Hospital Antibiotic Policy: ST Helens and Knowsley Hospitals Trust

HOSPITAL
ANTIBIOTIC POLICY
ST HELENS AND KNOWSLEY

HOSPITALS TRUST
2004
2
CONTENTS
Page
A. INTRODUCTION
General points 4
Intravenous additive service 6
Antibiotic assays 7
Reserved antibiotics 9
Antibiotic anaphylaxis 10
B. ANTIBIOTIC THERAPY
Septic arthritis 12
Candidiasis 14
Cholecystitis 15
Conjunctivitis 15
Ear infections 16
Endocarditis 17
Genital tract infections 18
Gastro-intestinal infections 21
Helicobacter pylori 22
Intra-abdominal sepsis 23
Meningitis/Brain abscess 25
MRSA infections 27
Osteomyelitis 28
Respiratory tract infections: upper 30
lower 31
Septicaemia 35
Skin and soft tissue infections 36
Toxic shock syndrome 40
Urinary tract infections 41
Special groups of patients:
Burns and plastics patients 42
Neonates 45
Neutropenic patients 48
Pregnant patients 50
C. ANTIBIOTIC PROPHYLAXIS
For surgical operations 52
For patients at risk of endocarditis 57
For patients with prosthetic cardiac valves 59
For meningitis contacts 60
After splenectomy 63
Prevention of spontaneous bacterial peritonitis 64
3
D. NEEDLESTICK INJURIES 65
E. ANTIVIRALS 66
Treatment 66
Chickenpox 66
Herpes simplex 66
Influenza 66
HIV/AIDS 66
RSV 67
Shingles 67
Prevention 67
Post exposure prophylaxis for HIV 67
Chickenpox prophylaxis 67
F. INDEX 68
4
GENERAL POINTS
The purpose of this booklet is to provide guidelines for initial “blind” therapy based on local sensitivity data. Doses
given are generally those for adults with normal renal and hepatic function. Further details of side effects and contra-
indications etc. can be obtained in the British National Formulary or from Drug Information ext. 1565.
Bacteriological specimens e.g. urine, sputum, pus etc must be taken before giving an antibiotic. Blood cultures
should be taken in all cases of serious infection. It may be necessary to alter antibiotic therapy on the basis of culture
and sensitivity results.
The guidelines do not cover every eventuality. Advice on antibiotic therapy can be obtained from the Consultant
Microbiologists, Dr K D Allen, Whiston Hospital, ext. 1834 or Dr M S Vardhan, Whiston Hospital, ext 2691. Contact
the duty Microbiologist via switchboard out of hours. When the diagnosis of tuberculosis is considered or confirmed
Dr J Corless (Bleep 0408) or Dr J Hendry (Ext. 1899) are always willing to give advice.
Duration of treatment
Most infections e.g. pneumonia, septicaemia respond to 5-7 days of antibiotics.
Cystitis: 3 days
Streptococcal pharyngitis: 10 days
Endocarditis: 2-6 weeks
Pyelonephritis: 2 weeks
Osteomyelitis: several weeks/months
Septic arthritis: 2-6 weeks
Lung abscess: 4-6 weeks
Liver abscess: 1-4 months
Switch therapy
Serious infections require intravenous antibiotics initially. The treatment can usually be changed to oral after 1-3
days, depending on the patient’s response.
It is acceptable to change to a different antibiotic if the infecting organism is sensitive e.g. iv cefuroxime may be
changed to oral trimethoprim, iv ceftazidime may be changed to oral ciprofloxacin.
Please note:
Metronidazole should only be used intravenously when the oral or rectal route is impractical or if high serum levels
are required quickly. Peak levels are reached immediately with iv administration, after 1 hour with oral and after 3
hours with rectal dosage. All have equivalent bio-availability. Intravenous infusion should be slow at approximately 5
ml/min.
Cefuroxime
Please note that oral cefuroxime is not equivalent to intravenous cefuroxime. The oral dose is much lower and poorly
absorbed. When switching to oral antibiotics, refer to sensitivity of infecting organism
5
Cotrimoxazole can cause serious side effects e.g. blood dyscrasias and severe skin reactions. Its use should be
avoided unless essential e.g. Pneumocystis pneumonia.
Aminoglycoside and vancomycin levels must be monitored (see p 7-9). For patients with impaired renal function
contact Medicines Information ext. 1565 or Antibiotic Pharmacist bleep 1256 or Ward Clinical Pharmacist for dosage
regime.
Vancomycin infusions should be infused slowly over 1hour 40 minutes (maximum rate 10mg/minute) to avoid red
man syndrome.
Topical antibiotics should be used very rarely, if at all (restrict to eye and ear only). For wounds, antiseptics are
generally more effective if necessary. Topical antibiotics encourage antibiotic resistance and may lead to
hypersensitivity. If considered essential, select an antibiotic that is not used systemically e.g. mupirocin.
Ampicillin/amoxicillin
Intravenous or oral preparations: Use amoxicillin.
Organisms sensitive to ampicillin are sensitive to amoxicillin
If oral combination with flucloxacillin is required: Use co-fluampicil.
Penicillin allergy and cephalosporins

Ten per cent of patients who are allergic to penicillin will also be allergic to cephalosporins. If the allergic reaction to
penicillin is minor e.g. rash, cephalosporins can be given. If the allergic reaction is serious e.g. anaphylaxis,
cephalosporins, imipenem, meropenem must be avoided. Note that Tazocin is penicillin based
Clarithromycin/Erythromycin (macrolide antibiotics)

Oral clarithromycin must ONLY be used for the treatment of Helicobacter pylori. Intravenous clarithromycin should be
used in placed of intravenous erythromycin e.g. for severe chest infections. As soon as the patient is well enough,
treatment should be changed to oral erythromycin (NOT oral clarithromycin).
Patients must NOT be treated with erythromycin AND clarithromycin together. If the laboratory reports an organism
as erythromycin sensitive, intravenous clarithromycin will also be effective.
Paediatric doses
Please see Medicines for Children (RCPCH Publications) or Paediatric BNF, available on children’s wards & in AED.
6
Intravenous additive service

Wherever possible, use iv antibiotics which have been prepared by the Pharmacy Department.
Drugs currently being prepared for certain wards are listed below:
DRUG FORM
(syringe/bag) Volume
Amphotericin infusion Glucose bag 500ml
Benzylpenicillin 600mg, SYRINGE 5 ml
Benzylpenicillin 1.2g, SYRINGE 10ml, 15
1.8g, 2.4g ml, 20ml
Cefotaxime 500mg 1g, SYRINGE 5ml 10 ml
2g
Ceftazidime 1g, 2g SYRINGE 10ml
Cefuroxime 750mg, SYRINGE 10ml, 20ml

1.5g
Cefuroxime 750mg plus Bag 100 ml
metronidazole 500mg
Cefuroxime 1.5g plus Bag 100 ml
metronidazole 500mg
Clarithromycin 250mg, Saline Bag 260ml
500mg
Flucloxacillin 500mg, 1g SYRINGE 5ml 10ml
Tazocin 2.25g, 4.5g Saline Bag 100ml
infusion
Vancomycin up to 1g Saline Bag 250ml
Vancomycin over 1g Saline Bag 500ml
For any drugs not listed in the above table please check with Pharmacy. If
you require any of the above drugs to be prepared for a patient on your
ward please inform Pharmacy staff when they visit in the morning or
telephone extension 1514 or 1749
7
ANTIBIOTIC ASSAYS
Gentamicin
Once daily gentamicin
Do NOT use once daily gentamicin for the treatment of patients with endocarditis (use the traditional regime instead,
see below).
If the patient is in severe renal failure, consider the use of alternative antibiotics e.g. cefuroxime
DOSE: 5mg/kg given as single daily dose in 100ml normal saline or glucose 5% over 20 minutes
Patients with severe burns: 7mg/kg as single daily dose.
For extremely obese patients: use estimate of ideal body weight.
Patients on dialysis or high dose frusemide (250mg or more): 2.5mg/Kg/day, not exceeding 200mg/day
LEVELS: Take 5-10 mls clotted blood 18-24 hours after the first dose. State dose on request form.
SECOND DOSE may be given without waiting for the level result, providing the patient has normal renal function.
DOSE ADJUSTMENT:
gentamicin level <1 mg/l:
keep on same daily dose of gentamicin.
gentamicin level 1-2 mg/l:
give half the daily dose of gentamicin.
gentamicin level >2mg/l:
stop gentamicin, take another level the next day and do not give any more doses until the level is <1mg/l.
(Contact Microbiology for advice on what dose to re-start).
REPEAT LEVELS
Levels should be repeated 2-3 times a week while the patient is on gentamicin.
For patients with endocarditis
Dose: Normal renal function:

Streptococcal endocarditis: 80mg iv 12 hourly
Staphylococcal endocarditis: 120mg iv 8 hourly
Renal failure: Please contact pharmacy for advice - Ext. 1565 or Bleep 1256
Check levels 48 hours after starting gentamicin
Pre-dose – immediately prior to dose
(5-10 mls clotted blood)
Post-dose – 1 hour after iv or im dose
8
ANTIBIOTIC ASSAYS (continued)

Send both specimens with one blue form to microbiology (before 4.00 pm)
Therapeutic range
Pre <2mg/l
Post 5-10mg/L (staphylococcal endocarditis)
Post 3-5mg/L (streptococcal endocarditis)
Subsequent assays 2-3 times a weeks according to levels.
Please note
Other aminoglycosides e.g. amikacin, streptomycin, tobramycin, netilmicin should be used only after consulting the
microbiologist
Vancomycin
Dose
If normal renal function and over 60Kg body weight: 1g 12 hourly (100 minute infusion)
Other patients: Please contact pharmacy for advice: Ext. 1565 or bleep 1256.
Check levels after 48 hours.

Pre-dose - immediately prior to infusion
Post-dose - 1 hour after end of infusion
Therapeutic range: Pre < 10 mg/L

Post 20-40 mg/L
Subsequent assays 2-3 times a week, according to levels.

9
RESERVED ANTIMICROBIALS
The following antimicrobials are not recommended for routine use other than as described in this policy. They should
be prescribed only after consultation with the microbiologist or Consultant in charge of the patient. These antibiotics
may be used if the sensitivity is reported on the microbiology report and the patient requires treatment.
AMIKACIN
AZITHROMYCIN
CO-AMOXICLAV (AUGMENTIN)
CEFIXIME
CEFOTAXIME (exception for meningitis)
CEFPODOXIME
CEFTAZIDIME
CHLORAMPHENICOL (exception: eye ointment/drops)
ORAL CLARITHROMYCIN (exception H. pylori)
CIPROFLOXACIN
IMIPENEM/CILASTATIN
LINEZOLID
LIPOSOMAL AMPHOTERICIN
MEROPENEM
MOXIFLOXACIN (Respiratory consultant use only)
NETILMICIN
NORFLOXACIN
OFLOXACIN (exception: PID)
QUINUPRISTIN/DALFOPRISTIN (SYNERCID)
STREPTOMYCIN
TAZOCIN
TEICOPLANIN
TELITHROMYCIN
TINIDAZOLE (use metronidazole instead)
TOBRAMYCIN
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ANTIBIOTIC ANAPHYLAXIS AND ANAPHYLACTOID REACTIONS
These reactions are clinically indistinguishable and will be considered as one. Antibiotics are associated with
anaphylaxis, this can be a life threatening event. Parental administration and atopic status are more frequently
associated with clinically significant events. Rapid intravenous administration is the most likely to produce such a
reaction.
Before Drug Administration
Enquire about previous allergy. There is limited (10%) cross sensitivity between penicillins and cephalosporins. Do
not ignore what the patient says.
Diagnosis and Management of Anaphylaxis
These should occur simultaneously. The major differential diagnosis of collapse and dyspnoea in the context of drug
administration are vaso-vagal faint, hysterical hyperventilation and anaphylaxis. Co-incidental pulmonary embolism
or infarction can of course occur at the time of drug administration and may merit consideration in the diagnosis.
The patient usually complains of itching, dyspnoea, is apprehensive and then collapses.
Typical effects are:

CNS: Apprehension and agitation, loss of consciousness due to cvs effects.
Cardiovascular: Hypotensive, weak rapid thready pulse, tachycardia, peripheral cyanosis and collapse.
Airway: Bronchospasm, tachypnoea and dyspnoea, laryngeal oedema.
Other: Itching, flushing, facial and dermal oedema, mottling of the skin.
Pathophysiology
Histamine release and/or complement activation causes vasodilatation and increased capillary permeability. This
produces a functional hypovolaemia and cardiovascular collapse. The oedema, if in the upper airway, may lead to the
stridor. Histamine produces the bronchospasm and itching.
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ANAPHYLAXIS (continued)
Treatment
Stop drug administration, remember that agents such as gelatin solutions (Haemacel, Gelofusin) can cause allergic
reactions as well as blood, dextrans, Vitamin K and other agents. Place the patient supine and administer oxygen,
obtain venous access if not already secured.
Adrenaline is the drug of choice
The route is of secondary importance.

Adult dosage 0.5mg – 1.0mg subcutaneously or Intramuscularly at 10 to 20 minute intervals. Remember the normal
presentation of adrenaline is 1 ml of 1:1000 i.e. 1 mg/ml.
Children’s doses:
12 – 18y: 500 micrograms (0.5ml) im or
250 micrograms if child is small or prepubertal
6 - 12y: 250 micrograms (0.25ml) im
6m – 6y: 120 micrograms (0.12ml) im
< 6 m: 50 micrograms (0.05ml) im.
It treatment is delayed or the reaction severe then intravenous adrenaline is appropriate. Dilute 1ml of 1:1000 into
500 mls of saline and give at 1-5 mls/min. There is a risk of supraventricular tachycardia or even ventricular
tachycardia and fibrillation.
Adjunctive treatment consists of fluid (Hartmann’s or saline) to correct for the extravasation and resulting
hypovolaemia Antihistamines and corticosteroids are of some use but remain secondary to adrenaline in the
treatment of anaphylaxis. Severe episodes should involve adequately experienced personnel of registrar grade or
above.
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Arthritis (septic)
Specimens: Joint aspirate

Blood cultures
Urethra, cervix, pharynx & rectum if gonococcal infection suspected.
Staphylococcus aureus is the most common isolate.
Initial therapy (depending on gram film of aspirate)
Staphylococci : Not penicillin allergic

(G+ coccus) Flucloxacillin 1g iv 6 hourly
and
Fusidic acid 500mg oral 8 hourly
Penicillin allergic
Cefuroxime 1.5g iv 8 hourly
and
MRSA
Vancomycin 1g iv 12 hourly
and
Gonococci: Cefotaxime 1g iv 8 hourly

(G- coccus) followed by
Ciprofloxacin 500mg orally 12 hourly
If organism is sensitive
Haemophilus: Cefuroxime
(affects children) Please see “Medicines for Children” or Paediatric BNF for Paediatric doses.
(G- coccobacillus)
Coliform Cefuroxime
(G- bacillus) 1.5g iv 8 hourly
No organism Child
Flucloxacillin and
Cefuroxime
Please see “Medicines for Children” or Paediatric BNF for Paediatric doses.
Healthy adult
As for staphylococcal
13
Arthritis (septic) (continued)
Please note:
Review treatment with culture results
Injection of antibiotics into the joint is not usually necessary, may cause chemical synovitis and should only be
performed on the advice of a consultant.
Erythromycin and clarithromycin do not cross into synovial fluid in adequate amounts and should not be used.
Duration of treatment
These are broad guidelines only. More prolonged therapy will be required when treatment has been delayed for more
than a week after the onset of symptoms or if the patient is immunocompromised or when signs of joint inflammation
have been slow to abate. Intravenous treatment should be given for at least 7-10 days (until inflammatory signs
have substantially diminished). The total course of antibiotics (intravenous plus oral) is shown below.
Staphylococci/Coliform: 6 weeks
Haemophilus/Streptococci: 2-3 weeks
Gonococci: arthritis-dermatitis syndrome:

2 days intravenous cefotaxime followed by 5-7 days oral ciprofloxacin
gonococcal septic arthritis:
3 weeks
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Candidiasis
Angular cheilitis: Topical clotrimazole cream
Oral: Amphotericin B lozenges 6 hourly to be dissolved slowly in the

mouth
or
Nystatin oral suspension 1ml 6hourly
Oral lesions not responding to the above:

Fluconazole 50mg oral daily for 7-14 days
Oesophageal:
Fluconazole 50mg oral daily for 14 days.
Deep lesions not responding to oral therapy may require parenteral amphotericin or fluconazole.
Intestinal:
Amphotericin 1-2 tablets (100mg) 6 hourly
or 1-2ml suspension (100mg/ml) 6 hourly.
Nystatin 1 tablet (500,000 units) or 5 mls suspension 6 hourly.
Vaginal: Clotrimazole 200mg vaginal tablets inserted each night for 3 nights.
or
Clotrimazole 500mg vaginal tablets inserted at night as a single dose.
Vaginal candidiasis not responding to above:

Fluconazole 150mg orally single dose
Skin: Clotrimazole cream applied 2-3 times daily for 14 days.

or
Nystatin cream applied 2-3 times daily until 7 days after lesions have healed.
Systemic candidiasis:
Consult Microbiologist for advice.
Perineal candidiasis in infants:

Oral nystatin or oral miconazole gel and
local nystatin cream applied after each nappy change.
15
Cholecystitis/Cholangitis
Specimen: Blood cultures
Initial therapy: Cefuroxime 750mg-1.5g iv 8 hourly

and
Metronidazole* 500mg iv 8 hourly
Then if clinical condition permits (after 1-3 days iv antibiotics):

Cefuroxime 500mg orally 12 hourly
and
Metronidazole* 400mg oral 8 hourly
or
Antibiotics according to blood culture isolate sensitivities
* see page 4 for prescribing information.
Conjunctivitis (in adults/children)

For neonatal conjunctivitis see page 47
Specimen: Eye swab
Antibiotic:
Chloramphenicol eye ointment applied 3-4 times daily
or
Chloramphenicol eye drops applied every 2-3 hours.
N.B. A combination of eye drops during the day and eye ointment at night can be used. This
avoids the blurred vision caused by ointment during the day and the need to disturb sleep while
applying drops throughout the night.
16
Ear infections
Acute otitis media
Pain relief
Wait and see (80% resolve spontaneously without antibiotics)
Amoxicillin
or Erythromycin
or Cefaclor
Otitis externa
Furunculosis
Pain relief e.g. paracetamol and local heat
If severe: flucloxacillin/erythromycin
Diffuse otitis externa
Keep ears dry. Do not pick.
Pain relief if required.
Avoid antibiotics wherever possible.
Aluminium acetate drops or 2% acetic acid
(e.g. EarCalm spray) may be helpful
Steroid preparations may be helpful in reducing itchiness and inflammation.
Malignant otitis externa

Ceftazidime 1-2g iv 8 hourly
17
Endocarditis
Always inform the Microbiology Department if endocarditis is suspected. Take 3 sets of blood cultures at intervals of
15 minutes or more.
Await culture results if possible.
If patient is ill start blind therapy. For patients with recent skin sepsis/iv drug abuse follow regime B.
For all other patients follow regime A.
A. Streptococci account for 70% of cases:
Benzylpenicillin 2MU (1.2g) iv 4 hourly

and
Gentamicin 80mg iv 12 hourly (for synergy)
Penicillin allergic patients:
Vancomycin 1g iv 12 hourly*
and
Gentamicin 80 mg iv 12 hourly
B. Staphylococci cause endocarditis in drug

abusers or following skin sepsis.
Flucloxacillin 2g iv 4 hourly
and
Gentamicin 80-120mg iv 8 hourly
Penicillin allergic patients:
Vancomycin 1g iv 12 hourly*
and
Gentamicin 80-120 mg iv 8 hourly
These are only initial guidelines. Treatment and duration of treatment will need to be reviewed according to species of
organism isolated, MIC of organism, patient risk factors, patient response and drug assays.
*This dose is appropriate for patients over 60kg with normal renal function.
Other patients: Please contact pharmacy for advice: Ext. 1565 or bleep 1256.
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Genital Tract Infections

Vaginal candidiasis:
Clotrimazole 200mg vaginal pessaries inserted each night for 3 nights.
or
Clotrimazole 500mg vaginal pessary inserted at night as a single dose.
Trichomonas vaginalis:
Metronidazole 400mg orally 12 hourly for 5-7 days
or
Metronidazole 2g oral as single dose (avoid high dose regimes in pregnancy)
Sexual partner must be referred for treatment.
Bacterial vaginosis:
Metronidazole 400mg oral 12 hourly for 7 days
or Metronidazole 2g oral single dose
Sexually transmitted diseases e.g. gonorrhoea, Chlamydia:

Consult a Venereologist for advice, diagnosis, treatment and contact tracing,
Chlamydia:
Uncomplicated
Doxycycline 100mg oral 12 hourly for 7 days (not in pregnancy or children under 12 years or breast feeding
women).
Uncomplicated but risk of pregnancy

Erythromycin 500mg oral 6 hourly for 7 days.
Upper genital infection (female, PID)

Ofloxacin 400mg oral 12 hourly
And
Metronidazole 400mg 12 hourly
For 14 days
(Doxycycline 100mg oral 12 hourly can be given instead of ofloxacin if patient is not pregnant)
Upper genital infection (male)

Doxycycline 100mg oral 12 hourly for 14 days
or
Ciprofloxacin 500mg oral 12 hourly for 14 days
Swab and treat sexual partner(s).
Balanitis:
Usually due to Candida species
Take swab
Clotrimazole cream
19
Genital Tract Infections (continued)

Epididymo-orchitis:
Send first void urine for C&S stating which antibiotic is to be started.
If STD is suspected also send urethral swab for gonococcal culture and first void urine for Chlamydia PCR.
Refer to genitourinary medicine clinic for diagnosis, treatment and contact tracing.
<35y N gonorrhoeae
C trachomatis
Doxycycline 100mg oral 12 hourly
for 14 days
or Ciprofloxacin 500mg oral 12 hourly for 14 days
Sexual partners must also be treated (see above)
>35y Enterobacteriaceae
Pseudomonas
Ciprofloxacin 500mg orally 12 hourly for 2-4 weeks
If patient is to be admitted give:
Gentamicin 5mg/kg iv once daily
or Cefuroxime 750mg-1.5g iv 8 hourly
Acute prostatitis:
Send first void urine (and urethral swab for gonococcal culture and first void urine for Chlamydia PCR
if indicated) and treat as for epididymo-orchitis.
20
Pelvic Inflammatory Disease

Aetiology: Chlamydia
Neisseria gonorrhoeae
Anaerobes
Enterobacteriaceae
Streptococci
Mycoplasma
Specimens: Cervical swabs for gonococci (plain transport medium)

Urethral and cervical swabs in Chlamydia transport medium
Culdocentesis fluid if available
Blood cultures if systemic illness
Syphilis serology
Antibiotics:
Oral regime: Ofloxacin 400mg oral 12 hourly
and
Metronidazole 400mg oral 12 hourly
Duration: 14 days
Ill patient: Cefuroxime 750mg -1.5g iv 8 hourly

and
Metronidazole 500mg iv 8 hourly
and
for 2-4 days followed by:
and
Total duration: 14 days
21
Gastro-intestinal Infection
a. Campylobacter:
Most Campylobacter infections are self-limiting and antimicrobials are usually not required.
If diarrhoea is very severe, very bloody or patient is febrile give erythromycin:
500mg orally 6 hourly for 5 days
b. Salmonella:
Most Salmonella infections are self-limiting and antimicrobials are usually not required.
Consult Microbiologist for advice.
c. Pseudomembranous colitis (C. difficile)

Most cases:
Metronidazole 400mg orally 8 hourly for 7 days
(Cost £0.87)
Failure to respond to metronidazole:

Vancomycin 125mg orally 6 hourly for 7 days
(Cost £66.23)
N.B. If patient is only able to take intravenous antibiotics, use metronidazole NOT vancomycin.
d. Giardiasis
Adult/child >10yr: Metronidazole 2 g orally daily for 3 days
or
Metronidazole 400mg orally 8 hourly for 5 days
e. Amoebiasis
Metronidazole 800mg orally 8 hourly for 5 days followed by diloxanide furoate 500mg 8 hourly for 10 days
to eradicate cysts.
22
Gastro-intestinal Infection (continued)

f. Typhoid fever – Consult Microbiologist
g. Threadworm (Enterobius vermicularis)

Over 2 years of age
Mebendazole 100mg single dose orally
1-2 years of age
Piperazine (Pripsen powder)
1 level 5 ml spoonful in small glass of milk/water
given in the morning
3 months – 1 year
Piperazine (Pripsen powder)
1 level 2.5 ml spoonful in small glass of milk/water
given in the morning
Repeat dose at 2 weeks

Treat entire family (refer to GP)
Pregnant women should not be treated until post partum.
BARRIER NURSING OF ALL PATIENTS ADMITTED WITH DIARRHOEA IS ESSENTIAL
Helicobacter pylori
If treatment is indicated use triple therapy for 7 days (Cost £38.13)
Heliclear i.e.:
Lansoprazole 30mg orally 12 hourly
AND
Amoxicillin 1g orally 12 hourly
AND
Clarithromycin 500mg orally 12 hourly
If patient is allergic to amoxicillin substitute

metronidazole 400mg orally 12 hourly i.e. Helimet (Cost 36.66)
23
Intra-Abdominal Sepsis
Specimens: Pus (in CSF container)
Peritoneal swab
Blood cultures
Peritonitis: Cefuroxime 750mg-1.5kg iv 8 hourly

And
*Metronidazole 500mg iv 8 hourly
Primary peritonitis (spontaneous bacterial peritonitis)
Organisms: Coliform species (56%)

Pneumococci (15%)
Specimens: Peritoneal fluid

Blood cultures
Antibiotic: Cefuroxime 750mg-1.5g iv 8 hourly
Intra-abdominal abscess:
Surgical drainage is essential
Antibiotic treatment as for peritonitis
Review treatment with culture and sensitivity results
24
Intra-Abdominal Sepsis (continued)

Liver abscess:
Drainage
Antibiotics according to sensitivity or empirical treatment:
Cefuroxime 1.5g iv 8 hourly

and
Continue antibiotics according to sensitivity for:

1-2 months (solitary abscess)
4 months (multiple abscesses)
(Long courses required to prevent relapse)
Acute pancreatitis:
Severe cases e.g. organ failure, pancreatic necrosis,
CRP >150 at 48 hours, obesity (BMI >30):
Cefuroxime 750mg-1.5g iv 8 hourly

and
* see note page 4

25
Meningitis
A. MENINGITIS
Specimens: CSF
Blood cultures
EDTA blood for meningococcal PCR
Nasopharyngeal swab
If viral aetiology is suspected send: throat swab in viral transport medium, clotted blood for
serology (with virology form).
BARRIER NURSE ALL CASES OF MENINGITIS INITIALLY SEE PAGE 60-62 FOR PROPHYLAXIS FOR
CONTACTS (Meningococcal and Hib meningitis)
ADULT PATIENT
Unknown organism (adult patient)
Cefotaxime 2g 6 hourly iv
Meningococcal (Gram negative coccus)
Benzylpenicillin 2.4g iv 4 hourly
or
Cefotaxime 2g iv 6 hourly if penicillin allergic (rash)
or
Chloramphenicol 1g iv 6 hourly if penicillin allergic (anaphylaxis)
Duration 5-10 days (iv for at least 5 days)
Pneumococcus (Gram positive diplococcus)
Cefotaxime 2g 6 hourly iv
Duration 10-14 days
Haemophilus influenzae (Gram negative bacillus)
Cefotaxime 2g iv 6 hourly
or
Chloramphenicol 1g iv 6 hourly (if penicillin allergic: anaphylaxis)
Duration 10-14 days
Listeria monocytogenes (Gram positive bacillus)
Amoxicillin 2g iv 4 hourly
and
Penicillin allergy:
Cotrimoxazole 1.44g iv 12 hourly
Duration 3 weeks
NB. The combination of penicillin/cephalosporins with chloramphenicol may be antagonistic.

26
Meningitis (continued)
PAEDIATRIC PATIENT (Blind therapy)
Neonates: Benzylpenicillin
And
Cefotaxime
Amoxicillin should be substituted for penicillin if Listeria is suspected in neonates.
Very young babies (1-5months)

Amoxicillin
and
Cefotaxime
Older babies and children:

Cefotaxime
Ceftriaxone should be reserved for Hospital at Home patients only.
NB Hib meningitis
Cases of Hib disease under 4 years should be given Hib vaccine as well as rifampicin to eradicate carriage before
discharge from hospital. Hib disease occasionally fails to generate immunity, especially in the very young.
B. BRAIN ABSCESS
Arrange an urgent CT scan by Radiology Department.
Contact on call Neurosurgeon at Walton Hospital. Tel: 525 3611
27
MRSA infections
Infection Severe case Mild case

UTI Gentamicin or Trimethoprim
Vancomycin
Wound infection Vancomycin (with Tetracycline or
rifampicin or fusidic acid if Trimethoprim
necessary)
Chest infection Linezolid alone or Tetracycline or
vancomycin with Trimethoprim
rifampicin/fusidic acid
Line infection Vancomycin Trimethoprim or
Tetracycline
Bacteraemia Vancomycin, switching to
oral trimethoprim or
tetracycline when
improving
Endocarditis Vancomycin for 4 weeks
with
gentamicin for the first
week
Osteomyelitis Vancomycin and either
rifampicin or fusidic acid
Septic arthritis Vancomycin and either
fusidic acid or rifampicin
Infected joint prosthesis Vancomycin and either
rifampicin or fusidic acid
Notes
Vancomycin must be given intravenously (oral vancomycin is not absorbed).
Rifampicin and fusidic acid should be given orally.
Vancomycin and gentamicin levels must be monitored.
These recommendations are empirical and will cover most of our MRSA strains. However sometimes more resistant
strains may occur and treatment may need to be adjusted according to sensitivity.
Our strains of MRSA are always resistant to penicillin, flucloxacillin, all cephalosporins, erythromycin, clarithromycin.
For MRSA eradication therapy, please refer to Infection Control Manual, Chapter 14.
28
Osteomyelitis
Specimens: Blood cultures
Bone/pus/aspirate/wound swab if available
Clotted blood for anti-staphylolysin titre if the above specimens are unhelpful
ACUTE
Neonates: Flucloxacillin
and
Cefuroxime
Duration: 3 weeks (minimum)
Child: Flucloxacillin
Duration: 2 weeks iv followed by 2-4 weeks oral antibiotics
Adult: Flucloxacillin 1-2g iv 6 hourly
and
Duration: 4-6 weeks
Adult: Clindamycin 600mg iv 6 hourly
(Penicillin allergy) Duration: 4-6 weeks
Adult: Vancomycin 1g iv 12 hourly

(Known MRSA) and
Rifampicin 600mg oral daily
Therapy may need to be changed when results of culture and sensitivity are available.
CHRONIC
It is critical to have good specimens for culture.
Await culture and sensitivity results before starting therapy. Parenteral antibiotics should be given for at least 3
weeks otherwise the relapse rate is 20%.
Prolonged courses of oral antibiotics may than be required (at least 12 weeks in total).
Diabetic foot osteomyelitis:

Osteomyelitis
NB Ability to inset probe to bone suggests
concomitant osteomyelitis.
For severe cases/severe ischaemia use:
Flucloxacillin 1-2g iv 6 hourly and
or
Clindamycin 600mg iv 6 hourly
Duration: 12 weeks (changing iv to oral treatment after 3 weeks)
In milder cases, or where blood supply is less compromised, oral treatment throughout may be effective.
Contact Consultant Diabetician if advice is required.
29
Infected joint prosthesis
Attempted salvage of a prosthesis may prove possible in the event of short-term clinical manifestation of infection.
Attempts to salvage a stable prosthetic implant under such circumstances may involve:
Aggressive surgical debridement/drainage of collection of pus
Antibiotics according to sensitivity
Intravenously for 2 weeks
Then orally for 3-6 months
Use a combination of antibiotics e.g. flucloxacillin and rifampicin
For 2-stage revision:

Stage 1: Removal of infected implant.
Insert antimicrobial spacer e.g. gentamicin plus additional appropriate antibiotic
and/or drainage-irrigation systems (with or without appropriate antibiotic).
Antibiotic combination for 6 weeks according to sensitivity
e.g. flucloxacillin and rifampicin, vancomycin and rifampicin.
Stage 2: Implant new prosthesis if infection cleared.

30
Upper Respiratory Tract Infection

Croup:
Antibiotics are not used in mild cases
Severe cases – use iv cefuroxime 200mg/kg/day in 3 divided doses for 5 days.
Ear infections – see page 16
Epiglottitis:
Beware trying to examine pharynx or taking throat swabs as respiratory obstruction may occur. (See
Paediatric protocol for epiglottitis).
Cefuroxime
Adult:1.5g iv 8 hourly
or
Chloramphenicol
Adult:1g iv 6 hourly.
Epiglottitis usually occurs in young children – but rarely may occur in adults.
Sinusitis (acute):
Many cases resolve spontaneously
If severe/persistent:
Amoxicillin 500mg orally 8 hourly

or Erythromycin 500 mg orally 6 hourly
Duration: 3 days
Tonsillitis (Streptococcal):
Penicillin V 500mg orally 6 hourly for 10 days
or Erythromycin 500mg orally 6 hourly for 10 days
NB Most throat infections are caused by viruses.

Await culture results of throat swabs if possible. Start treatment immediately after throat swab if patient is
ill or has rheumatic heart disease.
Avoid amoxicillin if possibility of glandular fever (EBV).
31
Lower Respiratory Tract Infections

NB Quinolones e.g. ciprofloxacin should only be used when patient is known to be infected with Pseudomonas.
This group of antibiotics has poor activity against pneumococci (the most common respiratory pathogen).
Exacerbation of COPD (Chronic Obstructive

Pulmonary Disease)
Obtain sputum for culture
Amoxicillin 500mg 8 hourly orally
or Erythromycin 500mg 6 hourly oral for 7 days
or Amoxicillin 500mg 8 hourly iv
or Clarithromycin 250-500mg iv 12 hourly
or Co-amoxiclav should be considered in patients with more
severe disease who have been recently treated with amoxicillin
and erythromycin
Pneumonia
1. Before antibiotic therapy obtain

a. Blood cultures
b. Sputum
c. 5mls clotted blood for serology (PHLS form)
Ill patients must receive the dose of antibiotics as quickly as possible.
2. The following features indicate increased risk of death:
Clinical features Laboratory features
Age >60 years Hypoxaemia p02<8kPa (60mmHg)

Underlying disease Leucopenia WBC<4,000x109/L
Confusion Leucocytosis WBC>20,000x109L
Respiratory rate>30/min Raised serum urea >7mmol/L
Diastolic BP, 60 mmHg Hypoalbuminaemia (albumin <30)
Atrial fibrillation Bacteraemia
Multilobar involvement Staphylococcal infection
3. Initial therapy: intravenous

4. Therapy may be changed where necessary with the results of culture and sensitivity tests.
5. Duration of therapy 7-10 days but 2-3 weeks may be necessary for patients with staphylococcal or gram
negative enteric pneumonia.
32
Lower Respiratory Tract Infection (continued)

Pneumonia
Most patients: Amoxicillin 1g iv 8 hourly

OR
Clarithromycin 500mg iv 12 hourly
(Use clarithromycin if atypical pneumonia)
Ill patient: Clarithromycin 500mg iv 12 hourly

AND
Ill, penicillin Clarithromycin 500mg iv 12 hourly

allergic patient AND
Cefuroxime 750 mg iv 8 hourly
Post influenza (Staph aureus pneumonia suspected):

AND
Flucloxacillin 2g stat then 1g iv 6 hourly
Aspiration pneumonia:
AND
Patient known to be colonised with Pseudomonas e.g. bronchiectasis

If ill: Ceftazidime 1g iv 8 hourly
*see note p 4
33

Atypical pneumonia (known pathogen)
Pneumocystis: Immunocompromised patients e.g. AIDS/chemotherapy:

Treatment
Cotrimoxazole (high dose) :
120mg/kg/day given in 4 divided doses for at least 3 weeks.
Give folinic acid 15mg 2-3 times per week while on this dose.
Prophylaxis: Cotrimoxazole 960mg orally once daily.

Diagnosis: Induced sputum or BAL fluid
Not ordinary sputum.
No serological test.
Adjunctive corticosteroid therapy can be life-saving in severe cases.
Legionella:
Clarithromycin 500mg iv 12 hourly.
Consider adding rifampicin 600mg/day if
patient is seriously ill or fails to respond.
Switch to oral erythromycin when response to treatment
Duration:
10 – 14 days (immunocompetent)
14 – 21 days (immunocompromised)
Diagnosis:
Urine for Legionella Ag (rapid test)
Blood for serology (acute and convalescent)
Mycoplasma:
Clarithromycin 500mg iv 12 hourly if ill
or Erythromycin 500mg oral 6 hourly if clinical condition permits.
Duration: 10-14 days
Chlamydia psittaci (psittacosis)/Chlamydia pneumoniae:

Tetracycline 500mg orally 6 hourly
or
Duration: 14-21 days
34

Lung abscess
Clindamycin 600mg iv or 300mg orally 6-8 hourly

Duration: 4-6 weeks (until CXR resolution)
Drainage if unrelenting sepsis.
Lower respiratory tract infections in children

Children 0-2 y:
If well enough to have oral antibiotics:
oral amoxicillin
If unwell enough to need iv antibiotics:

iv cefuroxime
Children 2-16 y
Lobar pneumonia
Benzylpenicillin iv:
Diffuse changes
Amoxicillin iv
or Cefaclor oral
or Clarithromycin iv
or Erythromycin oral
In severe pneumonia consider iv cefuroxime
Whooping cough:
Treatment: Erythromycin orally for 7 days
Prophylaxis: Household contacts where there are vulnerable children
(e.g. unimmunised children, newborn, chronic illness, immunocompromised)
may be given erythromycin 50mg/kg (max 2g) daily divided into 4 doses.
This must be given within 21 days of onset of the primary case.
Duration: 7 days
35
Septicaemia
Specimens: Blood cultures essential
Other specimens depending on suspected source of septicaemia e.g. urine, sputum, faeces,
CSF, pus etc.
All antibiotics must be given intravenously initially:
A. Septicaemia of unknown origin (adults)

and
and
B. Septicaemia from likely source (adults)

a. Urinary tract – see page 41.
b. Pneumonia – see page 31-34.
c. Infected intravenous line/infected thrombophlebitis
Remove line and send tip for culture.
Removal is more effective than antibiotics.
If ill: Flucloxacillin 1g iv 6 hourly
and
If well: Flucloxacillin 500mg oral 6 hourly
d. Cellulitis – see page 36.
e. Biliary tract – see page 15.
C. Special patient groups

a. Neutropenic patient: see page 48.
b. Neonate: see page 45.
c. Burns patient: see page 42.
d. Babies & Children (other than neonates)
Penicillin
and
Cefuroxime.
If there is a high chance of staphylococcal infection add flucloxacillin.
* See note page 4

36
Skin and Soft Tissue Infections

Always take a swab of lesion
Cellulitis/Erysipelas
Benzylpenicillin 1.2g iv 6 hourly
and
Flucloxacillin 500mg iv 6 hourly
If penicillin allergic:
Duration 1-2 weeks
Leg ulcers and pressure sores

Avoid antibiotics
Use local cleansing and topical antiseptics if required.
If cellulitis/fever treat according to laboratory reports.
Impetigo (Streptococcal or Staphylococcal)

Mupirocin topically 3 times a day for 7-10 days
If widespread:
Flucloxacillin orally for 7-10 days
or Erythromycin orally for 7-10 days if penicillin allergic
Animal bites
Topical cleansing, irrigation and debridement as indicated
Antibiotics:
If infected: co-amoxiclav 375mg 8 hourly for 5 days
If not infected and presenting within 24 hours of injury

give antibiotics as for infected bites ONLY IF high risk of infection i.e.
Deep, puncture-type bite that cannot be cleaned easily (e.g. cat bite)
Suspicion of bone or joint involvement
Severe bites to hands/face
Asplenic patient
Is tetanus immunisation up-to-date?
Is anti-rabies prophylaxis required?
Consult Microbiologist if advice is required
Human bites
Antibiotics (for all patients)
Co-amoxiclav 375mg 8 hourly for 5 days
Is Hepatitis B immunoglobulin/vaccine required?
37
Skin and Soft Tissue Infections (continued)

Diabetic foot ulcers
Cleaning and topical antiseptics e.g. honey and cod liver oil gauze (for clean superficial ulcers).
Sugar paste should be used ONLY if debridement of a sloughy ulcer is required.
If antibiotics are required:
Small ulcers, no osteomyelitis

Usually staphylococci/streptococci
Flucloxacillin 500mg oral 6 hourly and
Amoxicillin 500mg oral 8 hourly for 2 weeks
Use co-fluampicil if compliance is a problem
or Clindamycin 150-300mg oral 6 hourly for

2 weeks
Chronic, recurrent, limb threatening ulcers

Usually polymicrobial.
Avoidance of weight bearing
Flucloxacillin 500mg 6 hourly and

Amoxicillin 500mg 8 hourly and
*Metronidazole 400-500mg 8 hourly
Give intravenously initially if septic
Penicillin allergic patient

Clarithromycin iv 500mg 12 hourly
or erythromycin oral 500mg 6 hourly
and
metronidazole 400-500mg 8 hourly
or Cefuroxime 750mg iv 8 hourly and
Diabetic foot osteomyelitis

NB Ability to inset probe to bone suggests
concomitant osteomyelitis.
For severe cases/severe ischaemia use:
Flucloxacillin 1-2g iv 6 hourly
and Fusidic acid 500mg oral 8 hourly
or Clindamycin 600mg iv 6 hourly
Duration: 12 weeks (changing iv to oral
treatment after 3 weeks)
In milder cases, or where blood supply is less compromised,
oral treatment throughout may be effective.
Contact Consultant Diabetician if advice is required.
38

Necrotising fasciitis:
Early diagnosis can be difficult but marked systemic toxicity
out of proportion to the local findings should alert the clinician.
Surgery is the mainstay of treatment i.e. debridement of all infected/necrotic tissue.

Culture: Blood cultures
Tissue/aspirate from subcutaneous tissue
and
Gentamicin iv 5mg/Kg/day
and
*Metronidazole 500 mg iv 8 hourly
Clindamycin 1.2g iv 6 hourly should be considered as additional treatment in more aggressive cases.
*see note page 4

39
Dermatophyte infections
Refer patient to dermatologist if diagnosis is in doubt.
Scalp
Adults:
Terbinafine 250mg daily for 2-4 weeks
or
Itraconazole 100mg oral daily for 2-4 weeks
These products are not licensed for use in children.
Child:
Griseofulvin 10mg/kg body weight/day until no clinical or laboratory evidence of infection remains (can take
up to 3 months).
NB. If kerion (secondary bacterial infection) is present, treat concurrently with flucloxacillin or erythromycin for at least
the first 2 weeks.
Body and groin

Adult:
Localised: Topical terbinafine cream twice daily for 2-4 weeks
Widespread: Oral terbinafine 250mg/day for 2-4 weeks
Child:
Localised: Clotrimazole cream 1% 2-3 times daily for limited lesions until 2 weeks after lesions have
healed.
Widespread: Oral Griseofulvin 10mg/kg/day for 4 weeks.
Athletes foot
Keep feet dry. Wear cotton socks and non-synthetic footwear.
Topical tolnaftate is available over the counter.
Toe clefts only
Terbinafine cream 1% 2 times daily for 1-2 weeks.
Disease extending to sole and dorsum of foot
Terbinafine orally 250mg/day for 2 weeks (not for children)
Fungal nail infection

Terbinafine 250mg/day for 2-3 months (not for children)
Or
Griseofulvin 1g/day (10mg.kg/day) for 6-9 months (finger nail), 15-18 months (toe nail).
For severe nail infections 5% amorolfine nail lacquer can be applied once a week in combination with terbinafine as
above. This combination treatment can improve cure rate and reduce relapse.
Other Nail Infections

Scopulariopsis brevicaulis
This is one of the 10 most common fungal contaminants. It is omnipresent and rarely pathogenic but can cause nail
infections which usually respond to terbinafine or griseofulvin.
Rhodotorula sp.
This organism is widespread in the environment and can colonise moist skin. It can cause nail infections which
usually respond to topical clotrimazole.
Candida sp.
Topical clotrimazole 3 times daily
Keep hands dry
40
Toxic shock syndrome

TSS is often associated with tampon use, however, non-menstrual cases may occur after any staphylococcal
infection e.g. wound infections, post partum, burn infections. Wounds may not appear inflamed but may be colonised
with Staphylococcus aureus.
Case definition
Fever >38.9oC
Hypotension
Rash- diffuse macular erythroderma
Desquamation 1-2 weeks after onset
Multisystem involvement (3 or more of the following):
Gastro-intestinal: Vomiting/diarrhoea
Muscular: Severe myalgia or CPK x2 normal
Mucous membrane: Vaginal, oropharyngeal or conjunctival
hyperaemia
Renal: Urea/creatinine x 2 normal
or >10 WBC in urine
Hepatic: Total bilirubin, AST x 2 normal
Haematological: Platelets <100 x 109/l
CNS: Disorientation/altered consciousness
without focal neurology
Treatment
Supportive
Remove tampon (menstrual cases) and irrigate copiously (even non-inflamed wounds)
Clindamycin 900mg 8 hourly iv

or Flucloxacillin 1g 6 hourly iv
Take swabs prior to starting antibiotics e.g. HVS, wound swabs.
Menstrual cases
Recurrence is greatest within 3 months after attack.
Patient should be counselled to avoid tampon use for 6 months and to avoid high absorbency tampons unless
absolutely necessary.
41
Urinary Tract Infection

Cystitis
Oral therapy for 3 days (female patients)
Obtain urine specimen first
Male patients with UTI should be treated for 7 days
Trimethoprim
Adult/child over 12 years: 200mg oral 12 hourly
or Nitrofurantoin
If recent treatment with amoxicillin and/or trimethoprim:

Cefalexin
Pyelonephritis/Septicaemia
or
Adjust treatment when results of culture and sensitivity are available.

Duration: intravenous for 1-3 days followed by oral for a total of
12 days (pyelonephritis) or 5-7 days (septicaemia)
Catheter in situ
Most patients with catheters develop bacteruria.
Antibiotics are ONLY required if the patient is pyrexial or systemically ill. Then give:

or
Cefuroxime 750mg-1.5 iv 8 hourly
Duration: 5 days
Bladder washouts with antiseptics e.g. chlorhexidine are rarely indicated. They rarely eradicate organisms, may
introduce infection, select out multi-resistant organisms, can cause inflammation of the bladder wall and therefore
increase the likelihood of systemic invasion and they may also cause damage to the catheter. Saline bladder
washouts are available as an alternative.
Acute prostatitis/epididymo-orchitis: see page 19

42
Burns and plastics patients
BURNS PATIENTS
Prophylaxis during surgery e.g. escharectomy
Prophylaxis is NOT required for burns being excised within 24 hours.

If delayed referral or second excision give prophylaxis:
Non-life threatening burns:

1g flucloxacillin iv at induction
or 500mg clarithromycin iv at induction if penicillin allergic
Life threatening burns:

1g amoxicillin iv at induction
and 160mg gentamicin iv at induction
If patient is penicillin allergic give 500mg clarithromycin iv in place of amoxicillin.
Always check recent Bacteriology reports to ensure that the above regimes will cover the organisms colonising the
burn. Contact Microbiology if further sensitivities are required.
Treatment of infected burns
Give iv antibiotics to cover organisms infecting burn.

Blind treatment of severely infected burns patient (when no culture results available). Take specimens first e.g.
blood, sputum, urine, burns swabs etc.
Start Gentamicin 7mg/kg iv once daily
and
Flucloxacillin 1g iv 6 hourly
and
Review with culture results and patient response.

43
PLASTICS PATIENTS
PROPHYLAXIS
Prophylaxis for implants
Cefuroxime 1.5g iv at induction
Prophylaxis for head and neck surgery

Prophylaxis is needed only for major procedures involving oral/pharyngeal mucosa.
Uncontaminated head and neck surgery does not require prophylaxis.
Co-amoxiclav 1.2g iv at induction

or If penicillin allergic:
AND
Metronidazole 500mg iv at induction
Prophylaxis for surgery on infected sites
Be guided by recent culture results
Prophylaxis for hand surgery

Indications:
Elective
Antibiotics (see below) should be given for:
Implants/percutaneous K-wires/operations over 2 hours long
Emergency
Prophylaxis is not necessary for simple lacerations.
Prompt, meticulous wound management is crucial in all cases.
Antibiotics (see below) should be given for:
Implants/percutaneous K-wires/operations over 2 hours long
Dirty wounds
Clean wounds with more than 12 hour delay before surgery
Compound fractures
Choice of antibiotics for hand surgery:

Flucloxacillin 1g iv at induction (before tourniquet inflation)
If penicillin allergic or if patient has received oral flucloxacillin

for more than 48 hours while awaiting surgery use:
Clarithromycin 500mg iv at induction (before tourniquet inflation)
Repeat doses every 6 hours until surgery is completed.
If gross contamination e.g. soil, manure, raw meat/fish etc. also give
Metronidazole 500mg oral/iv on admission
44
PLASTIC PATIENTS (continued)

Prophylaxis for compound lower limb injuries

and
Metronidazole 500mg iv at induction
Prophylaxis for breast surgery
Only required for implants

Prophylaxis for leech therapy

To prevent Aeromonas wound infection:
Ciprofloxacin 500mg orally 12 hourly for duration of leech treatment.
TREATMENT
Animal bites
Antibiotics:
If infected: co-amoxiclav 375mg 8 hourly for 5 days
If not infected and presenting within 24 hours of injury

give antibiotics as for infected bites ONLY IF high risk of infection i.e.
Deep, puncture-type bite that cannot be cleaned easily (e.g. cat bite)
Suspicion of bone or joint involvement
Severe bites to hands/face
Asplenic patient
Is anti-rabies prophylaxis required?
Human bites
Antibiotics (for all patients)
Co-amoxiclav 375mg 8 hourly for 5 days
Is Hepatitis B immunoglobulin/vaccine required?
45
Neonates
A. Neonatal sepsis
Most common pathogens –

Group B streptococci
E. coli, Klebsiella, Enterobacter
(Listeria monocytogenes)
Specimens: Blood cultures

Urine
CSF
See Section B (below) if meningitis suspected
Antibiotics:
Penicillin
and
Cefuroxime
N.B. Amoxicillin should be substituted for penicillin if Listeria is suspected in neonates e.g. if
mother is febrile/unwell.
Discontinue antibiotics after 3 days if cultures and course do not support diagnosis of infection.
B. Neonatal meningitis
Benzylpenicillin
and
Cefotaxime:
Amoxicillin should be substituted for penicillin if Listeria is suspected in neonates:
C. Pneumonia
Culture: Blood
Respiratory secretions
Antibiotics: Penicillin or amoxicillin

and
Cefuroxime
D. Chlamydia pneumonia
Culture: Conjunctival swab or

Nasopharyngeal aspirate or
Throat swab
(In Chlamydia transport medium)
Antibiotic: Erythromycin 50mg/kg/day in 4 divided doses for 14-21 days.

Parents must be referred for culture, treatment and contact tracing.
46
Neonates (continued)
E. Diarrhoea
Barrier nurse
Send stool for culture (bacteriology and virology)
Treatment:
Rehydration
Antibiotics only required if invasive infection.
Consult Microbiologist for advice
F. Necrotising enterocolitis
Blood cultures
Stool for bacteriology and virology
Antibiotics:
Cefuroxime
and
Metronidazole
G. Urinary tract infection

Urine culture
Antibiotics:
Cefuroxime or gentamicin.
Adjust antibiotics according to
sensitivities
H Osteomyelitis/septic arthritis
Blood cultures
Needle aspiration of bone/joint
Antibiotics Flucloxacillin
and
Cefuroxime
intravenously for first 2 weeks
47
I Skin/soft tissue infections

Swab of lesion
e.g. staphylococcal scalded skin syndrome
Flucloxacillin
Fusidic acid may be added in very severe cases.
e.g. umbilical stump infection, circumcision wound infection
Penicillin
and
Cefuroxime
Adjust according to culture and sensitivity results
e.g. sticky cords
Dust with 1% chlorhexidine dusting powder
e.g. orbital cellulitis:

Cefuroxime alone
Metronidazole may also be required in some
cases.
J. Sticky eye
Neomycin eye ointment or eye drops.

Send swab for routine culture and for Chlamydia culture if indicated.
Chloramphenicol eye ointment or eye drops can be used but,

unlike neomycin, these will interfere with Chlamydia cultures if these are taken subsequently.
Chlamydia infected eyes (onset usually 3-10 days after delivery)

Oral erythromycin 50mg/kg/day divided into 4 doses for 14 days.
PLUS
Topical 0.3% ofloxacin eye drops
1-2 drops 2-4 hourly for the first 2 days and then
6 hourly for not more than 10 days.
(Chlortetracycline has been discontinued)
Parents must also be referred for culture, treatment and contact tracing.
In severe early conjunctivitis think of gonococcal infection (usually starts within 1-2 days after birth).
Send urgent eye swab and start:
Penicillin
or
Cefotaxime
Duration: 7 days
Prompt ophthalmic consultation should be obtained. The mother and her sexual partner must be referred
for culture, treatment and contact tracing.
48
Neutropenic Patients
Initial therapy
Gentamicin 5mg/kg/iv once daily
AND
Tazocin 4.5g iv 8 hourly
Metronidazole* 500mg iv 8 hourly if anaerobic infection is strongly suspected e.g. rectal abscess
*see note page 3
If penicillin allergy (but not anaphylaxis):

Gentamicin 5mg/kg/iv once daily
AND
If no clinical response after 48 hours (and culture results unhelpful)

AND
Vancomycin 1g iv 12 hourly (if normal renal function)
If no clinical response after a further 48 hours consider:

Changing ceftazidime to imipenem 1g iv 8 hourly and
Adding amphotericin B (Fungizone) to cover fungal infection (see next page)
49
Neutropenic Patients
Antifungal therapy in neutropenic patients
Neutropenic fever with no response to antibiotic for 96 hours

1. Amphotericin B (Fungizone) in patients with normal renal function:
Day 1 Test dose 1mg in 10mls 5% dextrose**
given over 20-30 minutes.
Then 0.25mg/kg diluted in 500mls 5% buffered dextrose
given over 4 hours.
Cover with hydrocortisone 100mg iv prior to starting each dose.
Prescribe amiloride 10mg daily
Check potassium levels daily
Day 2 Increase dose by 0.25mg/kg every 24 hours
until correct dose is reached i.e. 0.5-1mg/kg/day
Renal toxicity is inevitable. Monitor creatinine.
If creatinine >200umol/L stop for 2-3 days.
**Maximum concentration of amphotericin infusion = 0.1.mg/ml.
Use buffered dextrose available from pharmacy.
2. If no response, abnormal renal function or severe side effects

give Abelcet (liposomal amphotericin) 5mg/kg daily
Diagnosed fungal infections (clinically or microbiologically)

1. Abelcet (liposomal amphotericin) 5mg/kg daily
2. If no response or side effects substitute :
Caspofungin 70mg iv day 1 followed by
50mg iv daily thereafter (70mg if >80kg)
OR
Voriconazole 6mg/kg iv bd for 2 doses followed by
4mg/kg iv bd thereafter
or
400mg oral bd for 2 doses followed by
200mg oral bd thereafter
(may be increased to 300mg bd)
50
Antibiotics in pregnancy
General guidelines: The following antibiotics are considered relatively safe in pregnancy:
Penicillins
Cephalosporins
Erythromycin (except the estolate)
A. Urinary tract infections
Cystitis/asymptomatic bacteruria
Cefalexin 500mg orally 12 hourly

or
Amoxicillin 500mg orally 8 hourly
or
Nitrofurantoin 100mg orally 6 hourly (avoid nitrofurantoin at term)
Pyelonephritis/septicaemia
Cefuroxime 750mg - 1.5g iv 8 hourly
Check urine culture and sensitivity results
B. Prevention of bacterial endocarditis
Patients with prosthetic cardiac valve

(see p 59)
Patients with native cardiac valve disease requiring dental treatment during pregnancy (see p 57)
51
Antibiotics in pregnancy (continued)

C. Group B streptococcus (GBS) in pregnancy
Antenatal patient GBS isolated from:
HVS: GBS usually just colonises the vagina.
No need for antibiotics until labour (see below)
URINE: Treat UTI
Will also need antibiotic cover during labour (see below)
Intrapartum GBS prophylaxis

Intrapartum prophylaxis is indicated when:
GBS is detected incidentally in HVS during this pregnancy
GBS bacteruria is detected during pregnancy
Previous baby was born with GBS sepsis
Benzylpenicillin 3g (5MU) intravenously

followed by 1.5g (2.5MU) 4 hourly until delivery
If allergic to penicillin:
Clindamycin 900mg intravenously 8 hourly until delivery
Inform Paediatrician. Isolate mother & baby together.
N.B. Intrapartum prophylaxis is NOT indicated for GBS positive patients

who are to undergo planned Caesarean section with intact membranes
and patient not in labour.
Post-natal patient
Inform Paediatrician. Isolate mother & baby.
Septic baby
Give penicillin/amoxicillin and cefuroxime to cover GBS and other neonatal pathogens
Take blood cultures
Consider lumbar puncture, if appropriate
Baby is culture positive for GBS

Ear, throat or cord (well baby):
Observe for 12 hours.
90% of cases of GBS sepsis will present clinically before 12 hours of age
Ear, throat or cord (baby unwell):
5-7 days penicillin
Blood culture postive:5-7 days penicillin
Meningitis:14-21 days penicillin
Baby should have received prophylaxis but missed it or delivered within 2 hours of starting prophylaxis
Observe for 12 hours, starting antibiotics if necessary
Multiple birth, one baby has GBS sepsis

Treat ALL babies with penicillin, even if clinically well
Preterm rupture of membranes

Antibiotic prophylaxis for GBS is unnecessary unless the mother is in established labour.
52
Antibiotic Prophylaxis in surgery

Duration of prophylaxis
Where single dose regimes are recommended these have been shown to be as effective as multiple dose regimes.
The recommended number of doses must NOT be exceeded even for "difficult" operations as this confers absolutely
no advantage whatsoever and is associated with greater toxicity, more adverse effects, more bacterial resistance and
increased costs.
Operation: Antibiotics:
Cardiovascular surgery/procedures
High leg Metronidazole 500mg IV at induction then 8 hourly
amputation for 24 hours
(for ischaemia) or
Benzylpenicillin 600mg IV at induction then 6 hourly
for 24 hours
Reconstruction of abdominal aorta

Procedures on the leg involving groin incision
Insertion of prosthetic material
Cefuroxime 1.5g IV at induction
then 750mg at 8 and 16 hours.
Central venous Antibiotic prophylaxis NOT required

catheter
insertion
ENT surgery/procedures
Middle ear Co-amoxiclav 1.2g IV at induction
(only if draining or
cholesteatoma)
53
Antibiotic Prophylaxis in surgery (continued)
Gastric, biliary and colonic surgery/procedures

Appendicectomy Over 12 years
Metronidazole 500mg IV at time of diagnosis.
Second dose preparatory to going to theatre.
See “Medicines for Children” or Paediatric BNF for Paediatric doses.
Biliary tract Cefuroxime 1.5g IV at induction

(If stone/stricture/
recent cholecystitis/
elderly patient)
Colorectal Cefuroxime 1.5g IV at induction

and
Metronidazole 500mg IV at induction
Repeat doses not required.
Gastric Cefuroxime 1.5g IV at induction

(If neoplasm/ulcer/
haemorrhage)
ERCP Not necessary unless obstruction.

If obstruction:
Gentamicin 120mg IV immediately before procedure
Hernia (inguinal
repair with mesh) Cefuroxime 1.5g IV at induction
PTCD Not necessary unless obstruction.

(Percutaneous If obstruction:
transhepatic Gentamicin 120mg IV immediately before procedure
cholangiography)
PEG insertion Gentamicin 120 mg IV

(Percutaneous
endoscopic
gastrotomy)
54
Obstetric/Gynaecological surgery/procedures
Caesarean Co-amoxiclav 1.2g IV
section or
(emergency or Cefuroxime 1.5g IV and
elective) Metronidazole 500mg IV if penicillin allergic
Give antibiotics after clamping the cord
Insertion of Screen for STD and treat if necessary prior to insertion

IUCD
Hysterectomy Co-amoxiclav 1.2g IV

or
Cefuroxime 1.5g IV and
Metronidazole 500mg IV if penicillin
allergic
Termination of Metronidazole 1g PR
Pregnancy Screen for STD and treat if positive prior to surgery
If this is not possible give additional
Doxycycline 100mg bd for 7 days post-operatively
to cover for Chlamydia
Orthopaedic surgery/procedures
Dental treatment Antibiotic prophylaxis NOT required.
for patient with
joint prosthesis
Open fracture Cefuroxime 1.5g IV as soon as possible after injury

Type I, II & IIIA then 750mg 8 hourly until 24 hours after wound closure
Open fracture Cefuroxime 1.5g IV

Type IIIB & IIIC and
Metronidazole 500mg IV
as soon as possible after injury followed by
750mg 8 hourly for 72 hours total duration or until 24 hours
after adequate soft tissue coverage is achieved.
55
Orthopaedic surgery/procedures (continued)
Open reduction Cefuroxime 1.5g IV at induction followed by
of closed 750mg at 8 hours
fracture with
internal fixation
Total joint Cefuroxime 1.5g IV at induction then

replacement 750mg at 8 and 16 hours
Total joint Not more than 5 days prior to surgery start:

replacement Nasal mupirocin ointment applied to anterior nares tds
in MRSA patient Daily total body washing in Aquasept
1% chlorhexidine powder applied daily after washing & drying to axillae, perineum & groins.
Replace disposable items e.g. toothbrushes, loofahs, make-up brushes/sponges etc.
Hot wash bed linen, towels & clothes.
If throat/wound positive for MRSA also start:
Trimethoprim 200 mg oral 12 hourly and
At operation give
Cefuroxime 1.5g IV at induction
And
Vancomycin 1g IV infusion started at induction
then
Cefuroxime 750mg at 8 and 16 hours
Urological surgery/procedures
Transrectal Gentamicin 120 mg IV at induction
prostate biopsy or
Ciprofloxacin 500mg orally 2 hours before procedure
Urological
e.g. TURT, TURP Gentamicin 120mg IV at induction
open prostatectomy or
Shock wave Cefuroxime 1.5g IV at induction
Lithotripsy (SWL)
Urinary catheter Prophylaxis NOT required

insertion
Urinary catheter Prophylaxis ONLY if patient is at risk of endocarditis or

change has had a history of sepsis after previous catheter change.
Antibiotic according to recent sensitivity of urine isolate
Other
Head injury Antibiotics must NOT be given prophylactically
even if there is CSF leak.
56

Allergy to penicillin/cephalosporins
Patients who are allergic to penicillin may safely be given cephalosporins unless there is a history of serious reaction
e.g. anaphylaxis. If there is a history of anaphylaxis or the patient is allergic to cephalosporins give gentamicin
120mg IV in place of each dose of cefuroxime. If a patient has renal failure do not give more than one dose of
gentamicin. With normal renal function take great care not to exceed the recommended number of doses.
57
Antibiotic Prophylaxis in Patients at Risk of Endocarditis
PATIENTS REQUIRING PROPHYLAXIS INCLUDE:

High risk:
Prosthetic heart valves (see p 59)
Previous endocarditis
Cyanotic congenital heart disease
Transposition of great arteries
Fallot’s tetralogy
Gerbode’s defect
Surgically constructed systemic pulmonary shunts
Mitral valve prolapse with mitral regurgitation or thickened valve leaflets
Moderate risk
Acquired valvular heart disease e.g. rheumatic heart disease
Aortic stenosis or regurgitation
Mitral regurgitation
Bicuspid aortic valve
Primum atrial septal defect (if not repaired)
Atrial septal aneurysm
Ventricular septal defect (if not repaired)
Patent foramen ovale
Patent ductus arteriosus (if not repaired)
Aortic root replacement
Coarctation of aorta
Hypertrophic obstructive cardiomyopathy
Subaortic membrane
THE FOLLOWING PATIENTS DO NOT REQUIRE PROPHYLAXIS:

Isolated secundum atrial septal defect
Pulmonary stenosis
Surgically repaired atrial septal defect
Surgically repaired ventricular septal defect
Surgically repaired patent ductus arteriosus
Previous coronary artery bypass surgery
Mitral valve prolapse without regurgitation
Innocent heart murmurs
Cardiac pacemakers/defibrillators
Coronary artery stent implantation
Heart or heart and lung transplant
(antibiotic prophylaxis needed for first 6 months post-op)
Pulmonary stenosis
58
Antibiotic Prophylaxis in Patients at Risk of Endocarditis

(continued)
UNDER LOCAL ANAESTHETIC
3g oral amoxicillin 1 hour before procedure
Penicillin allergy/penicillin given in last 4 weeks:

600mg oral clindamycin 1 hour before procedure
UNDER GENERAL ANAESTHETIC

Most patients at risk
1g iv amoxicillin at induction and 500mg
oral amoxicillin 6 hours later
Particularly high risk patients
i.e.1. Allergic to penicillin
2. Penicillin given in last 4 weeks
3. Prosthetic valves
4. Previous endocarditis
Allergy to penicillin/penicillin in last 4 weeks
1g vancomycin iv infusion over 100 minutes
and
120mg gentamicin iv
both at induction*
No allergy to penicillin
1g amoxicillin
and
120mg gentamicin
both iv at induction
Followed by
500mg amoxicillin 6 hours later
Patients undergoing genitourinary surgery should also be covered with the “Particularly high risk patient” regime
above.
For patients with previous endocarditis also cover obstetrics and gynaecology/gastro-intestinal procedures with the
“Particularly high risk patient” regime above.
If repeat procedures are undertaken, do not use the same antibiotic(s) twice in the space of 4 weeks.
See “Medicines for Children” or Paediatric BNF for Paediatric doses.
New recommendations on endocarditis prophylaxis are expected from the British Cardiac Society in 2004/2005.
59
Antibiotic Prophylaxis in Patients with Prosthetic Cardiac Valves

Procedures requiring antibiotic cover:
Dental procedures
Gastro-intestinal procedures e.g.
Endoscopy
Barium enema
Genito-urinary procedure e.g.
Cystoscopy
Urethral dilation
Prostatectomy
Obstetric and gynaecological procedures including:

Vaginal delivery
D&C
Insertion/removal of IUCD
Caesarean section with general anaesthetic
Patients allergic to penicillin

1g vancomycin iv infusion over 100 minutes
and
120mg gentamicin iv
Both at induction
All other patients

1g amoxicillin iv
and
120mg gentamicin iv
Both at induction
AND
500mg amoxicillin 6 hours later
60
Meningitis Contacts: prophylaxis

Prophylaxis (antibiotics and vaccination) is normally organised by the Consultant in Communicable Disease Control
as soon as the case has been notified. All cases of meningitis must be notified by telephone to the appropriate
CCDC. Medical Microbiology staff will telephone and complete notification forms if informed about cases of
meningitis.
A. Meningococcal meningitis/septicaemia
Who for?
The patient with meningitis (penicillin/cefotaxime may not eradicate carriage) prior to discharge from
hospital.
Household contacts within 7 days before onset, including frequent visitors.
Boyfriend/girlfriend (mouth kissing contacts).
Staff who have given mouth to mouth resuscitation to the patient.
School contacts of single cases do not require prophylaxis.
Prophylaxis
Adults/child >12 years:

Rifampicin 600mg oral 12 hourly for 2 days
Child (1-12 years):
Rifampicin 10mg/kg oral 12 hourly for 2 days
Infants under 1 year:
Rifampicin 5mg/kg oral 12 hourly for 2 days
Patient information leaflet available in AED.
Warning
This antibiotic colours urine orange (warn the patient).
Patients on the pill should be warned to use alternative contraceptive measures for 1 month.
Patients should avoid alcohol.
Warfarin may be potentiated.
Soft contact lenses may be discoloured permanently (do not wear them while on rifampicin).
Nasopharyngeal swabs
Must not be taken before or after prophylaxis with the exception of the index case.
61
Meningitis Contacts: prophylaxis (continued)

Meningococcal A+C vaccine
This vaccine should be given in addition to chemoprophylaxis to contacts of Group A/Group C meningitis.
It is not given to contacts of Group B cases.
Pregnant contacts
Ceftriaxone 250mg im single dose
or
Rifampicin 600mg oral 12 hourly for 2 days
Although there is no information to suggest that meningococcal A+C vaccine is unsafe during pregnancy, it
should only be given when this is unavoidable.
B. Haemophilus meningitis
Prophylaxis is intended for protection of children under 4 years. It is not required if all household contracts
under 4 years have been fully vaccinated against Hib disease. (Children under 1 year need 3 doses of
vaccine. Children 1-4 years will be protected by a single dose of vaccine).
Who for?
1. All household members (irrespective of age) where there is an index case of this disease and a child
under 3 years except: pregnant women, breast feeding women, any person with severe impairment of
hepatic function and children under 3 months.
2. All room contacts, both teachers and children, where 2 or more cases of Hib disease have occurred in
a play group, nursery or crèche within 120 days (exceptions as above).
3. Index case of Hib disease prior to discharge from hospital except children less than 3 months.
Prophylaxis should not be offered routinely to household contacts where there are no other children under
3 years, or to contacts of single cases in playgroups, nurseries or crèches, or to ward contacts in hospital
outbreak.
If there are any unusual circumstances when it is not known whether prophylaxis is indicated please
contact the Consultant in Communicable Disease Control (CCDC) for advice.
Prophylaxis
Adults/child > 12y:
Rifampicin 600mg oral once daily for 4 days
Child 3 months-12 years:
Rifampicin 10mg/kg oral once daily for 4 days
Child 1-3 months:
Rifampicin 5mg/kg oral once daily for 4 days
Patient information leaflets available in AED.
62
Meningitis Contacts: prophylaxis (continued)

Warnings (rifampicin)
Use ceftriaxone instead of rifampicin in pregnancy (see below).
This antibiotic colours urine orange (warn the patient).
Patients on the pill should be warned to use alternative contraceptive measures for 1 month.
Patients should avoid alcohol.
Warfarin may be potentiated.
Soft contact lenses may be discoloured permanently (do not wear them while on rifampicin).
Recolonisation with sensitive strains and emergence of resistant strains may occur. Therefore, parents should be
warned to report fever in siblings to their doctor.
Pregnant/breast feeding contacts
Only those with Haemophilus influenzae type b in nasopharyngeal cultures need prophylaxis. Give carriers
ceftriaxone 250mg im single dose.
63
Post splenectomy prophylaxis

Splenectomised patients are at increased risk of infection, particularly
during the first 2 years after splenectomy. Some patients have developed
serious infections many years after removal of the spleen. To reduce the
risks of infection the following precautions should be taken. Patient
information leaflets are available from Consultant Microbiologist.
1. Antibiotics
Either Penicillin V 500mg orally once daily
or amoxicillin 500mg orally once daily or
erythromycin 500mg orally once daily
(if allergic to penicillin)
These antibiotics should be taken for the rest of the patient's life.
After a few years some people prefer to stop taking daily
antibiotics and just keep a stock of antibiotics to treat fever until
they can get to the doctor.
2. Vaccination
a. Pneumovax, preferably given at least 2 weeks before
splenectomy but as soon as possible afterwards with
boosters every 5-10 years.
b. Hib – single dose. Boosters are not necessary.
c. Influenza – annual to prevent risk of secondary bacterial
infection.
d. Conjugate meningococcal C vaccine
3. Carry card/Medic alert bracelet/locket.
4. Warn patient to contact doctor if he/she develops high temperature.
5. Contact Dr Allen for advice prior to travel abroad.
6. If bitten by an animal e.g. dog a 5 day course of co-amoxiclav (or
erythromycin if penicillin allergy) should be prescribed because of
the increased risk of infection due to Capnocytophaga canimorsis
(DF-2 bacillus)
64
Prevention of spontaneous bacterial peritonitis
Patients with advanced cirrhosis may develop spontaneous bacterial peritonitis.
Pathogen
60% Enterobacteriaceae
25% gram positive organisms (mainly streptococci)
Prevention
Ciprofloxacin 500mg 12 hourly orally (or 400mg 12 hourly iv) during hospitalisation (for not more than 7 days)
Long term use will result in quinolone resistant bacteria which can then cause peritonitis.
65
Needlestick injuries
Contact the Microbiologist for advice if required.
Needlesticks to members of public

1. First aid.
2. Take blood from victim for baseline storage only.
3. Start Hepatitis B vaccination (accelerated course 0, 1, 2 and 12
months). Sharps are no longer tested because of the low yield, poor sensitivity and for health and safety
reasons.
Needlesticks to staff:
1. First aid.
2. Take blood from donor for baseline storage. Test for HepBsAg if victim’s hepatitis B immune status is not
known or non-immune. Test for HIV Ab ONLY if high risk and after full counselling and consent. Request
Hepatitis C Ab if intravenous drug abuser.
3. Take blood from victim for baseline storage (or HepBsAb if history of immunisation but Ab levels never checked).
4. Start Hepatitis B vaccination if not immunised (accelerated course 0, 1, 2 and 12 months). Otherwise check if
booster needed.
Staff should be referred to Occupational Health during normal working hours or to AED (out of hours only).
HIV Ab positive donor

If donor is known/STRONGLY suspected to be HIV positive please refer the victim to AED immediately.
Full guidance is given in Chapter 11E, Infection Control Manual.
66
Antivirals
Antiviral Treatment
Chickenpox
Neonate or immunocompromised patient or if pneumonitis is present
Aciclovir intravenously
Adult or child under 3 months:
10mg/Kg every 8 hours iv for 5-10 days
Child 3m-12 years:
500mg/m2 every 8 hours
Immunocompetent adult or adolescent (not children)

Aciclovir 800mg oral five times daily for 7 days.
The oral form is only effective if started within 24 hours of rash.
Immunocompetent children
Aciclovir is NOT indicated
Herpes simplex encephalitis

Give aciclovir (acyclovir) for at least 10 days.
Adults or children over 12y: 10mg/kg every 8 hours
Children 1m-12y: 1500mg/m2 divided into 3 doses
Herpes simplex stomatitis

If necessary, give aciclovir (acyclovir) orally or intravenously depending on clinical condition.
See “Medicines for Children” or Paediatric BNF for doses.
HIV/AIDS
Patient must be referred to Infectious Diseases physician.
Influenza
Oseltamivir adult dose 75mg oral 12 hourly for 5 days.
Not recommended for otherwise healthy patients.
Only recommended for at risk adults (see below) who can start treatment within 48 hours of onset.
At risk patients:
Aged over 65 years
Chronic respiratory disease e.g. COPD, asthma
Significant cardiovascular disease (NOT hypertension)
Chronic renal disease
Immunosuppression
Diabetes mellitus
67
Antivirals (continued)
RSV (respiratory syncytial virus)

Give ribavirin only after discussion with Consultant Paediatrician.
Ribavirin:
6g in 300mls saline nebulised over 12-18 hours daily for 3-7 days
Shingles (Herpes zoster)

Pain relief e.g. paracetamol
Antivirals if elderly, immunocompromised, ophthalmic or motor involvement.
Famciclovir 750mg once daily for 7 days

If immunocompromised
Famciclovir 500mg 8 hourly for 10 days
Antiviral Prophylaxis
Prophylaxis for health care workers occupationally exposed to HIV
Refer the member of staff to AED immediately. Full guidance is given in Chapter 11E Infection Control Manual.
Chickenpox prophylaxis for neonates

VZIG (available via Microbiology) if mother develops chickenpox 7 days before until 28 days after delivery or if other
contact with chickenpox in first 28 days of life (with seronegative mother).
Aciclovir should be given additionally if mother developed chickenpox 4 days before until 2 days after delivery (high
risk period).
Chickenpox contact in pregnant/immunocompromised patient.

Contact Microbiology medical staff for advice.
68
INDEX
Page
Acute pancreatitis 24
AIDS 66
Amoebiasis 21
Amphotericin dosage 14, 49
Ampicillin/Amoxycillin 5
Amputation prophylaxis 52
Anaphylaxis 10
Angular cheilitis 14
Animal bites 36, 44
Antibiotic assays 7-8
Antibiotic prophylaxis 52-56
Appendicectomy 52
Arthritis, septic 12-13, 27, 46
Aspiration pneumonia 32
Athletes foot 39
Atypical pneumonia 33
Bacterial vaginosis 18
Balanitis 18
Biliary tract infections 15
Biliary tract surgery 53
Bites 36,44
Bone infection 28
Bordetella pertussis 34
Brain abscess 26
Breast surgery 44
Burns patients 42
Caesarean section 54
Campylobacter 21
Candida infections 14,18,39
Catheterised patient 41,52
C. difficile 21
Cellulitis 36,47
Central line infection 35
Cheilitis 14
Chest infection 31-34
Chickenpox 66,67
Chlamydia psittaci 33
Chlamydia trachomatis 18,47
Cholangitis 15
Cholecystitis 15
Clarithromycin 5
Clostridium difficile 21
COPD exacerbation 31
Colorectal surgery 53
Conjunctivitis 15,47
69
INDEX
Page
Cord infection 47
Cotrimoxazole 5, 25, 33
CSF leak 55
Cystitis 41, 50
Dermatophyte infections 39
Diabetic foot ulcers 28,37
Diarrhoea 21-22
Drug Information Pharmacist 4
Ear infection 16
Encephalitis 66
Endocarditis, treatment 17
Endocarditis, prophylaxis 57
Enterobius vermicularis 22
Epididymo-orchitis 19
Epiglottitis 30
ERCP 53
Erysipelas 36
Escharectomy prophylaxis 42
Exacerbation COPD 31
Eye infections 15,47
Famciclovir 67
Foot ulcers (diabetic) 37
Fungal infections:
Candida 14,18
Dermatophyte infections 39
in neutropenic patients 49
Gardnerella vaginalis 18
Gastric surgery prophylaxis 53
Gastro-intestinal infections 21-22
General information 4
Genital tract infections 18-19
Gentamicin dosage and levels 7
Giardiasis 21
Gonococcal arthritis 12-13
Group B streptococci 51
Hand surgery 43
Head and neck surgery 43
Head injury 55
Helicobacter pylori 22
Herpes simplex encephalitis 66
Herpex simplex stomatitis 66
Herpes zoster 67
70
INDEX
Page
Hib vaccine 26
HIV 66
Human bites 36, 44
Immunocompromised patients 48-49

Impetigo 33
Influenza 59
Intestinal candidiasis 14
Intra-abdominal sepsis 23-24
Intravenous additive service 6
IV line infection 35
Joint infection 12-13

Joint (prosthetic) infection 29
Leg amputation prophylaxis 52

Legionella 33
Leukaemic patient 45
Listeria 25
Liver abscess 24
Lung abscess 34
Malignant otitis externa 16

Meningococcal vaccine 61,63
Meningitis treatment 25-26
Meningitis, prophylaxis 60-62
Metronidazole 4
MRSA infections 27
Mycoplasma 33
Nail infections 39
Necrotising fasciitis 38
Needlestick injuries 65
Neonatal sepsis 45
Neutropenic patients 48-49
Oral candidiasis 14
Oesophageal candidiasis 14
Orthopaedic surgery prophylaxis 54-55
Otitis externa 16
Otitis media 16
Osteomyelitis 28
Pancreatitis 24
PEG insertion 53
Pelvic inflammatory disease 20
Peritonitis
Treatment of primary 23
Treatment of secondary 23
Prevention of spontaneous 64
71
INDEX
Page
Pertussis 34
Pharyngitis 30
Phlebitis 35
Plastic surgery prophylaxis 43-44
Pneumocystis pneumonia 33
Pneumocystis prophylaxis 33
Pneumonia 31-34
Pregnancy, infections in 50-51
Pressure sores 36
Prophylaxis 52-64
Prostatitis 19
Prosthetic cardiac valve prophylaxis 59
Prosthetic joint infection 29
Pseudomembranous colitis 21
Psittacosis 33
Pyelonephritis 41,50
Reserved antibiotics 9
Ribavirin 67
Ringworm 39
RSV 67
SABE 17
Salmonella 21
Scalded skin syndrome 47
Septicaemia 35, 60
Septic arthritis 12-13
Sexually transmitted diseases 18
Shingles 67
Shock, anaphylactic 10
Sinusitis 30
Skin infection 36-39
Splenectomy 63
Sores (Pressure) 36
Sore throat 30
Sticky cord 47
Streptomycin 8
Threadworms 22
Thrombophlebitis 35
Thrush 14,18
Tonsillitis 30
Topical antibiotics 5
Toxic shock syndrome 40
Transrectal prostate biopsy 55
Trichomonas vaginalis 18
Tuberculosis 4
72
INDEX
Page
Typhoid fever 22
Ulcers (skin) 36
Umbilical infection neonates 47
Urinary catheters 41, 52
Urinary tract infection 41,50
Urological surgery prophylaxis 55
Vaginal candidiasis 14
Vaginal infections 17
Vancomycin levels 8
Vascular surgery prophylaxis 52
Venflon infection 35
Whooping cough 34
Zoster 67

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HOSPITAL

ST HELENS AND KNOWSLEY

Penicillin allergy and cephalosporins

Clarithromycin/Erythromycin (macrolide antibiotics)

Intravenous additive service

Cefuroxime 750mg, SYRINGE 10ml, 20ml

For patients with endocarditis

Dose: Normal renal function:

ANTIBIOTIC ASSAYS (continued)

Check levels after 48 hours.

Therapeutic range: Pre < 10 mg/L

Subsequent assays 2-3 times a week, according to levels.

ANTIBIOTIC ANAPHYLAXIS AND ANAPHYLACTOID REACTIONS

Before Drug Administration

Diagnosis and Management of Anaphylaxis

Typical effects are:

Adrenaline is the drug of choice

The route is of secondary importance.

Specimens: Joint aspirate

Initial therapy (depending on gram film of aspirate)

Staphylococci : Not penicillin allergic

Gonococci: Cefotaxime 1g iv 8 hourly

Arthritis (septic) (continued)

Gonococci: arthritis-dermatitis syndrome:

Oral: Amphotericin B lozenges 6 hourly to be dissolved slowly in the

Oral lesions not responding to the above:

Nystatin 1 tablet (500,000 units) or 5 mls suspension 6 hourly.

Vaginal candidiasis not responding to above:

Skin: Clotrimazole cream applied 2-3 times daily for 14 days.

Perineal candidiasis in infants:

Initial therapy: Cefuroxime 750mg-1.5g iv 8 hourly

Then if clinical condition permits (after 1-3 days iv antibiotics):

* see page 4 for prescribing information.

Conjunctivitis (in adults/children)

Specimen: Eye swab

Malignant otitis externa

A. Streptococci account for 70% of cases:

Benzylpenicillin 2MU (1.2g) iv 4 hourly

Penicillin allergic patients:

B. Staphylococci cause endocarditis in drug

Penicillin allergic patients:

Genital Tract Infections

Sexual partner must be referred for treatment.

Sexually transmitted diseases e.g. gonorrhoea, Chlamydia:

Uncomplicated but risk of pregnancy

Upper genital infection (female, PID)

Upper genital infection (male)

Genital Tract Infections (continued)

Pelvic Inflammatory Disease

Specimens: Cervical swabs for gonococci (plain transport medium)

Ill patient: Cefuroxime 750mg -1.5g iv 8 hourly

c. Pseudomembranous colitis (C. difficile)

Failure to respond to metronidazole:

Gastro-intestinal Infection (continued)

g. Threadworm (Enterobius vermicularis)

Repeat dose at 2 weeks

BARRIER NURSING OF ALL PATIENTS ADMITTED WITH DIARRHOEA IS ESSENTIAL

If patient is allergic to amoxicillin substitute