities are known.
Co-amoxiclav may be used but cefalexin is preferred as more narrow spectrum
IV therapy
Antibiotics
Pyelonephritis /
Complicated UTI
Co-amoxiclav
Severe uro-sepsis
st
Failure of 1 line
Recent ITU
admission
Culture +ve for
pseudomonas
Piperacillin /
tazobactam (Tazocin)
Oral Phase
Trimethoprim
Cefalexin
Co-amoxiclav
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Route
Dose
Frequency
Duration
Alternative in penicillin
Comments
allergy
IV
1.2g
tds
7-14 days Non-severe delayed:
Cefuroxime 750mg-1.5g tds
Likely IgE / severe
delayed:
Gentamicin IV
Non-severe delayed:
IV
4.5g
tds
Meropenem 1g TDS
Likely IgE / severe
delayed:
Discuss with micro
Consider addition of gentamicin IV stat if >2 signs and symptoms of sepsis (SIRS)
Review at 24 hours
According to cultures and sensitivities
Avoid in 1st trimester
po
200mg
bd
10-14 days
See alternatives
in total
po
500mg
tds
po
625mg
tds
Obstetric Anti-Infective Prescribing Guidelines.
Page 8 of 13
IV
1g
tds
7-14 days
Comments
Unlicensed
Reduce frequency in renal impairment
IV option
Contaminated/dirty surgery
2nd line:
st
Non-response to 1 line
Oral continuation
MRSA skin colonisation
Antibiotics
Flucloxacillin
Route
IV
po
IV
Dose
1-2g
500mg
1.2g
Frequency
qds
qds
tds
Duration
Total duration 5
to 7 days
According to
response 7-14
days
Non-severe delayed:
Cefuroxime 1.5g IV tds plus metronidazole
po
625mg
tds
500mg IV tds
Likely IgE / severe delayed: Clarithromycin
500mg IV bd plus metronidazole 500mg IV
tds
Non-severe delayed:
Piperacillin /
IV
4.5g
tds
tazobactam
Meropenem 1g TDS
Likely IgE / severe delayed:
(Tazocin)
Clarithromycin 500mg IV bd + ciprofloxacin
500mg po bd + metronidazole 500mg IV tds
OR Clindamycin 450mg IV/po bd +
ciprofloxacin 500mg po bd
Consider adding IV gentamicin stat if >2 signs and symptoms of sepsis (SIRS)
Review at 24 hours
Modify this according to response & culture / sensitivity results.
Add / substitute (for flucloxacillin) vancomycin IV or teicoplanin if post delivery
Co-amoxiclav
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Antibiotics
Flucloxacillin
Co-amoxiclav
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Route
IV
Dose
1-2g
Frequency
qds
po
IV
500mg
1.2g
qds
tds
po
625mg
tds
Duration
Total
duration 5 to
7 days.
Up to 2
weeks if
abscess
present or
as clinically
indicated
Page 10 of 13
Genitourinary infections
Please refer to the Trusts Treatment Management Protocols for Sexually Transmitted Infections.
Gentamicin in pregnancy
Neonatal ototoxicity has not been observed with use of gentamicin in pregnancy however it has
been seen with other aminoglycosides, therefore gentamicin should be used with caution in
pregnancy. Where possible use only a stat dose or the shortest effective course.
For guidance on dosing gentamicin, please refer to the Trust policy on Once Daily Gentamicin
Dosing.
Please note that in pre-eclampsia, gentamicin clearance is reduced and levels should be
checked daily.
Standards
Ensure the choice of antibiotic complies with the antibiotic guidelines and you have
documented any clinical criteria relevant to the choice of agent.
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Appendices
Summary of safety information for antibiotics in pregnancy
Antibiotic class
Penicillins
Cephalosporins
Macrolides
Clarithromycin
Metronidazole
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Has been
extensively used
in pregnancy.
Erythromycin
preferred due to
limited data for
clarithromycin.
Has been
extensively used
in pregnancy.
Page 12 of 13
Antibiotic class
Carbapenems
Clindamycin
Fosfomycin
Glycopeptides
Pivmecillinam
(Note this is a
penicillin)
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