Guidance for initial hospital therapy in adults.

Specialist units may have separate policies

Infection Management Guidelines: Empirical Antibiotic Therapy
STOP AND THINK BEFORE YOU GIVE ANTIBIOTIC THERAPY! Antibiotics are overused in the elderly (particularly patients with urinary catheters or suspected UTIs) and in patients with viral or non-infective exacerbations
of COPD. Always obtain cultures and consider delay in therapy unless there is a clear anatomical site of infection with high probability of bacterial aetiology, if sepsis syndrome is present or if there is clinical deterioration.

ORAL THERAPY USUALLY RECOMMENDED

Severe Systemic
Severe Infection?
Systemic
Lower Respiratory Tract Bone/Joint Infection Urinary Tract Gastro-Intestinal Skin/Soft Tissue CNS Infection Source Endocarditis
Infection? Source
Pneumonia Lower Respiratory Tract Diabetic Foot Infection Lower UTI/cystitis female Gastroenteritis Limited soft tissue infection Urgent IV therapy
CURB65 score: Infection (LRTI) define Mild Antibiotics if symptoms + No antibiotic usually required. Flucloxacillin 500mg 6hrly
Confusion (new onset), diagnosis (e.g. acute bronchitis, Flucloxacillin 1g 6hrly positive urinalysis. Consider IV therapy to be Review all anatomical Possible infective endocarditis
Clostridium difficile If true penicillin allergy
Urea >7, RR>30, diast BP<60 exacerbation COPD, CAP) and In penicillin allergy or previous delaying antibiotic therapy administered systems
associated diarrhoea Clarithromycin 500mg 12hrly Seek senior specialist advice.
or syst BP<90, age >65yrs. treat accordingly antibiotic therapy, pending urine culture. URGENTLY on arrival at Hospital vs community-
Stop/simplify concomitant Duration 7 - 14 days. Indolent:
Additional adverse features: Exacerbation of COPD Doxycycline 100mg 12hrly Catheter specimen of urine is hospital and after blood acquired infection?
hypoxia (SAO2 <92%) or Duration 5-7 days then review unreliable. antibiotics and gastric acid cultures. E.coli, Staph aureus and Amoxicillin 2g IV 4hrly
Antibiotics only if purulent Infected bite
multilobar consolidation or and continue/discontinue as suppressive therapy if possible. Pneumococcus are + (optional) Gentamicin 1mg/
sputum and raised WCC or Trimethoprim 200mg 12hrly Human bite - duration 7 days CT scan before LP if seizures,
cavitation on x-ray. appropriate. or Refer to full guidance for list commonest community blood kg IV 12hrly
CRP. Use 1st line antibiotic Doxycycline 100mg 12hrly reduced GCS, papilloedema,
Moderate Nitrofurantoin 50mg 6hrly of severity factors. If severe, + Metronidazole CNS signs or culture isolates. Severe sepsis, acute
Non-severe community unless recent hospitalisation or
acquired pneumonia (CAP) recent antibiotic. Co-amoxiclav 625mg 8hrly (avoid if renal impairment) Non-severe: oral 400mg 8hrly. immunosuppression. Consider MRSA infection presentation or penicillin allergy:
In penicillin allergy or previous Duration 3 days. Metronidazole 400mg 8hrly Seek ID/microbiology advice. Vancomycin** IV
CURB65 score: 2 1st line hospital therapy Second line Healthcare associated
antibiotic therapy, Severe or no improvement sepsis, recent hospital + Gentamicin 1mg/kg 12hrly
Amoxicillin 500mg-1g 8hrly Amoxicillin 500mg-1g 8hrly Uncomplicated UTI - men Clarithromycin 500mg 12hrly
Co-trimoxazole 960mg 12hrly after 5 days of Metronidazole; discharge, post-operative
(IV or oral) or As above duration 7 days. + Metronidazole if severe. Intra-cardiac prosthesis:
Duration 5 days. Duration 5-7 days then review oral Vancomycin 125mg wound or line-related sepsis
if true penicillin allergy or Refer to full guidance if Vancomycin** IV
and continue/discontinue as 6hrly (add IV Metronidazole or sepsis in previous or
atypical suspected UTI in Pregnancy contraindication to 1st line + Gentamicin 1mg/kg 12hrly
2nd line hospital therapy appropriate. 500mg 8hrly if ileus or current MRSA carrier.
Clarithromycin 500mg 12hrly hypotension) options. + Rifampicin 300-600mg
Severe Trimethoprim 200mg 12hrly
(IV or oral). Clarithromycin 500mg 12hrly (Avoid in 1st trimester) Animal bite - duration 7 days
Refer to full guidance Total duration 10 days. oral / IV 12hrly
or or Co-amoxiclav 625mg oral SEVERE INFECTIONS OR INFECTIONS WHERE
Duration 5 days consider Doxycyline 200mg stat then (IV therapy required). Recurrent CDI discuss with IV THERAPY USUALLY RECOMMENDED
extending if symptoms not Nitrofurantoin 50mg 6hrly 8hrly REVIEW ANTIBIOTIC
100mg-200mg daily. microbiology / ID
improved after 3 days. (Avoid in 3rd trimester or renal In true penicillin allergy: Meningitis Source unknown - Moderate
(10 days if atypical). Duration 5 days. Septic Arthritis*, Osteomyelitis impairment) Doxycycline 100mg oral / severe (IV required): THERAPY DAILY:
Ceftriaxone 2g 12hrly IV
(*refer for emergency drainage If 1st line options unsuitable Appendicitis, Diverticulitis, 12hrly If true penicillin allergy Amoxicillin 1g 8hrly IV STOP?
Cefalexin 500mg 12hrly + Gentamicin**
Severe CAP Severe Infective where possible) Peritonitis + Metronidazole 400mg 8hrly Chloramphenicol 12.5-25mg/
+/- Metronidazole 500mg SIMPLIFY?
Exacerbation of COPD Duration 7 days. Gentamicin** kg 6hrly IV
CURB65 score: >3:
Co-trimoxazole 960mg IV
Flucloxacillin 2g 6hrly IV
+ Metronidazole 500mg 8hrly If age >55 to cover Listeria
8hrly IV (add if anaerobic cover SWITCH?
Co-amoxiclav 1.2g 8hrly IV +/- Rifampicin 300-600mg Complicated UTI Moderate to severe cellulitis required)
12hrly 12hrly IV (on specialist advice (renal tract abnormality) IV + Amoxicillin 2g 4hrly IV RATIONALISE ANTIBIOTIC
If atypical pneumonia +/- Amoxicillin 1g 8hrly IV Flucloxacillin 1-2g 6hrly IV In true penicillin allergy or
Switch to oral if prosthetic joints) or in penicillin allergy THERAPY when microbiology
suspected Co-amoxiclav 625mg 8hrly (use 2g if BMI>30)
Co-trimoxazole 960mg 12 hrly Switch to oral Flucloxacillin If true penicillin allergy or + Vancomycin IV** known MRSA
results become available or
+ Clarithromycin 500mg or Switch to oral Gentamicin**
or Doxycycline 200mg stat 500mg 6hrly gentamicin not appropriate Give Dexamethasone 10mg
12hrly IV Co-trimoxazole 960mg 12hrly Flucloxacillin 1g 6hrly + Vancomycin** IV clinical condition changes.
then 100mg-200mg daily when +/- Rifampicin 300-600mg Co-trimoxazole 960mg 6hrly IV for 4 days
Switch to oral
Co-amoxiclav 625mg 8hrly
condition improves. 12hrly Second line 12hrly IV# If true penicillin allergy or if +/- Metronidazole 500mg Review IV therapy daily
MRSA likely Vancomycin IV ** Duration 7 days for
+/- Clarithromycin 500mg Second line In true penicillin allergy or
Ciprofloxacin 500mg oral + Metronidazole 500mg 8hrly
meningococcal, 14 days for
8hrly IV and remember
Clarithromycin 500mg 12hrly 12hrly IV Switch to oral If eGFR < 30mL/min (CKD>4) IV-ORAL SWITCH see
12hrly or MRSA likely Doxycycline 100mg 12hrly pneumococcal
Doxycycline 100mg 12hrly IV then switch to oral when Duration 7-14 days. Switch to oral or known/ suspected AKI IVOST policy on intranet.
Vancomycin IV** Metronidazole 400mg 8hrly Refer to full guidance for further
condition improves. Switch to oral Duration 7-14 days. consider aztreonam IV as
If true penicillin allergy, + either Doxycycline 100- information. alternative to gentamicin. **Gentamicin/Vancomycin
Levofloxacin 500mg 12hrly IV Duration 7 days. Clindamycin 600mg 8hrly Suspected necrotising
Catheter-related UTI 200mg daily
Source unknown Mild (IV - see prescribing guidance
or Duration 4 - 6 weeks. or Co-trimoxazole 960mg fasciitis or severe or rapidly Encephalitis on intranet
Co-trimoxazole 960mg 12hrly Remove/replace catheter then progressive infection in an not required)
12hrly Aciclovir 10mg/kg 8hrly IV
IV and switch to oral culture urine. Antibiotics are IVDU Co-trimoxazole 960mg 12 Aztreonam see dosing
not indicated unless evidence Duration 3-7 days. (dose adjustment required in hourly oral
Doxycycline 100mg 12hrly or CONSIDER EARLY renal impairment) information on intranet
Co-trimoxazole 960mg 12hrly of systemic infection eg #See full guideline for advice if
Hospital acquired Pneumonia pyrexia, loin pain, raised WCC IV co-trimoxazole not available DEBRIDEMENT/EXPLORATION Duration 14 - 21 days Neutropenic Sepsis FURTHER ADVICE
Total duration (IV plus oral)
Early (4 days of admission)Treat as for CAP or acute confusion in elderly. Flucloxacillin 2g 6hrly IV (if confirmed). Standard risk patients: Can be obtained from the
10 days.
If systemic infection likely + Benzylpenicillin 2.4g 6hrly Piperacillin/Tazobactam 4.5g Duty Microbiologist or Clinical
Staphylococcal Pneumonia Late (>5 days of admission) treat as complicated UTI or Acute cholangitis, Biliary 6hrly IV
IV Pharmacist or the ID Unit
Non-severe pyelonephritis depending on sepsis, Cholecystitis In mild penicillin allergy Aberdeen Royal Infirmary.
Add Flucloxacillin 1g 6hrly (IV + Gentamicin**
or oral) to CAP treatment for Amoxicillin oral 500mg 8hrly clinical symptoms. Amoxicillin 1g 8hrly IV + Clindamycin IV 600mg-1.2g Ceftazidime 2g 8hrly IV Infection Control advice may be
14-21 days. If true penicillin allergy + Gentamicin** 6-8hrly (In severe penicillin allergy see given by the duty microbiologist.
Pyelonephritis / Urosepsis below)
If true penicillin allergy Doxycycline oral 100mg 12hrly +/- Metronidazole 500mg Switch to oral The full antibiotic guidelines and
or Co-trimoxazole oral 960mg 12hrly Gentamicin** (NB: if reduced High risk patients:
Add Linezolid 600mg 12hrly 8hrly IV Flucloxacillin 500mg-1g 6hrly Add Gentamicin** to options policies can be found on the
Duration 5 days. or unstable renal function give
(IV or oral) for 14 days. If true penicillin allergy or + Amoxicillin 500mg-1g 8hrly intranet at:
single dose only then review above
Moderate/severe Clindamycin 600mg 8hrly Septic shock or severe www.nhsgrampian.org/gjf -
with ID or microbiology) gentamicin not appropriate
Aspiration Pneumonia Co-amoxiclav IV 1.2g 8hrly penicillin allergy in Standard / Chapter 5 Infections.
+ Amoxicillin 1g IV 8hrly Co-trimoxazole 960mg In penicillin allergy:
+ Gentamicin IV 7mg/kg as per protocol if life threatening. Switch to oral option guided Vancomycin IV** High risk patients Produced by the NHS Grampian
Benzylpenicillin 1.2g 6hrly IV+ 12hrly IV#
Metronidazole 500mg 8hrly IV If true penicillin allergy by microbiology sensitivities. + Clindamycin 600mg-1.2g Meropenem 1g 8hrly IV Antimicrobial Management Team
Levofloxacin 500mg (IV or oral) 12hrly +/- Metronidazole 500mg IV 6-8hrly November 2015.
Switch to oral In penicillin allergy
Duration 7-10 days. 8hrly IV + Gentamicin** Review November 2017.
Amoxicillin 500mg 8hrly Ciprofloxacin 400mg IV or
+ Metronidazole 400mg 8hrly If MRSA likely add Vancomycin IV as per protocol. 500mg oral 12hrly. Switch to oral Switch to oral options
Duration 7 days (if urinary Doxycycline 100-200mg daily depending on sensitivities. Post-operative infection Clean sites Post-operative infection Dirty sites e.g.
If true penicillin allergy Abdominal, Female genital tract, Head/Neck
Clarithromycin 500mg 12hrly tract abnormality consider or Co-trimoxazole 960mg Duration 4- 6 weeks. Flucloxacillin 500mg-1g 6hrly IV or oral
(IV or oral) 10-14days). 12hrly In penicillin allergy Co-trimoxazole 960mg IV# 12hrly
+ Metronidazole (IV or oral) - consider adding (if required) Vancomycin IV** as per protocol +/- Metronidazole 500mg IV 8hrly
Duration 7 days. Prophylaxis of UTI and bacteraemia Switch to oral
Metronidazole 400mg 8hrly Switch to oral
Patients with clinical evidence of a UTI should be treated with appropriate Duration 7 days Co-trimoxazole 960mg 12hrly Co-trimoxazole 960mg 12hrly
antibiotics before or at the time of catheter insertion. +/- Metronidazole 400mg 8hrly
#See full guideline for advice Duration 10-14 days
Antibiotic prophylaxis at catheter insertion is only indicated in patients for whom Duration 10-14 days
if IV co-trimoxazole not
Version 5 bacteriuria is associated with a high risk of sepsis or those at particular risk of infective
endocarditis. See full guidance for high risk conditions and treatment options.
available #See full guideline for advice if IV
co-trimoxazole not available
ZA03441 CGD150805