Microbiological specimens (Where Tuberculosis is not under consideration)
Tuberculosis (TB)
All suspected cases of TB should be drawn to the attention of Microbiologist/ICTeam and TB Lead
Discuss Mantoux test with TB Health Visitor and TB Lead.
(Non-pneumonic LRTI) NO new CXR infiltrates [consolidation]
Duration of therapy 5 days
Common Pathogen(s)
Haemophilus influenzae; Streptococcus pneumoniae; Moraxella catarrhalis; Viruses;
Occasionally S. aureus (post viral episode). 20-40% episodes of non-infective aetiology and up to 30% of viral origin.
Antibiotic - 1st line |
2nd line |
Comment
Antibiotics ARE indicated in the following:
↑ sputum volume;
↑ purulence of sputum;
Dyspnoea.
Review treatment with culture and sensitivity results and switch to targeted antibiotic therapy. Consider pertussis if non-resolving cough – contact microbiologist
CURB 65: |
*No history of renal impairment or known cause for increased urea Assessing Severity of Community Acquired Pneumonia
Additional adverse prognostic factors
Discuss with On Call Physician / Critical Care Physician / Respiratory Physician any patients with a CURB-65 score > 3. Microbiological specimens for Community Acquired Pneumonia
|
Comment
Discuss with On Call Physician / Critical Care Physician / Respiratory Physician any patients with a CURB-65 score > 3
Severe Legionella / MRSA / previous C. diff or MDR Gram negatives - Discuss with Consultant Microbiologist
De-escalate therapy once microbiological results available.
Negative urinary antigen for Legionella may be used to de-escalate/ or stop Clarithromycin if on duo therapy start treatment as soon as possible (within 4 hours) of admission.
With no adverse prognostic factors.
Duration 5 days [guided by the clinical progress]
Antibiotic - 1st line Amoxicillin 500mg q8h PO. |
2nd line |
Duration 5days [guided by the clinical progress]
Antibiotic - 1st line |
2nd line |
Duration of therapy 7days [guided by clinical progress].
Antibiotic - 1st line |
2nd line |
Duration of therapy 7 days [guided by clinical progress].
Comment
All patients with HAP should be entered on HAP Care Bundle.
Severe HAP: RR>30/min;
Hypoxia (PaO2 <8 kPa or <92% on any FiO2); CXR changes;
BP systolic <90 or diastolic <=60;
New mental confusion
A. Early onset [2-5d of hosp. Adm.] & no prev. antibiotic
Antibiotic - 1st line Amoxicillin 2g q8h IV 5mg/kg IV one stat dose (max 500mg): if <70 years and CrCl≥30mL/min or |
2nd line |
B. Late onset [>5d hosp. adm. Or Early onset and received prev. antibiotic}.
Antibiotic - 1st line |
2nd line |
A. No previous antibiotic
Antibiotic - 1st line |
2nd line |
B. Previous antibiotic and not known to be colonised with pseudomonas or other resistant organisms
1st line Non-serious penicillin allergy (e.g. rash) - Cefuroxime 1.5 g IV q8h |
C. Previous antibiotic and patients known to be colonized with at least 2 consecutive pseudomonas in sputum or other relevant samples
For Late onset HAP severe - Serious penicillin allergy (history of anaphylaxis, urticaria, or rash immediately after penicillin administration) Non severe HAP Severe HAP Ciprofloxacin PO 500mg or IV 400mg q12h plus Vancomycin IV (dosed as per trust vancomycin guideline) |
Duration of therapy 5 days [guided by clinical progress]
Antibiotic - 1st line Admission < 5 DAYS: Admission > 5 DAYS: |
Comments
Aspiration pneumonitis is chemical and often self-limiting. Treatment not needed unless major aspiration or if chest x-ray confirms pneumonia (new consolidation).
Comments
Aspiration pneumonitis is chemical and often self-limiting. Treatment not needed unless major aspiration or if chest x-ray confirms pneumonia (new consolidation).
(> 48 hours of mechanical ventilation. CPIS ≥ 6)
Common Pathogen(s)
Must discuss with Microbiologist during working hours for:
Legionella, MRSA,
ESBL coliforms,
C. difficile,
Pneumocystis,
Neutropenic patients,
Multidrug resistant pathogens, and all haematology patients.
Antibiotic - 1st line Early VAP (< 5 days on ventilation): |
Late VAP (>5 days on ventilation)/ Previous C. difficile infection: |
Comment
All cases on ITU, HDU and Cardiac ITU should be reviewed regularly with Consultant Microbiologist.
Duration of therapy should be guided by radiological and clinical response. [4- 6 weeks].
Common Pathogen(s)
Streptococcus milleri;
Anaerobes;
Staphylococcus aureus;
aerobic/ microaerophilic Streptococci.
Antibiotic - 1st line Hospital acquired: |
2nd line |
Comment
All cases should be discussed with Microbiologist and a Respiratory Physician during working hours.
De-escalate to appropriate narrow spectrum antibiotic once culture/ sensitivity available
(minimum of 2 weeks depending on radiological/ surgical intervention/ clinical response).
Common Pathogen(s)
Streptococcus milleri;
Anaerobes;
Staphylococcus aureus;
aerobic/ microaerophilic Streptococci.
Antibiotic - 1st line |
2nd line |
Comment
All cases should be discussed with Microbiologist and a Respiratory Physician during working hours.
De-escalate to appropriate narrow spectrum antibiotic once culture/ sensitivity available.
Treatment should be individualised for each patient and sputum should be sent for culture before initiating empiric antibiotic therapy – total duration 14 days (IV plus oral de-escalation if possible)
Common Pathogen(s)
Haemophilus
Influenzae;
Streptococcus
pneumoniae;
Moraxella catarrhalis;
Viruses;
Occasionally S. aureus (post viral episode)
Pseudomonas – see below
Antibiotic - 1st line If IV antibiotics indicated, treatment should be guided by previous results. |
2nd Line |
If Pseudomonas detected and failed 1st line treatment , discuss with Microbiology / Respiratory physician during working hours.
1st line Piperacillin-tazobactam IV q8h 4.5g |
Serious penicillin allergy (history of anaphylaxis, urticaria, or rash immediately after penicillin administration) |
Comment
IV antibiotics should be considered when patients are particularly unwell, have resistant organisms or have failed to respond to oral therapy.
Review antibiotics once culture results are available.
Pulmonary exacerbations of cystic fibrosis (CF) can be treated with oral or intravenous antibiotics. When IV therapy is needed patients are usually managed with a combination of two or more IV antibiotics. Common organisms in the sputum of CF patients are Pseudomonas aeruginosa and Burkholderia cepacia.
Ideally an aminoglycoside in combination with an anti-pseudomonal beta-lactam should be used first line. For those colonised with Burkholderia species, a third IV antibiotic should normally be prescribed. IV treatment is normally continued for 14 days depending on response.
Patients with CF have a high prevalance of antibiotic intolerance (check the allergy card in the medical notes) and alternative antibiotic regimens may be needed; if in doubt discuss with the CF doctors or the CF specialist pharmacist in normal working hours, or the CF consultant on call out of hours.
If the patient uses a maintenance nebulised antibiotic (e.g. tobramycin) and the same antibiotic is also being used for IV treatment, the nebulised form of the antibiotic would usually be withheld.
If you need information on how to administer a particular IV antibiotic for a patient with CF please contact the CF specialist pharmacist.
See the CF Trust’s ‘Antibiotic Treatment for Cystic Fibrosis’ consensus document for further information.
First Line
Tobramycin IV 5mg/kg q24h
If patient is obese (20% over ideal body weight), use adjusted body weight to calculate dose – see below for details
plus
Ceftazidime IV 3g q6h (unlicensed dose)
or
Meropenem IV 2g q8h
or
Piperacillin/Tazobactam IV 4.5g q6h (max 14 days)
If colonised with Burkholderia add a 3rd IV antibiotic, preferably:
Co-trimoxazole IV 960mg q12h
Alternatives
In those with allergy, intolerance or previous failure on the above first line agents alternatives may be needed.
Other agents sometimes used for CF exacerbation
All doses assume normal renal and hepatic function - discuss with the CF pharmacist in hours, or the on call pharmacist out of hours if there is concern regarding renal or hepatic clearance of antibiotics. The list below is in alphabetical order, not order of preference.
Amikacin IV 15mg/kg q24h (do NOT use in combination with other aminoglycosides) - If patient is obese (20% over ideal body weight), use adjusted body weight to calculate dose – see below for details
Aztreonam IV 3g q6h (or 4g q8h) - both doses are unlicensed
Chloramphenicol IV 1g q6h (with alternate day FBC monitoring)
Ciprofloxacin IV 400mg q12h or q8h
Colistimethate Sodium (Colistin) IV 2MU q8h
Flucloxacillin IV 1-2g q6h
Fosfomycin IV 4g q8h (can give higher doses on discussion with consultant)
Teicoplanin IV 12mg/kg kg q12h for 3 doses then continue q24h (round to nearest 200mg or 400mg vial)
Temocillin IV 2g q12h
Ticarcillin with Clavulanic Acid (Timentin) IV 3.2g q6h
Tigecycline 100mg stat dose followed by 50mg q12h (12 hours after initial dose)
Vancomycin IV as per Trust guidance
Pregnancy and breastfeeding
If a patient is pregnant or breastfeeding and requires IV antibiotics please discuss treatment options with a CF consultant or the CF specialist pharmacist beforecommencing treatment.
Antibiotic desensitisations
These can be arranged by contacting the CF specialist pharmacist during working hours. Desensitisations should not be attempted outside of normal working hours.
Following a successful desensitisation, the patient must receive the antibiotic regularly. If the antibiotic is withheld for more than 24 hours a repeat desensitisation will be required and it must be given by intravenous infusion (not bolus).
Calculating Ideal and Adjusted Body Weight
Calculate the ideal body weight (IBW) first and then use this to calculate the adjusted body weight (AdjBW).
IBW men (kg) = 50 + (2.3 x every inch over 5 feet)
IBW women (kg) = 45.5 + (2.3 x every inch over 5 feet)
AdjBW = IBW + 0.4 x (actual body weight – IBW)