SKIN AND SOFT TISSUE
RESPIRATORY TRACT
INFECTION
1ST LINE
PENICILLIN
ALLERGY OR 2ND
LINE CHOICE
Community acquired
pneumonia (CAP)
Non–Severe : †CURB65
score 0-1
and
NOT previously treated
with antibiotics
Community acquired
pneumonia (CAP)
Non–Severe : †CURB65
score 2
OR
CURB65 score 0-1
AND previously treated
with antibiotics
Amoxicillin po
500mg tds
Doxycycline po
200mg STAT then
100mg-200mg daily
OR
Clarithromycin po
500mg bd
Community acquired
pneumonia (CAP)
*Severe: †CURB65
score 3 to 5
(In cases of confirmed
legionella discuss with
microbiology)
COPD exacerbation
(use a different class of
antibiotic if a recent
course of 1st line in the
prev 3 months)
Early-onset
hospital acquired
pneumonia
(less than 5 days after
admission to hospital)
including
aspiration pneumonia
Late-onset hospital
acquired pneumonia
(more than 5 days after
admission to hospital)
OR
*
(Moderate - Severe)
OR
(if recently prescribed
antibiotics or colonised
with resistant
organisms – speak to
Microbiology)
Amoxicillin po/iv
500mg – 1g tds
plus
Clarithromycin po/iv
500mg bd
Benzylpenicillin iv 1.2g qds
plus
Clarithromycin iv 500mg bd
OR
If known COPD/Chronic
lung disease/Recent
course of amoxicillin
Co-amoxiclav iv 1.2g tds
plus Clarithromycin iv
500mg bd
Amoxicillin po
500mg tds
Treat as in CAP
(for aspiration pneumonia
add metronidazole iv
500mg tds)
Piperacillin/Tazobactam
(Tazocin) iv 4.5g tds
+/ Amikacin iv
15mg/kg STAT dose for
severe infection
Doxycycline po
200mg STAT then
100mg-200mg daily
OR
Clarithromycin iv/po
500mg bd
INITIAL
DURAT ION
5-7
days
5-7 days
Vancomycin iv
(as per guideline)
plus
Clarithromycin iv
500mg bd
OR
Levofloxacin iv
500mg bd
(For intubated or
NIV patient)
Doxycycline po
200mg STAT then
100mg-200mg
daily OR
Clarithromycin po
500mg bd
Treat as in CAP
(for aspiration
pneumonia add
metronidazole iv
500mg tds)
7-10
days
5 days
Vancomycin iv
(as per guideline)
plus
Amikacin iv od
(as per guidelines)
5-7
days
5-7
days
(for aspiration
pneumonia add
metronidazole iv
500mg tds)
♦See overleaf for definition of severe and non-severe penicillin allergy
†
CURB65 is the severity scoring acronym used to determine the management
of CAP in patients admitted to hospital. Each risk factor scores one point:
Confusion (Abbreviated Mental Test (AMT) score of 8 or less); Urea >7mmol/L;
Respiratory rate ≥ 30/min; Blood pressure (SBP< 90mmHg or DBP≤ 60mmHg);
Age ≥ 65yrs
Please note: CURB65 is a guide and may not be applicable for all patients
e.g. young patients presenting with pneumonia. This is also not relevant
in patients incapable of mounting an adequate host response to infection.
*Severe symptoms = a SIRS score of two or more.
SIRS criteria: Temperature >38°C or <36°C; Heart rate >90 beats/min;
Respiratory rate >20 breaths/min or PaCO2<4.3 kPa; WBC <4 x 109/L or
>12 x 109/L or >10% immature forms.
Sepsis = Suspicious or proven infection + Severe symptoms
Severe Sepsis = Sepsis + acute organ failure ± hypotension
Septic Shock = Severe Sepsis despite adequate fluid resus
GASTROINTESTINAL TRACT
INFECTION
1ST LINE
PENICILLIN ALLERGY
OR 2ND LINE CHOICE
Cellulitis
(mild-moderate)
In mild, treat orally & send
patient home from A&E
Cellulitis
moderate with signs of
sepsis
Cellulitis
severe with signs of septic
shock) exclude necrotising
fasciitis
Flucloxacillin po/iv
500mg-1g qds
Clarithromycin po/iv
500mg bd
Benzylpenicillin iv 1.2g
qds plus
Flucloxacillin iv 1g qds
Benzylpenicillin iv 1.2g
qds plus
Flucloxacillin iv 1g qds
plus
Clindamycin iv
600mg-1.2g qds
Meropenem iv 1g tds
plus
Clindamycin iv 1.2g qds
Clindamycin po/iv
450mg qds
Vancomycin iv
(as per guidelines)
Vancomycin iv
(as per guidelines)
plus
Clindamycin iv
600mg-1.2g qds
Vancomycin iv
(as per guidelines)
plus
Clindamycin iv
600mg -1.2g qds
Cellulitis
severe involving
groin/scrotal/
labial region
Necrotising Fasciitis
seek urgent surgery
review
Surgical wound
Mild following clean
surgery
Flucloxacillin iv/po
1g qds
Surgical wound
Moderate to Severe
following clean surgery
with signs of sepsis
Benzylpenicillin iv
1.2g qds plus
Flucloxacillin iv 1g qds
plus Clindamycin iv 1.2g
qds
Co-amoxiclav po
625mg tds
Surgical wound
Mild to Moderate
following contaminated
surgery
Surgical wound
Moderate to
Severe following
contaminated surgery
with signs of sepsis
Human/
Animal bites
Diabetic Foot Ulcer
TREAT MENT IF
M RS A +V E
Discuss
sensitivities with
microbiology
Non-severe penicillin
Vancomycin iv
allergy
(as per guidelines)
plus
(same as 1st line
Meropenem iv 1g
treatment)
♦Severe penicillin allergy
tds plus
Vancomycin iv
Clindamycin iv
(as per guidelines)
1.2g qds
plus Clindamycin iv
1.2g qds
plus Amikacin iv od
(as per guidelines)
Doxycycline po 200mg
Vancomycin iv
daily OR
(as per guidelines)
Vancomycin iv
(as per guidelines)
Vancomycin iv
(as per guidelines)
plus Clindamycin iv
1.2g qds
INFECTION
1ST LINE
PENICILLIN ALLERGY OR
2ND LINE CHOICE
INITIAL
DURAT ION
Acute
Pancreatitis
Necrotising
Pancreatitis
No antibiotics needed
No antibiotics needed
N/A
Meropenem iv 1g tds
Non-severe allergy:
Meropenem iv 1g tds
7-14
days
Community
acquired Intraabdominal
sepsis:
(includingcholecystitis,
cholangitis,
appendicitis,
diverticulitis)
Post-surgical
intraabdominal
infection
(deep space)
Non-severe:
Co-amoxiclav iv 1.2g tds
*
Severe:
Piperacillin/Tazobactam
(Tazocin) iv 4.5g tds
plus Amikacin iv od
(as per guidelines)
If no previous treatment
course of antibiotics:
Co-amoxiclav iv 1.2g tds
If previous treatment
course of antibiotics:
Piperacillin/Tazobactam
(Tazocin) iv 4.5g tds
If septic plus
Amikacin iv od
(as per guidelines)
Same as
second-line
treatment
Clindamycin po 450mg
Same as
qds plus
second-line
Amikacin iv od 2 doses
treatment
only (as per guidelines)
Co-amoxiclav iv 1.2g tds Clindamycin iv 600mgAdd
plus Amikacin iv od
1.2g qds plus
Vancomycin iv
Ciprofloxacin iv 400mg bd
(as per guidelines)
to regimen
plus Amikacin iv od
(as per guidelines)
(as per guidelines)
Co-amoxiclav po
Doxycycline po 200mg
Same as second625mg tds
STAT then 100 daily
line treatment –
plus Metronidazole po
check sensitivity
400mg tds
Refer to separate guidelines
Spontaneous
Bacterial
Peritonitis
(SBP)
Piperacillin/Tazobactam
(Tazocin) iv 4.5g tds
If septic plus
Amikacin iv
(as per guidelines)
Metronidazole po 400mg
tds
Clostridium
difficile
(mild / moderate)
♦Severe penicillin allergy
Clindamycin iv 1.2g qds
plus
Amikacin iv od
(as per guidelines)
Ciprofloxacin iv
400mg bd plus
Metronidazole iv 500mg tds
plus Amikacin iv od
(as per guidelines)
If no previous course
of antibiotics in
Non-severe penicillin
allergy
Ceftriaxone iv 2g od plus
Metronidazole iv 500mg tds
If previous treatment
course of antibiotics
OR
♦Severe penicillin allergy
Ciprofloxacin iv 400mg bd
plus Metronidazole iv
500mg tds
plus Amikacin iv od
(as per guidelines)
Non-severe penicillin
allergy
Ceftriaxone iv 2g od
♦Severe penicillin allergy
Discuss with micro
Vancomycin po 125mg qds
If signs of necrotising fasciitis, immediately seek urgent surgical review
MUSCULOSKELETAL SYSTEM
Septic arthritis
(immunocompetent
patients only)
Acute
osteomyelitis
(immunocompetent
patients only)
Chronic Osteomyelitis/
infected implants
Flucloxacillin iv
2g qds
plus
Sodium fusidate
po 500mg tds for
initial 2 weeks
Clindamycin iv
600mg qds
plus
Sodium fusidate
po 500mg tds for
initial 2 weeks
Vancomycin iv
(as per guidelines)
plus
Sodium fusidate po
500mg tds
(confirm sensitivities for
fusidate)
Manage with Orthopaedics and Microbiology
INTRAVENOUS LINES
For peripheral line infections - remove line immediately. -Re-site if still necessary
Flucloxacillin iv
Vancomycin iv
Vancomycin iv
Peripheral line
Moderate to severe with signs
(as per guidelines) plus
1-2g qds
(as per guidelines)
of sepsis
Sodium fusidate po
500mg tds
(confirm sensitivities for
fusidate)
Prompt assessment of line & discussion of risk/benefit line removal with micro
Central line
See separate guidelines
TPN lines
Durations for Peripheral line infections: 5-10 days
10-14
days
10 days
URINARY TRACT
INFECTION
1ST LINE
PENICILLIN ALLERGY OR
2ND LINE CHOICE
‡
Nitrofurantoin po
50-100mg qds for 3 days
(Treat for 7 days in men)
Community acquired
Lower UTI
(No catheter)
Trimethoprim po 200mg bd
for 3 days
(Treat for 7 days in men)
‡
Caution: Failure may occur
with CrCl<45mL per min
Avoid if CrCl <30mL per min
Cephalexin po 500mg tds
for 7 days
Community acquired
Lower UTI in
Pregnant women
Trimethoprim 200mg bd for
7 days (avoid 1st trimester)
OR
‡
Nitrofuratoin po 50-100mg qds
for 7 days (avoid in 3rd trimester)
‡
Caution: Failure may occur with
CrCl<45mL per min
Avoid if CrCl <30mL per min
Ciprofloxacin po 500mg bd
plus Amikacin iv 15mg/kg
STAT
Durations: Septic arthritis and Acute osteomyelitis 4-6wks
(min 2wks iv except for sodium fusidate)
Caution: Clindamycin is associated with antibiotic-associated colitis –stop if diarrhoea occurs
Minimum
7 days
(See separate UTI guideline in addition on intranet )
Durations for SSTIs : 7-10 days depending on severity and response
Caution: Clindamycin is associated with antibiotic-associated colitis –stop if diarrhoea occurs
Review
after 5
days
Community acquired
Pyelonephritis
Hospital acquired UTIs
Catheter associated UTIs
Co-amoxiclav iv 1.2g tds
plus Amikacin iv 15mg/kg
STAT
(switch from IV to oral when
clinically appropriate)
Treat for 10-14days
Treat for 10-14days
Firstly check past microbiology results – please refer to
separate UTI guideline
do not treat unless systemically unwell
GENITOURINARY TRACT
See separate guidelines
CENTRAL NERVOUS SYSTEM
INFECTION
1ST LINE
Meningitis
Ceftriaxone iv 2g bd
If pregnant, elderly or
immunocompromised
add Amoxicillin iv 2g 4hrly
Non-severe penicillin allergy
Ceftriaxone iv 2g bd
If pregnant, elderly or immunocompromised
discuss with Microbiology
(plus Aciclovir iv 10mg/kg tds if encephalitic)
(plus Aciclovir iv 10mg/kg
tds if encephalitic)
♦Severe penicillin allergy
Chloramphenicol iv 25mg/kg 6hrly
(plus Aciclovir iv 10mg/kg tds if encephalitic)
Meningitis & Corticosteroid therapy:
Consider the use of dexamethasone in adolescents and adults with suspected Streptococcus
pneumoniae meningitis. Administer before or with the first dose of antibiotic:
IV dexamethasone 0.15mg/kg 6hourly for 4 days (Avoid in septic shock, meningococcal
septicaemia, immunocompromised patients and meningitis post surgery.
Durations of treatment for meningitis:
variable depending on causative organism – please see separate guideline
Encephalitis
Aciclovir iv 10mg/kg tds
o Patient’s allergy status MUST always be checked prior to prescribing and
administering antibiotics
o The exact nature, severity and time of onset of any reported allergy should
be ascertained. A distinction should be made between intolerance, e.g.
diarrhoea, nausea and vomiting, and ‘true’ immune-mediated allergy.
o For all true antibiotic allergy, it is important to differentiate between immediate
(type I) and delayed hypersensitivity reactions – please see table below.
o Nursing staff must contact the medical team immediately if the patient develops
any signs or symptoms of an allergic reaction.
o Penicillins (coded red) are contra-indicated in all patients with a true
penicillin allergy – mild or severe reaction.
o Non-penicillin beta-lactams (coded orange) should be avoided in patients
with severe reactions to penicillins (immediate or delayed).
o Non-penicillin non-beta-lactams (coded green) are safe to use in all forms
of penicillin allergy.
o See full penicillin policy for further details.
Characteristics of
Immediate (Type I)
Delayed
antibiotic allergy
Time interval
after drug administration
Clinical signs:
Severe
SEPTICAEMIA of unknown origin
Severe
Sepsis
Piperacillin/Tazobactam
(Tazocin) iv 4.5g tds
plus
Amikacin iv od
(as per guidelines)
Non-severe allergy:
Meropenem iv 1g tds
♦Severe penicillin allergy:
Vancomycin iv (as per guidelines)
plus Amikacin iv od (as per guidelines)
plus Metronidazole
Clinical signs:
Mild
< 4hrs
(rarely up to 72hrs)
Anaphylaxis(Airway obstruction
and/or Hypotension)
Angioedema (swelling)
Generalised urticaria (hives)
Diffuse erythema (redness)
Minor rash
CARDIOVASCULAR
See separate guidelines for endocarditis
OTHER
INFECTION
Conjunctivitis
Oral
Candidiasis
Postsplenectomy
prophylaxis
1ST LINE
Chloramphenicol eye
ointment qds
Fluconazole po 50mg
od
Amoxicillin po
500mg od plus
Vaccines (see intranet)
PENICILLIN ALLERGY OR
2ND LINE CHOICE
DURAT ION
Chloramphenicol eye drops
2-6 hrly dependant on
severity
Nystatin liquid po 1ml qds
48 hrs after
resolution
Clarithromycin po 500mg
od plus
Vaccines (see intranet)
Life-long
7 days
GENERAL ANTIMICROBIAL RULES
1.
Intravenous v Oral Antibiotics
3.


14 days
28 days


7 days
14 days
CrCl
(ml/min)
>110
90 – 110
75- 89
51 – 74
40-50
30-39
20-29
10-20
Restricted Antimicrobial List
These are only to be prescribed under the direction of Medical Microbiology unless they are
used as part of a Trust agreed protocol/guideline.
Antibiotics & Antifungals
Aztreonam, Colistin, Ertapenem, Imipenem, Linezolid, Meropenem, Synercid,
Teicoplanin, Temocillin, Tigecycline, Tobramycin, Caspofungin, Lipid based
amphotericin (Ambisome®), Posaconazole, Micafungin, Voriconazole
~~~Clostridium difficile and Antibiotics~~
To reduce the risk factors for Clostridium difficile disease ALL antibiotics
should be avoided wherever possible, especially those in the classes of
cephalosporins and fluoroquinolones
Minor rash
Contact dermatitis
Maculopapular rash
Morbilliform rash
Drug fever
Vancomycin IV dosing (see full fileshare guidelines)
Duration of Antibiotics for Bacteraemia
Staphylococcus aureus bacteraemia (no endocarditis)

Source removed :

Source unknown or non-removable:
Enterobacteriaceae bacteraemia (e.g. E.coli, Klebsiella)

Source removed:

Source unknown or non-removable:
Steven Johnson
Syndrome
Toxic Epidermal
Necrolysis
Give a loading dose followed by a maintenance dose
Loading dose based on weight only. No adjustment for age or renal function.
Check age and renal function to calculate maintenance dose.
Elderly patients (>65yrs old) should be dosed with a maximum starting
maintenance dose of 500mg BD despite normal serum creatinine.
 Take vancomycin level twice a week if normal renal function. Take level and
give dose unless suspicion of toxicity. For renal impairment see full guideline.
 Target level = 10-15mg/L or 15-20mg/L for serious, deep-seated infections,
MRSA pneumonia or infections with less sensitive strains of MRSA
 If levels are out of range, please adjust dose accordingly – see full guidelines
Weight
(actual body weight)
Loading dose
Vancomycin Loading dose (LD) calculator
Less than 60kg
60 to 90kg
More than 90kg
1g
1.5g
Vancomycin maintenance dose (MD)
Vancomycin
Start time
Maintenance
after LD
Dose (MD)
1.5g BD
12hrs
1.25g BD
12hrs
1g BD
12hrs
750mg BD
12hrs
500mg BD
12hrs
750mg OD
24hrs
500mg OD
24hrs
500mg every 48 hrs
48hrs
2g
Timing of 1st
vancomycin level
(based on CrCl)
Before 3rd MD
Before 2nd MD
Before 1st MD
Amikacin IV dosing (see full fileshare guidelines)





P
Poocckkeett ssuum
mm
maarryy vveerrssiioonn
ooff A
Adduulltt E
Em
mppiirriicc A
Annttiibbiioottiicc
TTrreeaattm
meenntt G
Guuiiddeelliinnee
JJaannuuaarryy 22001144
> 72hrs




1. IV antibiotics should only be initiated in patients with severe symptoms or where no
equivalent oral antibiotics are available or where the oral administration is contraindicated/compromised.
2. IV to oral switch should be considered in a patient who has shown clear evidence of
improvement with the following features:
a) Resolution of fever for >24hrs b) Pulse rate <100 beats/min c) Absence of hypoxia
d) Improving white cell count
e) Resolution of tachypnoea f) Resolution of hypotension
g) Taking oral fluids
h) Non-bacteraemic infection i) Gastrointestinal absorption
2.

ALLERGY INFORMATION
PENICILLIN ALLERGY OR
2ND LINE CHOICE
Check age, weight and renal function to calculate dose
Use IBW if patient if >20% obese, if >40% obese see full guidelines
If <65yrs AND CrCl >50ml/min, dose=15mg/kg every 24hrs (max 1.5g/day)
If > 65yrs or renal impairment, refer to full guidelines.
Give the first dose when clinically indicated. Give second dose and
subsequent doses 24hrs apart.
 Take trough level before the THIRD dose if no renal impairment. Do not delay
the third dose while waiting for level, unless suspicion of amikacin toxicity.
 Target level = <5mg/L
 If levels are out of range, please adjust dose accordingly – see full guidelines
Prescribing Standards
1.
2.
Follow prescribing guidelines
Specify clinical Indication for antibiotics in medical
notes and drug chart (unless clinically inappropriate)
Specify duration in medical notes and on drug chart
Only use IV antibiotics where clinically indicated or
oral route compromised
3.
4.
Date
01/09
Drug Amoxicillin
Route PO
1
09:00
500mg
14:00
500mg
22:00
500mg
Indication COPD exacerbation
Duration 5 days
2
3
4
5
IMPORTANT:
Always review treatment in light of microbiology results if available.
Consider the possibility of resistant organisms, e.g. MRSA and ESBL,
especially if recurrent admissions/recent antibiotic therapy.
For Outpatient Parenteral Antibiotic Treatment (OPAT)
Contact: 07507-894-927 (for Tower Hamlets pts only)
For further antimicrobial guidance please contact:
Medical Microbiology SpR via switchboard
Antimicrobial Pharmacists:
RLH on 14-60135 or bleep 0893
NGH Bleep 026 (via switchboard 0207-476-4000)
WXH Bleep: 528 (via switchboard 0208-539-5522)
For antibiotic allergy testing, where appropriate,
please fax referral to:
Consultant Allergists on 16-2279 or, if urgent, call Allergy CNS
on 07720 948385
Leaflet produced by Ms Lisa Boateng (Antimicrobial Pharmacist)
Updated January 2014 with the Barts Health Antimicrobial Review Group
Allergy information produced with Dr Runa Ali, Consultant Allergist