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/minor3mg/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 administrationCrCl 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/minor3mg/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 administrationCrCl 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/minor3mg/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/minor3mg/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 |
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 (see link on MHRA warning on quinolones) |
Comment
Diagnosis:
Ascitic neutrophil count >250 cells/mm3.
| Antibiotic – 1st line |
| Ciprofloxacin 500mg PO q24h indefinitely (see link on MHRA warning on quinolones) |
| 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) |