Hepato-bilary

Microbiological specimens
For complicated infections such as pancreatic necrosis and liver abscess it is important to remember that the regimes are initial recommendations and discussion with Microbiologist during work hours is essential.

  • Blood culture
  • Intra-abdominal pus
  • Ascitic fluid tap
  • Guided aspirates from abscess cavities
  • MRSA screen as per policy

The choice of agent should take into account the patient’s risk for C. difficile infection.

Common Pathogen(s)
Coliforms; Enterococci; Anaerobes.

Antibiotic – 1st line
No antibiotics required unless evidence of impending sepsis

Duration of therapy 5 days

Common Pathogen(s)
Coliforms; Enterococci; Anaerobes.

Antibiotic – 1st line
Amoxicillin 1g IV q8h
plus
Metronidazole 500mg IV q8h if stented or complex case.
plus 
Gentamicin (click here for full gentamicin policy)
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70 years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/minor

3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration

CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.

If patient is obese ie. 20% over ideal body weight – use adjusted body weight

Review after 48 hours.

Oral step down based on clinical response of patient.  If sensitivities not available use Co-amoxiclav (consider C difficile risk factor) 625mg PO q8h.

 

Antibiotic – 2nd line
If Gentamicin contra-indicated, use Co-amoxiclav (consider C difficile risk factor)1.2g IV q8h or 625mg PO q8h

If recurrent episode: Cefuroxime IV 1.5g q8h plus Metronidazole IV 500mg q8h

If penicillin allergy – gentamicin and metronidazole may be used  without amoxicillin – see above for doses

Comment
Discuss alternative regimes with Microbiologist or Gastroenterologist during working hours.

Duration of therapy based on clinical progress

Common Pathogen(s)
Coliforms; Enterococci; Anaerobes.

Antibiotic – 1st line
Amoxicillin 1g IV q8h
plus 
Metronidazole 500mg IV q8h 
plus 
Gentamicin (click here for full gentamicin policy) 
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/minor

3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)

Round to nearest 20mg for ease of administration

CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.

If patient is obese ie. 20% over ideal body weight – use adjusted body weight

Review after 48 hours.

Oral step down based on clinical response of patient.  If sensitivities not available use Co-amoxiclav (Consider C difficile risk) 625mg PO q8h.

 

Antibiotic – 2nd line
If Gentamicin contra-indicated, use Co-amoxiclav (consider C difficile risk) 1.2g IV q8h or 625mg PO q8h

If recurrent episode – Cefuroxime IV 1.5g q8h plus Metronidazole IV 500mg q8h

If penicillin allergy – gentamicin plus metronidazole may be used without amoxicillin  – see above for doses

Antibiotic – 1st line
No antibiotics required.

Oedematous or mild acute pancreatitis (predominant form/self-limiting)

Antibiotic – 1st line
No antibiotics required.

Duration 7 days

CT evidence of necrotising or severe acute pancreatitis (high mortality)

Antibiotic – 1st line
First Episode:
Amoxicillin 1g IV q8h
plus 
Metronidazole 500mg IVq8h
plus 
Gentamicin (click here for full gentamicin policy) 
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/minor

3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight – use adjusted body weight

 

Antibiotic – 2nd line
Penicillin allergic – start 1st line regime without Amoxicillin and contact microbiologist
Or
Cefuroxime 1.5g IV q8h (if ok with cephalosporins) plus metronidazole 500mg IV q8h
Or
if serious penicillin allergy (history of anaphylaxis, urticaria, or rash immediately after penicillin administration)
Teicoplanin 10mg/kg IV q12h for 3 doses, then 10mg/kg q24h (round to nearest 200mg or 400mg vial)
plus
Metronidazole 500mg IV q8h
plus
Gentamicin (click here for full gentamicin policy)
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/minor

3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight – use adjusted body weight

Comment
Diagnosis requires CT scan.
Early referral to Critical Care Team recommended.
Discuss with Microbiologist during working hours if previous results show MRSA / ESBL / CDI.

Common Pathogen(s)
Enterobacteriaceae;
Streptococci;
Enterococcus;
Anaerobes;
Entamoeba histolytica; Echinococcus.

Antibiotic – 1st line
Amoxicillin 1g IV q8h
plus 
Metronidazole 500mg IV q8h.
Plus
Gentamicin (click here for full gentamicin policy) 
Note: If serum creatinine is not yet known then 5mg/kg may still be initiated unless 70years or above or there is evidence of existing severe renal impairment. CrCl must still be calculated once U+Es are available. ALL SUBSEQUENT DOSES MUST BE ADJUSTED AS PER CrCl once known. Must check pre-dose level as per policy.5mg/kg IV q24h (max 500mg): if <70 years and CrCl≥30mL/min or
3mg/Kg IV q24h (max 300mg): If ≥70 years or CrCl 10-29.9ml/min, known renal impairment, or clinician has concerns about higher dose (e.g. clinical signs of renal impairment)
Round to nearest 20mg for ease of administration
CrCl known to be under <10ml/min discuss with microbiology during working hours for gentamicin dosing/or alternative antibiotic recommendation.
If patient is obese ie. 20% over ideal body weight – use adjusted body weightFollowing radiological confirmation: change to Co-amoxiclav (C difficile risk) 1.2g q8h IV and discussion with Microbiologist during working hours.

 

Antibiotic – 2nd line
Discuss with Microbiologist during working hours for any oral switch or targeted therapy

Mild penicillin allergy
Cefuroxime 1.5g IV q8h plus metronidazole PO 400mg q8h
Or
if serious penicillin allergy (history of anaphylaxis, urticaria, or rash immediately after penicillin administration)
Ciprofloxacin IV 400mg q12h plus metronidazole PO 400mg q8h

Comment
Discuss ALL cases and duration of therapy with a microbiologist during working hours. (usually 6 weeks)

MUST review and treat as per sensitivity

For single abscesses with a diameter ≤5 cm, either percutaneous catheter drainage or needle aspiration is acceptable

For percutaneous management of single abscesses with diameter >5 cm, catheter drainage is preferred over needle aspiration.

For single abscesses with diameter >5 cm, surgical intervention over percutaneous drainage should be considered

Please send pus for culture and sensitivity and parasitology and also Faecal sample for Ova cysts and parasites.

Duration of therapy 5 days

Common Pathogen(s)
E.coli; Streptococci; Enterococci. Secondary: Polymicrobial; Anaerobes.

Antibiotic – 1st line
Co-amoxiclav (consider C difficile risk)1.2g IV q8h or

Review after 48 hours and refer to culture results if available.

 

Antibiotic – 2nd line/recurrent/severe sepsis
Cefuroxime 1.5g IV q8h plus Metronidazole 500mg IV q8h

Serious penicillin allergy (history of anaphylaxis, urticaria, or rash immediately after penicillin administration) Ciprofloxacin PO 500mg q12h or IV 400mg q12h plus metronidazole IV 500mg q8h

Comment
Diagnosis:
Ascitic neutrophil count >250 cells/mm3.

Antibiotic – 1st line
Ciprofloxacin 500mg PO q24h indefinitely

 

Antibiotic – 2nd line
Co-trimoxazole 960mg PO q24h indefinitely (can be used first line where co-trimoxazole sensitivity is confirmed)

Comment
Primary = patients with ascitic fluid protein ≤10g/l AND bilirubin ≥ 50micromole/l who are potential liver transplant candidates
Secondary = all previous SBP patients

Please note that some patients who are on Liver transplant list may be receiving rifaximin for prevention of bacterial overgrowth/hepatic encephalopathy

To prevent SBP

Antibiotic – 1st line
Cefuroxime 1.5g IV q8h +/- Metronidazole 500mg IV q8h minimum for 48hrs after variceal bleed has been controlled

Serious penicillin allergy (history of anaphylaxis, urticaria, or rash immediately after penicillin administration)
Ciprofloxacin IV 200-400mg q12 plus metronidazole IV 500mg q8h minimum for 48hrs after variceal bleed has been controlled