Guidelines for Antimicrobial treatment for treatment of confirmed infections – adults

This guideline gives recommendations for treatment of confirmed infections in adults – for children please see the Paediatric antibiotic guidelines
on the trust intranet

Prescribers should be aware of the trust Antimicrobial Prescribing Policy which describes general requirements in relation to antimicrobial
prescribing

Prescribers should adhere to the guidelines where clinically practicable – further advice can be obtained from the duty Consultant Microbiologist as
needed

Antibiotic duration is given as general guidance, and should not be taken as a minimum duration. Antibiotics should be reviewed on a daily basis
and stopped as soon as possible. Some patients may require antibiotic courses to be lengthened if clinical response is slow or suboptimal – the
reason for this must be documented.

The use of broad spectrum spectrum / C.difficile risk antibiotics (the five Cs) should be avoided unless there are clear clinical indications for their
use – ciprofloxacin (and other quinolones), cephalosporins, clindamycin, co-amoxiclav and clarithromycin (and other macrolides)

Use of ultra-broad spectrum antibiotics should be restricted to recommended indications, or where recommended by a Microbiologist –
meropenem (and other carbapenems) and piperacillin-tazobactam
MRSA INFECTION
INDICATION
MRSA infections (see
below)
MRSA: Mild skin & soft
tissue infections
(bacteraemia unlikely –
hospital admission not
required)
1ST LINE
ALTERNATIVE
DURATION
NOTES
 The treatment of infections caused by MRSA may be complex, and cases should always be discussed with a
Microbiologist.
 Doxycycline or
Minocycline 100mg bd PO
or
 Clindamycin 300-450 mg
qds PO
7 days
Isolate must be sensitive to
antibiotic on laboratory
testing:
Tetracycline sensitive =
doxycycline or minocycline
1
MRSA: Uncomplicated
UTI
 Nitrofurantoin 50-100mg
qds PO
MRSA: conjunctivitis
(non-severe)
C. difficile INFECTION
INDICATION
Clostridium difficileassociated disease
(CDAD)
 Trimethroprim 200mg bd
PO or
Doxycycline 100mg bd PO
7 days
Chloramphenicol 0.5% eye
drops 2-hourly initially, then
4- to 6-hourly as infection
responds
 Gentamicin 0.3% eye
drops 2-hourly initially, then
4- to 6-hourly as infection
responds
Until 48 hours after
resolution.
1ST LINE
 Metronidazole 400mg tds
PO
ALTERNATIVE
 Vancomycin 125mg qds
PO
(for severe disease – WCC
>15 x 109/L, rapid rise in
creatinine or
symptoms/signs of severe
colitis)
DURATION
10 days
(for non-severe disease - <5
stools/day and WCC
<15x109/L)
 Metronidazole 500mg tds
IV (only in patients who
cannot tolerate
oral/nasogastric
medications).
 Recurrent disease (up to
30% of patients)
1st recurrence: Use
metronidazole 400mg tds
PO (or, only if
recommended by
Consultant Microbiologist,
fidaxomicin 200mg bd PO
sensitive
Erythromycin sensitive =
Clindamycin sensitive
 Discuss with
Ophthalmology if
severe infection.
 Check sensitivity from
Microbiology report
NOTES
-The broad-spectrum
antibiotic(s) that pre-disposed
to CDAD should be stopped
wherever possible.
-Nasogastric administration
can be used if the patient
cannot tolerate oral
medication.
-Review or stop unnecessary
proton pump inhibitors (PPIs)
-For more information,
including management of
severe disease and tapering
vancomycin regimen, refer to
Clostridium difficile infection –
Guideline for Patient
Management
2
-DO NOT use vancomycin
by IV route for treatment of
C.difficile infection
for 10 days)
2nd (or subsequent)
recurrence – use
vancomycin 125mg qds
PO.
GASTRO-INTESTINAL INFECTIONS
INDICATION
1st LINE
ALTERNATIVE
DURATION
NOTES
Salmonella enteritis
 Antibiotics do not reduce the duration or severity of uncomplicated infection, but do significantly increase the risk
of bacterial relapse.12
 Antibiotic treatment should be considered only for those at risk of bacteraemia & its complications: neonates,
elderly, immunosuppressed, cardiac valvular or mural abnormalities, prosthetic cardiac valves or vascular grafts. 16
 For "at risk" patients, who require antibiotics, the regimen of choice is Ciprofloxacin 500mg – 750mg bd PO.
Please discuss with Duty Consultant Microbiologist.
This is a notifiable disease
Campylobacter enteritis17
 Erythromycin 250mg qds
PO
Discuss with Microbiologist
5-7 days
Antibiotics should be reserved
for patients with:
 high fever (> 38.5C) +
bloody diarrhoea or more than
8 stools per day
 symptoms worsening at
diagnosis or persisting longer
than 1 week
This is a notifiable disease
3
Bacillary dysentery
(Shigella species)
 Ciprofloxacin 500mg bd
PO
 Trimethoprim 200 mg bd
PO
3-5 days
Antibiotics should be reserved
for patients with:
 high fever (> 38.5C) +
bloody diarrhoea or more
than 8 stools per day
 symptoms worsening at
diagnosis or persisting
longer than 1 week
 where there is an increased
risk of spread, eg for
patients or residents
requiring hands-on care
This is a notifiable disease
E coli O157
 Antibiotics should not be
given routinely because
there is evidence that this
increases the risk of
developing haemolyticuraemic syndrome13
Typhoid fever
 Cefotaxime 1-2g tds IV
Azithromycin 500mg once
daily or
10 days
(cefotaxime)
Ciprofloxacin 500-750mg
bd PO (only where shown to
be sensitivie)
7 days
(azithromycin or
ciprofloxacin)
 Typhoid fever is a notifiable
disease
 Note increasing incidence of
ciprofloxacin resistance,
especially from Indian
subcontinent. Use
ciprofloxacin only where
isolate has been shown to
be sensitive
 Azithromycin is alternative
for oral therapy, or as
additional agent if poor
4
Giardiasis
 Metronidazole 400mg tds
PO
 Metronidazole 2g od PO
(avoid 2g OD dosing
regimen in pregnancy)
 5 days for tds
regimen
 3 days for od
regimen
Helicobacter pylori
infection
 Omeprazole 20mg bd plus
Clarithromycin 500mg bd
plus Amoxycillin 1g bd (all
PO)
 If penicillin-allergic:
Omeprazole 20mg bd plus
Clarithromycin 250mg bd
plus Metronidazole 400mg
bd (all PO)
7 days
 If Metronidazole
resistance likely e.g. not
from EU/North America:
Tinidazole 500mg bd PO
instead
TB INFECTION
INDICATION
TB
1ST LINE
ALTERNATIVE
response
 OD dosing must not be used
in pregnant patients
 Notifiable disease
Screening and/or treatment of
household contacts
recommended
- Suspected active infection
must be confirmed before Rx,
e.g. by stool antigen if never
treated before or by breath
testing if previously treated.
- Complicated PUD, e.g.
haemorrhage, perforation,
requires Omeprazole 20mg od
for further 4 weeks.
- Treatment failure and
alternative regimens should
be discussed with Consultant
Gastroenterologist.
DURATION
NOTES
 The Joint TB Committee of the British Thoracic Society recommends that all cases of TB (including extrapulmonary disease) should be managed under the direct advice of a Respiratory Physician.
 Tuberculosis is a notifiable disease
GENITO-URINARY INFECTION
5
INDICATION
1ST LINE
ALTERNATIVE
DURATION
NOTES
Genital Chlamydia
 Azithromycin 1g stat PO
Doxycycline 100mg bd PO
Doxycycline for 7
days.
Refer to GUM for advice on
further management and
contact tracing.
Gonorrhoea (anogenital)
 Ceftriaxone 500mg stat IM
Discuss with GUM /
Microbiology
Stat dose.
Refer to GUM for advice on
further management and
contact tracing.
Not applicable.
5 days
Refer to GUM for advice on
further management and
contact tracing.
Plus
 Azithromycin 1g stat PO
Genital herpes
 Aciclovir 200mg 5x daily
PO
Syphilis
 A positive Syphilis antibody
ELISA (or TPHA  FTA)
indicates previous
treponemal infection, which,
in combination with a positive
IgM , indicates active
disease.
Refer to GUM for advice on
management and contact
tracing.
 Previous untreated infection
and current active infection
require treatment; such cases
6
should be managed by GUM.
VIRAL INFECTION
INDICATION
Chickenpox/zoster Uncomplicated
1ST LINE
 Aciclovir 800mg x 5 daily
PO
ALTERNATIVE
Not applicable.
DURATION
7 days.
NOTES
Only effective if started < 24
hours of onset of rash
Chickenpox/zoster Complicated
 Aciclovir 10mg/kg tds IV
(usually 750mg tds IV)
Not applicable.
10 days for
pneumonitis and
encephalitis;
otherwise 5 days.
Complications include:
 persistent fever and/or
appearance of new vesicles
after 5 days of the onset
 pneumonitis
 encephalitis
Herpes simplex
encephalitis
 Aciclovir 10mg/kg tds IV
(usually 750mg tds IV)
Not applicable.
At least 10 days,
possibly 14-21
days.
Ensure adequate hydration
with IV acyclovir – risk of renal
toxicity
For encephalitis need to give
all treatment IV
PARASITIC INFECTION
INDICATION
Falciparum malaria
1ST LINE
Uncomplicated malaria (see
notes)
 Quinine 600mg (of quinine
salt*) tds PO plus
ALTERNATIVE
Discuss all cases of
complicated malaria with
Infectious Diseases
Physician.
DURATION
Quinine plus
Doxycycline and/or
Clindamycin for 7
days
NOTES
Seriously ill patients require
IV Quinine, and their
management must be
discussed with a Infectious
Diseases Physician.
 Doxycycline 200mg od PO
7
or
 Clindamycin 450mg tds
PO
Complicated malaria or if
patient vomiting:
 Quinine 20mg/kg (max
1.4g) IV loading dose of
quinine salt over 4h
 No loading dose if patient
taking quinine or
mefloquine already during
the previous 12 hours).T
 Then 10mg/kg** (max
700mg) infused over 4
hours every 8 hours plus
 Doxycycline 200mg od PO
or
 Clindamycin 450mg tds
IV/PO
 When stable and able to
swallow, switch to oral
quinine 600mg tds PO,
plus doxycycline or
clindamycin as above.
Hospital of Tropical
Diseases UCL: tel 0845 155
5000 and ask for Duty
Doctor for Tropical Medicine
Complicated malaria = one
or more of:
 Impaired consciousness or
seizures
 Parasite count ≥ 2%
 Hb ≤ 8g/dL
 Spontaneous bleeding/DIC
 Haemoglobinuria (without
G6PD deficiency)
 Renal impairment or pH
<7.3
 Pulmonary oedema or
ARDS
 Shock ( may be due to
Gram negative sepsis)
Malaria is a notifiable disease
– notify to the CCDC at the
local HPU
* Valid for quinine
hydrochloride, dihydrochloride
and sulphate. Not valid for
quinine bisulphate which
contains smaller amount of
quinine.
* *Maintenance dose should
be reduced to 5 -7mg/kg of
quinine salt in patients with
severe renal impairment,
severe hepatic impairment, or
8
Vivax malaria
 Chloroquine 625 mg of
base stat PO then 310 mg of
base PO after 6-8 hours
Not applicable.
Primaquine for 14
days
if parenteral treatment is
required for more than 48
hours.
*Patients should be tested for
G6PD deficiency before
commencing primaquine
then 310 mg of base PO od
for 2 days
followed by:
 Primaquine* 30mg od PO
9