Empirical antimicrobial therapy for surgical infections in adults

Empirical antimicrobial therapy for surgical infections in adultsThis is guidance on the treatment of infection NOT prophylaxis (see surgical prophylaxis guidelines on antimicrobialwebsite and on anaesthetic room posters for surgical prophylaxis)Upper and lower GIAcute abdomen – from communityBiliary colic Antibiotics not indicatedAntibiotic choiceDurationUpper GI e.g.Cholecystitis (+/-empyema)CholangitisLower GI originfrom communitye.g.AppendicitisBowel perforationDiverticulitisIschaemic bowelIf had cefuroximeand metronidazole‘prophylaxis’ intheatre – startabove regimen 8hours later1 st choice: Amoxicillin 1g tds IV + Metronidazole 500mg tds IV +Gentamicin 5mg/Kg od IV (see Trust guideline)If Crcl ≤ 20mls/min: Piperacillin/Tazobactam (Tazocin ®) 4.5g bd IV.Consider addition of stat dose of gentamicin 2mg/Kg IV.Penicillin allergy: Co-trimoxazole 960mg bd IV replaces AmoxicillinMRSA or high risk of MRSA: Give Vancomycin IV (see Trustguideline) instead of Amoxicillin / Co-trimoxazole, send MRSA screen,and contact Microbiology for sensitivitiesIf failure to respond after 48 hours, or previous antibiotics in last10 days (excluding prophylaxis): Discuss with senior surgeon +/-MicrobiologyOral switch: Doxycycline 200mg od PO + Metronidazole 400mg tdsPO [this can be given from onset with addition of gentamicin 5mg/kg odIV for a minimum of 48 hours (see Trust guideline) if clinical conditionallows]Abscesses andcollections should bedrained. If sourcecontrol not achieved,discuss with consultantre: further surgicalintervention.Upper GI:4-7 days total based onCRP/WCC/Obs etcLower GI:12hrs contaminationor gross contamination:4-7 days total based onCRP/WCC/Obs etc.N.B. This guideline is for Adults only – Doxycycyline is not suitable forchildren – Co-amoxiclav is a suitable oral switch in paediatrics.CommunityoesophagealperforationUncomplicated surgical wound infectionsUpper GI andlower GIAs above for upper GI / lower GI origin from communityPLUS Fluconazole 400mg od IV1 st choice: Doxycycline 200mg od PO + Metronidazole 400mg tds POIf NBM: Co-trimoxazole 960mg bd IV + Metronidazole 500mg tds IVMRSA or high risk: As above but send MRSA screen, and contactMicrobiology for sensitivitiesComplicated post-op infections e.g. with intra-abdominal involvementUpper GI andlower GIIf had cefuroximeand metronidazole‘prophylaxis’ intheatre – starttreatment regimen8 hours laterAntibiotic naïve (excluding surgical prophylaxis):1 st choice: Amoxicillin 1g tds IV + Metronidazole 500mg tds IV +Gentamicin 5mg/Kg od IV (see Trust guideline)If Crcl ≤ 20mls/min: Piperacillin/Tazobactam (Tazocin ®) 4.5g bd IV.Consider addition of stat dose of gentamicin 2mg/Kg IV.Penicillin allergy: Co-trimoxazole 960mg bd IV replaces AmoxicillinIf anastamotic breakdown: add Fluconazole 400mg od IVRecent (last 10 days) treatment course with IV antibiotics /recurrent: Piperacillin/Tazobactam (Tazocin ®) 4.5g tds (if penicillinallergy contact Microbiology for treatment options)MRSA or high risk of MRSA: Give Vancomycin IV (see Trustguideline) instead of Amoxicilllin / Co-trimoxazole (or add VancomycinConsider oral switchafter 48 hours if clinicalimprovementDependant on surgicalmanagement4-7 days totalAbscesses andcollections should bedrained. If sourcecontrol not achieved,discuss with consultantre: further surgicalintervention.4-7 days total based onCRP/WCC/Obs etc.Consider oral switchafter 48 hours if clinicalimprovementEmpirical antimicrobial therapy for surgical infections in adults (Version10. 17.09.12)Approved by the Antimicrobial Stewardship Group: September 18 th 2012Review date: September 2014Page 1 of 4

IV if on Piperacillin/Tazobactam (Tazocin ®)), send MRSA screen, andcontact Microbiology for sensitivitiesIf failure to respond after 48 hours: Discuss with senior surgeon +/-MicrobiologyOral switch: Doxycycline 200mg od PO + Metronidazole 400mg tdsPO [this can be given from onset with addition of gentamicin 5mg/kg odIV for a minimum of 48 hours (see Trust guideline) if clinical conditionallows]As above for complicated post-op infectionsPLUS Fluconazole 400mg od IVPost-opoesophagealperforationSevere Sepsis (see definition below)Upper GI andlower GISevere Sepsis: ≥2SIRS criteriaAND evidence ofinfection ANDorgan dysfunctionAntibiotic naïve (excluding surgical prophylaxis): Amoxicillin 1g tdsIV + Metronidazole 500mg tds IV + Gentamicin 5mg/Kg od IV (seeTrust guideline)If Crcl ≤ 20mls/min: Piperacillin/Tazobactam (Tazocin ®) 4.5g bd IV.Consider addition of stat dose of gentamicin 2mg/Kg IV.Penicillin allergy: Co-trimoxazole 960mg bd IV replaces AmoxicillinMRSA or high risk of MRSA: Give Vancomycin IV (see Trustguideline) instead of Amoxicillin / Co-trimoxazole, send MRSA screen,and contact Microbiology for sensitivitiesHealthcare associated or recent treatment course (last 10 days)with IV antibiotics: Piperacillin/Tazobactam (Tazocin ®) 4.5g tds IV ±Vancomycin IV (see Trust guideline). Send MRSA screen and stopVancomycin if screen & diagnostic specimens negative. If penicillinallergy contact Microbiology for treatment optionsPANCREATITIS – calculate *Glasgow scoreMild (score 0-2) Antibiotics not indicatedDependant on surgicalmanagementTreat within ONE hourof diagnosis.Review daily – discusswith Microbiology withinnext 24 – 48 hoursSend MRSA screenIf source control notachieved, discuss withconsultant re: furthersurgical interventionSevere(score 3-8)>30% necrosis onCT scan at 48hours1st choice: Piperacillin/tazobactam (Tazocin®) 4.5g tds IVMild penicillin allergy: Meropenem 1g tds IVSevere allergy: Discuss with MicrobiologyMRSA: Add Vancomycin IV (see Trust guideline)Add Fluconazole 400mg od IV to above regimenMaximum 10 days*Glasgow score: score 1 point for any of the following occurring at any time in the first 48 hours of admission:• Age >55 years• Serum albumin 16.1 mmols/L (45 mg/dL)• WBC count >15 x 10^9/L (15 x 10^3/microlitre)Glasgow Score Severity Assessment0-2 Mild3-8 SevereEmpirical antimicrobial therapy for surgical infections in adults (Version 10. 17.09.12)Approved by the Antimicrobial Stewardship Group: September 18 th 2012Review date: September 2014Page 2 of 4

Breast Antibiotic choice DurationMastitis1 st choice: Flucloxacillin 1g qds PO/IVAbscessBreastuncomplicatedsurgical siteinfectionsPenicillin allergy: Doxycycline 200mg od PO or Vancomycin IV (seeTrust guideline)MRSA: Add Vancomycin IV if not already on (see Trust guideline) orcheck lab sensitivities for oral optionIf necrotising infection suspected: Add Clindamycin 1.2g qds IV anddiscuss urgently with senior surgeon +/- MicrobiologyN.B. Doxycycyline is not suitable if pregnant or breastfeeding – contactMicrobiology for alternative treatment options for these patients.Abscesses andcollections should bedrained4-10 days total basedon CRP/WCC/Obs etcAcute breastimplant infectionMust bediscussed withConsultantsurgeon1 st choice: Flucloxacillin 1-2 g qds IVPenicillin allergy: Vancomycin IV (see Trust guideline)If sub-acute or late infection: discuss antimicrobial management withMicrobiology14 days total (discussoral switch withMicrobiology)Urology Antibiotic choice DurationUTIUncomplicatedCheck cultureresults & modifytreatmentaccordingly1 st choice: Trimethoprim 200mg bd PO2 nd Choice: Nitrofurantoin 50–100mg qds POIf pregnant: Cefalexin 500mg bd PO for 7 days – send urine cultureseven days after completion to confirm cure3 days for female7 days for male7 days for pregnantComplicated (e.g. catheter, structural abnormality, post-op etc)7 days1 st choice: Amoxicillin 1g tds IV + Gentamicin 5mg/kg od IV (see Trustguideline, max 5 days). Oral switch asap Trimethoprim 200mg bd PO2 nd Choice (penicillin allergic): Gentamicin 5mg/kg od IV (see Trustguideline, max 5 days). Oral switch asap Trimethoprim 200mg bd POPyelonephritis:10-14 daysAcute prostatitisEpididymo-orchitisSee full guideline1 st choice: Amoxicillin 1g tds IV + Gentamicin 5mg/kg od IV (see Trustguideline, max 5 days). Oral switch asap Co-amoxiclav 625mg tds PO2 nd Choice (penicillin allergic): Gentamicin 5mg/kg od IV (see Trustguideline, max 5 days). Oral switch asap discuss with MicrobiologyUrological severe sepsis see below1 st choice: Trimethoprim 200mg bd PO2 nd choice after discussion with Microbiology: Ciprofloxacin 500mgbd POLikely STD cause: Doxycycline 100mg bd PO + Ceftriaxone 500mgIM single dose (omit if gonorrhoea unlikely)Likely enteric cause: Ciprofloxacin 500mg bd PO14 days10-14 days10 daysEmpirical antimicrobial therapy for surgical infections in adults (Version 10. 17.09.12)Approved by the Antimicrobial Stewardship Group: September 18 th 2012Review date: September 2014Page 3 of 4

Urologicaluncomplicatedsurgical woundinfectionsUrologicalcomplicated postopinfectionUrological severesepsisSevere Sepsis: ≥2SIRS criteriaAND evidence ofinfection ANDorgan dysfunction1 st choice: Doxycycline 200mg od PO + Metronidazole 400mg tds POIf NBM: Co-trimoxazole 960mg bd IV + Metronidazole 500mg tds IVMRSA or high risk: as above, send MRSA screen, and contactMicrobiology for sensitivitiesAntibiotic naïve (excluding surgical prophylaxis):1 st choice: Co-trimoxazole 960mg bd IV + Metronidazole 500mg tdsIV + Gentamicin 5mg/Kg od IV (see Trust guideline)If Crcl ≤ 20mls/min: Piperacillin/Tazobactam (Tazocin ®) 4.5g bd IV.Consider addition of stat dose of gentamicin 2mg/Kg IV.Recent (last 10 days) treatment course with IV antibiotics /recurrent: Piperacillin/Tazobactam (Tazocin ®) 4.5g tds IV (if penicillinallergy contact Microbiology for treatment options)MRSA or high risk of MRSA: Give Vancomycin IV (see Trustguideline) instead of Co-trimoxazole (or add Vancomycin IV if onPiperacillin/Tazobactam (Tazocin ®)), send MRSA screen, and contactMicrobiology for sensitivitiesIf failure to respond after 48 hours: Discuss with senior surgeon +/-MicrobiologyOral switch: Doxycycline 200mg od PO + Metronidazole 400mg tdsPO [this can be given from onset with addition of gentamicin 5mg/kg odIV for a minimum of 48 hours (see Trust guideline) if clinical conditionallows]1 st choice (community acquired or healthcare associated):Piperacillin/Tazobactam (Tazocin ®) 4.5g tds IV + Gentamicin 5mg/kgstat IV (see Trust guideline). Send MRSA screenSevere penicillin allergy: Discuss with Microbiology4-7 days total based onCRP/WCC/Obs etcAbscesses andcollections should bedrained4-7 days total based onCRP/WCC/Obs etc.Treat within ONE hourof diagnosis.Review daily – discusswith Microbiology withinnext 24 -48 hours• This does not cover Surgical Prophylaxis – there is separate guidance on IaN & on posters inanaesthetic rooms.• Source control (i.e. surgery or drainage) is the primary treatment – antibiotics are at best an adjunct.• Severe sepsis definition from ‘Surviving Sepsis’: ≥2 SIRS criteriao Temp38.3°Co Heart rate >90 beats/minuteo Respiratory rate >20 breaths/minute or Pa CO 2 12 x10 9 /L or 5 days without discussing withMicrobiology.• Antibiotic treatment must be reviewed in light of significant cultures and targeted appropriately.Empirical antimicrobial therapy for surgical infections in adults (Version 10. 17.09.12)Approved by the Antimicrobial Stewardship Group: September 18 th 2012Review date: September 2014Page 4 of 4