Antibiotic Guidelines

Issue1 June 2014

Obstetric Anti-Infective Prescribing Guidelines.

Current Version is held on the Intranet Check with Intranet that this printed copy is the latest issue

of 13

Contents

Section

Page

Intro Who should read this document 2

Key practice points 2

Background 2

Guideline

Empiric treatment for unknown source of maternal infection / sepsis 4

Pyrexia in labour 5

Treatment of a secondary postpartum haemorrhage due to retained products

6

Group B Haemolytic Streptococcus prophylaxis 6

Intra-abdominal infections 7

Urinary tract infections 8

Post-operative wound infection – post delivery 9 Mastitis / breast abscess

Genitourinary infections 11

Gentamicin in pregnancy 11

Standards 11

Roles and Responsibilities 11

Appendix 12

Document control information (Published as separate document) 14

Document Control

Policy Implementation Plan

Monitoring and Review

Endorsement

Equality analysis

Antibiotic Guidelines: Obstetric Anti-Infective Prescribing Guidelines

Classification: Clinical Guideline Lead Author: Antibiotic Steering Committee Additional author(s): Kelly Alexander / Frances Garraghan / Dr Ahmed Qamruddin / Dr Melissa Whitworth / Dr Teresa Kelly from Central Manchester Foundation Trust Hospitals. Authors Division: DCSS & Tertiary Medicine Unique ID: 144TD(C)25(J2) Issue number: 1 Date approved: Medicines Management Group - May 2014

Issue1 June 2014



of 13

Who should read this document? This policy applies to all clinical staff involved the prescribing of antimicrobials.

Key Practice Points The recommendations below consider safety during pregnancy. For ladies who have given birth, the general Trust antibiotic guidelines may be followed, with consideration on safety in breast feeding if applicable. Contact Pharmacy or Medicines Information (ext 65223) for further advice. When considering treatment with antibacterial agents during pregnancy, the following factors should be considered: the severity of the maternal infection, the effects of any fever present on the pregnancy, the effects of failing to treat the mother, and the potential fetotoxicity of the drugs to be used. Where possible, the results of culture and sensitivity tests should be available before making a treatment choice, however treatment should NOT be delayed in patients who are unwell or septic. Administration of intravenous broad spectrum antibiotics is recommended within one hour of suspicion of severe sepsis, with or without septic shock. If genital tract sepsis is suspected, prompt early treatment with a combination of high-dose broad spectrum intravenous antibiotics may be lifesaving. Breastfeeding This document is not a resource for determining antibiotic safety in breastfeeding. Do not assume if potential toxicity in breastfeeding has not been highlighted that the drug is safe in this situation. Please refer to medicines information for further information.

Issue1 June 2014



of 13

Background Antimicrobial agents are among the most commonly prescribed drugs and account for 20% of the hospital pharmacy budget. Unfortunately, the benefits of antibiotics to individual patients are compromised by the development of bacterial drug resistance. Resistance is a natural and inevitable result of exposing bacteria to antimicrobials.

Good antimicrobial prescribing will help to reduce the rate at which antibiotic resistance emerges and spreads. It will also minimise the many side effects associated with antibiotic prescribing, such as Clostridium difficile infection. It should be borne in mind that antibiotics are not needed for simple coughs and colds. In some clinical situations, where infection is one of several possibilities and the patient is not showing signs of systemic sepsis, a wait and see approach to antibiotic prescribing is often justified while relevant cultures are performed.

This document provides treatment guidelines for the most common situations in which antibiotic treatment is required. The products and regimens listed here have been selected by the Trust's Medicines Management Group on the basis of published evidence. Doses assume a weight of 60-80kg with normal renal and hepatic function. Adjustments may be needed for the treatment of some patients.

This document provides treatment guidelines for the appropriate use of antibiotics. The recommendations that follow are for empirical therapy and do not cover all clinical circumstances. Alternative antimicrobial therapy may be needed in up to 20% of cases. Alternative recommendations will be made by the microbiologist in consultation with the clinical team.

This document refers to the treatment of adult patients (unless otherwise stated). Please refer to up to date BNF/SPC for a full list of cautions, contra-indications, interactions and adverse effects of individual drugs.

Issue1 May 2014



of 13

Guideline Empiric treatment for unknown source of maternal infection / sepsis

IV treatment Oral treatment

Infection First line Penicillin allergy First line Penicillin allergy Total duration

Maternal sepsis (unknown origin)

Clinically stable

Co-amoxiclav 1.2g tds plus metronidazole 500mg tds if intra-abdominal collection suspected

Non-severe delayed: Cefuroxime 1.5g tds plus Metronidazole 500mg tds Likely IgE / severe delayed: Clindamycin 600mg qds plus metronidazole 500mg tds plus Gentamicin stat

Co-amoxiclav 625mg tds plus metronidazole 400mg tds if intra-abdominal collection suspected

No ideal oral options consider completion of IV antibiotic course. Clindamycin 450mg IV/po qds plus ciprofloxacin 500mg orally bd may be used where benefit outweighs risk.

Review at 24 hours. If no improvement discuss with micro Total course length 7 - 10 days

Choose appropriate route based on clinical condition

Maternal sepsis

Severe sepsis, septic shock

Piperacillin/tazobactam 4.5g tds plus metronidazole 500mg tds if intra-abdominal collections suspected

Non-severe delayed: Meropenem 1g tds Likely IgE / severe delayed: Clindamycin 600mg qds PLUS metronidazole 500mg tds. Plus gentamicin IV

Step down based on culture and sensitivity results

Review at 24 hours. If no improvement at 24 hours discuss with microbiology. Total course length 7 - 10 days

First dose of antibiotics should be given within 1 hour. Consider risk of MRSA and consult microbiology if needed.

Consider a stat dose of gentamicin IV – review at 24 hours

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/directorate-department-clinical/ag/144tdc25h2/

Issue1 May 2014



of 13

Pyrexia in labour

Procedure 1st line prophylaxis Penicillin allergy Previous / current MRSA colonised

Post delivery doses

Non-severe delayed:

Likely IgE / severe delayed:

Pyrexia in labour – defined as: 38.0 °C once or 37.5 °C on two occasions 2 hours apart

Intrapartum fever (>38°C) carries a 1 in 167 risk of early onset group B streptococcus infection in the newborn. It may also indicate intrauterine infection / chorioamnionitis. Therefore therapy is targeted to cover all of these possibilities. Less common causes include UTI’s – symptoms should be investigated. Temperature should be checked every 4 hours during labour. Once pyrexia has been detected, temperature should be checked hourly. Investigations: FBC, CRP, blood cultures, urine for culture and sensitivity and a vaginal swab as a minimum. Other investigations e.g, swabs/pus as directed by Obstetrician. Monitor for other signs of infection; maternal or fetal tachycardia, uterine tenderness and offensive smelling amniotic fluid General management: to reduce pyrexia, anti-pyretic (paracetamol), hydration with cold fluids, tepid sponging, reduce ambient temperature. Non-infective causes of raised temperature (e.g. misoprostol) are common during labour but usually resolve within 6 hours of delivery

Co-amoxiclav 1.2g IV tds Cefuroxime 1.5g IV (+ metronidazole 500mg IV if c-section) tds

Clindamycin 600mg IV stat then qds plus IV gentamicin

Discuss with microbiology

Continue antibiotics for 24 hours post delivery. If no further episodes of pyrexia have occurred and there are no other signs of infection stop antibiotics.

For patients with ongoing signs of infection (raised temperature, CRP, WCC, tachycardia etc.) post delivery antibiotics should be continued for a minimum of 5 days and investigations performed to identify the source of infection. For patients with pyrexia in labour associated with a surgical intervention e.g. caesarean section, continue recommended prophylactic antibiotics for 24 hours post delivery. If no further episodes of pyrexia have occurred and there are no other signs of infection stop antibiotics.


Issue1 May 2014



of 13

Treatment of a secondary postpartum haemorrhage due to retained products

Refer to empiric treatment for unknown source of maternal infection / sepsis.

Group B Haemolytic Streptococcus prophylaxis

Procedure 1st line prophylaxis Penicillin allergy Previous / current MRSA colonised

Post delivery doses

Non-severe delayed:

Likely IgE / severe delayed:

Group B Haemolytic Streptococcus prophylaxis

Benzylpenicillin 3g IV stat. Then Benzylpenicillin 1.5g four hourly until delivery

Clindamicin 900mg IV stat then Clindamycin 900mg eight hourly until delivery

Discontinue unless clinical signs of infection present in patient

Issue1 May 2014



of 13

Intra-abdominal infections

***NB*** Please note that the following treatment guideline for intra-abdominal infections refer to treatment in pregnant women ONLY. For the Trust policy on intra-abdominal sepsis in other patient groups, click here.

Antibiotics Route Dose Frequency Duration Alternative in penicillin allergy

Intra-abdominal sepsis 1st line

Co-amoxiclav Add Metronidazole if collection present

IV

IV

1.2g

500mg

tds

tds

5-10 days therapy, but

may be longer (e.g

liver abscess, 4-6 weeks)

Non-severe delayed: Cefuroxime 1.5g IV tds + metronidazole 500mg IV tds Likely IgE / severe delayed: Clindamycin 450mg IV/po qds + gentamicin IV

2nd line Non- response to first line Recent ITU admission Likely pseudomonas infection

Piperacillin / tazobactam

IV 4.5g

tds

Discuss with micro

3rd line Meropenem Only after discussion with microbiology

IV 1g tds Non-severe delayed: Meropenem 1g TDS Likely IgE / severe delayed: Discuss with micro

Consider adding gentamicin IV stat if >2 signs and symptoms of sepsis (SIRS)

Review at 24 hours

Oral continuation Co-amoxiclav Add Metronidazole if collection present

po

po

625mg

400mg

tds

tds

No ideal oral options consider completion of IV antibiotic course. Clindamycin 450mg IV/po qds plus ciprofloxacin 500mg orally bd may be used where benefit outweighs risk.

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/directorate-department-clinical/ag/144tdc25d2/


Issue1 May 2014



of 13

Urinary tract infections


Comments

Simple cystitis / lower UTI 1st line

Cefalexin po 500mg tds 7 days

See below (if anaphylaxis)

2nd line Trimethoprim po 200mg bd 7 days NA Avoid in 1st trimester

Nitrofurantoin po 50mg qds Avoid in renal impairment or 3rd trimester or breast feeding

Clindamycin and macrolides (erythromycin, clarithromycin) are not excreted in the urine therefore are not suitable treatment Amoxicillin may be used where sensitivities are known. Co-amoxiclav may be used but cefalexin is preferred as more narrow spectrum

IV therapy


Comments

Pyelonephritis / Complicated UTI

Co-amoxiclav IV 1.2g tds 7-14 days Non-severe delayed: Cefuroxime 750mg-1.5g tds Likely IgE / severe delayed: Gentamicin IV

Severe uro-sepsis Failure of 1st line Recent ITU

admission Culture +ve for

pseudomonas

Piperacillin / tazobactam (Tazocin)

IV 4.5g tds Non-severe delayed: Meropenem 1g TDS Likely IgE / severe delayed: Discuss with micro

Consider addition of gentamicin IV stat if >2 signs and symptoms of sepsis (SIRS) Review at 24 hours

Oral Phase

According to cultures and sensitivities

Trimethoprim po 200mg bd 10-14 days in total

See alternatives Avoid in 1st trimester

Cefalexin po 500mg tds

Co-amoxiclav po 625mg tds


Issue1 May 2014



of 13

Options for treatment of resistant organisms ESBL / Amp C Discuss sensitivities with microbiology

Antibiotics Route Dose Frequency Duration Alternative in penicillin allergy Comments

Fosfomycin po 3g Alternate days 3-7 doses

NA

Unlicensed Reduce frequency in renal impairment

Meropenem

IV 1g tds 7-14 days Non-severe delayed: Meropenem 1g TDS Likely IgE / severe delayed: Discuss with micro

IV option

Post-operative wound infection – post delivery

Procedure Antibiotics Route Dose Frequency Duration Alternative in penicillin allergy

Clean or clean/contaminated surgery

Flucloxacillin IV po

1-2g 500mg

qds qds

Total duration 5 to 7 days

Clarithromycin 500mg IV/po bd

Contaminated/dirty surgery 1st line

Co-amoxiclav IV

po

1.2g

625mg

tds

tds

According to response 7-14

days

Non-severe delayed: Cefuroxime 1.5g IV tds plus metronidazole 500mg IV tds Likely IgE / severe delayed: Clarithromycin 500mg IV bd plus metronidazole 500mg IV tds

Contaminated/dirty surgery 2nd line: Non-response to 1st line

Piperacillin / tazobactam (Tazocin)

IV 4.5g tds Non-severe delayed: Meropenem 1g TDS Likely IgE / severe delayed: Clarithromycin 500mg IV bd + ciprofloxacin 500mg po bd + metronidazole 500mg IV tds OR Clindamycin 450mg IV/po bd + ciprofloxacin 500mg po bd

Consider adding IV gentamicin stat if >2 signs and symptoms of sepsis (SIRS) Review at 24 hours

Oral continuation Modify this according to response & culture / sensitivity results.

MRSA skin colonisation Add / substitute (for flucloxacillin) vancomycin IV or teicoplanin if post delivery


Issue1 May 2014



of 13

Mastitis / breast abscess

Mastitis / breast abscess Antibiotics Route Dose Frequency Duration Alternative in penicillin allergy

1st line Flucloxacillin IV

po

1-2g

500mg

qds

qds

Total duration 5 to

7 days.

Up to 2 weeks if abscess

present or as clinically indicated

Non-severe delayed: Oral: Cefalexin 500mg po TDS IV: Cefuroxime 1.5g IV TDS Likely IgE / severe delayed: Clarithromycin 500mg IV/po bd Plus metronidazole 500mg IV / 400mg po tds for mixed infection or failure to respond to 1st line

2nd line / mixed infection Co-amoxiclav IV

po

1.2g

625mg

tds

tds

Issue1 May 2014



of 13

Genitourinary infections

Please refer to the Trust’s Treatment Management Protocols for Sexually Transmitted Infections.

Gentamicin in pregnancy

Neonatal ototoxicity has not been observed with use of gentamicin in pregnancy however it has been seen with other aminoglycosides, therefore gentamicin should be used with caution in pregnancy. Where possible use only a stat dose or the shortest effective course. For guidance on dosing gentamicin, please refer to the Trust policy on Once Daily Gentamicin Dosing. Please note that in pre-eclampsia, gentamicin clearance is reduced and levels should be checked daily.

Standards

Document the Indication/rationale for antimicrobial therapy, including clinical criteria relevant to this.

Review and document the patient’s allergy status

Ensure the choice of antibiotic complies with the antibiotic guidelines and you have documented any clinical criteria relevant to the choice of agent.

Document a management plan including a stop or review date.

Where relevant, consider drainage of pus or surgical debridement/removal of foreign material.

Explanation of terms & Definitions NA

Roles and responsibilities All clinical staff involved in the prescribing of antimicrobials to adhere to this policy including full documentation on EPMAR as detailed.

http://intranet.srht.nhs.uk/policies-resources/trust-policy-documents/trust-wide-clinical/gen/twcg112/



Issue1 May 2014



of 13

Appendices

Summary of safety information for antibiotics in pregnancy

Drugs considered safe for routine use in pregnancy

Antibiotic class Examples Safety in pregnancy

Details

Penicillins Amoxicillin First line

Co-amoxiclav First line No adverse effects have been attributed in studies of amoxicillin and clavulanate in pregnant women.

Pipercillin / tazobactam

Suitable for use in severe infections.

Limited human data. Animal data suggests Non-severe delayed:.

Cephalosporins Cefalexin Cefotaxime Ceftriaxone Cefuroxime

First line

Macrolides Erythromycin (excluding estolate salt)

Second line to penicillins or cephalosporins. Has been extensively used in pregnancy.

Available data does not indicate an increased risk of congenital malformations / adverse fetal effects. Standard treatment for pre-term premature rupture of membranes

Clarithromycin Erythromycin preferred due to limited data for clarithromycin.

To date, exposure to during pregnancy has not been associated with teratogenic effects.

Metronidazole Has been extensively used in pregnancy.

Mutagenic and carcinogenic in some animal studies. Available data, in humans does not indicate an increased risk of adverse fetal effects. High dose regimens e.g. 2g stat are generally not recommended

Issue1 May 2014



of 13

Reserve antibiotic agents or caution in pregnancy Antibiotic class Examples Safety in

pregnancy Details

Carbapenems Meropenem Reserved for serious or life-threatening infections.

Limited human data. Animal data suggests Non-severe delayed:.

Ertapenem No human studies. Animal data suggests Non-severe delayed:.

Imipenem Use meropenem Limited human data suggests Non-severe delayed:.

Clindamycin May be used in pregnancy for indicated infections.

No reports of congenital defects identified.

Fosfomycin Strictly microbiology only agent. Non-severe delayed: to fetus, may be used in pregnancy for indicated infections

Number of published reports in humans, including 1st trimester, without apparent harm to newborn

Glycopeptides Vancomycin May be used in pregnancy for indicated infections Ensure strict monitoring of levels

No reports of congenital defects. Potential risk of ototoxicity if recommended plasma levels exceeded

Pivmecillinam (Note this is a penicillin)

Microbiology only agent.

Crosses placenta. Limited data in UK texts. Extensively used in Scandinavian countries (first line agent). Cohort studies do not suggest an increase in malformations. One cohort study concluded pivmecillinam was associated with an increased risk of miscarriage compared to control (but not a comparator agent). The study design did not allow conclusions as to whether risk was associated with infection or drug exposure.

Antibiotic Guidelines

Documents

Transcript of Antibiotic Guidelines