January 2025 - IV alternative text added.
Oral therapy
Co-trimoxazole 960mg 12 hourly
+
Metronidazole 400mg 8 hourly if abdominal source suspected
IV Therapy
Hospital admission
Duration: depends on eventual diagnosis
If IV treatment is still needed after three days, discuss with Microbiology
True penicillin allergy: Discuss with Microbiology
Oral therapy
Co-trimoxazole 960mg 12 hourly
+
Metronidazole 400mg 8 hourly
IV Therapy
Hospital admission
Duration: depends on eventual diagnosis. Usually 5-7 days
PO Metronidazole is as good as IV if route available
If IV treatment is still needed after three days, discuss with Microbiology
True penicillin allergy: Discuss with Microbiology
Oral therapy
Amoxicillin 500mg 8 hourly
Or
Doxycycline 200mg stat, then 100mg 24 hourly
IV Therapy unless otherwise stated
Co-amoxiclav2 1.2g 8 hourly
Where it is not possible to give TDS IV dosing, the evening dose of co-amoxiclav could be replaced by an oral dose of Co-amoxiclav 625mg + amoxicillin 500mg if oral route available. See above3. Alternatively, discuss with Cons. Microbiologist.
Duration 5 days
If clinical failure of oral therapy, send sputum and consider Co-amoxiclav2 625mg TDS PO / 1.2g 8 hourly IV
Oral therapy
Amoxicillin 500mg -1g 8 hourly
Plus
Metronidazole 400mg 8 hourly
Or
Doxycycline 200mg stat, then 100mg 24 hourly
+
Metronidazole 400mg 8 hourly
IV Therapy unless otherwise stated
Amoxicillin 1g 8 hourly
+
Gentamicin5
+
Metronidazole 500mg 8 hourly (400mg 8 hourly PO if route is available)
True penicillin allergy:
Discuss with Microbiology
Where it is not possible to give TDS IV dosing, the evening dose of amoxicillin could be replaced by an oral dose of amoxicillin 1g if oral route available. See above3. Alternatively, discuss with Cons. Microbiologist
Duration 5-7 days
If IV treatment is still needed after three days, discuss with Microbiology
Oral therapy
Doxycycline 200mg stat, then 100mg 24 hourly
Or
Co-trimoxazole 960mg 12 hourly
IV Therapy unless otherwise stated
Amoxicillin 1g 8 hourly
+
Gentamicin5
True penicillin allergy: discuss with Microbiology
Where it is not possible to give TDS IV dosing, the evening dose of amoxicillin could be replaced by an oral dose of amoxicillin 1g if oral route available. See above3. Alternatively, discuss with Cons. Microbiologist
Duration 5-7 days
If IV treatment is still needed after three days, discuss with Microbiology
True penicillin allergy: discuss with Microbiology
CURB-65 score can help assess severity.
Score 1 point for each of:
- New confusion (AMT ≤ 8)
- Urea > 7 mmol / L
- Resp rate ≥ 30 / minute
- BP (diastolic ≤ 60 mmHg or systolic < 90 mmHg)
- Age ≥ 65
Treatment regimens are suitable for use in patients with or without suspected or known COVID-19 infection
Treat only if there is clinical suspicion of bacterial infection, such as purulent sputum, or evidence of consolidation
CURB-65 = 0 or 1
Oral therapy
Doxycycline 200mg stat, then 100mg 24 hourly
Or
Amoxicillin 500mg-1g 8 hourly
IV Therapy
Amoxicillin 1g 8 hourly
CURB-65 = 2
Oral therapy
Amoxicillin500mg-1g 8 hourly
True penicillin allergy
Doxycycline 200mg stat, then 100mg 24 hourly
IV Therapy (unless otherwise stated)
Seek medical advice
Amoxicillin 1g 8 hourly
+
If Legionella, Mycoplasma or other atypical bacterial pathogens suspected, add clarithromycin4 500mg 12 hourly
True penicillin allergy:
Clarithromycin4 oral 500mg 12 hourly
CURB-65 ≥ 3
Use IV
Seek medical advice
Co-amoxiclav2 1.2g 8 hourly
+
Clarithromycin4 oral 500mg 12 hourly
Where it is not possible to give TDS IV dosing, the evening dose of co-amoxiclav could be replaced by an oral dose of Co-amoxiclav 625mg + amoxicillin 500mg if oral route available. See above3. Alternatively, discuss with Cons. Microbiologist.
True penicillin allergy
Levofloxacin 2, 6 oral 500mg 12 hourly
Duration 5 days
If treated for UTI in the last 6 months, check Microbiology history for suitable antibiotic choice
Oral therapy
Nitrofurantoin1
100mg MR 12 hourly
Or
Trimethoprim 200mg 12 hourly
IV Therapy
See upper UTI
Duration
Females 3 – 5 days
Males 7 days
Oral therapy
Co-trimoxazole 960mg BD for 7 days
Or, if eGFR<30, Ciprofloxacin 2, 6 see BNF for dosing in renal impairment
IV Therapy (unless otherwise stated)
Amoxicillin 1g 8 hourly
+
Gentamicin5
Where it is not possible to give TDS IV dosing, the evening dose of amoxicillin could be replaced by an oral dose of amoxicillin 1g if oral route available. See above3. Alternatively, discuss with Cons. Microbiologist
True penicillin allergy
Gentamicin5 as a single agent
Duration
Oral: as per antibiotic choice
IV: aim to convert to oral and complete total duration as per IV choice
If IV treatment is still needed after three days discuss with Microbiology
True penicillin allergy: Discuss with Microbiology
Do not use dipsticks with catheter samples. Treat only if symptomatic
Assess need for ongoing therapy after stat dose of gentamicin
Catheter change AND
Amoxicillin IV 1g 8 hourly
+
Gentamicin5
Where it is not possible to give TDS IV dosing, the evening dose of amoxicillin could be replaced by an oral dose of amoxicillin 1g if oral route available. See above3. Alternatively, discuss with Cons. Microbiologist
Or, if true penicillin allergy
Gentamicin5 as a single agent
If no features of systemic infection or osteomyelitis and infection is localised, PO can be used
Therapeutic drug monitoring of teicoplanin is not required for short courses
Duration 7-14 days
Oral therapy
Flucloxacillin 1g 6 hourly
If true penicillin allergy
Clarithromycin4 500mg 12 hourly
If MRSA suspected or known
Doxycycline 100mg 12 hourly
(check isolate is sensitive)
IV Therapy
Teicoplanin
NOTE: there are other teicoplanin regimens in use in NHS Borders. This guideline is for HOSPITAL AT HOME USE ONLY
Teicoplanin is loaded over three consecutive days (Days 1, 2 and 3) and this will provide equivalent to 5 days of treatment.
Teicoplanin should not be extended past the initial 5 days loading duration without input from an Infection specialist.
Patient’s age, height, weight and a stable serum creatinine are required to calculate the teicoplanin loading dose using the following steps:
|
Step 1: Calculate creatinine clearance |
• Use Cockroft-Gault formula CrCl (ml/min)=[(140-Age) X weight* X 1.23(male)or 1.04(female) ] Serum creatinine (micromol/L)** *Use total body weight (Kg) **If Cr <60 micromol/L , use a value of 60 micromol/L |
|
Step 2: Decide on using Ideal or Actual Body Weight |
• Use SAPG weight tables
• Use either Ideal or Total bodyweight, whichever is LOWER |
|
Step 3: Prescribe doses |
Prescribe daily for first 3 days:
See Medusa monograph for reconstitution guidance. Doses <800mg as IV infusion in 100ml over 30 minutes Doses ≥800mg as IV infusion in 100ml over 60 minutes |
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Reference
Lamont et al. Journal of Antimicrobial Chemotherapy 2009; 64 : 181-187
*1 May be used with caution if eGFR 30-44 ml/minute as a short course only (3-7 days) to treat uncomplicated lower UTI if caused by suspected or proven multidrug resistant bacteria only if potential benefit outweighs risk.
2These antibiotics are associated with a higher risk of developing Clostridium difficile infection, particularly in elderly patients
3Substitution of the evening IV dose of co-amoxiclav or amoxicillin with an oral dose is suboptimal treatment and should only be considered where the clinician considers the risk versus benefit of the alternative of hospital admission to be outweighed by the benefits of treatment via Hospital at Home. The patient or their appropriate representatives should give consent to this regimen and this should be recorded in the patient’s medical notes.
4Significant drug interactions
5See Gentamicin dosing calculator. Do not give more than 3 days of Gentamicin unless advised by Microbiology. Check culture results to guide ongoing treatment
6Fluroquinolones
Refer to important safety information for all quinolones prior to prescribing.
See MHRA Drug Safety Update January 2024: Fluoroquinolones must only be used in situations when other antibiotics, that are commonly recommended for the infection, are inappropriate such as:
Patients should be advised to stop fluoroquinolone treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint swelling, peripheral neuropathy and central nervous system effects, and to contact their doctor immediately
Refer to MHRA’s sheet for patients (regular print or large print) for further advice
Antimicrobial prescribing: NHS Borders