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Published: 01/11/2016

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Published: 01/11/2016

      

Antimicrobial stewardship (AMS)      

In this section you will find resources for health professionals about empiric antimicrobial treatment, antimicrobial resistance and Auckland DHBs Antimicrobial Stewardship programme.

Resources

Adults

Paediatrics

Auckland DHB Inpatient Restricted† Antimicrobials list: Adult & Paediatrics
†The antimicrobials highlighted in yellow may be exempted pre-approval if one of the relevant listed criteria is met:

  • A special authority number exists for community prescription

  • Prescription is for an approved indication

  • Prescription is by an approved prescriber

 There are no exemptions for antimicrobials highlighted in red. When pre-approval is required, this will be issued after telephone consultation with an Infectious Diseases or Microbiology SMO or RMO.  Adult and Paediatric ID provides a 24-hr on call service for this and clinical advice. Restricted antimicrobials may only be dispensed or administered if the medication chart is completed correctly.  All prescriptions should be clearly annotated with:

  • the indication (e.g. “CAP”) and

  • the planned duration (e.g. “x3/7”) and

  • name of approver (e.g. App’d Dr Handy) or

  • relevant exemption (e.g. “CHEM/123456789/July 2013 or “TB SMO, Dr Nisbet”)

These changes have been necessary to facilitate post-prescription audit and the introduction of electronic prescribing in the future. Should the approved agent be required after hours, supplies can be obtained from the Pharmacy After Hours Cupboard.

 

 

 

Auckland DHB Adult Empirical Antimicrobial Treatment Guidelines

The recommendations given in this guide are meant to serve as treatment guidelines. They should NOT supplant clinical judgment or Infectious Diseases consultation when indicated. The recommendations were developed for use at Auckland DHB and thus may not be appropriate for other settings. We have attempted to verify that all information is correct, but because of on-going research, practice may change.

Sepsis

Respiratory tract 

Ear, nose and throat 

Ophthalmology 

CNS 

Cardiothoracic 

Skin and soft tissue 

Gastrointestinal tract 

Genito-urinary tract 

Sepsis

Neutropenic sepsis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Haematology

piperacillin-tazobactam 4.5g IV q6h ± gentamicin 5mg/kg IV q24h

Oral therapy not appropriate

A minimum of 72hours to a maximum of 14 days.

See full guidelines for advice.

Oncology low risk

cefuroxime 1.5g IV q8h

Oncology high risk

 

cefuroxime 1.5g IV q8h
+
gentamicin 5mg/kg IV q24h
or

ceftriaxone 1g IV q12h

Patients colonised with ESBL MROs Consult ID

Community onset sepsis – unknown source. Need to assess MRO risk, travel history, recent inpatient stays, source

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Normal host

 

flucloxacillin 2g IV q6h
+
benzylpenicillin 1.2g IV q6h
+
gentamicin 5mg/kg IV q24h

Oral therapy not appropriate

Review at 48 hours.

 5 days for culture negative sepsis.

See Febrile Neutropenia policy for further advice.

Compromised host

 

amoxicillin-clavulanate 1.2g IV q8h
+ gentamicin 5mg/kg IV q24h

 

Respiratory tract

Community acquired pneumonia

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

CURB-65 0-1:

 

 

Oral treatment only

amoxicillin 500mg po TDS

OR

doxycycline 200mg po BD on day 1 then
100mg po BD

 

5 – 7 days in total

S. pneumonia (penicillin S)

benzylpenicillin 600mg IV q6h
penicillin V 500mg oral QDS

S. aureus
(penicillin S)

benzylpenicillin 600mg IV q6h
penicillin V 500mg oral QDS

S. aureus
(penicillin R)

flucloxacillin 2g IV q6h
→  500mg oral QDS

CURB65 2:

 

amoxicillin 1g IV q6h or 500mg po TDS

+ roxithromycin 300mg po daily

S. aureus
(methicillin R)

vancomycin (as per Vanculator)
oral as per sensitivities

H. influenzae (amoxicillin S)

amoxicillin 1g IV q6h
500mg oral TDS

H. influenzae (amoxicillin R)

amoxicillin + clavulanic acid 1.2g IV q8h
625mg oral TDS

CURB65 3-5:

 

amoxicillin + clavulanic acid 1.2g IV q8h

+ erythromycin 1g IV q6h

OR, if anaphylaxis with penicillins/cephalosporins

moxifloxacinID 400mg IV daily

M. pneumoniae

erythromycin 1g IV q6h
roxithromycin 300mg oral daily

Chlamydophila spp.

erythromycin 1g IV q6h
roxithromycin 300mg oral daily

Legionella spp.

ciprofloxacin ID 400mg IV q8h
750mg oral BD

Aspiration pneumonia – Many are not infective and represent chemical pneumonitis.

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

amoxicillin + clavulanic acid 1.2g IV q8h

amoxicillin + clavulanic acid 625mg po TDS

5 days

-

Hospital acquired pneumonia

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

High Risk

 

piperacillin-tazobactamID  4.5g IV q8h
+ gentamicin 5mg/kg IV q24h

 

amoxicillin + clavulanic acid 625mg po TDS

7 days

 

Low Risk

amoxicillin + clavulanic acid 1.2g IV q8h

Acute exacerbation of COPD or chronic bronchitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV treatment unnecessary

Amoxicillin 500mg po TDS

or

doxycycline 200mg BD on d1 then 100mg BD

5 days

S.pneumoniae 

 

Penicillin VK 500mg po QDS

M.catarrhalis

Trimethoprim 300mg po daily

H.influenzae

Amoxicillin 500mg po TDS

Acute bronchitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

No antibiotics required

Influenza

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

No IV treatment available

See end

5 days

Treatment is an option in critically ill or immunocompromised patients.

Oseltamivir 75mg po BD

 

Ear, nose and throat

Sinusitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Complicated:

amoxicillin + clavulanic acid 1.2g IV q8h

Uncomplicated:

Most patients with sinusitis will not have a bacterial infection. Even for those that do, antibiotics only offer a marginal benefit and symptoms will resolve in most patients in 14 days, without antibiotics.

Consider antibiotics for patients with severe sinusitis symptoms (e.g. purulent nasal discharge, nasal congestion and/or facial pain or pressure) for more than five to seven days plus any of the following features: fever, unilateral maxillary sinus tenderness, severe headache, symptoms worsening after initial improvement.

 

Amoxicillin 500mg po TDS

or

Doxycycline 200mg on day 1 then 100mg daily

 

Complicated:

No improvement on amoxicillin then

amoxicillin + clavulanic acid 625mg po TDS

7 days

Pathogens often not identified.

Otitis media

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV Treatment is unnecessary

Oral treatment is also usually unnecessary

Amoxicillin or cotrimoxazole if severe or bilateral disease.

5 days

Pathogens often not identified.

Pharyngitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV Treatment is unnecessary

No antibiotics necessary unless at risk of rheumatic fever

-          Past history of Rh fever

-          Maori/Pacific ethnicity

-          Aged 3 – 30

-          With: fever, cervical nodes, tonsillar swelling

 

Throat swab to guide treatment.

 

Penicillin VK 500mg po BD

or erythromycin 400mg po BD
or benzathine benzylpenicillin 900mg IM single dose

10 days

Group A Strep:

 

Penicillin VK 500mg po BD

Amoxicillin is avoided due to rash in co-infected EBV patients.

Other pathogens do not require treatment

Epiglottitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Amoxicillin-clavulanate 1.2g IV q8h

or

Cefuroxime 750mg IV q6h

amoxicillin + clavulanic acid 625mg po TDS

5 days

H.influenzae  S – Amoxicillin 500mg po TDS

Tonsillitis (incl quinsy and deep neck space infections)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Benzylpenicillin 1.2g IV q6h

±metronidazole 400mg po TDS (equivalent to IV)

Penicillin VK 500mg QDS

 or

Roxithromycin 300mg daily

10 days

Group A Strep/S.milleri group:
Penicillin VK 500mg po QDS

 

Ophthalmology

Blepharitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV Treatment is unnecessary

Use of non-pharmaceutical intervention is most helpful including warm compress and cleansing of the eyelid margins

chloramphenicol 1% eye ointment topically BD

 

5 days

Pathogens often not identified.

Conjunctivitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV Treatment is unnecessary

Can be viral, bacterial or allergic. Bacterial infection is usually associated with mucopurulent discharge.  Most bacterial conjunctivitis is self-limiting and the majority of people improve without treatment, in two to five days.

 

chloramphenicol 0.5% eye drops 1 drop every 4 hours
+ chloramphenicol 1% eye ointment at night

7 days

Chlamydia:

 

Azithromycin 1g po single dose

 

Viral/allergic:

 

No antibiotic

 

CNS

Meningitis - Phone ID for consult advice if bacterial meningitis or post-neurosurgical meningitis.

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Treatment should be initiated after blood cultures are taken, and after consultation with infectious diseases

 

benzylpenicillin 1.2g IV q4h

± vancomycin as per Vanculator®

+ dexamethasone 10mg IV q6h for 4 days
 starting before or with the first dose of antimicrobial (stop if not S. pneumoniae meningitis

 

Oral therapy not appropriate

Pathogen specific

N.meningitidis

Benpenicillin 2.4g IV q4h for 3 days

H.influenzae:

 

Amoxicillin 2g IV q4h for 7 days

S.pneumoniae:

 

Benzylpenicillin 2.4g IV q4h for 10 days

Listeria

Benpen/amox/cotrimoxazole  for 14 days

Encephalitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Aciclovir 10mg/kg IV q8h

+ Benzylpenicillin 1.2g IV q4h

Oral therapy not appropriate

14 – 21 days

HSV: Aciclovir 10mg/kg IV q8h

Brain abscess

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Treatment should be initiated after blood cultures are taken, and after consultation with infectious diseases

 

Unknown source/mastoiditis:

Amoxicillin 2g IV q4h
+metronidazole 400mg po TDS

                                 

Secondary to trauma/neurosurg:

Amoxicillin 2g IV q4h
+metronidazole 400mg po TDS

+ flucloxacillin 2g IV q4h

Oral therapy not appropriate (except metronidazole)

28 days

P.acnes

 

Benzylpenicillin

S.aureus

Flucloxacillin

S.milleri group

 

Benzylpenicillin

Anaerobes

Metronidazole

 

Cardiothoracic

Endocarditis (native valve)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Treatment should be initiated after blood cultures are taken, and after consultation with cardiology and infectious diseases

 

*benzylpenicillin 1.2g IV q4h
+ gentamicin 3mg/kg IV once daily

 

(*flucloxacillin 2g IV q4h should be used instead of penicillin if staphylococcal sepsis suspected e.g. IV drug user)

Advice will be provided from infectious diseases about ongoing therapy

Oral treatment is inappropriate

As per organism below

S.aureus (MSSA)

 

Flucloxacillin 2g IV q4h 4 weeks

 

S.aureus (MRSA)

 

Vancomycin IV as per Vanculator 4 weeks

 

Viridans strep:

Benzylpenicillin 1.2g IV q4h 4 weeks

or

+ gentamicin 3mg/kg IV daily for 2 weeks

Enteroccci

 

Benzylpenicillin 2.4g IV q4-6h

+ gentamicin 3m/kg IV daily for 2 weeks

 

 

Skin and soft tissue

Cellulitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Flucloxacillin 1g IV q6h
(no need to add benzylpenicillin)

or

cefazolin 1g IV q8h if intolerant

Flucloxacillin 500mg po QDS

or

cephalexin 500mg po QDS

5 days

MSSA:

 

Flucloxacillin 500mg po QDS

Beta-haemolytic Strep

Penicillin VK 500mg po QDS

MRSA

cotrimoxazole 960mg po BD

Diabetic foot infection - May need referral if recurrent or fails to settle to exclude underlying osteomyelitis.  Evaluate PVD.

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Mild/early:

 

flucloxacillin 2g IV q6h

or

cephazolin 2g IV q8h

 

Flucloxacillin 500mg po QDS

 

14 days

MSSA

 

Flucloxacillin 500mg po QDS

Beta-haemolytic Strep

Penicillin VK 500mg po QDS

Severe/refractory:

 

amoxicillin + clavulanic acid 1.2g IV q8h 
or

cefuroxime 750mg IV q6h
+ metronidazole 400mg po TDS

amoxicillin + clavulanic acid 625mg po TDS

or

cephalexin 500mg po QDS
+ metronidazole 400mg po TDS

MRSA

cotrimoxazole 960mg po BD

Gram negatives

As per culture results

Mastitis/breast abscess

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Conservative management of mastitis to alleviate symptoms and ensure on going breast emptying may be all that is required for treatment.

 

Flucloxacillin 1g IV q6h
or

cefazolin 1g IV q8h if intolerant

Flucloxacillin 500mg po QDS

 

5 days

MSSA

 

Flucloxacillin 500mg po QDS

Beta-haemolytic Strep

Penicillin VK 500mg po QDS

Gram negatives

amoxicillin + clavulanic acid 625mg po TDS

Impetigo

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV therapy unnecessary

<3 lesions:

Hydrogen peroxide 1% cream applied BD

 

Extensive disease:

Penicillin VK 500mg po QDS
or Flucloxacillin 500mg po QDS

5 days

MRSA – Cotrimoxazole 960mg po BD

Boils

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV therapy unnecessary

Most lesions may be treated with incision and drainage alone.

Antibiotics may be considered if there is fever, surrounding cellulitis or co-morbidity, e.g. diabetes, or if the lesion is in a site associated with complications, e.g. face.

 

Flucloxacillin 500mg po QDS

5 days

MRSA – Cotrimoxazole 960mg po BD

Bites – human and animal

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV therapy unnecessary

Clean and debride wound thoroughly and assess the need for tetanus immunisation.

 

amoxicillin + clavulanic acid 625mg po TDS

or

Doxycycline  200mg on day 1 then 100mg po BD
+ metronidazole 400mg po TDS

7 days

Usually polymicrobial


Bone and joint

Osteomyelitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

flucloxacillin 2g IV q6h

Oral therapy not appropriate

6 weeks – Consult ID
Consider oral switch

MRSA:  vancomycin as per vanculator®

Septic arthritis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

flucloxacillin 2g IV q6h

Flucloxacillin 500mg po qDS

3 weeks with an early oral switch (e.g. 7-10 days)

Extend to 4 weeks if slow to settle or S,aureus.

 

MRSA

vancomycin as per vanculator®

MSSA

Flucloxacillin

Group A Strep

Penicillin

Compound fractures (prophylaxis)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

amoxicillin + clavulanic acid 1.2g IV q8h

Oral therapy not appropriate

Until surgery or 72hours whichever is sooner

Prophylactic polymicrobial cover

 

Gastrointestinal tract

Peritonitis, severe diverticulitis, intra-abdominal abscesses

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Amoxicillin 1g IV q6h
+gentamicin 5mg/kg IV q24h
+metronidazole 400mg po TDS

or

Cefuroxime 750mg IV q6h
+metronidazole 400mg po TDS

amoxicillin + clavulanic acid 625mg po TDS

5 days unless undrained

S.milleri

Penicillin VK

Enterococci

Amoxicillin
or amoxicillin + clavulanic acid

Gram negatives

As per culture

Biliary tree infections (cholangitis or cholecystitis)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Amoxicillin 1g IV q6h
+gentamicin 5mg/kg IV q24h
or

Cefuroxime 750mg IV q6h

amoxicillin + clavulanic acid 625mg po TDS

5 days

S.milleri

Penicillin VK

Enterococci

Amoxicillin
or amoxicillin + clavulanic acid

Gram negatives

As per culture

Gastroenteritis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV Treatment is unnecessary

See for pathogens

Campylobacter

Most people will recover with symptomatic treatment only. Antibiotics have little impact on the duration and severity of symptoms but eradicate stool carriage.

Treatment is indicated for severe or prolonged infection, for pregnant women nearing term and for people who are immunocompromised. Treatment may also be appropriate for food handlers, childcare workers and those caring for immunocompromised patients.

Erythromycin 400mg po QDS 5/7

 

Clostridum difficile

metronidazole 400mg po TDS for 10 days

or vancomycinID 125mg po QDS for 14 days if no response to 2 courses of metronidazole

Giardia

Metronidazole 2g po daily for 3 days

or 400mg po TDS for 7 days

Oral/mucocutaneous candidiasis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV treatment is unnecessary

Immunocompetent

Nystatin topical q2-3h

7 days

-

Immunocompromised

 

As above.
If no response consider  fluconazoleID 800mg as a single dose.

H.pylori eradication

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV treatment is unnecessary

Amoxicillin 1g po BD/metronidazole 400mg po BD
+clarithromycin 500mg BD

+omeprazole 40mg BD

 

Amoxicillin 1g po BD

+tetracycline 250-500mg po QDS

+omeprazole 40mg po BD

+bismuth 120mg po QDS

7 days

-

 

Genito-urinary tract

Cystitis (lower UTI)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV treatment is unnecessary

Trimethoprim 300mg po nocte

or

Nitrofurantoin 100mg po QDS

Women: 3 days

Men: 7 days

MSSA

 

Flucloxacillin 500mg po QDS

Group B Strep

 

Penicillin VK 500mg po QDS

Gram negatives

 

As per culture but prefer trimethoprim and nitrofurantoin over beta-lactams.

ESBL

FosfomycinID 3g po single dose

or pivemecillinamID 400mg load then 200mg po TDS

Pyelonephritis (severe upper UTI)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Uncomplicated

 

Gentamicin 5mg/kg IV q24h

or if renal imapirment:

cefuroxime 750mg IV q12h

Trimethoprim 300mg po nocte

 

14 days

MSSA

 

Flucloxacillin 500mg po QDS

Group B Strep

 

Penicillin VK 500mg po QDS

Complicated

 

Gentamicin 5mg/kg IV q24h

+amoxicillin 1g IV q6h

Gram negatives

 

As per culture but prefer trimethoprim over beta-lactams.

ESBL

FosfomycinID 3g po q72h (2 doses)

or pivemecillinamID 400mg po TDS

PID/Endometritis/Cervicitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Ceftriaxone 1g IV single dose
+ doxycycline 100mg po BD
+ metronidazole 400mg po TDS

14 days

-

 

Antimicrobial Stewardship Committee

Auckland DHB has a multi-disciplinary committee that ensures a rational, appropriate and cost effective approach to the use of antimicrobials.  The committee meets every two months and the minutes will be posted here following ratification at the subsequent meeting.  Any questions regarding the committee or antimicrobial use at Auckland DHB please contact either the Chair or Secretary.

Current committee members:

  • Rupert Handy (Chair)           Clinical Director Adult Infectious Diseases

  • Eamon Duffy (Sec)                Lead Antimicrobial Stewardship Pharmacist

  • Emma Best                           Paediatric Infectious Diseases Consultant

  • Vacancy                                Surgical Representative

  • Joshua Freeman                   Clinical Microbiologist

  • Lesley Voss                          Clinical Director Paediatric Infectious Diseases

  • Margaret Johnston               Nurse Specialist Liver Transplant and Nurse Practitioner

  • Nigel Patton                         Haematologist

  • Rob Ticehurst                       Principal Pharmacist Medication Safety

  • Sally Roberts                        Clinical Director Clinical Microbiology and Infectious Disease Physician

  • Stephen Ritchie                    Infectious Disease Physician

  • Stephen Streat                      Intensivist and Clinical Director Organ Donation New Zealand

Advanced trainees in Infectious Diseases or Microbiology also attend.

Minutes and Terms of Reference  (Internal Only):

Please note that due to sensitive information and particular cases discussed, these are internal access only.

2012

March

May

July

November

 

 

2013

March

May

August

November

 

 

2014

February

April

July

August

October

December

2015

 

 

 

 

 

 

 


 

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