Antimicrobial prescribing: NHS Lothian
Source control includes:
- Line removal
- Draining pus (surgically or radiologically)
- Debriding tissue
- Definitive operation
These guidelines apply only to Wards 116 and 118 at RIE, Ward 20 at WGH and ITU at SJH.
They should not be used in any other clinical area of NHS Lothian.
Early appropriate antimicrobial therapy with source control improves survival.
- Take appropriate samples for microbiological testing before starting antimicrobials.
- Send pus in a universal container over swabs where possible.
- Consider recent antibiotic therapy over the last three months and previous microbiology results.
- Be aware of the risk of C.diff infection see Prevention, diagnosis and management of CDI
- Where an isolate from a sterile site in the last three months is resistant to the recommended antimicrobial consider an alternative (e.g. a coamoxiclav or piperacillin/tazobactam resistant organism consider using meropenem).
- Where a patient has recently completed a course of the antibiotic recommended consider an alternative (as above).
Review and revise
- Aim to de-escalate therapy and use targetted antibiotics when microbiology results are available in discussion on the microbiology round.
- Duration of treatment for pneumonia is usually 5 days. VAP may need more extended duration.
Escalation of antimicrobials needs a considered approach; a senior clinical review must be undertaken to determine if escalation if appropriate. Appropriate investigations (including blood cultures) and management plan dependent on most likely source must be undertaken.
Is there a deep source / collection / alternative diagnosis to consider? An antimicrobial escalation plan may already be put in place for the patient; please review whether this is sill applicable to clinical scenario. Can discuss, where relevant, with on-call microbiology.
- Most antibiotics (except metronidazole and clindamycin) will need dose adjustment in renal dysfunction/CVVHD - see BNF/renal dosing handbook.
- Yeasts in respiratory samples are usually colonisers and do not normally require antifungals.
- Vancomycin is used for Gram +ve cover (Staphylococci, Enterococci and Streptococci) when ciprofloxacin is used in a penicillin allergic patient or whenMRSAis suspected.
- Use pipercillin-tazobactam at 4.5g every 6 hours or ciprofloxacin 400mg every 8 hours for ventilator associated pneumonia when targeting Pseudomonas spp.
- Alternatives are listed for all indications.
- In patients with reported minor reactions from penicillins, such as rash, cross reaction to cephalosporins, aztreonam, or meropenem is unlikely.
- Further information on penicillin allergy can be found here.