1603 - 11th July 2013 - Attachement 1 - Adult Antibiotic Policy PDF

Antibiotic Guidelines
Treatment and Prophylaxis for

Adults
Document Type: Guideline
Version: Three
Date of Issue: October 2012
Review Date: October 2013
Lead Director: Consultant Microbiologists
Consultant Microbiologists / Antibiotic

Post Responsible for Update:
Pharmacist
Approving Committee: Antimicrobial Stewardship Committee
Approved by them in the

5th October 2012
minutes of:
Distribution to: All Trust staff via the Trust Intranet

Contents:
Heading Page
Heading (Insert Title)
Number Number
Contents / Risk rating 2
1 Introduction / Purpose 10
Aims of the guidance 10
Important Points 10
Prescribing an antimicrobial? 11
Considerations 12
Penicillin allergy 13
Conversion from Intravenous to Oral Antibiotics (Antibiotic 14
Switch)
Antibiotic Stop Policy 14
Extended duration of antibiotic treatment 15
Contact Numbers 15
Restricted Antimicrobials 16
Notification of infectious diseases 17
2.1 Bone and Joint Infections 20
Acute hematogenous osteomyelitis (Not associated with 20
bone/joint problems)
Contiguous osteomyelitis (associated with fracture or post 21
surgical bone reconstruction)
Contiguous osteomyelitis secondary to vascular 22
insufficiency and diabetic foot infection
Chronic osteomyelitis 22
Prosthetic joint infections 23
Septic arthritis (native joint) 24
Septic bursitis (Olecranon bursitis, prepatellar bursitis) 25
2.2 Central Nervous System Infections 26
Acute Bacterial Meningitis (empirical treatment) 26
Pathogen Specific Therapy 27
27
• Neisseria Meningitides
27
• Streptococcus Pneumoniae
27
• Haemophilus Influenzae
Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Page 2 of 120
27
• Listeria Monocytogenes
Viral Meningitis 28
Encephalitis 28
Brain abscess / subdural empyema 28
2.3 Ear, Nose and Throat Infections 29
2.3.1 Ear 29
29
• Otitis externa
29
• Acute localised (Furuncle)
29
• Acute, diffuse (swimmer’s ear)
29
• Fungal otitis externa
30
• Perichondritis
30
• Invasive “malignant” otitis externa
30
• Acute otitis media
31
• Acute mastoiditis
2.3.2 Nose 32
32
• Acute rhinosinusitis
33
• Orbital cellulitis
2.3.3 Throat 34
34
• Acute sore throat
34
• Peritonsillitis / Peritonsillar abscess or quinsy
35
• Epiglottitis / Supraglottitis
36
• Salivary gland infection
2.4 Gastrointestinal Infections 37
Gastro-enteritis 37
Empirical Treatment 37
Treatment Algorithm for C. Difficile Infection (CDI) 38
Pathogen SpecificTherapy 39

Page 3 of 120
39
• Campylobacter
39
• Salmonella
39
• Shigella
39
• E coli 0157:H7
39
• Vibro cholerae 01 or 0139
39
• Giardia Lamblia, Giardiasis
39
• Entamoeba histolytica, amebiasis
2.5 41
Genital Tract Infections
41
Bacterial vaginosis
41
Vaginal candidiasis
41
Trichomoniasis
42
Chlamydia trachomatis
42
Neisseria gonorrhoea
42
Pelvic inflammatory disease
2.6 43
Gynaecological and Pregnancy Related Infections
2.6.1 43
Obstetrics
• Lower Urinary Tract Infection (cystitis / 43
asymptomatic bacteriuria) in pregnancy
43
• Pyelonephritis in pregnancy
44
• Chorioamnionitis
44
• Post partum endometritis
45
• Post abortion infection
46
• Episiotomy infection
• Prevention of early onset neonatal group B 46
streptococcal (GBS) disease
47
• Preterm prelabour rupture of membranes
47
• Sepsis of unknown origin
2.6.2 48
Gynaecology
48
• Mastitis
48
• Surgical site infection after gynaecologic surgery
50
• Pelvic inflammatory disease
2.7 51
Infective Endocarditis
51
Empirical Treatment
Page 4 of 120
2.8 53
Intra-Abdominal Infections
53
• Diverticulitis
53
• Secondary peritonitis
54
• Primary (spontaneous) bacterial peritonitis
55
• Acute pancreatitis
2.8.1 56
Liver and biliary system
56
• Acute Chloecystitis
57
• Acute Cholangitis
57
• Pyogenic liver abscess
58
• Amoebic liver abscess
2.9 59
MRSA
2.10 60
Respiratory Tract Infections
60
Community acquired pneumonia (empirical)
62
Hospital Acquired, Postoperative or Ventilator Associated
Pneumonia
Acute Infective Exacerbation of Chronic Obstructive 63
Pulmonary Disease and Chronic Bronchitis
63
Acute Bronchitis
63
Upper Respiratory Tract Infections
63
Aspiration pneumonia
Infective Exacerbation of Bronchiectasis (not Cystic 64
Fibrosis)
Exacerbation of Bronchiectasis in Cystic Fibrosis 65
Lung Abscess 65
Pleural Empyema 67
Pathogen specific therapy 68
68
• Pneumococcal
68
• Staphylococcal
69
• Legionella
69
• Confirmed Q fever, psittacosis
69
• Mycoplasma, Chlamydia
69
• PCP
2.11 Sepsis, Severe Sepsis and Septic Shock 71

Page 5 of 120
Neutropenic sepsis 71
2.12 Skin and Soft Tissue Infections 73
73
• Cellulitis
74
• Erysipelas
74
• Furuncle or carbuncle
75
• Impetigo
75
• Infected chronic ulcers or pressure sores (non
diabetic)
76
• Diabetic Foot Infection
78
• Gangrenous cellulitis (Necrotising fasciitis or gas
gangrene)
78
• Burn wound infections
79
• Post-Operative wound infection
2.13 Urinary Tract Infections (UTI) 81
81
• Lower UTI uncomplicated (no urinary catheter)
81
• Systemic UTI’s
82
• Pyelonephritis
82
• Complicated UTI (functional or structural urinary
tract abnormalities)
83
• UTI with urinary catheter
83
• Acute Prostatitis
84
• Chronic Bacterial Prostatitis
84
• Bacterial epdidymitis / Bacterial orchitis
2.14 Surgical Prophylaxis 85
Antibacterial Prophylaxis in Ear, Nose and Throat Surgery 85

Ear, nose and throat – Benign 85
Head and neck – Facial 85

Page 6 of 120
Head and neck surgery 85
Antibacterial Prophylaxis for Gastrointestinal, Biliary, 87
Vascular and General Surgery
Upper gastrointestinal surgery 87
Lower gastrointestinal surgery 87
Hepatobiliary surgery 87
Diagnostic endoscopic procedures 88
Abdomen 88
Breast surgery 88
Vascular surgery 88
Antibacterial Prophylaxis for Obstetric and 89
Gynaecological Surgery
Obstetrics 89
89
• Caesarean section
89
• Third and fourth degree perineal tears
89
• Manual removal of placenta
89
• Assisted Delivery
89
• Surgical termination of pregnancy
Gynaecology 90
90
• Hysterectomy
90
• Laparotomy
90
• Radical pelvic surgery for gynaecological cancer
90
• Vaginal repair
90
• Vaginal sling procedures
Antibacterial Prophylaxis for Orthopaedic Surgery 91
Clean non-implant surgery 91
Arthroplasty 91
Surgery for closed fractures 91
Hip fracture 91
Spinal surgery 91
Lower limb amputation 91

Page 7 of 120
Open fractures 91
Antibacterial Prophylaxis for Urological Surgery 93
Transurethral resection of a bladder tumour 93
Open or transurethral resection of the prostate 93
Transrectal prostate biopsy 93
Cystoscopy – uncomplicated 93
Cystoscopy – complicated 93
Urethral dilatation / optical urethrotomy 93
Shock-wave lithotripsy 93
Nephrectomy 93
Percutaneous nephrolithotomy 93
Cystectomy 94
Radical prostatectomy 94
2.15 Prophylaxis – Other 95
Prevention of infection after bites from humans and other 95
mammals
96
• Human Bite
96
• Dog Bite
96
• Cat Bite
Antibacterial prophylaxis for open fractures of the fingers 96
Prophylaxis against Infective Endocartitis (IE) in adults 97
and children undergoing interventional procedures
Prevention of infection in patients with an absent or 99
dysfunctional spleen
2.16 Antibiotic Assays 102
Gentamicin – Once Daily Dosing 102
106
• Infusion Chart
Gentamicin – Multiple Daily Dosing 107
Vancomycin 108
Antibiotic Therapeutic Drug Ranges 109
3 Definitions 110
4 Associated Documents 110
5 Duties 110
6 Consultation and Communication with Stakeholders 111
7 Implementation 111

Page 8 of 120
8 Education and training 111
9 Monitoring and review 111
10 References / Bibliography 111
11 Appendices 111
Risk Rating
Who will be affected by this
Trust Employees / Patients
Procedure?
Have any existing risk Yes Details: Still current
assessments related to this
procedure been appropriately
updated
Is a new risk assessment No Yes- Date completed
required by this procedure?
Does this procedure require No Details if Yes
Health and Safety training?
Does this procedure require No Details if Yes
specialist equipment?
Name: Jennifer Willis Date: 1st October 2012
A B C
Potential Severity Likelihood of Occurrence Risk Rating
(1-5) (1-5) (A x B = C)
Raw Risk Rating 4 4 16
Final Risk rating 4 2 8

Page 9 of 120
1 Introduction / Purpose
It is the policy of the Trust that no one will be discriminated against on grounds of
age, disability, gender reassignment, marriage and civil partnership, pregnancy
and maternity, race, religion or belief, sex or sexual orientation. The Trust will
provide interpretation services or documentation in other mediums as requested
and necessary to ensure natural justice and equality of access.
Aim of the Guidelines

The purpose of these guidelines is to provide guidelines for empirical antimicrobial
therapy. The guidelines are not intended to cover all clinical circumstances. Further
advice can be obtained from the consultant microbiologists (see contact details
below).
Important Points
To minimise infections caused by MRSA and C. difficile, avoid cephalosporins
and quinolones as much as possible. Whenever possible use beta- lactam /
beta- lactamase inhibitor combinations e.g. Co-amoxiclav (community-acquired
infections) or Piperacillin / Tazobactam (hospital-acquired infections).
Antimicrobials should only be prescribed if there is a clear indication and

the potential benefit outweighs the risk. Inappropriate prescribing promotes
the emergence and spread of resistant organisms, causes unnecessary side
effects and complications such as Clostridium difficile colitis which may be fatal,
and is costly.
Recommendations that follow are for empirical antimicrobial therapy in

adults with normal renal and hepatic function, unless stated otherwise.
Treatment should be modified according to laboratory results. A change

from empirical (often broad spectrum, expensive and likely to encourage
resistance), to definitive, specific therapy (often narrow spectrum, cheaper and
less likely to produce resistance) can be made when culture and sensitivity
results are available.
ALWAYS document indication and duration of the treatment on the drug

chart when prescribing.

Page 10 of 120
Prescribing an Antimicrobial?
In accordance with the Trust Antibiotic Guidelines and to improve

prescribing practice,
Please add to ALL antimicrobial prescriptions:
REGULAR PRESCRIPTION PHARMACY USE ONLY

YEAR 2011 Date
SPECIFY TIME IF
1 2 3 4 5 6 7 8 9 10
MONTH May REQUIRED
Drug
CLARITHROMYCIN
Morning 08.00
Dose Route Start date
Midday
500mg PO 1/10/10
Duration Signature A Doctor Evening
5 day course
Bleep No: (Doctor) 1234 Bedtime 20.00
Pharm Print name & profession
A Doctor
Special Instructions:
Community acquired pneumonia
An Indication Duration or Review Date

YEAR 2011 Date
SPECIFY TIME IF
1 2 3 4 5 6 7 8 9 10
MONTH May REQUIRED
Drug
CO-AMOXICLAV
Morning 06.00
1.2g IV 1/10/10
Midday 14.00 R/V
Review 48
hours Bleep No: (Doctor) 1234 Bedtime 22.00
Pharm Print name & profession
A Doctor
Special Instructions:
Community acquired pneumonia
“Review” dates should generally be endorsed for IVs.

Aim for the lunchtime doses for review where possible.
Avoid weekends/holidays unless senior review planned.
Nurses should continue to give antimicrobials whilst awaiting review.

Page 11 of 120
CONSIDERATIONS
Does the patient have a bacterial infection?

The most common error of antimicrobial therapy is unnecessary use.
Unexplained pyrexia should not be treated with antimicrobials unless the

patient is septic or otherwise suspected of a life threatening infection. Pre-
emptive antimicrobials in such cases usually lead to further difficulties in
establishing a correct diagnosis.
If the condition is mild and bacterial infection not obvious, treatment can be
delayed until the results of investigations are available.
If the condition is serious and treatable infection is likely, empirical antimicrobial

therapy should start immediately, the choice being based on the likely infecting
organism(s), the current local antimicrobial resistance rates and severity of the
disease. This has been reflected in the production of these guidelines.
Antibiotics should not be prescribed for a raised CRP unless other infection
markers are also present.
Have relevant specimens been collected?

Obtain all necessary bacteriological specimens before antimicrobial therapy is
started.
Blood cultures should be taken in all cases of serious infection including before
starting intravenous antibiotics.
Antimicrobial therapy however, should never be delayed in an emergency.
Is parenteral (IV) treatment necessary?

Use oral route whenever possible, e.g. metronidazole, rifampicin, fluconazole and
ciprofloxacin are well absorbed from the gut (good bioavailability).
Antibiotics should be prescribed intravenously for severe infection, e.g.

septicaemia, pyelonephritis, endocarditis, meningitis, osteomyelitis, neutropenic
fever.
Most other conditions only require intravenous antimicrobials if particularly

severe and then only one or two doses (at most 48 hr) is usually sufficient.
Is the patient allergic to any antibiotics?

Document all drug allergies clearly with the nature of the patient’s reaction on the
drug chart.

Page 12 of 120
PENICILLIN ALLERGY
Allergic reactions to penicillins occur in 1-10% of exposed individuals;
anaphylactic reactions occur in fewer than 0.05% of treated patients.
All patients reporting allergy to penicillin should be questioned to determine the
likelihood of true allergy and assessed as to whether their symptoms are
consistent with a type 1 allergic reaction.
Type 1 – immediate hypersensitivity to penicillin

i.e. anaphylaxis, urticaria, laryngeal oedema, bronchospasm, hypotension, or rash
immediately after penicillin administration:
Avoid all penicillins
Avoid other β-lactams (cephalosporins, carbapenems)
If a cephalosporin is essential in these patients because a suitable alternative
antibacterial is not available, then cefuroxime, cefotaxime, ceftazidime, ceftriaxone,
or cefixime can be used with caution; cefaclor, cefadroxil, cefalexin, and cefradine
should be avoided.
NOT type 1 penicillin allergy

i.e. minor rash (i.e. non-confluent, non-pruritic rash restricted to a small area of the
body) or a rash that occurs more than 72 hours after penicillin administration.
Penicillins – use with caution and under supervision only for serious infections
Other β-lactams (cephalosporins, carbapenems) – can be used safely
Type 1 – immediate
β-lactam antibiotics kept by NOT Type 1 penicillin
hypersensitivity to
MCHFT allergy
penicillin
Penicillins
Amoxicillin
Co-amoxiclav/Augmentin® May be used with
Flucloxacillin caution and under
Avoid
Pivmecillinam supervision for
Penicillin G (benzylpenicillin) serious infections.
Piperacillin & tazobactam
(Tazocin®)
Cephalosporins
Cefradine
Avoid
Cefalexin
Cefaclor
Considered safe
Cefotaxime
Use with caution ONLY if
Ceftriaxone
essential and under
Cefuroxime
supervision
Ceftazidime
Carbapenems
Use with caution ONLY if
Meropenem
essential and under Considered safe
Imipenem (Primaxin®)
supervision
Ertapenem
Weak cross-reactivity with

Monobactams
other β-lactams Considered safe
Aztreonam
Considered safe

Page 13 of 120
CONVERSION FROM INTRAVENOUS TO ORAL ANTIBIOTICS (ANTIBIOTIC
SWITCH)
In the majority of cases, one or two doses (at most 48 hours) of intravenous
antibiotics are sufficient.
Prescriptions for intravenous antibiotics must be reviewed after 48 hours and

changed to oral administration according to microbiology results. If these are
not available change to oral administration of the same drug or an acceptable
oral alternative as per antibiotic guidelines.
Exceptionally, in some cases it is usual to administer the whole course of

antibiotics by the IV route for reasons of severity and / or poor penetration to
the site of infection e.g. endocarditis, meningitis, and cerebral abscess.
The oral switch should ideally be prescribed at the same time as the IV
treatment and the administration section blocked out to indicate when the
switch should occur.
Criteria for changing to oral antibiotics:
- temperature <38° C for >24hours
- signs of clinical improvement
- no clinical indication for continuation of IV therapy, e.g. endocarditis,

meningitis, osteomyelitis
- oral fluids tolerated
- no ongoing or potential GI tract absorption problems
- oral formulation or suitable oral alternative is available
ANTIBIOTIC STOP POLICY
This guidance aims to prevent unintended long duration of antimicrobial

therapy.
Five days duration of antibiotic treatment is usually sufficient. Please refer to

antibiotic guidelines for specific recommendations for duration of treatment of
specific infections.
The duration/review date box must always be completed and made clear if
it is a stop or review date by deleting as appropriate.

Page 14 of 120
Extended duration of antibiotic treatment is acceptable for patients that are
being investigated or treated for the following conditions where it is known that
antibiotics will be required for a prolonged duration such as:
Cavitating pneumonia
Empyema
Exacerbation of cystic fibrosis/ bronchiectasis
Endocarditis
Inadequately drained abscesses
Infected implants/prosthetics
Intracranial abscesses
Meningitis
Mediastinitis
Liver abscess
Osteomyelitis / Septic arthritis
Prostatitis
Prolonged prophylaxis where there is proven benefit e.g.
splenectomy, PCP.
Staphylococcus aureus bacteraemia
Severe or necrotising soft tissue infections
Severe infections during chemotherapy-related neutropenia
Tuberculosis
The indication for all antibiotic therapy must be clearly documented on the drug
chart (in the special instructions box) and in the medical notes.
Antibiotic prescriptions should be reviewed daily.

Page 15 of 120
RESTRICTED ANTIMICROBIALS
The following antibiotics should not be prescribed unless specifically

recommended in the antibiotic policy.
Other than these specific indications, they can only be prescribed after consultation
with the Consultant Microbiologist.
Pharmacy will be unable to supply restricted antimicrobials unless these conditions

have been met.
All cephalosporins e.g. cefuroxime, cefotaxime, ceftazidime, ceftriaxone,

cefixime, cefaclor, cefadroxil, cefalexin and cefradine unless recommended for
specific conditions in this policy (e.g. cefradine for UTI)
All quinolones e.g. ciprofloxacin, levofloxacin unless recommended for specific

conditions in this policy
Amikacin
Chloramphenicol (systemic)
Linezolid
IV Vancomycin (except renal dialysis unit)
Tigecycline
Daptomycin

Page 16 of 120
Notification of Infectious Diseases
Health Protection Legislation (England) Guidance 2010
• All notifications must be sent to the offices of the Proper Officers appointed by local
authorities for that purpose. In Cheshire & Merseyside the Proper Officers for this
purpose are the Consultants in Communicable Disease Control (CCDC) based at
Cheshire & Merseyside Health Protection Unit (CMHPU).
• All notifications should be made using the forms contained in Health Protection
Legislation (England) Guidance 2010 and faxed to Cheshire & Merseyside
confidential fax number 0151 708 8417.
A copy of the notification form is included on this site to print off
Please do not return completed notification forms by email.
• In addition, for urgent notification of matters of serious public health significance,

the Proper Officers may be notified by telephone on a 24-hour basis.
o During office hours they can be contacted on 0844 225 1295.
o Outside office hours the Proper Officer can be reached via the public health
on-call rota on 0151 706 3134 or 0151 706 2000 (via the Royal Liverpool
University Hospital switchboard) or 01244 365 000 (via the Countess of
Chester Hospital switchboard); the same rota is held at both hospitals.
The criteria for notification by registered medical practitioners (RMPs) attending

patients are as below:
• Cases of notifiable infectious diseases (as listed in Table1)

• Cases of other infections not included in Table 1 if they present, or could present,
significant harm to human health (e.g. emerging or new infections)
• Cases of contamination, such as with chemicals or radiation, that may present or
could present significant harm to human health
• Cases of patients who die with, but not necessarily because of, a notifiable disease
or other infectious disease or contamination that presents, or could present, or that
presented or could have presented significant harm to human health.
Notification of infections not included in Table 1 and contamination are expected to be

exceptional occurrences. Factors the RMP may wish to consider in deciding whether to
notify a case of infection that is not included in Table 1 or a case of contamination include:
The risk of transmission or spread to others and
The potential to cause significant harm to human health
RMPs should not wait for laboratory confirmation of the suspected infection or
contamination before notification. They must notify cases if they have reasonable clinical
suspicion that their patient is suffering from a notifiable disease or other relevant infection
or contamination.
Notifiable diseases, with explanatory notes and guidance on the need for urgent
notification
NB: This table is only for guidance and each case should be considered
individually.

Page 17 of 120
Table 1
Notifiable diseases Definition / comment Likely to be urgent?
Acute encephalitis No
Acute meningitis Viral and bacterial. Yes, if suspected bacterial
infection.
Acute poliomyelitis Yes
Acute infectious hepatitis Close contacts of acute Yes
hepatitis A and hepatitis B
cases need rapid
prophylaxis. Urgent
notification will facilitate
prompt laboratory testing.
Hepatitis C cases known to
be acute need to be
followed up rapidly as this
may signify recent
transmission from a source
that could be controlled.
Anthrax Yes
Botulism Yes
Brucellosis No – unless thought to be UK-
acquired
Cholera Yes
Diphtheria Yes
Enteric fever (typhoid or Clinical diagnosis of a case Yes
paratyphoid fever) before microbiological
confirmation (e.g. case with
fever, constipation, rose
spots and travel history)
would be an appropriate
trigger for initial public
health measures, such as
exclusion of cases and
contacts in high risk groups
(e.g. food handlers).
Food poisoning Any disease of infectious or Clusters and outbreaks, yes.
toxic nature caused by, or For specific organisms see
thought to be caused by Table 2.
consumption of food or
water (definition of the
Advisory Committee on the
Microbiological Safety of
Food).
Haemolytic uraemic Yes
syndrome (HUS)
Infectious bloody diarrhoea See also HUS in Schedule Yes
1 and VTEC in Schedule 2.

Page 18 of 120
Notifiable diseases Definition / comment Likely to be urgent?
Invasive group A Yes, if IGAS. No, if scarlet
streptococcal disease and fever
scarlet fever
Legionnaires’ Disease Yes,
Leprosy No
Malaria No, unless thought to be UK-
acquired
Measles Yes
Meningococcal septicaemia Yes
Mumps Post-exposure No
immunization (MMR or
HNIG) does not provide
protection for contacts.
Plague Yes
Rabies A person bitten by a Yes
suspected rabid animal
should be reported and
managed urgently, but if a
patient is diagnosed with
symptoms of rabies, they
will not pose a risk to
human health.
Rubella Post-exposure No
immunisation (MMR or
HNIG) does not provide
protection for contacts.
SARS Yes
Smallpox Yes
Tetanus No, unless associated with
injecting drug use
Tuberculosis No, unless healthcare worker
or suspected cluster or multi
drug resistance
Typhus No
Viral haemorrhagic fever Yes
(VHF)
Whooping cough Yes, if diagnosed during acute
phase
Yellow fever No, unless thought to be UK-
acquired

Page 19 of 120
2 General Document Principles
BONE AND JOINT INFECTIONS
Infection Acute hematogenous osteomyelitis (not associated with

bone/joint prosthesis)
Vertebral osteomyelitis, spondylodiskitis, +/- epidural abscess, other sites
High risk:
- immunocompromised
- diabetics
- IV drug users
- catheter-related bloodstream infection
- elderly
Specimen Microbiological diagnosis is essential
Obtain samples before starting antimicrobials if possible
Blood culture
Bone biopsy - at least 3 deep samples obtained during surgery
Disk biopsy - multiple specimens in sterile container and in blood culture
bottles
Needle aspirate under radiological guidance
Request TB cultures if at risk of TB
Likely Organisms Staphylococcus aureus (including MRSA) most common
Other organisms depending on age and risk factors (coagulase negative
staphylococci, gram negative bacilli, fungi)
Treatment (empirical)
Type of patient First line Alternative (penicillin allergy)
Not high risk Flucloxacillin 2 g IV by infusion 6 Teicoplanin 600 mg IV 12 hrly for 3
hrly doses then 24 hrly thereafter
High risk Flucloxacillin 2 g IV by infusion 6 Teicoplanin 600 mg IV 12 hrly for 3

hrly doses then 24 hrly thereafter
plus plus
Aztreonam 2 g IV 8 hrly Aztreonam 2 g IV 8 hrly
Severe infection Add sodium fusidate tablets 500 mg orally 8 hrly to above regimens
Tagged for MRSA Teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter
Definitive therapy Once bacterial sensitivities are known contact consultant microbiologist
to adjust antimicrobials if necessary and determine duration of treatment
Duration Usually 6 weeks, preferably intravenously.
Treatment should not be stopped until symptoms (e.g. fever) and signs
(e.g. joint effusion) resolve, and the WBC and CRP return to normal.

Page 20 of 120
Infection Contiguous osteomyelitis
Associated with fracture or post surgical bone reconstruction
Specimen Microbiological diagnosis is essential
Obtain samples before starting antimicrobials
Bone biopsy, at least 3 deep samples obtained during
surgery/debridement
Blood culture if systemic infection
Likely Organisms Staphylococci, gram negative bacilli, other
Treatment • Surgical debridement
• Often necessary to remove hardware
• Antimicrobial therapy must be pathogen-directed
Empirical First line Alternative (penicillin allergy)
Teicoplanin 600 mg IV 12 hrly for Teicoplanin 600 mg IV 12 hrly for
3 doses then 24 hrly thereafter 3 doses then 24 hrly thereafter
plus plus
Piperacillin/tazobactam Aztreonam 2 g IV 8 hrly
®
(Tazocin ) 4.5 g IV 8 hrly
Definitive Adjust after culture results available
Duration Prolonged course required, ≥ 6 weeks
Intravenous initially and to cover the period of any surgical

intervention and for at least 2 weeks after.
May switch to oral after that time if good clinical response to IV

therapy, CRP falling and good information on organism and its
sensitivities.
Treatment should not be stopped until symptoms (e.g. fever) and

signs (e.g. joint effusion) resolve, and the WBC and CRP return to
normal.
Contact consultant microbiologist

Page 21 of 120
Infection Contiguous osteomyelitis secondary to vascular
insufficiency and diabetic foot infection
See Diabetic Foot Infection page 79
Infection Chronic osteomyelitis

Long-standing infection evolving over months, relapses in the same
area, low grade inflammation, presence of necrotic bone and fistulous
tracks
Specimen Biopsy of bone - at least 3 deep samples obtained during surgery
before starting antimicrobials
Needle aspirate under radiological guidance before starting
antimicrobials
Culture of sinus tract drainage NOT predictive of bone culture
Request TB cultures if at risk of TB
Blood culture if acute exacerbation with systemic infection
Likely Organisms Staphylococcus aureus (including MRSA)
Streptococcus spp
Enterobacteriaceae
Pseudomonas spp
Anaerobes
Treatment Empirical treatment: not recommended, need cultures
If acute exacerbation of chronic osteomyelitis, check previous
microbiology results if available and treat as acute hematogenous
osteomyelitis
Surgical debridement
Duration Prolonged course required, usually > 6 weeks
Intravenous initially and to cover the period of any surgical
intervention and for at least 2 weeks after
May switch to oral after that time if good clinical response to IV

therapy, CRP falling and good information on organism and its
sensitivities

normal.

Page 22 of 120
Infection Prosthetic joint infections
Specimen • Aspiration of joint fluid (should be carried out by an orthopaedic
surgeon in an operating theatre) before commencing antibiotics
• At least 3 intraoperative periprosthetic tissue specimens (swab
cultures have a low sensitivity and should be avoided)
If revision surgery is planned, perioperative prophylaxis should not be
administered until after tissue specimens have been collected for culture
• Blood culture if septic
Likely Organisms Coagulase negative staphylococci, Staphylococcus aureus, Streptococci
Gram negative bacilli, Enterococcus, Anaerobes
Treatment Remove infected prosthesis if possible
Early post-operative and acute late hematogenous infections can be

treated with adequate debridement and appropriate systemic antibiotics
(provided short duration of symptoms, for < 2 weeks)
In other cases, surgical drainage with retention of prosthesis followed by

antimicrobial therapy often results in treatment failure
Empirical treatment First line Alternative (penicillin allergy)

Teicoplanin 600 mg IV 12 hrly for 3 Teicoplanin 600 mg IV 12 hrly for 3
(start antibiotics after doses then 24 hrly thereafter doses then 24 hrly thereafter
cultures have been plus plus
obtained if possible) ®
Piperacillin/tazobactam (Tazocin ) Aztreonam 2 g IV 8 hrly
4.5 g IV 8 hrly
Definitive treatment Meticillin Sensitive S aureus (MSSA)
Flucloxacillin 2 g IV by infusion 6 hrly
Antimicrobial therapy plus
must be pathogen- Rifampicin 600 mg orally 12 hrly
directed
MRSA or
Coagulase negative staphylococci or
Once bacterial
sensitivities are MSSA and penicillin allergy
known adjust Continue IV teicoplanin 600mg 24hrly (check teicoplanin trough level
antimicrobials after 5 days of treatment)
plus
Rifampicin 600 mg orally 12 hrly
For other organisms discuss with consultant microbiologist
Duration Usually 6 weeks or longer
Intravenous - continue to cover the period of any surgical intervention

and for at least 2 weeks after
Switch to oral after that time if good clinical response to IV therapy, CRP
falling and good information on organism and its sensitivities
Treatment should not be stopped until symptoms (e.g. fever) and signs
(e.g. joint effusion) resolve, and the WBC and CRP return to normal.

Page 23 of 120
Infection Septic arthritis (native joint)
Specimen Aspirate joint (avoid introducing needle through skin affected by
cellulitis) - synovial fluid for microscopy and culture
Blood cultures 1 - 3 sets
Samples should be sent for culture from skin/wound swab if in
relation to trauma
Likely Organisms Staphylococcus aureus (including MRSA), Streptococci
Gram negative bacilli, N. gonorrhoea
Treatment Joint lavage or open incision and drainage is essential
Initial choice of antibiotics should be based on gram stain of joint
fluid and type of patient
If at risk for sexually transmitted disease – consider N. gonorrhoea
Type of patient First line Alternative (penicillin allergy)
Immunocompetent Flucloxacillin 2 g IV by infusion 6 Teicoplanin 600 mg IV 12 hrly
patient with no risk hrly for 3 doses then 24 hrly
factors for atypical thereafter
organisms
or
Gram stain: gram
positive cocci
High risk of Gram Flucloxacillin 2 g IV by infusion 6 Teicoplanin 600 mg IV 12 hrly

negative organisms hrly for 3 doses then 24 hrly
(e.g. elderly, plus thereafter
immunocompromised, Piperacillin/tazobactam plus
IV drug users) ®
(Tazocin ) 4.5 g IV 8 hrly to Once daily gentamicin IV (see
and above regimen Prescribing Regimen)
Gram stain negative
Gram stain: gram Piperacillin/tazobactam Aztreonam IV 2 g 8 hrly
®
negative rods (Tazocin ) 4.5 g IV 8 hrly
Tagged for MRSA Teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter
If high risk of Gram negative organisms, additional antibiotics as

above
Duration 3-4 weeks
Intravenous - continue for at least 2 weeks
Switch to oral after that time if good clinical response to IV therapy,

CRP falling and good information on organism and its sensitivities

normal.

Page 24 of 120
Infection Septic bursitis
Olecranon bursitis, prepatellar bursitis
Specimen Bursa aspirate
Blood culture if septic
Likely Organisms Staphylococcus aureus >80%
Treatment Aspiration of bursa
Select antibiotics on basis of gram stain of aspirate
Adjust therapy according to culture results and sensitivities
First line Alternative (penicillin allergy)
Flucloxacillin 2 g IV by infusion 6 Teicoplanin 600 mg IV 12 hrly

hrly for 3 doses then 24 hrly
thereafter
Flucloxacillin orally 500 mg 6 hrly Doxycycline orally 200 mg daily
may be given for mild cases may be given for mild cases
Duration 2-3 weeks total

Switch to oral if good clinical response to IV therapy, CRP falling
and good information on organism and its sensitivities
References
1. Prosthetic-Joint Infections. Werner Zimmerli, Andrej Trampuz, Peter E Ochsner. The New
England Journal of Medicine. 2004;351:1645-55
2. Osteomyelitis Lew DP, Waldvogel FA, Lancet 2004;364:369-79
3. Medical treatment of diabetic foot infections. Lipsky A. Clinical Infectious Diseases 2004; 39
(S2): S104-114
4. Septic arthritis. Goldenberg DL. Lancet 1998;351:197-202
5. The Sanford guide to antimicrobial therapy, 2010
6. Guidelines for the management of hot swollen joint in adults, BER&BHPR, BOA, RCGP, BSAC,
Rheumatology 2006;45:1039-41

Page 25 of 120
CENTRAL NERVOUS SYSTEM INFECTIONS
Infection Acute Bacterial meningitis (empirical treatment)
Specimen CSF (unless contraindicated) for microscopy, culture and PCR

Blood culture
Blood EDTA tube for meningococcus and pneumococcus PCR
Throat swab for meningococcus
Likely Organisms Neisseria meningitidis
Streptococcus pneumoniae
Listeria monocytogenes (> 50 years old or immunocompromised)
Haemophilus influenzae (children)
Treatment Inform CCDC immediately and follow up in writing within 7 days
• During office hours they can be contacted on 0844 225 1295.
• Outside office hours the Proper Officer can be reached via the
public health on-call rota on 0151 706 3134 or 0151 706 2000
(via the Royal Liverpool University Hospital switchboard) or
01244 365 000 (via the Countess of Chester Hospital
switchboard); the same rota is held at both hospitals.
Chemoprophylaxis for close contacts if meningococcal infection is

likely (ciprofloxacin 500mg orally single dose)
Consider adjunctive treatment with dexamethasone (particularly if

pneumococcal meningitis suspected) starting before or with first dose of
antibacterial
Ceftriaxone 2 g IV by infusion 12 Contact consultant microbiologist
hrly
If > 50 years old, pregnant or with

impaired cellular immunity:
Add amoxicillin 2 g IV by infusion 4
hrly
If Herpes simplex encephalitis suspected:
Add aciclovir 10 mg/kg IV by infusion 8 hrly
Duration Depends on organism cultured (see below)

Page 26 of 120
Pathogen specific therapy
For penicillin allergic patients contact consultant microbiologist.
Infection: Neisseria meningitides
Treatment Benzylpenicillin 2.4 g IV by infusion 4 hrly
Duration 7-10 days
Chemoprophylaxis Ciprofloxacin 500mg orally single dose when able to take oral medication
for index case and before discharge from hospital,UNLESS the disease has already
been treated with ceftriaxone.
Vaccination for Cases of confirmed serogroup C disease who have previously been
index case immunised with MenC conjugate (or polysaccharide) vaccines should be
offered a booster dose of MenC vaccine around the time of discharge
from hospital.
MenC conjugate vaccine should also be offered according to the

recommended national schedule to any unimmunised index cases under
the age of 25 years (whatever the serogroup).
Index cases who are in the risk-group for meningococcal disease (e.g.
asplenia, complement deficiency) and have not been immunised (or are
incompletely immunised for age) with the quadrivalent MenACWY
conjugate vaccine should complete the recommended immunisation
course (2 doses one month apart if aged <1 year; 1 dose after first
birthday), while those who received the quadrivalent MenACWY
conjugate vaccine more than 12 months previously should receive an
extra dose of the quadrivalent MenACWY conjugate vaccine.
Infection: Streptococcus pneumoniae
Treatment Benzylpenicillin 2.4 g IV by infusion 4 hrly if organism sensitive to

penicillin (MIC < 0.1 mg/L)
If penicillin MIC ≥0.1 mg/L, contact consultant microbiologist
Duration 10 – 14 days
Infection: Haemophilus influenzae
Treatment Ceftriaxone 2 g IV by infusion 12 hrly
Duration 7-10 days
Infection: Listeria monocytogenes
Treatment First line Alternative (penicillin allergy)

Amoxicillin 2 g IV by infusion Co-trimoxazole 5mg/Kg (based on
4 hrly trimethoprim component) IV or orally 6
plus hourly
Once daily gentamicin IV Note: 480mg of co-trimoxazole consists of
(see prescribing regimen) 400mg sulfamethoxazole and 80mg
trimethoprim
Duration 21 days
Gentamicin may be stopped sooner – contact consultant microbiologist

Page 27 of 120
Infection Viral meningitis
Specimen CSF for microscopy, culture, viral PCR (HSV, enterovirus)
Throat swab in viral transport media for enterovirus PCR
Likely Organisms Herpes simplex,
Enteroviruses
Treatment Supportive treatment only
Infection Encephalitis
Specimen CSF (if not contraindicated) for HSV, VZV PCR, cell count and
differentiation
Likely Organisms Herpes simplex, Varicella zoster
Treatment Aciclovir 10 mg/kg IV by infusion 8 hrly until result of PCR known
If patient immunocompromised, recent travel abroad or recent exposure

to warm surface water, and abnormal CSF, or if initial PCR tests and
bacterial cultures negative AND still suspected of encephalitis:
Contact consultant microbiologist to discuss testing for unusual but
potentially treatable causes of meningo-encephalitis/myelitis such as
Cryptococcus, tuberculosis, neurosyphilis, neuroborreliosis, Mycoplasma,
Bartonella, amoebas, Toxoplasma, or Tropheryma whippelii.
Consider HIV test if immune deficiency suspected.
Duration Herpes simplex: Varicella zoster:

14 - 21 days 7 – 10 days
Infection Brain abscess / subdural empyema

Specimen Pus from aspirate
CSF if not contraindicated
Blood culture
Likely Organisms Streptococcus spp
Anaerobes
Staphylococcus aureus
Gram negative bacilli
Treatment Drainage as appropriate
Ceftriaxone 2 g IV by infusion 12 hrly
plus
metronidazole 500 mg IV by infusion 8 hrly
If tagged for MRSA:
Add vancomycin IV 1 g 12 hrly (if renal impairment contact pharmacy)
Adjust antibacterials once organism identified and sensitivities

known
Duration Until abscess resolved (6 weeks minimum)

Page 28 of 120
EAR, NOSE AND THROAT INFECTIONS
Ear
Infection Otitis externa
Types
Acute localised severe ear pain
(furuncle) localised swelling of ear canal
mild fever (≤ 38°C)
lymphadenopathy (pre-auricular)
Likely Organisms Staphylococcus aureus
Specimen Ear swab for culture only if treatment failure or chronic / recurrent cases
Incision and Flucloxacillin 500 mg orally 6 hrly Clarithromycin 500 mg orally 12 hrly
drainage (may be given initially IV 1 g 6hrly (may be given initially IV 500 mg 12
and dressings in severe cases) hrly by infusion in severe cases)
may be necessary
Duration 5 days total (including IV)
Acute, diffuse pain of variable severity

(swimmer’s ear) generalised swelling of ear canal
mild fever (≤ 38°C)
lymphadenopathy (pre-auricular)
scanty discharge
Likely Organisms Pseudomonas aeruginosa., Enterobacteriaceae
Specimen Ear swab for culture only if treatment failure or chronic / recurrent cases
Treatment First line Alternative
®
Gentisone HC ear drops or Ciprofloxacin eye drops 0.3% in the
® ®
Sofradex ear drops or Otosporin ear. 2-3 drops to affected ear(s) 3-4
ear drops 2-3 drops to affected times daily
ear(s) 3-4 times daily Only after discussion with ENT
Additionally, oral antibiotics may be Consultant
given in severe cases
Note: Nurse Practitioner protocol
Duration 10 days
Fungal otitis externa

Likely Organisms Aspergillus sp., candida sp.
Treatment Aural toilet
®
Clotrimazole solution 1% (Canesten ), 2-3 drops to affected ear(s) 2-3 times
daily, continue for 14 days after disappearance of infection
or
®
Daktarin cream, topical application to affected ear(s) twice daily, continue
for 10 days after disappearance of infection
or
®
Daktacort cream, topical application to affected ear(s) twice daily

Page 29 of 120
Infection Perichondritis
Likely Organisms Staphylococcus aureus, Pseudomonas aeruginosa
Treatment Ciprofloxacin orally 500 mg 12 hrly
Duration 7 days
Infection Invasive “malignant” otitis externa

Severe necrotising infection that spreads from the squamous epithelium
of the ear canal to adjacent areas
Risk groups:
- immunocompromised
- diabetics
- elderly
Specimen Pus or tissue biopsy
Likely Organisms Pseudomonas aeruginosa
Treatment Include topical treatment i.e. dressings, gentamicin or ciprofloxacin
drops (as for acute diffuse otitis externa, swimmer’s ear)

Early Ciprofloxacin 750 mg orally 12 hrly
®
Advanced Piperacillin/tazobactam (Tazocin ) Aztreonam 1-2 g IV 8 hrly
4.5 g IV 8 hrly
Consider adding once daily gentamicin IV (see prescribing regimen)
®
Duration Ciprofloxacin, piperacillin/tazobactam (Tazocin ) or aztreonam 4 – 6
weeks
Gentamicin 3 - 5 days (discuss with consultant microbiologist)
Oral stepdown
Ciprofloxacin 750 mg orally 12 hrly if sensitivities allow
Infection Acute otitis media

Acute onset of signs and symptoms (otalgia, otorrhoea, fever)
Otoscopic appearances include:
- bulging tympanic membrane with loss of landmarks
- changes in membrane colour (typically red or yellow)
- perforated tympanic membrane with discharge of pus
Specimen Pus if perforated tympanic membrane
If severe, treatment failure, chronic / recurrent: needle aspirate from
middle ear effusion
Likely Organisms Streptococcus pneumoniae, Haemophilus influenzae, Moraxella
catarrhalis, Viruses
Treatment Antibacterials should not be routinely prescribed, the following
indications may support their selective use:
- bilateral infection

Page 30 of 120
- systemic symptoms, including fever (> 38.5°C) or vomiting
- local signs that suggest infection severe e.g. bulging or inflamed
tympanic membrane
- infection at the only hearing ear
- mixed hearing loss
- cochlear implants, previous surgery
Type First line Alternative (penicillin allergy)
Uncomplicated Amoxicillin 500 mg orally 8 hrly Clarithromycin 500 mg orally 12
hrly
Treatment failure Co-amoxiclav Doxycycline 100 mg orally 12 hrly
(symptoms persist 625 mg orally 8 hrly
past 3 days, or or
reoccur within 14
1.2 g IV 8 hrly
days)
Duration Uncomplicated 5 days
Treatment failure 7 – 10 days
Infection Acute Mastoiditis

Specimen Ear drainage fluid or tissue if mastoiditis explored
Likely Organisms Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus
pyogenes (group A β-haemolytic streptococcus), S. aureus
Co-amoxiclav 1.2 g IV 8 hrly Meropenem* 1 g IV 8 hrly
*Use with caution and under

Oral stepdown
supervision if history of
Co-amoxiclav immediate hypersensitivity
625 mg orally 8 hrly reaction to penicillins (e.g.
anaphylaxis, urticaria)
If anaphylaxis to penicillin:
Aztreonam 1-2 g IV 8 hrly
plus
Teicoplanin 600 mg IV 12 hrly for
3 doses then 24 hrly thereafter
Oral stepdown
According to sensitivities
or
Doxycycline 100 mg orally 12
hrly

Page 31 of 120
Nose
Infection Acute rhinosinusitis
Specimen Sinus discharge
Swab from middle meatus
If treatment failure, chronic / recurrent or nosocomial infection:
Sinus puncture aspirate
Likely Organisms Community acquired: Nosocomial:
Viruses Often polymicrobial including
Streptococcus pneumoniae S.aureus
Haemophilus influenzae Pseudomonas aeruginosa,
Streptococcus spp gram negative bacilli,
Moraxella catarrhalis yeasts
S. aureus
Anaerobes
Treatment Many are viral. Infection resolves without antimicrobial treatment in most
cases.
Reserve antibiotics for patients with
high fever and purulent nasal discharge or severe facial pain
Community Co-amoxiclav 625 mg orally 8 hrly Clarithromycin 500 mg orally 12
acquired hrly
(systemically well) Or
Doxycycline 100 mg orally 12 hrly
Community Co-amoxiclav 1.2 g IV 8 hrly Clarithromycin 500 mg IV by

acquired Oral stepdown infusion 12 hrly
(systemically According to sensitivities plus
unwell) Once daily gentamicin IV (see
or
Co-amoxiclav prescribing regimen)
625 mg orally 8 hrly
Oral stepdown
or
Clarithromycin 500 mg orally 12
hrly
® Meropenem* 1 g IV 8 hrly
Nosocomial Piperacillin/tazobactam (Tazocin )
(hospitalised and 4.5 g IV 8 hrly
intubated) *Use with caution and under
supervision if history of immediate
Oral stepdown
hypersensitivity reaction to
According to sensitivities penicillins (e.g. anaphylaxis,
urticaria)
plus
Teicoplanin 600 mg IV 12 hrly for 3
doses then 24 hrly thereafter
plus

Page 32 of 120
Metronidazole 500 mg IV by
infusion 8 hrly
Oral stepdown
Duration Review IV route after 24 - 48 hrs - convert to oral therapy, if tolerated.

Usually 5-10 days total (including IV treatment)
If no improvement, consider fungal sinusitis
Infection Orbital cellulitis

Specimen Eye swab of pus if present
Nasal swab for Gram stain and culture
Blood culture
Streptococcus spp
Haemophilus influenzae
Gram negative rods
anaerobes
Ceftriaxone* 2 g IV by infusion If anaphylaxis to penicillin:
daily or cefotaxime 2g IV 8hrly Aztreonam 2 g IV 8 hrly
plus plus
Metronidazole 500 mg IV by Teicoplanin 600 mg IV 12 hrly for 3
infusion 8 hrly doses then 24 hrly thereafter
plus
*If anaphylaxis to penicillin use Metronidazole 500 mg IV by
with caution and under close infusion 8 hrly
observation
Oral stepdown:
Oral stepdown: Discuss with Microbiologist
Co-amoxiclav 625 mg orally 8 hrly
plus
Metronidazole 400 mg orally 8 hrly
(depending on culture and
sensitivities results)
Duration IV should be switched to oral as soon as clinical improvement
occurs and the temperature has been normal for 72 hrs, providing
there is no contra-indication to oral therapy.
21 days total (including IV treatment)

Page 33 of 120
Throat
Infection Acute sore throat
Specimen Throat swab if antibacterials are recommended (see below)
Likely Organisms Respiratory and other viruses (e.g., EBV)
β haemolytic streptococcus (group A, C and G)
Treatment Antibacterials should not be routinely prescribed, the following
indications may support their selective use:
- features of marked systemic upset secondary to acute sore throat
- unilateral peritonsillitis
- history of rheumatic fever
- at increased risk from acute infection e.g. immunocompromised
Phenoxymethylpenicillin 500 mg Clarithromycin 500 mg orally 12
orally 6 hrly hrly
If unable to swallow: If unable to swallow:

Benzylpenicillin 1.2 g IV 6 hrly Clarithromycin 500 mg IV by
infusion 12 hrly
Duration Review IV route after 24 - 48 hrs - convert to oral therapy, if tolerated, as
prolonged IV therapy has been shown to have no clinical benefit.
β haemolytic streptococcus group A:

10 days total (including IV treatment) if penicillin is used.
5 days total (including IV treatment) if clarithromycin is used
Other / no organism identified: 5 days total (including IV treatment)
Infection Peritonsillitis / Peritonsillar abscess or quinsy

Specimen Aspirate from abscess
Likely Organisms β haemolytic streptococcus group A
Anaerobes
Treatment Needle aspiration or incision and drainage
infusion 12 hrly
add
Metronidazole 500 mg IV by add
infusion 8 hrly if not settling Metronidazole 500 mg IV by
after 24 hours treatment and/or infusion 8 hrly if not settling
abscess drainage after 24 hours treatment and/or
abscess drainage
Oral step down:
Phenoxymethylpenicillin 500 mg Oral step down:
orally 6 hrly Clarithromycin 500 mg orally 12
hrly
Duration IV should be converted to oral as soon as clinical improvement occurs
and the temperature has been normal for 24 hrs, providing there is no

Page 34 of 120
contra-indication to oral therapy
β haemolytic streptococcus group A:
10 days total (including IV treatment) if penicillin is used.
7 days total (including IV treatment) if clarithromycin is used.
Other / no organism identified: 7 days total (including IV treatment)
Infection Epiglottitis / Supraglottitis

Specimen After establishment of an airway:
Blood culture
Likely Organisms Haemophilus influenzae, streptococci, Staphylococcus aureus,
Streptococcus pneumoniae, other organisms
Treatment Maintenance of an adequate airway should be the primary concern
Ceftriaxone 2 g IV by infusion daily
If anaphylaxis to penicillin use with caution and under close
observation
If ceftriaxone cannot be given:

Oral stepdown
Co-amoxiclav 625 mg orally 8 hrly
If penicillin allergic (not anaphylaxis)
Cefaclor 500 mg orally 8 hrly
If Haemophilus influenzae type b confirmed, contact consultant

microbiologist to determine who should receive prophylaxis
contra-indication to oral therapy and a suitable agent is available
7 - 10 days total (including IV treatment)

Page 35 of 120
Infection Salivary gland infection
Specimen Aspirate of duct orifice
or
If aspirate not possible, swab papilla of parotid
Blood culture
Likely Organisms Staphylococcus aureus, Streptococcus spp, oral flora
Treatment First line Alternative (penicillin allergy or
tagged for MRSA)
Flucloxacillin 2g IV 6hrly Teicoplanin 600 mg IV 12 hrly for 3
Plus doses then 24 hrly thereafter
Metronidazole 400mg orally 8hrly Plus
Or metronidazole IV 500mg 8hrly if Metronidazole 400mg orally 8hrly
no oral intake Or metronidazole IV 500mg 8hrly if
no oral intake
contra-indication to oral therapy
10 – 14 days total (including IV treatment)
References
1. The Sanford guide to antimicrobial therapy 2010
2. Clinical practice guideline: otitis externa. Otolaryngol Head Neck Surg 2006;134:S4-23.
3. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007;137:S1-31.
4. IDSA Clinical practice guideline of acute bacterial rhinosinusitis in adults and children. CID
2012; 54 (12).
5. European position paper on rhinosinusitis and nasal polyps 2012.
http://www.rhinologyjournal.com/supplement_23.pdf
6. Antibiotics for sore throat. Cochrane database systematic review 2006.
th
7. Principles and Practice of Infectious Diseases. Mandell, Douglas and Bennett’s. 6 edition
2006

Page 36 of 120
GASTROINTESTINAL INFECTIONS
Gastro-enteritis
• Most cases do not require treatment with antibiotics. Antibiotics may be
indicated in the immunosuppressed, extremes of age, traveller’s diarrhoea,
prolonged course of diarrhoeal illness and severe /complicated cases.
• All cases thought to be due to infectious diarrhoea need to be in a side room
and infection control nurses should be informed. Please take enteric
precautions.
• Cases of food poisoning, typhoid fever, paratyphoid fever, dysentery and
cholera should be notified to Consultant for Communicable Disease Control
(CCDC) at Cheshire and Merseyside H.P.U. and followed up in writing using
the form available on this site.
• During office hours they can be contacted on 0844 225 1295.

• Outside office hours the Proper Officer can be reached via the public health
on-call rota on 0151 706 3134 or 0151 706 2000 (via the Royal Liverpool
University Hospital switchboard) or 01244 365 000 (via the Countess of
Chester Hospital switchboard); the same rota is held at both hospitals.
Empirical treatment
Treatment Comments
Mild diarrhoea
Oral rehydration
(≤ 3 unformed stools per day,
minimal symptomatology)
Do not use antimotility agents if
dysenteric symptoms
Moderate diarrhoea Oral rehydration
or
plus
if suspected
(≥ 4 unformed stools per day, Antimotility agents
C. difficile infection,
and/or systemic symptoms)
E. coli 0157:H7 infection,
Haemolytic Uraemic Syndrome (HUS)
Obtain stool for
Severe diarrhoea
culture,
Clostridium difficile testing, Afebrile bloody diarrhoea should raise
≥ 6 unformed stools per day suspicion of E. coli 0157:H7 infection –
and/or dysenteric symptoms parasites if travel history
avoid antibiotics as there is an
(pyrexia, blood, tenesmus), increasing risk of precipitating
and/or high risk patient Consider antibiotic treatment
haemolytic uraemic syndrome.
(immunosuppression, Ciprofloxacin PO 500 mg 12
advanced age) hrly for 5 days

Page 37 of 120
Treatment algorithm for C. difficile Infection (CDI)
N.B. Treatment is not necessary for asymptomatic carriers
Diarrhoea AND one of following:

Positive CDT test or CDT test pending AND clinical suspicion of CDI
• Isolate patient
• Stop non-C diff antibiotics if possible
• Stop PPIs if not necessary
• Maintain hydration
• Daily assessment
1st episode of CDI Complications / Life threatening CDI

• Ileus
Oral vancomycin (DO NOT use • Toxic megacolon
vancomycin IV for treatment of CDI) • Hypotension
250 mg qds for 10-14 days • Severe colitis on CT
If at any time during course of CDI
complications occur – see box on *Vancomycin 500 mg PO/NG qds
the right AND
Metronidazole 500mg IV tds
PLUS
Urgent Surgery, Gastro, Micro consultation
*Depending on degree of ileus consider

Symptoms not improving intracolonic vancomycin (500mg in 100-500ml
(after at least 7 days of treatment) saline 4-12hrly) given as retention enema: 18
gauge Foley catheter with 30ml balloon inserted
Add Metronidazole 400 mg PO tds per rectum, balloon inflated, vancomycin instilled,
catheter clamped for 60 minutes, deflate and
remove
Symptoms not improving (after further 7 days of treatment)
• Continue vancomycin and metronidazole

• Normal immunoglobulin 400 mg/kg single iv dose followed by
second dose after 3 weeks (if still inpatient) only available via
Consultant Microbiologist during normal working hours
Symptoms persist (after further 7 days of treatment)
• Consider sigmoidoscopy
• Consider loperamide and stopping vancomycin/metronidazole (ONLY if patient stable, WBC, CRP
normal, no abdominal pain or distension AND only after discussion with Consultant gastro/micro)
• Consider rifaximin 400mg PO bd (If diarrhoea reduced to type 5 stool 1-2/day only available via
Consultant Microbiologist during normal working hours)
• If at any time during course of CDI patient doesn’t open bowel for 4 days, obtain AXR and if
constipation confirmed stop vancomycin+/- metronidazole (once 10-14 day course has been
completed)
• Colestyramine may also be used – (NOT together with vancomycin and only on the advice of
Consultant Gastroenterologist)
Recurrent CDI (2nd or subsequent episodes)

Antibiotic st
Guidelines:
Repeat treatment as for 1 episodeTreatment and Prophylaxis for Adults
Page
Once diarrhoea 38 of 120
controlled stop vancomycin +/- metronidazole and start
rifaximin 400mg PO bd for 14 days (only available via Consultant
Microbiologist during normal working hours)
Campylobacter
Treatment For most cases antibiotic treatment is not indicated (self-limiting illness)
Erythromycin 500 mg orally 6 hrly if indicated (severe cases,
immunosuppression, continuing symptoms)
Duration 5 days
Salmonella (non-typhi)
Treatment For most cases antibiotic treatment is not indicated (self-limiting illness)
Treat if <1 year old, >60 year old, immunocompromised, vascular grafts
or prosthesis
Duration 7 days (14 days if immunocompromised)
Shigella
Treatment Mild: none
Severe: ciprofloxacin 500 mg orally 12 hrly
Duration 3 days
E coli 0157:H7
Treatment NO TREATMENT with antimicrobials or antimotility agents, may enhance
toxin release and increase risk of haemolytic uraemic syndrome.
Hydration important
Monitor FBC and U+Es
Vibrio cholerae 01 or 0139

Treatment Doxycycline 300 mg orally as a single dose
Duration Single dose
Giardia lamblia, Giardiasis

Treatment Metronidazole 400 mg orally 8 hrly
Duration 5 days
Entamoeba histolytica, amebiasis

Treatment Duration
Asymptomatic cyst Diloxanide furoate 500 mg orally 8 hrly for 10 days
passes (metronidazole not effective vs cysts)
Invasive intestinal Metronidazole 800 mg orally 8 hrly for 5 days
amebiasis then See Treatment
Diloxanide furoate 500 mg orally 8 hrly for 10 days
Amoebic liver Metronidazole 800 mg orally 8 hrly for 10 days
abscess then
Diloxanide furoate 500 mg orally 8 hrly for 10 days
Page 39 of 120
References
2. Practice guidelines for the management of infectious diarrhoea, IDSA 2001
3. The management of infectious gastroenteritis in adults. A consensus statement
by an expert panel convened by the British Society for the Study of Infection. J
Infection 1996;33:143-152

Page 40 of 120
GENITAL TRACT INFECTIONS
Bacterial vaginosis
Specimen High vaginal swab
(pregnancy)
Metronidazole 400 mg orally 12 Clindamycin 2% cream (PV) nocte
hrly
Duration 7 days 7 days
Vaginal candidiasis
Specimen High vaginal swab
Clotrimazole pessary 500 mg nocte Fluconazole 150 mg orally
If concurrent vulvitis add

Clotrimazole 2% cream
Duration Single dose Single dose
Seek specialist advice if recurrent or refractory to treatment.
Trichomoniasis
Specimen Vaginal swab for trichomonas culture
Duration 7 days
Pregnancy As above
Prescribing Notes
Comments Treat partner(s) simultaneously
Refer to GUM

Page 41 of 120
Infection Chlamydia trachomatis
All patients with chlamydia should be referred to GUM.
If severe or upper tract infection consult GUM prior to initiating
treatment.
Specimen Endocervical swab or urine for chlamydia testing by NAAT (nucleic acid
amplification assay)
Uncomplicated Doxycycline 100 mg orally 12 hrly Azithromycin 1 g orally as a single
genital infection for 7 days dose
Uncomplicated Erythromycin 500 mg orally 6 hrly for 7 days
genital infection in or
pregnancy Amoxicillin 500 mg orally 8 hrly for 7 days
or
Azithromycin 1 g orally as a single dose
A test of cure is required in pregnancy
Test of cure/reinfection established by NAAT should be performed at

least 5 weeks after initiation of therapy (6 weeks after azithromycin)
Chlamydial Doxycycline 100 mg orally 12 hrly Ofloxacin 400 mg orally 12 hrly
salpingitis plus plus
Metronidazole 400 mg orally 12 Metronidazole 400 mg orally 12
hrly hrly
for 14 days for 14 days
Chlamydial Doxycycline PO 100 mg 12 hrly for 10-14 days
epidimo-orchitis
Duration See Treatment
Neisseria gonorrhoea
Specimen Endocervical, urethral, rectal, pharyngeal swab for culture
Treatment Refer to GUM

See Gynaecological infections (page 51)
References
1. Management of genital Chlamydia trachomatis infection, SIGN national clinical
guideline 2009
2. NHS evidence at http://www.library.nhs.uk/Infections/

Page 42 of 120
GYNAECOLOGY AND PREGNANCY RELATED INFECTIONS
Obstetrics
Lower Urinary Tract Infection (cystitis / asymptomatic bacteriuria) in

pregnancy
Specimen Midstream specimen of urine
Likely organisms Enterobacteria
Treatment Cefradine 500 mg orally 6 hrly or according to sensitivities
Women with asymptomatic bacteriuria confirmed by a second urine

culture should be treated and have repeat urine culture at each
antenatal visit until delivery
Duration 7 days
Given the risks of asymptomatic bacteriuria in pregnancy, a urine
culture should be performed 7 days after completion of
antibacterials as a test of cure.
Pyelonephritis in pregnancy
Specimen Blood culture
Midstream specimen of urine
Likely organisms Enterobacteria
Check previous Co-amoxiclav 1.2 g IV 8 hrly Cefuroxime 750 mg IV 8 hrly

urine culture plus plus
results if available Gentamicin IV 5mg/kg single Gentamicin IV 5mg/kg single dose
dose (max. 560 mg) (max. 560 mg)
Oral stepdown: If anaphylaxis to penicillin

Co-amoxiclav 625 mg orally 8 discuss with Microbiologist
hrly
Oral stepdown:
Trimethoprim 200 mg orally 12 hrly
if sensitive and >20 weeks gestation
Always check the urine culture and sensitivities results
Duration 14 days total

Page 43 of 120
Chorioamnionitis
Specimen Diagnosis largely based on clinical findings
Amniotic fluid can be useful if available
Blood culture
Likely organisms Group B streptococci
E. coli
Anaerobes
Infection is often polymicrobial
Amoxicillin 2 g IV 8 hrly Cefuroxime 1.5 g IV 8 hrly
plus plus
Gentamicin 1.5 mg/kg IV 8 hrly Metronidazole 500 mg IV by
plus infusion 8 hrly
infusion 8 hrly If history of immediate
penicillins (e.g. anaphylaxis,
urticaria)
Clindamycin 600 mg IV 6 hrly
plus
Gentamicin1.5 mg/kg IV 8 hrly
Duration One additional dose of above combination is usually sufficient

postpartum therapy
Post partum endometritis

Specimen Blood cultures
Uterine cultures
Cervical swab for Chlamydia
Likely organisms β-haemolytic streptococci, E. coli, other gram negative aerobes,

anaerobes, Gardnerella. vaginalis, Chlamydia thachomatis
Polymicrobial infection common (mixed aerobic + anaerobic flora)
Co-amoxiclav 1.2 g IV 8 Cefuroxime 1.5 g IV 8 hrly
hrly plus
plus Metronidazole 500 mg IV by infusion 8
hrly
Gentamicin IV 5mg/kg
single dose (max. 560 mg) plus
Gentamicin IV 5mg/kg single dose (max.
560 mg)
If history of immediate
hypersensitivity reaction to penicillins
(e.g. anaphylaxis, urticaria)
Clindamycin 600 mg IV 6hrly
plus
Once daily gentamicin IV (see prescribing
regimen)
Duration Continue parenteral therapy until patient afebrile for >24-48hrs, pain free
and normal WBC
Follow up oral antibiotics after discharge are NOT necessary

Page 44 of 120
Post abortion infection
Specimen Blood cultures
Uterine cultures
Cervical swab for culture, chlamydia
Urine culture
Likely organisms Vagina flora organisms, sexually transmitted pathogens, Clostridium

perfringens
Treatment Uterine evacuation usually necessary

Early post abortion Ceftriaxone 250 mg IM stat Ofloxacin 400 mg PO 12 hrly
infection then plus
(simple endometritis, Doxycycline 100 mg orally 12 hrly Metronidazole 400 mg PO 12 hrly
low grade fever, mild plus
uterine tenderness Metronidazole 400 mg orally 12
following hrly
uncomplicated
elective abortion)
Established Co-amoxiclav 1.2 g IV 8 hrly Cefuroxime 1.5 g IV 8 hrly
infection plus plus
Gentamicin IV 5mg/kg single
(Fever >38°C, pelvic infusion 8 hrly
dose (max. 560 mg)
peritonitis, plus
tachycardia) Gentamicin IV 5mg/kg single dose
(max. 560 mg)
urticaria)
Clindamycin 600 mg IV 6hrly
plus
Once daily gentamicin IV (see
prescribing regimen)
Duration 5-7 days

Page 45 of 120
Episiotomy infection
Specimen Pus if present
Wound swab
Likely organisms Streptococci, staphylococci, enterobacteriaceae, anaerobes
Simple episiotomy Co-amoxiclav 625 mg orally 8 Clarithromycin 500 mg orally 12
infection hrly hrly
Local infection along plus
episiotomy incision,
no systemic
manifestations
Superficial fascia Co-amoxiclav 1.2 g IV 8 hrly Clarithromycin 500 mg IV by
infection infusion 12 hrly
Surgical exploration plus
Add once daily gentamicin IV if
may be required
fails to respond (see prescribing Metronidazole 500 mg IV by
regimen) infusion 8 hrly
plus
Duration 5-7 days
Infection Prevention of early onset neonatal group B streptococcal

(GBS) disease
Indicated for vaginal deliveries or emergency Caesarean Section if:

- Previous infant with invasive GBS disease
- GBS bacteriuria in this pregnancy
Should be considered if any of the following risk factors present:

- Intrapartum fever ≥ 38°C
- Prematurity < 37 weeks
- Prolonged rupture of membranes (> 18 hr) at term
- GBS carriage in this pregnancy
Treatment Antibacterial prophylaxis
Benzylpenicillin 3 g IV
then Clindamycin 900 mg IV 8 hrly
Benzylpenicillin 1.5 g IV 4 hrly until
delivery
Start as soon as possible after onset of labour and at least 2 hours before
delivery
Continue until delivery
If intrapartum fever and chorioamnionitis is suspected broad-spectrum

antibiotic therapy including an agent active against GBS should replace
GBS-specific antibacterial prophylaxis
(see chorioamnionitis above)
Duration See treatment

Page 46 of 120
Infection Preterm prelabour rupture of membranes
Antibacterial prophylaxis
Treatment
Erythromycin 250 mg orally 6 hrly
Duration 10 days
Sepsis of unknown origin

• See also guidelines for Sepsis, severe sepsis and septic shock (Page 71)
• If source identified, treat as per appropriate condition
Specimens Obtain appropriate cultures before starting antibiotics provided

this does not significantly delay antibiotic administration
Blood cultures at least 2 sets

at least one BC should be percutaneous,
one BC from each vascular access device
Culture other sites as clinically indicated e.g.:
urine
faeces
wound or vaginal swabs
Treatment Start antibiotics ASAP and within the first hour of recognising
severe sepsis or septic shock
Check previous microbiology results if available
Remove source if appropriate e.g. infected lines, abscess,
perforated bowel
For severe sepsis/septic shock, add gentamicin 1.5 mg/kg IV

8 hrly to appropriate regimen
Piperacillin/tazobactam Meropenem* 1g IV 8 hrly

®
(Tazocin ) 4.5 g IV 8 hrly *Use with caution and under
immediate hypersensitivity
reaction to penicillins (e.g.
anaphylaxis, urticaria)
penicillins contact consultant
microbiologist
Known ESBL Meropenem* 1g IV 8 hrly
positive patient
Known / suspected Add teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter
MRSA positive to above regimen
or
line infection
suspected
Adjust treatment following culture results and susceptibilities
Empirical use of gentamicin as part of combination therapy
Duration should not continue for > 3-5 days
7-10 days total

Page 47 of 120
Gynaecology
Mastitis
Specimen Aspirate of pus or swab if aspirate not possible
Likely organisms Staphylococcus aureus most common
Streprococci, anaerobes, coagulase negative staphylococci
Post partum mastitis Flucloxacillin 2 g IV 6 hrly Clarithromycin 500 mg IV by

or infusion 12 hrly
Drain abscess if Flucloxacillin 500 mg orally 6 hrly or
present depending on severity Clarithromycin 500 mg orally 12
hrly
Oral step down: Flucloxacillin 500
mg orally 6 hrly Oral step down: Clarithromycin
500 mg orally 12 hrly
Non-puerperal Flucloxacillin 2 g IV 6 hrly Clarithromycin 500 mg IV by

mastitis or infusion 12 hrly
Flucloxacillin 500 mg orally 6 hrly or
Depending on severity Clarithromycin 500 mg orally 12
Drain abscess if hrly
present
If subareolar and odoriferous If subareolar and odoriferous
Add Add
hrly or IV 500 mg 8 hrly hrly or IV 500 mg 8 hrly
Oral step down: Flucloxacillin 500 Oral step down: Clarithromycin

mg orally 6 hrly 500 mg orally 12 hrly
+/- +/-
hrly hrly
Known / suspected Teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter
MRSA positive Or
Doxycycline 200mg orally 24hrly (contraindicated in breastfeeding)
depending on severity
Surgical site infection after gynaecologic surgery

Likely organisms Mixed aerobic and anaerobic flora (streptococci, enterobacteriaceae,
G. vaginallis, anaerobes)
Not severe Co-amoxiclav 625 mg orally 8 hrly Clarithromycin 500 mg orally 12

Page 48 of 120
hrly
plus
Metronidazole 400 mg orally 8
hrly

fails to respond (see prescribing
regimen)
Severe Co-amoxiclav 1.2 g IV 8 hrly Clarithromycin 500 mg IV by
infusion 12 hrly
Add once daily gentamicin IV if plus
plus
Duration Non-severe: 5 - 7 days total
Severe: 7 - 14 days total (including IV treatment)

Page 49 of 120
Specimen Cervical and urethral swab for gonorrhoea
Cervical swab for Chlamydia
High vaginal swab
Likely organisms Chlamydia trachomatis, Neisseria gonorrhoeae, anaerobes,
streptococci, gram negative rods, mycoplasmas
Outpatient Ceftriaxone 500 mg IM stat Ofloxacin 400 mg orally 12 hrly
(mild-moderate PID) then plus
Doxycycline 100 mg orally 12 hrly Metronidazole 400 mg orally 12
plus hrly
hrly
For 14 days For 14 days
Inpatient Ceftriaxone 2 g IV 24 hrly Clindamycin 900 mg IV 8 hrly
(severe disease, plus plus
tubo-ovarian abscess, Doxycycline 100 mg orally 12 hrly Once daily gentamicin IV (see
pregnancy, plus prescribing regimen)
lack of response or Metronidazole 400 mg orally 12
intolerance to oral hrly Oral step down
therapy) Doxycycline 100 mg orally 12 hrly
Oral step down plus
Doxycycline 100 mg orally 12 hrly Metronidazole 400 mg orally 12
plus hrly
hrly
Pregnancy Ceftriaxone 2 g IV 24 hrly

plus
Erythromycin 500 mg IV 6 hrly
plus
Metronidazole 500 mg IV 8 hrly
Oral step down
Erythromycin 500 mg orally 6 hrly

plus
hrly
Duration Switch to oral >24hours after clinical improvement
14 days total
References
1. Stubblefield PG and Grimes DA. Septic abortion. NEJM 1994;331:310-314.
2. French L, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database of
Systematic Reviews 2004.
3. Hopkins L, Smaill FM. Antibiotic regimens for management of intraamniotic infection. Cochrane
Database of Systematic Reviews 2002.
4. Prevention of early onset neonatal group B streptococcal disease RCOG 2003 Green top
guideline 36.
5. Preterm prelabour rupture of membranes RCOG 2006 Green top guideline 44.
6. Management of acute pelvic inflammatory disease RCOG 2008 Green top guideline 32.
7. UK National guideline for management of PID BASHH 2011.

Page 50 of 120
Infection Infective endocarditis (IE)
(Empirical treatment)
Specimen • Blood cultures (ensure meticulous aseptic technique)
o 3 sets from peripheral sites with >=6 hr between them
before commencing antimicrobial therapy (in
chronic/subacute cases)
o If the diagnosis of IE is in doubt, the patient is clinically
stable and has already received antibiotics, stop
antibiotics and reculture
o If patient acutely ill (severe sepsis or septic shock), take 2
blood culture sets within 1hr before starting empirical
therapy
• Serology
o In patients with culture negative IE send serum for
Coxiella burnetii (Q fever) and Bartonella testing. If
negative, discuss with Microbiologist further serological
testing.
Likely Organisms Streptococci
Enterococci
Coagulase negative staphylococci
HACEK group
Doses require adjustment according to renal function
NVE- Indolent
presentation
Amoxycillin IV 2 g 4 hrly *Vancomycin IV 1 g 12 hrly
plus plus
If patient is clinically *Gentamicin IV 1mg/kg 12 hrly
stable, ideally wait blood *Gentamicin IV 1mg/kg 12 hrly
cultures
NVE -Acute *Vancomycin IV 1 g 12 hrly
presentation (severe plus
sepsis) *Gentamicin IV 1mg/kg 12 hrly
If patient is critically ill and has risk factors for unusual/resistant

organisms (e.g. colonisation with ESBL-producing coliforms or
intravenous drug use) substitute meropenem 2g IV 8hrly for
gentamicin
PVE pending blood *Vancomycin IV 1 g 12 hrly
cultures or with plus
negative blood *Gentamicin IV 1mg/kg 12 hrly
cultures plus
NVE, native valve endocarditis

PVE, prosthetic valve endocardits
* Gentamicin and vancomycin require careful monitoring, especially in renal impairment

Monitor twice weekly if renal function normal and stable, otherwise daily
Dose modification is required according to renal function
Gentamicin (multiple daily dosing for infective endocarditis)
• Pre-dose (trough) level should be maintained <1 mg/L
Page 51 of 120
• Post-dose (peak) level 3-5 mg/L
Vancomycin
• Pre-dose level 15-20mg/L.
Duration Prolonged IV antibiotic therapy necessary (4-6 weeks)

Depends on organism cultured and presence or absence of intra-
cardiac prosthesis
Routine switch to oral antimicrobials is not recommended
Empirical therapy must be followed by pathogen specific therapy

once culture results available
Always discuss with Consultant Microbiologist
References
1. Guidelines for the diagnosis and antibiotic treatment of endocarditis in adults: report of the
Working Party of the British Society for Antimicrobial Chemotherapy 2011. J Antimicrob
Chemother doi:10.1093/jac/dkr450

Page 52 of 120
INTRA-ABDOMINAL INFECTIONS
Infection Diverticulitis
Specimen Blood culture (if clinically toxic or immunocompromised)
Pus from abscess if drained
Likely Organisms Enterobacteriacae
Anaerobes
Enterococci, streptococci
Co-amoxiclav 1.2 g IV 8 hrly Once daily gentamicin IV (see
Oral stepdown: plus
Co-amoxiclav 625 mg orally 8 Metronidazole 500 mg IV by
hrly infusion (or 400 mg orally) 8 hrly
Oral stepdown:
Or
Co-trimoxazole 960 mg orally 12
hrly plus
Metronidazole 400 mg orally 8hrly
Duration Review IV route after 24 - 48 hrs - convert to oral therapy, if
tolerated and available.
Usually 5 - 7 days total (including IV treatment)
If persistent or recurrent evidence of infection after 5 – 7 days
treatment, discuss with consultant surgeon and consider appropriate
diagnostic investigations
Infection Secondary peritonitis

Spillage of gastrointestinal or genitourinary microorganisms into the
peritoneal cavity due to loss of integrity of mucosal barrier e.g.
ruptured appendix, perforated peptic ulcer
Specimen Blood culture (if clinically toxic or immunocompromised)
Peritoneal aspirate/pus for gram stain and culture. Request culture for
mycobacteriae if chronic peritonitis or TB suspected
Likely Organisms Typically polymicrobial infection - Colonic flora
Gram negative bacilli, Anaerobes, Candida spp
Mycobacterium tuberculosis (chronic peritonitis)
Treatment of First line Alternative (penicillin allergy)
secondary bacterial
peritonitis
Mild/moderate Co-amoxiclav 1.2 g IV 8 hrly Once daily gentamicin IV (see
And prescribing regimen)
Community- Oral stepdown: plus
acquired According to sensitivities or Metronidazole 500 mg IV by
Co-amoxiclav 625 mg orally 8 infusion (or 400 mg orally) 8 hrly
hrly Oral stepdown:
According to sensitivities or
hrly plus
Page 53 of 120
Severe Piperacillin/tazobactam Meropenem 1 g IV 8 hrly
®
Or (Tazocin ) 4.5 g IV 8 hrly
Hospital-acquired Oral stepdown: If anaphylaxis to penicillin
According to sensitivities Aztreonam 1-2 g IV 8 hrly
plus
infusion (or 400 mg orally) 8 hrly
plus
Oral stepdown:
For established infection continue for total of 5 - 7 days (including IV).
Upper gastrointestinal perforations operated on within 24hrs (in the
absence of malignancy or acid-reducing therapy), traumatic or
iatrogenic bowel injuries operated on within 12hrs and acute
appendicitis without evidence of perforation, abscess, or local
peritonitis require treatment for ≤24hrs post-op.
Infection Primary (spontaneous) bacterial peritonitis

Peritoneal infection that is not related directly to other intra-abdominal
abnormalities
Specimen Ascitic fluid >=10ml inoculated into blood culture bottles at bedside
Ascitic fluid in sterile container for cell count, differential and culture
Likely Organisms Escherichia coli, Klebsiella pneumoniae, Anaerobes, Streptococcus
pneumoniae
Treatment
Empirical antibiotic therapy should be started in patients with an ascitic fluid neutrophil count
3. 3
of >250 cells/mm . In patients with hemorrhagic ascites with fluid RBC count >10000mm , a
subtraction of 1 neutrophil per 250 RBC should be made to adjust for the presence of blood in
ascites.
Timing First line Alternative (penicillin allergy)
Initial empiric Co-amoxiclav 1.2 g IV 8 hrly Ertapenem IV 1 g daily
treatment Oral step down
(oral treatment can Co-amoxiclav 625mg orally 8hrly If anaphylaxis to penicillin use
be initiated if patient ciprofloxacin 750mg orally 12 hrly
is clinically well, with or
bowel sounds) Ciprofloxacin 400mg IV 12 hrly
(if patient is on ciprofloxacin
prophylaxis, use IV regimen
below)
If not responding Modify antibiotic treatment Modify antibiotic treatment
after 48 hr according to sensitivity results according to sensitivity results
(<25% reduction in
ascitic fluid If culture negative switch to If culture negative switch to
neutrophil count) Piperacillin/tazobactam Aztreonam 2g IV 8 hrly
®
(Tazocin ) 4.5 g IV 8 hrly plus

Page 54 of 120
Also consider secondary infusion 8 hrly
peritonitis plus
Also consider secondary

peritonitis
Prophylaxis Only in cirrhotic patients after first confirmed episode of
Started after spontaneous bacterial peritonitis
completion of Ciprofloxacin 500 mg orally 24 hrly
treatment course
Duration Treatment: Prophylaxis:
Review IV route after 24 - 48 Until ascites resolved
hrs - convert to oral therapy, if
improving and organism sensitive
Total 5 days
Infection Acute pancreatitis

Specimen Blood culture if septic
Pancreatic tissue if debrided
Likely Organisms Enteric organisms
Treatment Avoid routine prophylactic antibacterials especially if <30%
necrosis of the pancreas on CT
Give antibiotics only if proven infection, newly developed sepsis,
failure of ≥ 2 organ systems
Meropenem 1 g IV 8 hrly
If anaphylaxis to penicillin contact consultant microbiologist
Duration 7-14 days

Page 55 of 120
LIVER AND BILIARY SYSTEM
Infection Acute Cholecystitis

Specimen Blood culture if septic
Likely Organisms Enterobacteriacae, Anaerobes, Enterococci, streptococci
Mild cases: Once daily gentamicin IV (see
Co-amoxiclav 625 mg orally 8 hrly prescribing regimen)
or
Moderate severity (WBC>18.0, Once daily gentamicin IV (see

marked local inflammation, tender prescribing regimen)
mass RUQ): or
Co-amoxiclav 1.2 g IV 8 hrly Aztreonam 1-2 g IV 8 hrly
plus
infusion (or 400 mg orally) 8
hrly
Severe (organ dysfunction present)
or Hospital-acquired:
®
Piperacillin/tazobactam (Tazocin )
4.5 g IV 8 hrly
Oral stepdown Oral stepdown
According to sensitivities or According to sensitivities or
Co-amoxiclav 625 mg orally 8 hrly Co-trimoxazole 960 mg orally
(if no positive cultures) 12 hrly plus
Metronidazole 400 mg orally
8hrly (if no positive cultures)
Duration Review IV route after 24 - 48 hrs - convert to oral therapy, if tolerated
and available.
Usually 5 - 7 days total (including IV treatment)

Page 56 of 120
Infection Acute Cholangitis
Treatment Biliary drainage by either urgent ERCP or PTC is likely to be
necessary
Mild/moderate Aztreonam 1-2 g IV 8 hrly
Co-amoxiclav 1.2 g IV 8 hrly plus
infusion (or 400 mg orally) 8 hrly
Severe (organ dysfunction Aztreonam 1-2 g IV 8 hrly

present) or Hospital-acquired: plus
Piperacillin/tazobactam Metronidazole 500 mg IV by
®
(Tazocin ) 4.5 g IV 8 hrly infusion (or 400 mg orally) 8 hrly
plus
According to sensitivities or According to sensitivities or
Co-amoxiclav 625 mg orally 8 Co-trimoxazole 960 mg orally 12
hrly (if no positive cultures) hrly plus
(if no positive cultures)
For mild cases 3 days is usually sufficient
For other cases usually 5 - 7 days total (including IV treatment)
Infection Pyogenic liver abscess

Aspirate of abscess contents for gram stain and culture
Treatment Drainage of abscess

Piperacillin/tazobactam Meropenem 1 g IV 8 hrly
®
Discuss with consultant
microbiologist
Oral stepdown
Duration Intravenous - up to 2 weeks may be necessary

Page 57 of 120
Oral stepdown once clinical parameters improving, depending on
culture results.
Total 2 - 6 weeks (10 - 14 days may be sufficient for abscesses that
are drained)
Infection Amoebic liver abscess

Specimen Stool for ova, cysts and parasites
Amoebic serology
Blood culture if pyrexial
Likely Organisms Entamoeba histolytica
then
Diloxanide furoate 500 mg orally 8 hrly
Duration Metronidazole 10 days
Diloxanide furoate 10 days
References
th
1. Principles and practice of Infectious Diseases. 6 ed. Mandell, Douglas and Bennett.
3. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus
document, International ascites club. J of Hepatology 2000;32:142-153
4. Guidelines on the management of ascites in cirrhosis. KP Moore, GP Aithal. Gut 2006; 55:1-12.
5. UK guidelines for the management of acute pancreatitis Gut 2005;54:1-9
6. Tokyo guidelines for the management of acute cholecystitis and cholangitis. J Heapato-biliary
Pancreat surg 2007;14
7. Diagnosis and management of complicated intra-abdominal infection in adults and children:
IDSA guidelines. Clinical Infectious diseases 2010;50:133-64

Page 58 of 120
MRSA positive in-patient at MCHFT
(MRSA isolated from admission screen, weekly screen, clinical specimen etc)
Obtain full MRSA screen if not already done
Infection with MRSA Colonisation with MRSA Prior to any surgical procedure
(multiplication of MRSA in the tissues (the presence and multiplication of MRSA at a (for elective, outpatient surgical cases follow
with associated host response leading body site without tissue invasion or host the “elective MRSA screening pathway”)
to symptoms such as pyrexia, response i.e. no signs of infection)
septicaemia, skin and soft tissue
infections, pneumonia etc)
MRSA Suppression Treatment (5 day course) MRSA Suppression Treatment

®
• Mupirocin 2% nasal ointment (Bactroban ) ● start 5 days pre-operatively and
Systemic antibiotic treatment complete on the day of operation
topically to each nostril tds for 5 days.
(with antibiotics that are active ®
• Triclosan 1% skin cleanser (Skinsan ) ● if treatment cannot be commenced
against MRSA e.g. teicoplanin I.V.
Body: daily for 5 days 5 days pre-op, start at the earliest
Oral options depend on susceptibility
Hair: on days 2 and 4 opportunity and continue for a full 5 days
testing –refer to microbiology results
and to relevant hospital antibiotic Plus
Systemic antibiotic treatment is NOT required Surgical antibiotic prophylaxis
treatment guidelines)
Plus (if indicated) should include
Teicoplanin 600mg I.V. at induction
MRSA Suppression Treatment
(follow instructions on the right)
(See Guidelines
“Antimicrobial prophylaxis for surgery”
on intranet under Policies and Procedures
Re-screen > Antibiotic Management)
● 2 days after suppression treatment and all
antibacterials (topical or systemic) have been stopped
Re-screen MRSA positive Re-screen MRSA negative

● Repeat course of suppression treatment ● Obtain 2 more negative MRSA screens taken
at weekly intervals before patient is considered to
● If medical device in situ that breaches skin or mucous membranes be clear of MRSA
(central line, trachea cannula, drain etc), or a urinary catheter, carry out
nd
2 suppression treatment only after all devices have been removed ● If any subsequent screens are positive, follow
instructions on box on the left
● DO NOT give more than two courses during a single inpatient
episode
Page 59 of 120
RESPIRATORY TRACT INFECTIONS
Infection Community Acquired Pneumonia (empirical)

Assessment of severity using CURB 65 as an aid to clinical
judgement
Consider ‘core’ adverse prognostic features (score 1 point for
each feature present):
- New mental confusion (mental test score of ≤ 8 or new
disorientation in person, place or time
- Urea > 7 mmol/L
- Respiratory rate ≥ 30 breaths/min
- Systolic BP < 90 mmHg or diastolic BP ≤ 60 mmHg
- Age ≥ 65 years
Number of features present Management
0-1 Low severity

2-3 Moderate severity
Treat as severe if one of the
following ‘additional’ adverse
prognostic features present:
- PaO2 < 8 kPa / SaO2 < 92%
(any FiO2)
- CXR: bilateral / multilobar
shadowing
- Co-morbidity
3 with co-morbidity, 4 or 5 High severity
Specimen Blood culture for moderate/severe infection
Sputum for culture and sensitivity prior to antibiotic treatment
If severe CAP, serology for atypical organisms:

- influenza A and B
- Coxiella burnetii
- Chlamydia psittaci
- Mycoplasma pneumoniae
- Legionella pneumophilia
If severe CAP, or in patients with a travel history / hotel stay in 2

weeks prior to admission, urine for:
- Legionella antigen
Likely Organisms Streptococcus pneumoniae
Beta haemolytic Streptococcus
Haemophilus influenzae
Legionella spp
Mycoplasma
I.V. to oral switch IV should be converted to oral as soon as clinical improvement occurs
contra-indication to oral therapy and a suitable agent is available.

Page 60 of 120
Treatment
Severity First line Alternative (penicillin allergy)
Low severity Amoxicillin 500 mg orally 8 hrly Clarithromycin 500 mg orally 12
(CURB 65 = 0 or 1) hrly
If IV needed: or
IV only needed if no Amoxicillin 500 mg IV 8 hrly Doxycycline 100 mg orally 12 hrly
NG/PEG and unable If IV needed:
to swallow or absorb Clarithromycin 500 mg IV by
oral drugs infusion 12 hrly
Moderate severity Amoxicillin 500 mg IV 8 hrly Teicoplanin 600 mg IV 12 hrly for
(CURB 65 = 2 or 3) plus 3 doses then 24 hrly thereafter
plus
Clarithromycin 500 mg orally
Clarithromycin 500 mg orally
12 hrly 12 hrly
(or clarithromycin 500 mg IV by (or clarithromycin 500 mg IV by
infusion 12 hrly if IV needed) infusion 12 hrly if IV needed)
High severity Co-amoxiclav 1.2 g IV 8 hrly Teicoplanin 600 mg IV 12 hrly for

(CURB 65 = 3 plus plus 3 doses then 24 hrly thereafter
comorbidity, 4 or 5) plus
Clarithromycin 500 mg IV by
infusion 12 hrly Clarithromycin 500 mg IV 12 hrly
Oral stepdown to amoxicillin and

clarithromycin or according to Stepdown to oral clarithromycin
organisms isolated. or according to organisms
isolated.
If Legionella suspected:
Add rifampicin 600 mg orally or
IV by infusion (use oral if possible
as it is well absorbed) 12 hrly
Very severe and in Co-amoxiclav 1.2 g IV 8 hrly IV meropenem* 1 g 8 hrly
HDU/ICU plus plus
Clarithromycin 500 mg IV by IV clarithromycin 500 mg 12 hrly.
infusion 12 hrly *Use with caution and under
immediate hypersensitivity
If Legionella suspected:
reaction to penicillins (e.g.
Add rifampicin 600 mg orally or anaphylaxis, urticaria)
IV by infusion (use oral if possible
as it is well absorbed) 12 hrly
Duration If no improvement in 3 days, discuss with consultant microbiologist

Not severe: 5 days total (including IV treatment)
Severe: 7-10 days total (including IV treatment)

Page 61 of 120
Infection Hospital Acquired, Postoperative or Ventilator
Associated Pneumonia
The presence of any of the following indicates a severe illness:
- Respiratory failure (PaO2 < 8 kPa and/or PaCO2 > 6.4 kPa)
- Respiratory rate > 25 breaths/min
- Rapid radiographic progression, multilobar pneumonia, or cavitation
of lung infiltrate
- Diastolic BP < 60 mmHg
9 9
- WBC < 4 x 10 /L or > 20 x 10 /L
- Poor urine output or rising creatinine
- Metabolic acidosis
Specimen Sputum for culture and sensitivity
Blood cultures - two sets from separate sites
Likely Organisms Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus
influenzae, Enerobacteriaceae, Pseudomonas aeruginosa
Treatment
Severity First line Alternative (incl. penicillin
allergy)
Not severe Doxycycline 100 mg orally 12 hrly Clarithromycin 500 mg orally 12
hrly
or
hrly
If not responding within 24 – 48

hrs, treat as severe
Severe Piperacillin and tazobactam Teicoplanin 600 mg IV 12 hrly for 3
® doses then 24 hrly thereafter
If source unclear, can add stat plus
dose of gentamicin 5mg/kg Aztreonam 2 g IV 8 hrly

According to sensitivities According to sensitivities
If history of MRSA add Teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter
(if not already included)
If ESBL positive Meropenem* 1 g IV 8 hrly If history of immediate
urticaria), contact consultant
microbiologist
If ICU patient As above. In addition:

If proven MRSA pneumonia (usually ventilator associated, infiltrates on
chest X-ray, sputum culture yields MRSA only) does not respond to
teicoplanin as expected (within 48 – 72 hrs), contact consultant
microbiologist to discuss switching to linezolid.
Linezolid must only be prescribed on the advice of a consultant

microbiologist
Duration Non severe: 5 - 7 days total (including IV treatment)
Severe: 14 days total (including IV treatment)
Page 62 of 120
Infection Acute Infective Exacerbation of Chronic Obstructive
Pulmonary Disease and Chronic Bronchitis
Specimen Sputum
Blood culture if pyrexial
Likely Organisms Viruses, Haemophilus influenzae, Streptococcus pneumoniae, Moraxella
catarrhalis, Staphylococcus aureus (consider if influenza present)
Treatment First line Alternative (severe infection)
Antibiotic treatment Doxycycline 100mg orally 12 hrly Teicoplanin 600 mg IV 12 hrly for 3
should be given only doses then 24 hrly thereafter
if COPD and
exacerbation is Once daily gentamicin IV (see
associated with prescribing regimen)
increased sputum
purulence.
In the absence of
increased sputum
purulence do not use
antibiotics, unless
patient has clinical
signs of pneumonia
or CXR consolidation
Duration 5 - 7 days total
Infection Acute Bronchitis

Likely Organisms Usually viral
Treatment Antibacterials not recommended
Infection Upper Respiratory Tract Infections

Likely Organisms Usually viral
Treatment Antibacterials not recommended
Infection Aspiration pneumonia

Prophylactic antibiotics to patients in whom aspiration is suspected or
witnessed, or for patients with aspiration pneumonitis (acute chemical
injury following the inhalation of acidic gastric acid contents) is
NOT RECOMMENDED.
Empirical antibiotic therapy should be considered in patients with
aspiration pneumonitis that fails to resolve within 48 hours of
aspiration and/or in patients whose sputa become mucopurulent or
purulent and who exhibit other features consistent with pneumonia.
Sputum for culture and sensitivity
Likely Organisms Streptococcus pneumoniae, Streptococcus spp, Anaerobes,
Gram negative bacilli

Page 63 of 120
Treatment
Not severe Benzylpenicillin 1.2 g IV 6 hrly Clarithromycin 500 mg IV by

plus infusion 12 hrly
Metronidazole 500 mg IV by plus
infusion 8 hrly Metronidazole 500 mg IV by
infusion 8 hrly
Oral step down:
Amoxicillin 500 mg orally 8 hrly
plus
hrly
Severe and Co-amoxiclav 1.2 g IV 8 hrly Teicoplanin 600 mg IV 12 hrly for
community 3 doses then 24 hrly thereafter
acquired If source unclear, can add stat plus
dose of gentamicin 5mg/kg Metronidazole 500 mg IV by
infusion 8 hrly
Oral stepdown
Co-amoxiclav 625 mg orally 8 If source unclear, can add stat
hrly dose of gentamicin 5mg/kg
Oral stepdown
hrly
plus
hrly
Severe and Piperacillin and tazobactam Teicoplanin 600 mg IV 12 hrly for

® 3 doses then 24 hrly thereafter
hospital acquired (Tazocin ) 4.5 g IV 8 hrly
plus
If source unclear, can add stat Aztreonam 2 g IV 8 hrly
dose of gentamicin 5mg/kg plus
infusion 8 hrly
Duration 7 days total (including IV treatment)
Infection Infective Exacerbation of Bronchiectasis (not Cystic

Fibrosis)
Specimen Sputum
Bronchoalveolar lavage
Likely Organisms Haemophilus influenzae, Pseudomonas aeruginosa, Streptococcus
pneumoniae, Staph aureus
Treatment Check last sputum result If last culture report within 3 months treat
according to sensitivities. If sensitivities not known treat according to
regimen below

Page 64 of 120
Not severe and no Co-amoxiclav 625 mg orally 8 hrly Clarithromycin 500 mg orally 12
history of hrly
Pseudomonas
Not severe and Ciprofloxacin 750 mg orally 12 hrly
history of
Pseudomonas:
®
Severe impairment Piperacillin/tazobactam (Tazocin ) Meropenem 1 g IV 8 hrly
of lung function or 4.5 g IV 8 hrly
acute respiratory If anaphylaxis to penicillin:
failure and
Aztreonam 2 g IV 8 hrly
sensitivities not
plus
known
Duration Switch to oral (if sensitivities allow) as soon as clinical improvement

occurs
Infection Exacerbation of Bronchiectasis in Cystic Fibrosis

Specimen Sputum for culture and sensitivity
Likely Organisms Pseudomonas aeruginosa
Treatment Check last sputum result If last culture report within 3 months treat
according to sensitivities. If sensitivities not known treat according to
regimen below
If history of Pseudomonas (most patients), give the following

antibacterials unless bacteria resistant or patient sensitive to
antibacterial:
Ceftazidime 4 g IV 8 hrly
plus
Gentamicin IV 8 hrly (same dose as last admission; if not known 10
mg/kg daily in divided doses 8 hrly)
th
Monitoring Gentamicin or tobramycin levels before and after the 5 dose (within 48
hr of starting treatment)
Trough < 2 mg/L
Peak (1 hr post-dose) 8 - 12 mg/L
Duration 14 days
Infection Lung Abscess

Fluid from lung abscess
Likely Organisms Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus spp,
Anaerobes

Page 65 of 120
®
Piperacillin/tazobactam (Tazocin ) If not anaphylaxis or urticaria (Type
4.5 g IV 8 hrly 1 allergy)
Meropenem 1 g IV 8 hrly
Discuss with consultant
microbiologist
Adjust antibiotic treatment according to culture results
Oral stepdown:
Dependent on sensitivities, clinical and radiological response
Duration Dependent on clinical and radiological response, but may be 6 weeks or
more
Switch to oral antibiotics once clinical and biochemical improvement and

suitable oral agent available.

Page 66 of 120
Infection Pleural Empyema
Features of ongoing sepsis and raised CRP in patients with pneumonia
after >=3 days may indicate progression to pleural infection
Fluid from pleural cavity
Likely Organisms Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus
pyogenes, Streptococcus milleri, Escherichia coli, Pseudomonas
aeruginosa, Klebsiella spp, Anaerobes
Treatment
Chest tube drainage is usually required
Community Co-amoxiclav 1.2 g IV 8 hrly Teicoplanin 600 mg IV 12 hrly for 3
acquired doses then 24 hrly thereafter
plus
Aztreonam 2 g IV 8 hrly
plus
infusion 8 hrly
®
Hospital acquired Piperacillin/tazobactam (Tazocin ) Aztreonam 2 g IV 8 hrly
4.5 g IV 8 hrly plus
plus
infusion 8 hrly
Positive for ESBL Meropenem 1 g IV 8 hrly
Discuss with consultant microbiologist
Tagged for MRSA Add teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter
to above regimens if not already included
If MRSA proven (cultured in pleural fluid) or likely cause of empyema

(e.g. recent relevant specimen other than pleural fluid positive for MRSA):
Discuss use of additional antibacterial with consultant microbiologist
Duration IV should be transferred to oral as soon as clinical and biochemical
improvement occurs and the temperature has been normal for 24 hrs,
providing there is no contra-indication to oral therapy. Use oral
antibacterial with good tissue penetration to which organism sensitive
(discuss with Consultant Microbiologist).
Continue antibacterial therapy for a prolonged period of time (at least 3
weeks), based on clinical, biochemical and radiological respone (usually
beyond when all the fluid has gone and the drain removed).

Page 67 of 120
Type of pneumonia Pneumococcal
Likely Organisms Streptococcus pneumoniae

or infusion 12 hrly
Amoxicillin 500 mg orally 8 hrly or
(according to severity) Clarithromycin 500 mg orally 12
hrly
If not sensitive to clarithromycin,

discuss with consultant
microbiologist
Type of pneumonia Staphylococcal

Uncommon, but consider if ventilated or influenza suspected
Staphylococcal pneumonia may cause lung abscess or cavitating
pneumonia. In the latter case, also send 3 sputums or a BAL for AFB
Likely Organisms Staphylococcus aureus (including MRSA)
Treatment For assessment of severity see Community Acquired Pneumonia
(empirical)
Treat Staphylococcal pneumonia aggressively, but do not treat every
Staphylococcus aureus isolated in sputum as this commonly represents
oropharyngeal colonisation
Severity First line Alternative (penicillin allergy or
tagged for MRSA)
Not severe Flucloxacillin 1 g IV 6 hrly Teicoplanin 600 mg IV 12 hrly for 3
Severe Add rifampicin 600 mg orally (IV by infusion if unable to swallow or

absorb oral drugs) 12 hrly to above regimens and check that organism
cultured is sensitive to rifampicin
Severe necrotizing Linezolid 600 mg IV 12 hrly
pneumonia due to plus
PVL S. aureus Clindamycin 1.2 g IV 6 hrly
plus
Rifampicin 600 mg IV 12 hrly
Duration Not severe 10-14 days total (including IV treatment)
Severe 14 - 21 days total (including IV treatment)

Page 68 of 120
Type of pneumonia Legionella
Likely Organisms Legionella spp
(empirical)
Not severe Severe
Clarithromycin 500 mg orally 12 Clarithromycin 500 mg IV by
hrly infusion 12 hrly
plus
Rifampicin 600 mg orally (IV by
infusion if unable to swallow or
absorb oral drugs) 12 hrly
Oral stepdown
hrly
plus
Duration Not severe 7 days total (including IV treatment)
Severe 10 - 21 days total (including IV treatment)
Type of pneumonia Confirmed Q fever, psittacosis

Likely Organisms Coxiella burnetti
Chlamydia psittaci
Treatment Doxycycline 100 mg orally 12 hrly
Type of pneumonia Mycoplasma, Chlamydia

Likely Organisms Mycoplasma pneumoniae, Chlamydia pneumoniae
(empirical)
Not severe Severe
Clarithromycin 500 mg orally 12 Clarithromycin 500 mg IV by
hrly infusion 12 hrly
Type of pneumonia PCP

Occurs in patients who are immunosuppressed due to disease or
treatment
PaO2 < 8 kPa on air
Metabolically compensated respiratory acidosis
Specimen Bronchoalveolar lavage for Pneumocystis PCR
(Induced) sputum for Pneumocystis PCR
Organism Pneumocystis jirovecii
Treatment Discuss urgently with consultant microbiologist or consultant
haematologist before starting treatment
Co-trimoxazole 120 mg/kg IV by infusion / orally daily in 2 – 4 divided
doses
If PaO2 < 8 kPa on air:

Page 69 of 120
Add prednisolone 40 mg orally each morning
Duration Convert to oral (same dose) as soon as clinical improvement occurs
References
1. Guidelines for the Management of Community Acquired Pneumonia in Adults 2009 update
2. Management of pleural infection in adults, BTS pleural disease guideline 2010. H E Davies, R J O
Davies, C W H Davies, on behalf of the BTS Pleural Disease Group, Thorax 2010;65(Suppl
2):ii41–ii53.
3. BTS guidelines for non-CF bronchiectasis Thorax 2010, vol 65 suppl 1.
4. management of COPD in adults. NICE CG 101, 2010.
5. Saving Lives: reducing infection, delivering clean and safe care Antimicrobial prescribing A
summary of best practice
http://www.dh.gov.uk/en/Publichealth/Healthprotection/Healthcareacquiredinfection/Healthcareac
quiredgeneralinformation/ThedeliveryprogrammetoreducehealthcareassociatedinfectionsHCAIincl
udingMRSA/index.htm
6. Healthcare associated infections, in particular infection caused by Clostridium difficile
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/DH_0
63090

Page 70 of 120
SEPSIS, SEVERE SEPSIS AND SEPTIC SHOCK
Definitions
Presence of documented or suspected infection plus systemic inflammatory response
Sepsis (SIRS) (e.g. temperature >38.3°C or <36°C, tachycardia, tachypnoea, leukocytosis)
Sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion (e.g. hypotension,
Severe sepsis diminishing renal function, clotting disturbance, hypoxia, ARDS, raised lactate)
Severe sepsis plus hypotension (systolic BP <90 mmHg) persisting despite adequate
Septic shock fluid resuscitation
Likely organisms Wide variety of organisms, depends on source of infection
Obtain appropriate cultures before starting antibiotics provided this does not
significantly delay antibiotic administration
Blood cultures at least 2 sets
at least one BC should be percutaneous,
Specimens one BC from each vascular access device
Culture other sites as clinically indicated e.g.:
urine
faeces
CSF
Start antibiotics as soon as possible and within the first hour of recognising
Treatment severe sepsis or septic shock
Check previous microbiology results if available
Treat as per appropriate guideline e.g. severe pneumonia, meningitis, intra-abdominal
Source identified infection
Remove source if appropriate e.g. infected lines, abscess, perforated bowel
Meropenem* 1 g IV 8 hrly
Source unclear If history of immediate hypersensitivity

® reaction to penicillins
Piperacillin/tazobactam (Tazocin )
4.5 g IV 8 hrly Aztreonam 2 g IV 8 hrly
plus
Teicoplanin 600mg IV 12 hrly for 3 doses then
24 hrly thereafter
Severe sepsis Add
Septic shock or
Pseudomonas Once daily gentamicin IV (see prescribing regimen)
infection suspected
®
Suspected Piperacillin/tazobactam (Tazocin ) Meropenem* 1 g IV 8 hrly
Neutropenic sepsis 4.5 g IV 8 hrly *Use with caution and under supervision if
(neutrophil count < 1.0 plus history of immediate hypersensitivity
9
x 10 /L) Once daily gentamicin IV (see reaction to penicillins (e.g. anaphylaxis,
prescribing regimen) unless had urticaria)
Do not wait for platinum based chemotherapy within
confirmatory bloods last 28 days (e.g. cisplatin, If history of immediate hypersensitivity reaction
for any patient who carboplatin, oxaliplatin) to penicillins contact consultant microbiologist
is unwell and has
had chemotherapy in Always discuss cases of neutropenic sepsis with oncologist or haematologist and
the last 28 days consider the need for G-CSF.
Known / suspected
Add
MRSA positive
or
Teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter (if not already
line infection
included)
suspected

Page 71 of 120
Meropenem* 1 g IV 8 hrly
*Use with caution and under supervision if history of immediate hypersensitivity
Known ESBL
reaction to penicillins (e.g. anaphylaxis, urticaria)
positive patient
If history of immediate hypersensitivity reaction to penicillins contact consultant
microbiologist
Adjust treatment following culture results and susceptibilities
Empirical use of gentamicin as part of combination therapy should not continue
Duration
for > 3-5 days
7-10 days total
References
1. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic
shock. Crit Care Med 2008; 36: 296-327.

Page 72 of 120
SKIN AND SOFT TISSUE INFECTIONS
Infection Cellulitis
Not severe:
systemically well with temperature 36 - 38°C
cellulitis not involving the face or hand
not previously treated with adequate oral antibacterials for the same
complaint
Severe if any of the following present:

lesion spreading rapidly
systemic features e.g. temperature > 38°C or < 36°C, hypotension,
tachycardia
cellulitis involving the face or hand
progression despite adequate doses of appropriate oral antibiotics
significant co-morbidities e.g.asplenia, neutropenia, cirrhosis,
immunocompromised, cardiac or renal failure, or pre-existing oedema
Specimen Swab from port of entry or aspirate of pus
Swab of cannula site and tip for culture (if source)
Likely Organisms Staphylococcus aureus, β haemolytic streptococci
Anaerobes particularly in diabetics or ischaemic limbs
Treatment Treat underlying cause e.g. portal of entry such as tinea pedis or remove
cannula if source
Not severe Flucloxacillin 500 mg orally 6 hrly Clarithromycin 500 mg orally 12 hrly
Severe Flucloxacillin 2 g IV 6 hrly Teicoplanin 600 mg IV 12 hrly for

Outline area plus 3 doses then 24 hrly thereafter
Benzylpenicillin 1.2 g IV 6 hrly
If patient is unwell, Oral step down:
the presence of Oral step down: According to sensitivities
marked systemic According to sensitivites Or
toxicity or pain out Clarithromycin 500 mg orally 12 hrly
or
of proportion to the (once apyrexial and skin lesions
local findings Flucloxacillin 500 mg orally 6 hrly
(once apyrexial and skin lesions improving unless blood culture has
should alert the become positive)
physician to the improving unless blood culture has
possibility of become positive)
necrotising
fasciitis. If this
cannot be
excluded, obtain
urgent surgical
opinion
If MRSA likely Teicoplanin 600 mg IV 12 hrly for 3 doses then 24 hrly thereafter
Oral step down: Doxycycline 100mg orally 12hrly (if susceptible)
Duration 10 - 14 days total (including IV treatment)

Page 73 of 120
Infection Erysipelas
Non-severe:
- systemically well with temperature < 38°C
- not involving the face or hand
- not previously treated with adequate oral antibacterials for the same
complaint
Severe if any of the following present:

- systemic features e.g. temperature ≥ 38°C, hypotension, tachycardia
- involving the face or hand
- progression despite adequate doses of appropriate oral antibiotics
significant co-morbidities e.g.asplenia, neutropenia, cirrhosis,
immunocompromised, cardiac or renal failure, or pre-existing
oedema
Specimen Swab site/port of entry
Likely Organisms Streptococcus pyogenes
Treatment Treat underlying cause e.g. portal of entry such as tinea pedis
Not severe Amoxicillin 500 mg orally 8 hrly Clarithromycin 500 mg orally 12 hrly
Severe Benzylpenicillin 1.2 g IV 6 hrly Clarithromycin 500 mg IV by infusion

12 hrly
Oral stepdown
According to sensitivites If significant co-morbidities consider
Or IV meropenem (not if type 1 penicillin
allergy e.g. anaphylaxis) and/or
Amoxicillin 500 mg orally 8 hrly
discuss with consultant
microbiologist
Oral stepdown
According to sensitivites
Or
Clarithromycin 500 mg orally 12 hrly
Duration Not severe: 5 - 7 days total
Infection Furuncle or carbuncle

Treatment Incision and drainage of pus if abscess formation
Most furuncles can be conservatively treated without antibacterials

Antibacterials only required for furuncle or carbuncle with systemic signs
of infection e.g. cellulitis or fever
Flucloxacillin 500 mg orally 6 hrly Clarithromycin 500 mg orally 12
hrly
Duration 5 - 7 days

Page 74 of 120
Infection Impetigo
Specimen Wound swab
Likely organisms Streptococcus pyogenes
Treatment
Mild, very localised Fusidic acid 2% cream topically 6 hrly

lesion
Severe Flucloxacillin 500 mg orally 6 hrly Clarithromycin 500 mg orally 12

hrly
Duration Topical: 5 days
Systemic: 7 days
Infection Infected chronic ulcers or pressure sores (non diabetic)

Specimen Routine wound swabs not recommended, swab if evidence of cellulitis
Likely Organisms Staphylococcus aureus (including MRSA), Streptococcus pyogenes
Anaerobes
Treatment Antibacterials only required if evidence of active infection e.g.
pyrexia
increasing pain
enlarging ulcer
cellulitis
Treat as cellulitis (see cellulitis page 74)
If osteomyelitis present refer to Bone and Joint Infections section (page
22)
Duration See appropriate guideline

Page 75 of 120
Infection Diabetic foot infection
Clinical classification of a diabetic foot infection

Clinical manifestations of infection Infection severity
Wound lacking purulence or any manifestations of inflammation Uninfected
Presence of >= 2 manifestations of inflammation (purulence, or erythema, Mild

pain, tenderness, warmth, or induration), but any cellulitis/erythema
extends <_2cm around the ulcer, and infection is limited to the skin or
superficial subcutaneous tissues; no other local complications or
systemic illness.
Infection (as above) in a patient who is systemically well and metabolically Moderate
Stable but which has >=1 of the following characteristics: cellulitis extending
>2 cm, lymphangitic streaking, spread beneath the superficial fascia,
deep-tissue abscess, gangrene, and involvement of muscle, tendon,
joint or bone
Infection in a patient with systemic toxicity or metabolic instability Severe

(e.g., fever, chills, tachycardia, hypotension, confusion, vomiting,
leukocytosis, acidosis, severe hyperglycemia, or azottemia)
Specimen Obtain specimens prior to starting empiric antibiotic therapy if

possible
Deep tissue cultures obtained by biopsy or curettage after wound
has been cleansed and debrided are recommended
a superficial swab after wound has been cleansed could be an
alternative
bone biopsies should be collected if possible if osteomyelitis is
present (soft tissue or sinus-tract cultures do not accurately predict
bone pathogens
Swab cultures are not useful in clinically uninfected patients
Likely Organisms Cellulitis without open wound or recent ulcers: Staphylococcus aureus
and beta-haemolytic streptococci
Chronic ulcers, long standing infection: Polymicrobial infections including
staphylococci, streptococci, gram negative bacilli, anaerobes
Treatment
mild, antibiotic Flucloxacillin 500 mg orally 6 hrly Clarithromycin 500mg orally 12hrly
naive
If MRSA likely:
doxycycline 100mg orally 12 hrly
mild with prior Or co-amoxiclav 625 mg orally 8 Co-trimoxazole 960mg orally 12
antibiotic therapy hrly hrly
If MRSA likely: or
doxycycline 100mg orally 12 hrly doxycycline 100mg orally 12 hrly
or
Co-trimoxazole 960mg orally 12
hrly
(check previous sensitivities)
Page 76 of 120
Moderate Co-amoxiclav IV 1.2g 8hrly Clarithromycin 500mg IV 12hrly
Plus
Gentamicin once daily (see
protocol)
If MRSA likely: If MRSA likely:

Add teicoplanin 600 mg IV 12 hrly Gentamicin once daily (see
for 3 doses then 24hrly protocol)
plus
teicoplanin 600 mg IV 12 hrly for 3
doses then 24hrly thereafter
According to sensitivities According to sensitivities
Or Or
co-amoxiclav 625 mg orally 8 hrly Co-trimoxazole 960mg orally 12
hrly
severe Tazocin 4.5g IV 8hrly Meropenem 1 g IV 8 hrly

If anaphylaxis to penicillin
Oral stepdown (when patient is Aztreonam 2 g IV 8 hrly
systemically well) plus
According to sensitivities Metronidazole 500 mg IV by
infusion 8 hrly
plus
Oral stepdown (when patient is

systemically well)
If MRSA likely:
Add teicoplanin 600 mg IV 12 hrly for 3 doses then 24hrly thereafter if not
already included
Osteomyelitis in Consider osteomyelitis in any infected, deep, or large ulcer, especially

DFI one that is chronic or overlies bony prominence
If X-ray is not diagnostic, use MRI or WBC scanning if MRI is
contraindicated
Treat according to severity as above
Tissue/bone cultures should be obtained whenever possible
Duration
Mild 7-10 days
Moderate 10-14 days
Severe 14 days
Osteomyelitis in Prolonged, >4 weeks
DFI Intravenous initially (except co-trimoxazole) and to cover the period of
any surgical intervention and for at least 2 weeks after

Page 77 of 120
May switch to oral after that time if good clinical response to IV therapy,
CRP falling and good information on organism and its sensitivities
If radical resection performed with no remaining infected tissue short

antibiotic course (3-5 days) post –op should be sufficient
1. Diabetic foot problems NICE Clinical Guideline 119, 2012

2. 2012 Infectious Diseases Society of America, clinical practice guideline for the diagnosis and
treatment of diabetic foot infections, Clinical Infectious Diseases 2012;54(12): 1679-84.
Infection Gangrenous cellulitis (Necrotising fasciitis or gas

gangrene)
Specimen Aspirate or tissue biopsy for gram stain and culture
Deep tissue specimens are essential for immediate gram stain and
culture if necrotising fasciitis suspected
Blood culture
Likely Organisms Gas gangrene: Clostridium spp
Necrotising fasciitis type 1: Mixed aerobes and anaerobes
Necrotising fasciitis type 2: β-haemolytic streptococcus group A either
alone or in combination with Staphylococcus aureus
Treatment This is a surgical emergency. Immediate surgical opinion for
exploration and debridement of necrotic tissue
Meropenem 1g IV 8 hrly If penicillin allergy is anaphylaxis,
plus contact consultant microbiologist
Clindamycin 1.2 g IV by infusion 6
hrly
Review antibiotic treatment when culture results available. Discuss with
consultant microbiologist
Duration Switch to oral when apyrexial for 48 hrs and infection parameters normal
At least 10 days total (including IV treatment)
Infection Burn wound infections

Specimen Aspirate or tissue biopsy if possible
If sepsis cannot be attributed to any other source, send biopsy or aspirate
(not swabs)
Likely Organisms Staphylococcus aureus, Pseudomonas aeruginosa, Enterobacteriaceae
Enterococcus spp
Prophylaxis Current data do not support use of antibacterials in the in-patient
population
Treatment Urgent surgical intervention if bacteraemia present and other sources
eliminated
Surgical excision to the level of the fascia when wound invaded with
gram negative organisms
Choice of antibacterial is based on previous biopsy sensitivity data or

data on sensitivity in the current population of burns patients. Discuss
with consultant microbiologist
Duration Discuss with consultant microbiologist

Page 78 of 120
Infection Post-operative wound infection
Likely Organisms Staphylococci, Streptococci
Mixed aerobic and anaerobic flora in wounds on perineum or surgery on
gastrointestinal or female genital tract
Treatment Antibacterials only required if evidence of active infection e.g.
pyrexia
purulent drainage
pain or tenderness
localised swelling
redness
heat
A higher index of suspicion should be exercised in the presence of post-
operative vascular or orthopaedic implants
Clean wound, head, According to culture results
neck, trunk, If no culture results available or no significant growth obtained, treat as
extremity cellulitis (see cellulitis page 74)
Wound on perineum or surgery on gastrointestinal or female genital tract or vascular graft

surgery (see below)
For severity assessment (see cellulitis page 74)
Not severe Co-amoxiclav 625 mg orally 8 hrly Clarithromycin 500 mg orally 12
hrly
plus

fails to respond (see prescribing
regimen)
Severe Co-amoxiclav 1.2 g IV 8 hrly Teicoplanin 600 mg IV 12 hrly for 3
doses then 24hrly thereafter y
Add once daily gentamicin IV if plus
plus
Oral stepdown Once daily gentamicin IV (see
According to sensitivities prescribing regimen)
Oral stepdown
If MRSA likely: Add teicoplanin 600 mg IV 12 hrly for 3 doses then 24hrly thereafter if not
already included
Duration Non-severe: 5 - 7 days total

References
1. Managing skin and soft tissue infections: expert panel recommendations on key decision
points. The British Society for Antimicrobial Chemotherapy 2003 Journal of Antimicrobial
Chemotherapy (2003) 52, Suppl. S1, i3–i17.
2. Practice Guidelines for the Diagnosis and Management of Skin and Soft-Tissue Infections
(IDSA) Clinical Infectious Diseases 2005; 41:1373–406
Page 79 of 120
3. Medical treatment of diabetic foot infections. Lipsky A. Clinical Infectious Diseases 2004; 39
(S2): S104-114
4. Healthcare associated infections, in particular infection caused by Clostridium difficile
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleagueletters/D
H_063090
5. Diabetic foot problems NICE Clinical Guideline 119, 2012
6. 2012 Infectious Diseases Society of America, clinical practice guideline for the diagnosis and
treatment of diabetic foot infections, Clinical Infectious Diseases 2012;54(12): 1679-84.

Page 80 of 120
URINARY TRACT INFECTIONS (UTI)
Infection Lower UTI uncomplicated (no urinary catheter)

Likely Organisms Enterobacteriaceae, enterococci
Pivmecillinam 400 mg stat, then Nitrofurantoin 100 mg orally 6 hrly
200 mg orally 8 hrly Do not use if recent isolate
resistant
Pregnancy Cefradine 500 mg orally 6 hrly or according to sensitivities
Women with Given the risks of asymptomatic bacteriuria in pregnancy, a urine

asymptomatic culture should be performed 7 days after completion of
bacteriuria confirmed antibacterials as a test of cure
by a second urine
culture should be
treated and have
repeat urine culture
at each antenatal
visit until delivery
Duration Uncomplicated non-pregnant females 3 days (5 days for nitrofurantoin)
Pregnancy 7 days
If anatomical or neurological abnormality is present a longer course may

be required
Infection Systemic UTIs

Treatment Once daily gentamicin IV (see prescribing regimen)
Or
Cefradine 500 mg orally 6 hrly
Oral stepdown:
Cefradine 500 mg orally 6 hrly or according to sensitivities
Duration Adjust treatment according to sensitivities
5 – 7 days

Page 81 of 120
Infection Pyelonephritis
Likely Organisms Enterobacteriaceae
Treatment
Community Once daily gentamicin IV (see prescribing regimen)*
acquired
Oral stepdown:
(Cefradine 500 mg orally 6 hrly or trimethoprim 200 mg orally 12 hrly)
Hospital acquired Once daily gentamicin IV (see prescribing regimen)
Oral stepdown:
According to sensitivities (ciprofloxacin should only be used for patients
discharged from hospital if no other oral alternative. If patient remains in
hospital, IV treatment would be preferable to an oral quinolone)
ESBL positive Ertapenem 1g IV by infusion 24 hrly
Duration Adjust treatment according to sensitivities
Review IV route after 48 hrs - convert to oral therapy, if available and
tolerated.
14 days total
Infection Complicated UTI (functional or structural urinary tract

abnormalities) and all UTIs in men
Blood culture
Likely Organisms Depends on cause
Treatment Once daily gentamicin IV (see prescribing regimen)
Or
Cefradine 500 mg orally 6 hrly
Oral stepdown:
If ESBL positive: ertapenem 1 g IV by infusion 24 hrly
Duration 7-14 days

Page 82 of 120
Infection UTI with urinary catheter

Catheter specimens of urine (if pyrexial or systemic signs of infection)
Urine samples should only be sent for laboratory culture if clinical sepsis
present, not because the appearance or smell of the urine or the urine
dipstick suggests that bacteriuria is present
Likely Organisms Enterobacteriaceae, enterococci, Pseudomonas aeruginosa,
Treatment According to recent urine culture if available, otherwise
Once daily gentamicin IV (see prescribing regimen)
Oral stepdown:
Remove catheter if possible, or change urinary catheter while on

treatment
If ESBL positive: Ertapenem 1g IV by infusion daily

Prophylaxis Antibacterial prophylaxis for the prevention of UTI in catheterised patients
is not recommended.
Mixed growth of organisms in an asymptomatic patient does not indicate
infection and investigation and treatment is not indicated.
Duration If catheter:
- removed 5 days
- replaced 7 days
Infection Acute Prostatitis

Consider sexually transmitted infections
Specimen Midstream specimen of urine for culture
Urine for chlamydia PCR
Blood culture
Co-amoxiclav 1.2 g IV 8 hrly Once daily gentamicin IV (see
plus prescribing regimen)
Gentamicin IV 5mg/Kg single
dose (max. 560 mg)
Oral stepdown:
Oral stepdown: Ciprofloxacin 500 mg orally 12 hrly
Ciprofloxacin 500 mg orally 12 hrly
Duration Adjust according to culture results
4 weeks total (including IV treatment)

Page 83 of 120
Infection Chronic Bacterial Prostatitis
Specimen Send and process immediately
- urethral urine
- midstream specimen of urine
- prostatic secretions expressed by massage
- urine voided after massage
Treatment Ciprofloxacin 500 mg orally 12 hrly
Minimum 4 weeks
If recurrent 6 - 12 weeks
Infection Bacterial epididymitis/Bacterial orchitis
Specimen Urethral swab for culture

Midstream specimen of urine for culture
Urine for chlamydia and gonococcal PCR
Likely Organisms < 35 yrs old: > 35 yrs old:
Neisseria gonorrhoea Enterobacteriaceae
Chlamydia trachomatis Pseudomonas spp
Gram positive cocci
Treatment
Age First line Alternative (penicillin allergy)
<35 years old or Ceftriaxone 500 mg IM single dose
infection likely due plus
to sexually Doxycycline 100 mg orally 12 hrly
transmitted
pathogens
®
>35 years old or Piperacillin/tazobactam (Tazocin ) Ciprofloxacin 500 mg orally 12 hrly
infection likely due 4.5 g IV 8 hrly
to enteric
organisms
2 weeks
2010 United Kingdom national guideline for the management of epididymo-orchitis, Clinical
Effectiveness Group, British Association for Sexual Health and HIV. www.bashh.org/guidelines
United Kingdom National guideline for the management of prostatitis (2008) Clinical Effectiveness
Group British Association of Sexual Health and HIV, www.bashh.org/guidelines

Page 84 of 120
ANTIBACTERIAL PROPHYLAXIS IN EAR, NOSE AND THROAT SURGERY
General notes
The following recommendations apply to the administration of prophylactic antibiotics at the pre-
operative phase. If there is significant unexpected contamination encountered during an operation or
existing infection then prophylaxis should be followed by a treatment regime. Please refer to the
relevant treatment antibiotic guidelines on the hospital intranet.
If patient has history of MRSA in preceding 12 months see last row of table
Ear, nose and Likely Organisms Antibacterial Prophylaxis

throat – benign
• Ear surgery
(clean/clean-
contaminated)
• Routine nose, sinus
and endoscopic sinus Uncommon Not recommended
surgery
• Tonsillectomy
• Adenoidectomy
1
• Stapedectomy / Staphylococcus Co-amoxiclav 1.2 g IV at induction
ossiculoplasty aureus
Streptococcus spp If penicillin allergic or MRSA positive:
1
Teicoplanin 600 mg IV at induction
1
• Complex Staphylococcus Co-amoxiclav 1.2 g IV at induction
septorhinoplasty aureus
(if prosthetic material is Streptococcus spp If penicillin allergic or MRSA positive:
used) 1
Head and neck – Likely Organisms Antibacterial Prophylaxis
facial
• Facial surgery - clean Uncommon Not recommended
1
• Facial plastic surgery Staphylococcus Co-amoxiclav 1.2 g IV at induction
with implant aureus
Streptococcus spp
If penicillin allergic or MRSA positive:
1
Head and neck Likely Organisms Antibacterial Prophylaxis

surgery
• Clean, benign Uncommon Not recommended
including
parathyroidectomy,
thyroidectomy

Page 85 of 120
1
• Clean, malignant; Prophylaxis may Co-amoxiclav 1.2 g IV at induction
neck dissection be considered
If penicillin allergic:
1
plus
Metronidazole 500 mg IV by infusion at
1
induction
plus
1
Gentamicin 3 mg/kg IV at induction
1
• Clean-contaminated Staphylococcus Co-amoxiclav 1.2 g IV at induction
or contaminated aureus
surgery Streptococcus spp If penicillin allergic:
Anaerobes 1
Haemophilus
plus
influenzae
Metronidazole 500 mg IV by infusion at
Gram negative 1
induction
bacilli
plus
1
Gentamicin 3 mg/kg IV at induction
History of MRSA in Add teicoplanin 600 mg IV to appropriate

1
preceding 12 months regimen at induction if not already included
NOTES:
1. In the event of major intraoperative blood loss (>1500 mL), give an additional dose of prophylactic
antibacterials after fluid replacement.
If surgery > 90 minutes, give additional dose of co-amoxiclav. Metronidazole, gentamicin and
teicoplanin have longer half-lives and do not need to be repeated
References
Antibiotic prophylaxis in surgery, SIGN 2008, www.sign.ac.uk
Surgical site infection, NICE CG74, 2008

Page 86 of 120
ANTIBACTERIAL PROPHYLAXIS FOR GASTROINTESTINAL, BILIARY,
VASCULAR AND GENERAL SURGERY
General notes
If patient has history of MRSA in preceding 12 months see last row of table
Operation Likely Antibacterial prophylaxis

organisms
First line Alternative
(penicillin allergy)
Upper gastrointestinal surgery
• Oesophageal Aerobic and Co-amoxiclav 1.2 g IV Gentamicin 3 mg/kg
1 1
• Gastroduodenal anaerobic GI at induction IV at induction
tract flora plus
• Small intestine
Metronidazole 500
mg IV by infusion at
1
induction
• Percutaneous endoscopic GI tract flora Co-amoxiclav 1.2 g IV Gentamicin 3 mg/kg
1 1
gastrostomy at induction IV at induction
Lower gastrointestinal surgery

Aerobic and Co-amoxiclav 1.2 g IV Gentamicin 3 mg/kg
1 1
• Appendicectomy anaerobic GI at induction IV at induction
tract flora plus
• Colorectal Metronidazole 500
1
induction
Hepatobiliary surgery
• Pancreatic surgery Aerobic and Co-amoxiclav 1.2 g IV Gentamicin 3 mg/kg
1 1
• Liver surgery anaerobic GI at induction IV at induction
tract flora plus
• Bile duct surgery
• Gall bladder surgery Metronidazole 500
(open) mg IV by infusion at
1
induction
Endoscopic retrograde Should be considered in high risk patients only (pancreatic
cholangiopancreatography pseudocyst, immunosuppression, incomplete biliary drainage)
(ERCP)
Gram negative Co-amoxiclav 1.2 g IV Gentamicin 3 mg/kg
1 1
bacilli at induction IV at induction
enterococci
staphylococci
• Gall bladder surgery Uncommon Not recommended
(laparoscopic)
Consider prophylaxis in high risk patients
(intraoperative cholangiogram, bile spillage,
conversion to laparotomy, acute
cholecystitis/pancreatitis, jaundice, pregnancy,
immunosuppression, insertion of prosthetic
devices

Page 87 of 120
If prophylaxis required follow recommendations
for open gall bladder surgery
• Insertion of surgical and Uncommon Not recommended
radiological drains
Diagnostic endoscopic Uncommon Not recommended
procedures
Abdomen
• Laparoscopic or non- Uncommon Not recommended
laparoscopic hernia repair
with mesh
Breast surgery
Breast surgery with implant staphylococci, Co-amoxiclav 1.2 g IV If penicillin allergic
1
streptococci at induction or history of MRSA
in preceding 12
months:
Teicoplanin 600 mg
1
IV at induction
Breast cancer surgery Prophylaxis should be considered (types of antibiotics as above) in
Breast reshaping procedures patients with risk factors (e.g. immunosuppression, diabetes
mellitus, reconstructive surgery)
Vascular surgery staphylococci, Co-amoxiclav 1.2 g IV Teicoplanin 600 mg
1 1
gram negative at induction IV at induction
bacilli, plus
anaerobes Gentamicin 3 mg/kg
1
IV at induction
plus
Metronidazole 500
1
induction
1
History of MRSA in Add teicoplanin 600 mg IV at induction to appropriate regimen if
preceding 12 months not already included (except breast surgery)
NOTES:
1. In event of major intraoperative blood loss (>1500 mL), give additional dose of prophylactic
If surgery >90 minutes, give additional dose of co-amoxiclav. Metronidazole, gentamicin and
teicoplanin have longer half-lives and do not need to be repeated.
References
Surgical site infection, NICE CG74 2008

Page 88 of 120
ANTIBACTERIAL PROPHYLAXIS FOR OBSTETRIC AND GYNAECOLOGICAL
SURGERY
General notes
Obstetrics
Surgery Likely Organisms Antibacterial Prophylaxis
Caesarean Streptococci Cefuroxime 1.5 g IV If anaphylaxis to penicillin
section 1
S. aureus prior to incision Clindamycin 600 mg IV by
1
Enterococcus infusion prior to incision
faecalis
Gardnerella If MRSA positive in last 12 months
vaginalis
Add
Bacteroides spp 1
Teicoplanin 600 mg IV prior to incision
Peptostreptococci
1
Third and fourth Gram negative Co-amoxiclav 1.2 g IV at induction Gentamicin 3 mg/kg IV
degree perineal bacilli then plus
tears Anaerobes Co-amoxiclav 625 mg orally 8 hrly Clindamycin 600 mg IV by
Streptococci infusion
Injury to 1
For 5 days at induction
perineum then
involving anal
Clindamycin 450 mg orally 6hrly
sphincter / rectal
mucosa plus
Trimethoprim 200 mg orally 12
hrly
For 5 days
If MRSA positive in last 12 If MRSA positive in last 12
months months
Add Teicoplanin 600 mg IV
1
Teicoplanin 600 mg IV at induction plus
Follow on therapy depends on Gentamicin 3 mg/kg IV
MRSA susceptibility – discuss with plus
Microbiologist Metronidazole 500 mg IV by
infusion
1
at induction
Follow on therapy depends on
MRSA susceptibility – discuss
with Microbiologist
1
Manual removal Streptococcus spp Co-amoxiclav 1.2 g IV at induction Gentamicin 3 mg/kg IV at
of placenta Gram negative bacilli plus
Anaerobes Clindamycin 600 mg IV by
1
infusion at induction
Assisted uncommon NOT recommended
delivery
Surgical Anaerobes Metronidazole 1 g PR with pre-med
termination of plus
pregnancy Doxycycline 100 mg orally 12 hrly for 7 days, commencing on the day
of abortion, unless pre-operative screening has excluded genital tract
chlamydial infection

Page 89 of 120
Gynaecology
If patient has history of MRSA in preceding 12 months, see last row of table

First line Alternative (penicillin
allergy)
Hysterectomy Escherichia coli Co-amoxiclav 1.2 g Gentamicin 3 mg/kg IV
1
Other gram negative IV at induction plus
bacilli Metronidazole 500 mg
Laparotomy
Streptococci IV by infusion
1
S. aureus at induction
Radical pelvic Enterococci
surgery for
Gardnerella vaginalis
gynaecological
Bacteroides spp
cancer
Peptostreptococcus
Vaginal repair
Vaginal sling
procedures
History of MRSA in preceding 12 months

Add
1
teicoplanin 600 mg IV at induction to
appropriate regimen
NOTES:
1. In event of major intraoperative blood loss (>1500 mL), give additional dose of prophylactic
If surgery > 90 minutes, give additional dose of co-amoxiclav.
Metronidazole, gentamicin and teicoplanin have longer half-lives and do not need to be repeated
References
The Care of Women Requesting Induced Abortion. Clinical Guideline No 7, RCOG 2004.
Surgical site infection, NICE CG74 2008.
The management of third and fourth degree perineal tears. Green top guideline No 29, RCOG
2007.
Caeserian Section. NICE CG132 November 2011.

Page 90 of 120
ANTIBACTERIAL PROPHYLAXIS FOR ORTHOPAEDIC SURGERY
General notes

First line Alternative (penicillin
allergy)
Clean non-implant
surgery Uncommon Not recommended
o Arthroscopy
o Joint aspiration
Arthroplasty Staphylococcus Co-amoxiclav 1.2 g IV at Teicoplanin 600 mg IV at

1,2 1,2
aureus, induction induction
Surgery for closed coagulase negative
fractures staphylococci,
streptococci, If history of MRSA in
Hip fracture enterococci, preceding 12 months
diphtheroids,
Spinal surgery gram negative Teicoplanin 600 mg IV at
1,2
organisms induction
Lower limb amputation Staphylococcus Co-amoxiclav 1.2 g IV at Teicoplanin 600 mg IV at
1,2 1,2
aureus, induction induction
streptococci,
anaerobes, plus
gram negative Metronidazole 500 mg IV
organisms If history of MRSA in by infusion at induction
1,2
preceding 12 months
Add
Teicoplanin 600 mg IV at
1,2
induction
Open fractures Wide spectrum, with Co-amoxiclav 1.2 g IV 8
higher proportion of hrly plus
Gram negative and
anaerobic infections Teicoplanin IV 600 mg 12
(N.B. Tetanus If history of MRSA in hrly for 3 doses then 24
prophylaxis) preceding 12 months hrly thereafter
Add plus
Teicoplanin 600 mg IV
Metronidazole 500 mg IV
by infusion 8 hrly
Start as soon as possible and continue for 72 hours
after injury or for 24 hours post-op
NOTES:
1. In the event of major intraoperative blood loss (>1500 mL), give an additional dose of
prophylactic antibacterials after fluid replacement.
If surgery > 90 minutes, give an additional dose of co-amoxiclav.
Teicoplanin and gentamicin have longer half-lives and do not need to be repeated.
2. Give prophylaxis earlier for operations in which a tourniquet is used.

Page 91 of 120
References
Antibiotics in trauma and orthopaedic surgery – a primer of evidence-based recommendations. Injury,
Int.J.Care Injured 2006;37:s74-80.

Page 92 of 120
ANTIBACTERIAL PROPHYLAXIS FOR UROLOGICAL SURGERY
General notes
If patient has history of MRSA in preceding 12 months, see last row of table
Send MSU at pre-admission screening and where possible treat urinary tract
infections before admission
Surgery Likely Antibacterial Prophylaxis

Organisms
1
Transurethral Gram negative Gentamicin 3mg/kg IV at induction
resection of a bacilli
bladder tumour Enterococci
(TURBT)
1
Open or Gram negative Gentamicin 3mg/kg IV at induction
transurethral bacilli
resection of the Enterococci
prostate (TURP)
Transrectal prostate Gram negative Ciprofloxacin 750 mg orally 2 hours before procedure
biopsy bacilli
Enterococci If risk factors present i.e. bacteriuria, prostatitis,
Anaerobes diabetes, immunosuppression or steroids,
Continue ciprofloxacin 500 mg orally 12 hrly for 3

days post-op
Cystoscopy – Uncommon Not recommended
uncomplicated (no
recent or current
infection, pre-op urine
culture negative, no
urinary catheter)
1
Cystoscopy – Gram negative Gentamicin 3mg/kg IV at induction
complicated or bacilli
patient catheterised Enterococci
Urethral dilatation /
optical urethrotomy
Shock-wave
lithotripsy
2
Nephrectomy
Percutaneous Gram negative if pre-op cultures negative give oral antibiotics for
nephrolithotomy bacilli 48hrs pre-op as follows:
No known penicillin allergy: co-amoxiclav
500/125mg 8hrly
Penicillin allergic (rash): cefradine 500mg
6hrly
Penicillin anaphylaxis: ciprofloxacin 500mg
12hrly
If pre-op cultures positive, treat according to

Page 93 of 120
sensitivity results:
i.e. trimethoprim, mecillinam (pivmecillinam) or
cefradine, but avoid nitrofurantoin.
On Induction:
Gentamicin 3mg/kg IV (check pre-op urine cultures
if positive to ensure susceptibility to gentamicin. If
resistant to gentamicin, choose a different antibiotic
according to sensitivities)
Intra-operatively:
Send initial pelvic puncture urine for MC&S
Send stone fragments for MC&S
Post-Op; First 48hrs

Continue the same antibiotic which was started pre-
op.
Give a second dose of gentamicin 5mg/kg IV the day
after the operation
Post-Op; Beyond 48 hrs

Review intra-operative pelvic urine and stone culture.
If cultures are positive treat as complicated UTI and
according to culture results. (Continue with same
antibiotic the patient is already on if organism isolated
is susceptible to it. See also Urinary tract infections
section page 80).
If cultures negative and pre-op urine was also culture
negative, stop antibiotics after 48 hours even if stone
fragments are known to have been left behind.
Cystectomy Gram negative Co-amoxiclav 1.2g IV at Gentamicin 3mg/kg IV at
1 1
Radical bacilli induction induction
prostatectomy Anaerobes plus
Metronidazole 500 mg IV
1
by infusion at induction
History of MRSA in Add teicoplanin 600 mg IV to appropriate regimen at
1
preceding 12 months induction
AND antibiotic
prophylaxis is
indicated
NOTES:
1. In the event of major intraoperative blood loss (> 1500 ml), give an additional dose of
prophylactic antibacterials after fluid replacement.
If surgery > 90 minutes, give additional dose of co-amoxiclav.
Metronidazole, gentamicin and teicoplanin have longer half-lives and do not need to be
repeated.
2. If nephrectomy is expected to be clean surgery, then no prophylaxis indicated.
References

Page 94 of 120
PROPHYLAXIS - OTHER
Prevention of infection after bites from humans and other mammals
Introduction
After initial management, give prophylactic antibacterials to:
All human bite wounds less than 72 hours old, even if there is no sign of infection.
Animal bite wounds if the wound is less than 48 hours old and the risk of infection is
high as follows:
- Animal bites to the hand, foot, and face; puncture wounds; wounds requiring
surgical debridement; crush wounds with devitalised tissue; wounds in genital
areas; wounds with associated oedema; wounds involving joints, tendons,
ligaments, or suspected fractures.
- Wounds that have undergone primary closure.
- People who are at risk of serious wound infection (e.g. those who are
diabetic, cirrhotic, asplenic, immunosuppressed, or had mastectomy).
- Asplenic and cirrhotic patients are especially susceptible to Capnocytophaga
canimorsus infection and should receive prophylaxis even after trivial animal
bites.
- People with a prosthetic valve or a prosthetic joint.
- Antibiotics are not generally needed if the wound is more than 2 days old and
there is no sign of local or systemic infection.
Seek advice from consultant microbiologist or consultant in infectious diseases if
source is known or suspected to be positive for HIV, hepatitis B or C, or rabies.
Outpatients should be warned of signs of developing infection and to attend urgently
for review should this happen.
For bites from other mammals, contact consultant microbiologist
Specimens
- tissue, aspirate or swab for bacterial cultures if clinical infection present
- blood cultures if the patient is systemically unwell
Tetanus vaccine (single antigen tetanus vaccine is no longer available, use
diptheria, tetanus and poliomyelitis vaccine, dTP vaccine) and human tetanus
immunoglobulin if indicated (see current BNF).

Page 95 of 120
Type of Bite Likely Organisms Antibacterial Prophylaxis Duration
Human, dog or cat See below Co-amoxiclav 625 mg orally 8 5 days
Not penicillin allergic hrly
Human Streptococci Doxycycline 200 mg orally 24
Penicillin allergic Staphylococcus hrly 5 days
aureus plus
Haemophiilus spp Metronidazole 400 mg orally 8
Bacteroides hrly
Fusobacterium spp
Other anaerobes
Eikenella corrodens
Dog or cat Pasteurella spp Doxycycline 200 mg orally 24 5 days
Penicillin allergic Capnocytophaga hrly
Streptococci plus
Staphylococci Metronidazole 400 mg orally 8
Anaerobes hrly
References:
1. http://www.cks.library.nhs.uk/bites_human_and_animal/view_whole_topic_rev
iew
2. Morgan M. "Hospital management of animal and human bites" Journal Hosp
Infection 2005, 61:1-10.
3. Practice guidelines for the diagnosis and management of skin and soft-tissue
infections, IDSA guidelines, Clinical Infectious Diseases 2005;41:1373-406.
Antibacterial prophylaxis for open fractures of the fingers

Prophylactic antibiotics may be unnecessary in wounds presented early, with thorough wound
toilet and careful soft tissue repair in patients without risk factors for developing infection (e.g.
diabetes, peripheral vascular disease, steroids, immunosuppression)
Likely Organisms staphylococci
Antibacterial First line Alternative (penicillin allergy)
Prophylaxis
Flucloxacillin orally 500 mg 6 Clarithromycin orally 500 mg 12

hrly hrly
for 5 days for 5 days
References:
1. Hand Surg Am 1990 Sep;15(5):761-4.Role of antibiotics in open fractures of
the finger. Suprock MD, Hood JM, Lubahn JD.
2. J Hand Surg Br. 2003 Oct;28(5):388-94. The use of prophylactic flucloxacillin
in treatment of open fractures of the distal phalanx within an accident and
emergency department: a double-blind randomized placebo-controlled trial.
Stevenson J, McNaughton G, Riley J.

Page 96 of 120
PROPHYLAXIS AGAINST INFECTIVE ENDOCARDITIS (IE)
In adults and children undergoing interventional procedures
Introduction
Past practice has been to routinely offer prophylactic antibiotics to patients
undergoing interventional procedures who are considered at risk of IE. In a
significant change to this approach, the National Institute for Health and Clinical
Excellence (NICE) guideline now recommends that preventive antibiotics should
not be given to adults and children with structural cardiac defects at risk of IE who
are undergoing dental and non-dental interventional procedures.
i.e. antibiotic prophylaxis is no longer routinely recommended for defined

interventional procedures including dental procedures and procedures
involving the gastrointestinal, genitourinary and respiratory tracts.
Summary of NICE recommendations
(Reproduced from NICE CG64 - Prophylaxis against infective endocarditis:

March 2008)
1. Adults and children with structural cardiac defects at risk of developing

Infective Endocarditis
Acquired valvular heart disease with stenosis or regurgitation
Valve replacement
Structural congenital heart disease, including surgically corrected or palliated
structural conditions, but excluding isolated atrial septal defect, fully repaired
ventricular septal defect or fully repaired patent ductus arteriosus, and closure
devices that are judged to be endothelialized
Hypertrophic cardiomyopathy
Previous infective endocarditis
2. Offer patients at risk of IE clear and consistent information about

prevention:
The benefits and risks of antibiotic prophylaxis, and an explanation of why
antibiotic prophylaxis is no longer routinely recommended
The importance of maintaining good oral health
Symptoms that may indicate IE and when to seek expert advice
The risks of undergoing invasive procedures, including non-medical
procedures such as body piercing or tattooing.
3. Prophylaxis against Infective Endocarditis
Antibiotic prophylaxis against IE is not recommended:
for people undergoing dental procedures
for people undergoing non-dental procedures at the following sites:

Page 97 of 120
− upper and lower gastrointestinal tract
− genitourinary tract; this includes urological, gynaecological and obstetric
procedures, and childbirth
− upper and lower respiratory tract; this includes ear, nose and throat
procedures and bronchoscopy.
Chlorhexidine mouthwash should not be offered as prophylaxis against

infective endocarditis to people at risk of infective endocarditis undergoing dental
procedures.
4. Managing infection
Investigate & treat promptly any episodes of infection in people at risk of IE to

reduce the risk of endocarditis developing
Offer an antibiotic:
If a person at risk of IE is receiving antimicrobial therapy because they are
undergoing a gastrointestinal or genitourinary procedure at a site where there is
a suspected infection, the person should receive an antibiotic that covers
organisms that cause IE.
If patients regarded as at risk of developing IE (see above) are undergoing such

a procedure at a site where infection is suspected or established, additional IE
prophylaxis is required with an antibiotic(s) that includes cover against organisms
associated with endocarditis that may be present e.g. enterococci, viridans
streptococci and staphylococci unless such cover is already part of the treatment
regimen. Standard peri-operative prophylaxis may need modification and exact
choice of antibiotic regimen will depend on the site of infection, nature of the
infection and microbiological results. The appropriate choice should therefore be
discussed with a Consultant Microbiologist.

Page 98 of 120
PREVENTION OF INFECTION IN PATIENTS WITH AN ABSENT OR
DYSFUNCTIONAL SPLEEN
A. IMMUNISATION
Patients should be offered the following vaccines:
• Hib vaccine (irrespective of age)
• influenza vaccine (yearly)
• meningococcal ACWY conjugate vaccine (irrespective of age)
• pneumococcal vaccine (revaccination every 5 years with 23-valent PPV
vaccine is recommended)
Vaccines should ideally be administered 2 weeks before or 2 weeks after

splenectomy
The following table has been copied from the “DH Immunisation against infectious disease (Green
Book), chapter 7”
Suggested schedule for immunisation with conjugate vaccines in individuals with
asplenia, splenic dysfunction, immunosuppression or complement deficiency
Age at which asplenia, Vaccination schedule
splenic dysfunction, or Where possible, vaccination course should ideally be started at
immunosuppression is least two weeks before surgery or commencement of
acquired or when immunosuppressive treatment. If not possible, see advice in
complement deficiency pneumo chapter.
diagnosed
Month 0 Month 1 Later
First presenting under Complete according A dose of After the second
two years to national routine MenACWY birthday, one
childhood schedule conjugate vaccine additional dose of
including booster should be given at Hib/MenC and a
doses of Hib/MenC least one month dose of PPV should
and PCV13. after the Hib/MenC be given.
and PCV13 booster
doses.
First presenting over two Hib/MenC Booster MenACWY PPV
years and under five conjugate vaccine (at least 2 months
years (previously PCV13 after PCV13)
completed routine
childhood vaccinations
with PCV7)
First presenting over two Hib/MenC Booster MenACWY
years and under five conjugate vaccine
years (previously PPV
completed routine
childhood vaccinations
with PCV13)
First presenting over two Hib/MenC vaccine MenACWY Second dose of
years and under five conjugate vaccine PCV13 and then
years (unvaccinated or First dose of PCV13 PPV (at least 2
previously partially months after
vaccinated with PCV7) PCV13)
First presenting over five Hib/MenC vaccine MenACWY
years (regardless of PPV conjugate vaccine
vaccination history)

Page 99 of 120
PCV = pneumococcal conjugate vaccine, PPV = pneumococcal polysaccharide vaccine
Data on long-term antibody levels in these groups of patients are limited. Additional doses to
cover the highr risks of Hib, meningococcal and pneumococcal disease during childhood, should
be considered, depending on the child’s underlying condition. Specialist advice may be required.
B. ANTIBIOTIC PROPHYLAXIS
Life long prophylactic antibiotics should be offered to patients considered at

continued high risk of pneumococcal infection including
• aged less than 16 years or greater than 50 years,
• inadequate serological response to pneumococcal vaccination,
• history of previous invasive pneumococcal disease,
• splenectomy for underlying haematological malignancy particularly
in the context of on-going immunosuppression
Patients not at high risk should be counselled regarding the risks and benefits of
lifelong antibiotics and may choose to continue or discontinue prophylaxis
After splenectomy for trauma the risk is greatest in the immediate post-operative
period, and antibiotic prophylaxis should include this period at least.
Phenoxymethylpenicillin (oral) Oral Prophylaxis

Child under age 6 years 125 mg 12 hourly
Child aged 6 – 12 years 250 mg 12 hourly
Adult 500mg 12 hourly or once daily if
compliance a problem
Erythromycin only in Penicillin allergic

patients
Child under 2 years 125 mg daily
Child aged 2 – 8 years 250 mg daily
Adult and child over 8 years 500 mg daily
Amoxicillin (only if Haemophilus influenzae

cover required)
Adult 250 – 500 mg daily
C) Early treatment packs should be kept at home to take immediately if

patients develop raised temperature, malaise or shivering. Suitable packs
would include:
Oral Amoxicillin
Oral Clarithromycin
D) Advice should be given about foreign travel including:

(i) The inadvisability of visiting malaria endemic areas.
(ii) The risks of meningitis A in endemic countries (a vaccine is available).
(iii) The risks of tick bites causing babesiosis.
(iv) Antibiotic prophylaxis when holidaying in countries with a high risk of
penicillin resistance e.g. Spain, USA etc.
Page 100 of 120
References
1. DH Immunisation against infectious disease (Green book), chapter 7.
Available at www.dh.gov.uk
2. Davies JM 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. BJH
2011; 155: 308-317.

Page 101 of 120
GENTAMICIN – ONCE - DAILY DOSING
Please also print off the gentamicin infusion sheet and attach to the patient’s drug chart
This protocol should NOT be used for patients in the following categories:
• paediatrics
• ascites
• pregnant women
• endocarditis
• cystic fibrosis (CF)
• major burns
• creatinine clearance (CrCl) < 30 ml/min – see end of guideline for advice
In these situations, unless a specific protocol exists, use multiple daily dose regimens
If there are no contraindications to its use, once daily dosing with gentamicin is safer, more
convenient, and cheaper than multiple daily dose regimens
Dosing
This regimen gives a standard dose of gentamicin of 7mg/Kg calculated from ideal body weight (usual
maximum dose is 560mg).
A serum gentamicin level should be measured 6-14 hours after the first dose to determine the dosage
interval.
Step 1: Check renal function

If the patient has an eGFR < 40 ml/min, calculate their creatinine clearance (ml/min) using the
Cockroft and Gault equation:
Men = 1.23 x (140-age) x weight (Kg) Women = 1.04 x (140-age) x weight (Kg)
Serum creatinine (µmol/L) Serum creatinine (µmol/L)
If the calculated creatinine clearance is less than 30ml/min, see end of this guideline for advice.
Step 2: Calculate the dose

• Find out the patient's sex, height, weight in kg
• Read off the patient’s ideal body weight (IBW) for their sex and their height from the
appropriate chart below
• Compare the patient’s actual body weight (ABW) with their ideal body weight (IBW)
• If the patient’s ABW is less than their IBW (i.e. they are underweight), use their ABW to
estimate the gentamicin dose from the charts below
• If the patient’s ABW is more than, or the same as, their IBW, use their IBW to estimate the
gentamicin dose from the charts below
• If patient is > 20% above IBW, use Obese Dosing body Weight (ODW).
ODW = IBW + 0.4 (actual body weight – ideal body weight)
(To convert from imperial weight measurements to metric 1 stone = 6.35kg 1 lb = 0.45kg)

Page 102 of 120
Step 3: Prescribe the dose
Prescribe the selected gentamicin dose on the Gentamicin Administration Sheet AND on the patient’s
drug chart (stating to please refer to the attached Gentamicin Administration Sheet).

YEAR 2011
Date 1 2 3 4 5 6 7 8 9 10
SPECIFY TIME
MONTH June IF REQUIRED
Drug
Gentamicin
Morning
Midday
Please see separate Gentamicin Administration Sheet
See chart IV 01/06/11
5 days Bleep No: (Doctor) 1234 Bedtime
Pharm: Print name & profession Special Instructions UTI
A Doctor
ADULT MALES (>16 yrs) ADULT FEMALES (> 16 yrs)
ABW ABW
(use if (use if
IBW Gentamicin less Gentamicin less
Height Height IBW (kg)
(kg) dose (mg) than dose (mg) than
IBW) IBW)
(kg) (kg)
6’1” or over Over 79.9 560 6’ 3” (1.9m) or 79.5 560

78 – 82 78 - 82
(1.85m or over) over
5’10” – 6’ 73 – 77.6 520 6’ – 6’2” 72.6 – 77.2 520

72 - 77 72 - 77
(1.77 – 1.82m) (1.82 – 1.88m)
5’7” – 5’9” 66.1 – 70.7 480 5’10” – 5’11” 68 – 70.3 480

66 - 71 66 - 71
(1.7 – 1.75m) (1.77 – 1.8m)
5’5” – 5’6” 61.5 – 63.8 440 5’7” – 5’9” 61.1 – 65.7 440
60 - 65 60 - 65
(1.65 – 1.68m) (1.7 – 1.75m)
5’2” – 5’4” 54.6 – 59.2 400 5’4” – 5’6” 54.2 – 58.8 400
55 - 59 55 - 59
(1.57 – 1.63m) (1.63 – 1.68m)
5’1” or under Under 52.3 360 5’2” – 5’3” 49.6 – 51.9 360
49 - 54 49 - 54
(1.55m or under) (1.57 – 1.6m)
5’1” or under Under 47.3 320

43 - 48
(1.55m or under)

Page 103 of 120
Step 4: How to give the gentamicin
Dilute the gentamicin dose in 100ml sodium chloride 0.9% and give by intravenous infusion over 60
minutes
Number of ml gentamicin
Gentamicin dose (mg)
80mg/2ml
560 14
520 13
480 12
440 11
400 10
360 9
320 8
Record on the Gentamicin Administration Sheet the exact start time of the infusion (this
information will be needed to calculate the dose interval in step 6)
Step 5: How to measure gentamicin levels

Obtain a serum gentamicin level (10 mL clotted blood) and creatinine level 6-14 hr after the
start of the first infusion. Do not sample via cannula used for infusion
Document the EXACT time and date the sample was taken and the EXACT time and
date the infusion was set up on the microbiology request form (the lab will then note these
times on the system)
Step 6: Dose interval selection

Using Figure 1, plot the level (plasma concentration mg/ml) against the time between start of
infusion and sample drawn and to select a dose interval (24 hrly, 36 hrly or 48 hrly)
If a point is on the line, choose the longer dosing interval
If result falls above upper limit for Q48h, STOP the gentamicin and obtain random gentamicin
levels until the level is <1mg/L. Reduce next dose to 5mg/Kg.
Discuss with Microbiologist or a pharmacist if in doubt.
Key
Q24h = give dose every 24 hours
Antimicrob Agents Chemother

1995;39(3):650-655

Page 104 of 120
If Creatinine Clearance is <30 ml/min, give initial dose and obtain serial levels (e.g. at 24, 36 and
48 hours) to determine the appropriate time for the next dose (when the gentamicin level is <1mg/L
the next dose may be given). Discuss with Microbiologist if in doubt.
CrCl 10-30 ml/min, initial dose 5mg/kg (usual maximum dose 560mg)
CrCl <10 ml/min, initial dose 2.5mg/kg (usual maximum dose 560mg)
Step 7: Repeated monitoring

(Please note that this is only for ONCE DAILY dosing. If prescribed more than ONCE daily,
follow multiple daily dosing and monitoring guideline)
In stable patients, repeat gentamicin levels 1-2 times per week and check creatinine level 2-3
times per week
If the clinical state, especially renal function, is unstable, repeat levels daily
If result falls in Q24h sector it is not necessary to recheck gentamicin concentration within five
days unless patient’s condition suggests renal function may be compromised
If dose interval >Q24h, check serum creatinine every 2-3 days (more frequently if renal function
unstable). Calculate creatinine clearance (CrCl) to check dose interval has not changed
If dose interval has to be changed, check gentamicin concentration 6-14 hr after start of next
infusion (note time of start of infusion and time of sampling) and use Figure 1 to verify correct
dose interval

Page 105 of 120
First name:
Last name:
DOB:
Hospital No.:
Once Daily Gentamicin Infusion

(In 100ml glucose 5% or sodium chloride 0.9% by IV infusion over 60 minutes)
NB: Gentamicin still needs to be prescribed on the drug chart.
Initial dose
Dose
Infusion Witnessed
Date Time Drug Route (maximum Drs signature Given by
start time by
560mg)
Gentamicin IV ..……mg
Initial level (6 - 14 hours post dose)
Gentamicin level Dosing interval chosen

Date of Time of Time after start Creatinine
result (mg/l) (24 / 36 / 48 HOURS according
level level of infusion (hrs) µmol/L
to nomogram)
Every ……….…………. hours
Subsequent doses
Gentamicin IV to be given every 24 / 36 / 48 hours (please circle appropriate dosing interval)
(refer to nomogram in gentamicin once daily dosing guidelines and on quick reference guides)
If dose changes or renal function deteriorates, prescribe new dose on a separate gentamicin sheet and
cross through the old gentamicin sheet.
Time Dose Due
Dose
Date Dose (NB check this
Dose (maximum Drs signature Given Witnessed
Due corresponds Date Time
No 560mg) by by
with dosing
interval above)
2
3
4
5
PLEASE RECORD ALL LEVELS TAKEN BELOW

Gentamicin Levels (take twice weekly if renal function remains stable)
Date of Time of Time after start of infusion Level result Creatinine Dosing
level level (hrs) (mg/l) µmol/L interval

Page 106 of 120
GENTAMICIN - MULTIPLE DAILY DOSING
This protocol is based on that used at the Tayside area hospitals, Scotland
Gentamicin nomogram for multiple daily dose regimens
This nomogram is NOT to be used for patients with CF or children
Nomogram for gentamicin

dosage (devised by Prof. G.
Mawer), which provides a
loading dose (L), a
maintenance dose (M), and a
suitable interval between
doses for an adult patient
whose serum creatinine
concentration (A), age (B)
and body weight (D) are
known
To use, join A to B with a line

that crosses C; then join this
intercept on C to D with a line
which crosses M and L
Monitoring multiple daily dose regimens

Measure serum gentamicin after 24 hr. A trough sample should be taken
immediately before the 3rd to 5th dose, and a peak sample 1 hr after the dose
The target peak concentration is 5-10 mg/L
The trough concentration should be maintained <2 mg/L
The relationship between maintenance dose and steady state concentration is
linear. Doubling the dose will double the peak and trough serum concentrations,
assuming renal function is stable

Page 107 of 120
VANCOMYCIN
Dosage
1) Normal renal function

1g 12 hourly (infuse over at least 60 minutes)
2) Renal failure
Please contact Medicines Information on Ext. 2267 or Consultant Microbiologist
for advice.
Assays
Levels should always be checked after 48 hours.

Pre dose – immediately prior to infusion
Specimen should contain 5-10mls of clotted blood and should be sent with a single
form.
Subsequent assays should be repeated 2-3 times per week according to levels.
Levels
Pre dose levels should be 10-15 mg/L.

There is no need to take post dose levels.

Page 108 of 120
ANTIBIOTIC THERAPEUTIC DRUG RANGES
Pre dose Post dose
Trough Peak Notes
Gentamicin See separate guideline
Teicoplanin 20 - 40 mg/L For severe infections

only (e.g. MRSA,
Please see notes osteomyelitis, septic
(take immediately arthritis) when
th
before giving the 5 or treatment is likely to
th
6 dose i.e. 4-5 days continue for more than
after starting 2 weeks.
treatment)
Tobramycin < 2 mg/L 8 -12 mg/L
(multiple daily dosing
for cystic fibrosis
patients only)
Tobramycin < 2 mg/L 6 - 10 mg/L On the advice of

consultant
(multiple daily dosing microbiologist only
for NON cystic fibrosis
patients)
Vancomycin 10 -15 mg/L

Page 109 of 120
3 Definitions
AFB: acid fast bacilli
ARDS: acute respiratory distress syndrome
AXR: abdominal x-ray
BAL: bronchoalveolar lavage
BNF: British National Formulary
CDT: Clostridium difficile toxin
CRP: C-reactive protein
CSF: cerebrospinal fluid
CSU: catheter specimen of urine
EBV: Epstein-Barr virus
ESBL: extended spectrum beta lactamase
FBC: full blood count
G-CSF: granulocyte colony stimulating factor
HACEK: Haemophilus spp., Actinobacillus actinomycetemcomitans,
Cardiobacterium hominis, Eikenella spp., Kingella spp.
HIV: human immunodeficiency virus
HNIG: human normal immunoglobulin
HPU: Health Protection Unit
HSV: herpes simplex virus
HUS: haemolytic uraemic syndrome
IGAS invasive Group A streptococcal disease
IM: intramuscularly
IV: intravenous
MMR: measles/mumps/rubella
MRSA: meticillin resistant Staphylococcus aureus
NG: nasogastric
PCP: Pneumocystis jirovecii (carinii) pneumonia
PCR: polymerase chain reaction
PEG: percutaneous gastrostomy
PID: pelvic inflammatory disease
PO: per oral
PPI: proton pump inhibitors
PR: per rectum
PVL: Panton-Valentine leukocidin
RUQ Right Upper Quadrant
TB: tuberculosis
U+Es: urea + electrolytes
UTI: urinary tract infection
VTEC: verotoxin producing E coli
VZV: varicella zoster virus
WBC: white blood cell
4 Associated Documents
None
5 Duties
The Consultant Microbiologists and Antibiotic Pharmacists are responsible for
updating this document and maintaining the Antimicrobial Management section on
the MCHFT Intranet. The document will be approved by the Antimicrobial
Stewardship Committee.

Page 110 of 120
6 Consultation and Communication with Stakeholders
This document has been reviewed by the Consultant Microbiologists taking into
consideration National Guidance, latest research and local resistance patterns.
Details of the relevant sections have been emailed directly to Consultants for
comments prior to document approval.
7 Implementation
The guidelines will replace the previous guidelines on the Antimicrobial Management
section of the intranet. A memo will be sent to all prescribers to state that the
guidelines have been updated and a reminder will be set on the trust intranet.
Pharmacists and Consultant Microbiologists will remind prescribers that the
guidelines have been updated.
8 Education and Training

No direct education and training on usage of the document is required as the main
format has not changed.
9 Monitoring and Review

The table below must be completed in the document to demonstrate effective
monitoring of all documents.
Monitoring and Audit

Standard/process/issue Process Responsible
required to be Frequency
for individual Responsible
monitored of
monitoring /group committee
monitoring
e.g. audit
Adherence to antibiotic Audit ASC Annual ASC

guidelines
9.1 Audit Proforma
The MCHFT Audit proforma must be used to demonstrate effective monitoring

and implementation of planned actions. This can be found on the intranet in
frequently used forms/clinical audit.
10 References / Bibliography
Please see individual sections within the guidelines for relevant references.
11 Appendices
All Appendices must be in numerical order 1, 2, 3 etc and positioned before the
mandatory appendices below.
A Version Control Document

B Communication / Training plan
C Equality Impact and Assessment Tool

Page 111 of 120
APPENIDX A - Control Sheet
This must be completed and form part of the document appendices each time the document
is updated and approved.
VERSION CONTROL SHEET
Date Version Author Reason for changes

dd/mm/yy
01/10/12 Three Dr S Panagea / Dr M Updated guidelines to bring in line with
O’Donoghue / J Willis current evidence, national guidelines and
local resistance patterns.
Changed format to comply with trust
format.

Page 112 of 120
APPENDIX B - Training needs analysis
Communication/Training Plan (for all new / reviewed documents)
Goal/purpose of the Awareness of updated guidelines

communication/training plan
Target groups for the Prescribers, pharmacists, nursing staff
communication/training plan
Target numbers 300
Methodology – how will the Intranet and personal communication. A memo
communication or training be carried will also be sent out to all prescribers.
out?
Communication/training delivery Consultant Microbiologists / Antibiotic
Pharmacist
Funding N/A
Measurement of success. Learning Audit results
outcomes and/or objectives
Review effectiveness – learning N/A
outputs
Issue date of Document 5th October 2012
Start and completion date of Start 5th October 2012 until guidelines are
communication/training plan reviewed
Support from Learning & Development N/A
Services
For assistance in completing the Communication / Training Plan please contact the MCHT
Learning and Development Services

Page 113 of 120
APPENDIX C - Form 1
Equality Impact Screening Assessment
Please read the Guide to Equality Impact Assessment before completing this form. To be
completed and form part of the policy or other document appendices when submitted to
governance-policies@mcht.nhs.uk for consideration and approval or to be completed and form
part of the appendices for proposals/business cases to amend, introduce or discontinue
services.
POLICY/DOCUMENT/SERVICE
Yes/
Justification and Data Sources
No
Does the document, proposal or service

A affect one group less or more favourably
than another on the basis of:
Race, ethnic origins (including gypsies and
1 No
travellers) or nationality
2 Sex No
3 Transgender No
4 Pregnancy or maternity No
5 Marriage or civil partnership No

Sexual orientation including lesbian, gay
6 No
and bisexual people
7 Religion or belief No
8 Age No
Disability - learning disabilities, physical

9 disability, sensory impairment and mental No
health problems
10 Economic/social background No
Human Rights – are there any issues

B
which may affect human rights
1 Right to Life No
2 Freedom from Degrading Treatment No
3 Right to Privacy or Family Life No
4 Other Human Rights (see guidance note) No
NOTES
If you have identified a potential discriminatory impact of this document, proposal or service, please complete
form 2 or 3 as appropriate.
st
Date: 1 October 2012 Name: Jennifer Willis
Signature: J A Willis Job Title: Antibiotic Pharmacist
Date: ………………………………….. Name: ………………………………..

Page 114 of 120
Signature: …………………………… Job Title: ..…………………………

Page 115 of 120
Form 2
Equality Impact Assessment
Please read the Guide to Equality Impact Assessment before completing this form. To be completed when
potential impact has been identified, but necessary steps to address that impact have been identified, agreed
and included in the document or proposal. If you have identified a potential discriminatory impact of the
document or proposal for which actions need to be identified or for which actions are complex in nature,
please complete form 3 instead. To form part of the policy or other document appendices when submitted to
governance-policies@mcht.nhs.uk for consideration and approval or to form part of the appendices for
proposals/business cases to amend, introduce or discontinue services. Any actions listed in this form
should be highlighted in red, with timescales for action and lead responsibility noted.
POLICY/DOCUMENT/SERVICE………………………………………………
Justification & data sources.
Include nature of impact for which
Yes/ action has been agreed and
No details of that action. Also record
provisions already in place to
mitigate impact.
A Does the document, proposal or service

affect one group less or more favourably
1 Race, ethnic origins (including gypsies and

2 Sex
3 Transgender
4 Pregnancy or maternity
5 Marriage or civil partnership
6 Sexual orientation including lesbian, gay and

bisexual people
7 Religion or belief
8 Age
9 Disability - learning disabilities, physical
disability, sensory impairment and mental
health problems
10 Economic/social background
B Human Rights – are there any issues

1 Right to Life
2 Freedom from Degrading Treatment
3 Right to Privacy or Family Life
4 Other Human Rights (see guidance note)

NOTES:
Date………………………………….. Name………………………………..
Signature…………………………… Job Title..……………… …………..
Date………………………………….. Name………………………………..

Page 116 of 120
Signature…………………………… Job Title..………………….………..

Page 117 of 120
Form 3
Please read the Guide to Equality Impact Assessment before completing this form. To be completed when
potential impact has been identified, but necessary steps to address that impact have been identified, agreed
and included in the document or proposal. If you have identified a potential discriminatory impact of the
document or proposal for which actions need to be identified or for which actions are complex in nature,
please complete form 3 instead. To form part of the policy or other document appendices when submitted to
governance-policies@mcht.nhs.uk for consideration and approval or to form part of the appendices for
proposals/business cases to amend, introduce or discontinue services. Any actions listed in this form
should be highlighted in red, with timescales for action and lead responsibility noted.
POLICY/DOCUMENT/SERVICE………………………………………………
Section A
Justification & data sources.
Include nature of impact for which
Yes/ action has been agreed and
No details of that action. Also record
provisions already in place to
mitigate impact.
A Does the document, proposal or service

affect one group less or more favourably
1 Race, ethnic origins (including gypsies and

2 Sex
3 Transgender
6 Sexual orientation including lesbian, gay and

bisexual people
8 Age
9 Disability - learning disabilities, physical
disability, sensory impairment and mental
health problems
B Human Rights – are there any issues

1 Right to Life

NOTES

Page 118 of 120
SECTION B
Justification and data sources.

Issues for which action needs to be Yes/ Include nature of impact for which
agreed. No action needs to be agreed.
Then complete section C.
Does the document, proposal or service

A affect one group less or more favourably
Race, ethnic origins (including gypsies and
1
2 Sex
3 Transgender

Sexual orientation including lesbian, gay and
6
bisexual people
8 Age
Disability - learning disabilities, physical

9 disability, sensory impairment and mental
health problems
Human Rights – are there any issues

B
1 Right to Life
NOTES

Page 119 of 120
SECTION C
Please expand tables below as necessary
SECTION B
NUMBER NATURE OF IMPACT EVIDENCE
A1-10, B1-4
SECTION B
NUMBER STAKEHOLDER INVOLVEMENT ACTION
A1-10, B1-4
SECTION B
NUMBER RISK ASSESSMENT
COST LEAD TIMESCALE
SCORE
A1-10, B1-4
Date………………………………….. Name………………………………..
Signature…………………………… Job Title..…………………………..
Date………………………………….. Name………………………………..
Signature…………………………… Job Title..…………………………..

Page 120 of 120

1603 - 11th July 2013 - Attachement 1 - Adult Antibiotic Policy PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

1603 - 11th July 2013 - Attachement 1 - Adult Antibiotic Policy PDF

Uploaded by

Copyright:

Available Formats

Antibiotic Guidelines

Treatment and Prophylaxis for

Document Type: Guideline

Date of Issue: October 2012

Review Date: October 2013

Lead Director: Consultant Microbiologists

Consultant Microbiologists / Antibiotic

Approving Committee: Antimicrobial Stewardship Committee

Approved by them in the

Distribution to: All Trust staff via the Trust Intranet

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Antibacterial Prophylaxis in Ear, Nose and Throat Surgery 85

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Final Risk rating 4 2 8

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Aim of the Guidelines

Antimicrobials should only be prescribed if there is a clear indication and

Recommendations that follow are for empirical antimicrobial therapy in

Treatment should be modified according to laboratory results. A change

ALWAYS document indication and duration of the treatment on the drug

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

In accordance with the Trust Antibiotic Guidelines and to improve

REGULAR PRESCRIPTION PHARMACY USE ONLY

An Indication Duration or Review Date

“Review” dates should generally be endorsed for IVs.

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Does the patient have a bacterial infection?

Unexplained pyrexia should not be treated with antimicrobials unless the

If the condition is serious and treatable infection is likely, empirical antimicrobial

Have relevant specimens been collected?

Antimicrobial therapy however, should never be delayed in an emergency.

Is parenteral (IV) treatment necessary?

Antibiotics should be prescribed intravenously for severe infection, e.g.

Most other conditions only require intravenous antimicrobials if particularly

Is the patient allergic to any antibiotics?

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Type 1 – immediate hypersensitivity to penicillin

NOT type 1 penicillin allergy

Weak cross-reactivity with

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Prescriptions for intravenous antibiotics must be reviewed after 48 hours and

Exceptionally, in some cases it is usual to administer the whole course of

Criteria for changing to oral antibiotics:

- temperature <38° C for >24hours

- signs of clinical improvement

- no clinical indication for continuation of IV therapy, e.g. endocarditis,

- oral fluids tolerated

- no ongoing or potential GI tract absorption problems

- oral formulation or suitable oral alternative is available

ANTIBIOTIC STOP POLICY

This guidance aims to prevent unintended long duration of antimicrobial

Five days duration of antibiotic treatment is usually sufficient. Please refer to

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

Antibiotic prescriptions should be reviewed daily.

Antibiotic Guidelines: Treatment and Prophylaxis for Adults

The following antibiotics should not be prescribed unless specifically

Pharmacy will be unable to supply restricted antimicrobials unless these conditions

All cephalosporins e.g. cefuroxime, cefotaxime, ceftazidime, ceftriaxone,

All quinolones e.g. ciprofloxacin, levofloxacin unless recommended for specific