TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Please email any recommendations for improvement (big or small) to amy.legg@nt.gov.au

For guidelines, see the Infectious Diseases and Antimicrobial Stewardship homepage


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Choose an organism for local susceptibilities

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Antibiogram

2020 TEHS Staphylococcus aureus susceptibility profile

MSSA nmMRSA MRSA
Amikacin - - -
Ampicillin 13 0 0
Amoxicillin-clavulanic acid 100 0 0
Cefazolin 100 0 0
Ceftriaxone 100 0 0
Ceftazidime - - -
Ciprofloxacin 98 98 16
Clindamycin 82 87 28
Erythromycin 82 87 28
Flucloxacillin 100 0 0
Fusidic acid 96 96 71
Gentamicin 100 100 0
Meropenem - - -
Nitrofurantoin - - -
Penicillin 13 0 0
Piperacillin/tazobactam - - -
Rifampicin 100 100 86
Tobramycin - - -
Trimethoprim - - -
Trimethoprim-SMX 98 81 57
Vancomycin 100 100 100
Teicoplanin - - -
Linezolid - 100 100
Total percentage of isolates: 63.4% 36.0% 0.6%

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Antibiogram

2020 TEHS Streptococcus pneumoniae susceptibility profile

S. pneumoniae (meningitis) S. pneumoniae (non meningitis)
Amikacin - -
Ampicillin - -
Amoxicillin-clavulanic acid - -
Cefazolin - -
Ceftriaxone 97 100
Ceftazidime - -
Ciprofloxacin - -
Clindamycin - -
Erythromycin - -
Flucloxacillin - -
Fusidic acid - -
Gentamicin - -
Meropenem - -
Nitrofurantoin - -
Penicillin 81 100
Piperacillin/tazobactam - -
Rifampicin - -
Tobramycin - -
Trimethoprim - -
Trimethoprim-SMX - -
Vancomycin 100 100
Teicoplanin - -
Linezolid - -

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Antibiogram

2020 TEHS Enterococcus sp susceptibility profile

E. faecalis E. faecium
Amikacin - -
Ampicillin 100 0
Amoxicillin-clavulanic acid 100 0
Cefazolin - -
Ceftriaxone - -
Ceftazidime - -
Ciprofloxacin 89 0
Clindamycin - -
Erythromycin - -
Flucloxacillin - -
Fusidic acid - -
Gentamicin - -
Meropenem - -
Nitrofurantoin 100 42
Penicillin 98 0
Piperacillin/tazobactam - -
Rifampicin - -
Tobramycin - -
Trimethoprim - -
Trimethoprim-SMX - -
Vancomycin 100 15
Teicoplanin 100 100
Linezolid 96 100

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Antibiogram

2020 TEHS Escherichia coli susceptibility profile

E. coli (urine) E. coli (other)
Amikacin 100 100
Ampicillin 44 46
Amoxicillin-clavulanic acid 83 83
Cefazolin 84 72
Ceftriaxone 88 80
Ceftazidime 96 96
Ciprofloxacin 80 74
Clindamycin - -
Erythromycin - -
Flucloxacillin - -
Fusidic acid - -
Gentamicin 91 87
Meropenem 100 100
Nitrofurantoin 96 -
Penicillin - -
Piperacillin/tazobactam 93 94
Rifampicin - -
Trimethoprim 58 -
Trimethoprim-SMX 62 60
Vancomycin - -
Teicoplanin - -
Linezolid - -

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Antibiogram

2020 TEHS Klebsiella pneumoniae susceptibility profile

K. pneumoniae
Amikacin 100
Ampicillin -
Amoxicillin-clavulanic acid 93
Cefazolin 86
Ceftriaxone 93
Ceftazidime 95
Ciprofloxacin 88
Clindamycin -
Erythromycin -
Flucloxacillin -
Fusidic acid -
Gentamicin 97
Meropenem 99
Nitrofurantoin 21
Penicillin -
Piperacillin/tazobactam 93
Rifampicin -
Trimethoprim 83
Trimethoprim-SMX 85
Vancomycin -
Teicoplanin -
Linezolid -

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Antibiogram

2020 TEHS Proteus mirabilis susceptibility profile

P. mirabilis
Amikacin 100
Ampicillin 84
Amoxicillin-clavulanic acid 97
Cefazolin 95
Ceftriaxone 97
Ceftazidime 100
Ciprofloxacin 95
Clindamycin -
Erythromycin -
Flucloxacillin -
Fusidic acid -
Gentamicin 95
Meropenem 100
Nitrofurantoin -
Penicillin -
Piperacillin/tazobactam 100
Rifampicin -
Trimethoprim 81
Trimethoprim-SMX 81
Vancomycin -
Teicoplanin -
Linezolid -

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Antibiogram

2020 TEHS Enterobacter sp susceptibility profile

Enterobacter sp
Amikacin 100
Ampicillin -
Amoxicillin-clavulanic acid -
Cefazolin -
Ceftriaxone -
Ceftazidime 80
Ciprofloxacin 100
Clindamycin -
Erythromycin -
Flucloxacillin -
Fusidic acid -
Gentamicin 94
Meropenem 100
Nitrofurantoin -
Penicillin -
Piperacillin/tazobactam 77
Rifampicin -
Trimethoprim -
Trimethoprim-SMX 89
Vancomycin -
Teicoplanin -
Linezolid -

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Antibiogram

2020 TEHS Salmonella sp susceptibility profile

Salmonella sp
Amikacin -
Ampicillin 100
Amoxicillin-clavulanic acid 100
Cefazolin -
Ceftriaxone 100
Ceftazidime -
Ciprofloxacin 100
Clindamycin -
Erythromycin -
Flucloxacillin -
Fusidic acid -
Gentamicin -
Meropenem 100
Nitrofurantoin -
Penicillin -
Piperacillin/tazobactam -
Rifampicin -
Trimethoprim -
Trimethoprim-SMX 100
Vancomycin -
Teicoplanin -
Linezolid -

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Antibiogram

2020 TEHS Pseudomonas aeruginosa susceptibility profile

Pseudomonas
Amikacin 98
Ampicillin -
Amoxicillin-clavulanic acid -
Cefazolin -
Ceftriaxone -
Ceftazidime 95
Ciprofloxacin 98
Clindamycin -
Erythromycin -
Flucloxacillin -
Fusidic acid -
Gentamicin 98
Meropenem 96
Nitrofurantoin -
Penicillin -
Piperacillin/tazobactam 92
Rifampicin -
Trimethoprim -
Trimethoprim-SMX -
Vancomycin -
Teicoplanin -
Linezolid -

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Antibiogram

2020 TEHS Acinetobacter sp susceptibility profile

Acinetobacter
Amikacin 100
Ampicillin -
Amoxicillin-clavulanic acid -
Cefazolin -
Ceftriaxone -
Ceftazidime 86
Ciprofloxacin 96
Clindamycin -
Erythromycin -
Flucloxacillin -
Fusidic acid -
Gentamicin 100
Meropenem 100
Nitrofurantoin -
Penicillin -
Piperacillin/tazobactam 85
Rifampicin -
Trimethoprim -
Trimethoprim-SMX 89
Vancomycin -
Teicoplanin -
Linezolid -

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Antibiogram

2020 TEHS Burkholderia pseudomallei (melioid) susceptibility profile

Melioid
Amikacin -
Ampicillin -
Amoxicillin-clavulanic acid -
Cefazolin -
Ceftriaxone -
Ceftazidime 100
Ciprofloxacin -
Clindamycin -
Erythromycin -
Flucloxacillin -
Fusidic acid -
Gentamicin -
Meropenem 100
Nitrofurantoin -
Penicillin -
Piperacillin/tazobactam -
Rifampicin -
Tobramycin -
Trimethoprim -
Trimethoprim-SMX 100
Vancomycin -
Teicoplanin -
Linezolid -

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Ascending cholangitis

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


History of penicillin allergy or adverse reaction

No penicillin allergy

Immediate or delayed non-severe penicillin hypersensitivity

Immediate or delayed severe penicillin hypersensitivity


Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
  • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • OR
  • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

OR

2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
  • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
  • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
  • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

OR

3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
  • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
  • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
    • i.e. Less than 70 mmHg from 1 month up to 1 year
    • Less than (70 mmHg + [2 x age]) from 1 to 10 years
    • Less than 90 mmHg from 11 to 17 years
TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Ascending cholangitis

Is gentamicin contraindicated in this patient? (See below for contraindications)

Aminoglycoside Contraindications and Precautions

Contraindications Precautions
History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
Advanced liver disease
Advanced age (eg 80 years or older), depending on calculated renal function
Use of concomitant drugs that cause nephrotoxicity or ototoxicity

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Ascending Cholangitis

Is gentamicin contraindicated in this patient? (See below for contraindications)

Aminoglycoside Contraindications and Precautions

Contraindications Precautions
History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
Advanced liver disease
Advanced age (eg 80 years or older), depending on calculated renal function
Use of concomitant drugs that cause nephrotoxicity or ototoxicity

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Ascending cholangitis treatment

For ascending cholangitis in a patient with nonsevere penicillin hypersensitivity:

Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 1 g) IV, daily

PLUS if the patient has a history of biliary obstruction ADD:

Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly


Code for ceftriaxone is: 3asc
This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Ascending Cholangitis Treatment

For ascending cholangitis in a patient with life threatening penicillin hypersensitivity intolerant of gentamicin:

Please contact IFD for advice



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Ascending cholangitis treatment

For ascending cholangitis in a patient with life threatening penicillin hypersensitivity use:

Gentamicin IV, dosed as per nomograms below or use the gentamicin empiric dose calculator for adults

AND if the patient has a history of biliary obstruction ADD

Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly

Please contact IFD for advice for ongoing therapy past 72 hours


Code for gentamicin is: 2asc
This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



Initial Paediatric Gentamicin Dosing (Age < 12 years)

Age Initial dose
(for children with renal impairment, see text below)
Dosing
frequency
Maximum number
of empirical doses
Neonates <30 weeks
postmenstrual age
5 mg/kg 48-hourly 2 doses
(at 0 and 48 hours)
neonates 30 to 34
weeks postmenstrual age
5 mg/kg 36-hourly 2 doses
(at 0 and 36 hours)
neonates 35 weeks
postmenstrual age or older
5 mg/kg 24-hourly 3 doses
(at 0, 24 and 48 hours)
infants (1 month or older)
and children (up to 10 years old)
7.5 mg/kg (max 320 mg) 24-hourly 3 doses
(at 0, 24 and 48 hours)
children 10 years and older 6 mg/kg (max 560 mg)
increase to 7 mg/kg if critically unwell (max 560 mg)
24-hourly 3 doses
(at 0, 24 and 48 hours)

Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

Creatinine clearance
(mL/min)
Initial
dose
Dosing
frequency
Maximum number
of empirical doses
More than
60 mL/min
4 to 5 mg/kg 24-hourly 3 doses
(at 0, 24 and 48 hours)
40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
(at 0 and 36 hours)
less than
40 mL/min
4mg/kg Single dose, then seek expert advice


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Ascending Cholangitis Treatment

For ascending cholangitis in a patient who can tolerate penicillin and gentamicin:

Ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly

AND

Gentamicin IV, dosed as per nomograms below or use the gentamicin empiric dose calculator for adults

AND if the patient has a history of biliary obstruction ADD

Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly

If IV treatment is required after 72 hours change to ceftriaxone 2 g daily +/- metronidazole if biliary obstruction present, or use piperacillin and tazobactam 4.5 g IV, 8-hourly (Please contact IFD for advice)


Code for gentamicin is: 2asc
This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



Initial Gentamicin/Tobramycin Dosing (age > 12 years)

Creatinine clearance
(mL/min)
Initial
dose
Dosing
frequency
Maximum number
of empirical doses
More than
60 mL/min
4 to 5 mg/kg 24-hourly 3 doses
(at 0, 24 and 48 hours)
40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
(at 0 and 36 hours)
less than
40 mL/min
4mg/kg Single dose, then seek expert advice

Initial Paediatric Gentamicin Dosing (Age < 12 years)

Age Initial dose
(for children with renal impairment, see text below)
Dosing
frequency
Maximum number
of empirical doses
Neonates <30 weeks
postmenstrual age
5 mg/kg 48-hourly 2 doses
(at 0 and 48 hours)
neonates 30 to 34
weeks postmenstrual age
5 mg/kg 36-hourly 2 doses
(at 0 and 36 hours)
neonates 35 weeks
postmenstrual age or older
5 mg/kg 24-hourly 3 doses
(at 0, 24 and 48 hours)
infants (1 month or older)
and children (up to 10 years old)
7.5 mg/kg (max 320 mg) 24-hourly 3 doses
(at 0, 24 and 48 hours)
children 10 years and older 6 mg/kg (max 560 mg)
increase to 7 mg/kg if critically unwell (max 560 mg)
24-hourly 3 doses
(at 0, 24 and 48 hours)


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Ascending Cholangitis Treatment

For ascending cholangitis in a patient tolerant of penicillin but intolerant of gentamicin:

Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 1 g) IV, daily

AND if the patient has a history of biliary obstruction ADD

Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly

OR as a single agent (without metronidazole)

Piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) IV, 8-hourly


Code for either piperacillin or ceftriaxone is: 3asc
This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Carbuncle


Are there signs of spreading cellulitis or significant systemic features?

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Carbuncle


Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


History of penicillin allergy or adverse reaction

No penicillin allergy

Immediate or delayed non-severe penicillin hypersensitivity

Immediate or delayed severe penicillin hypersensitivity


Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
  • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • OR
  • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

OR

2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
  • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
  • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
  • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

OR

3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
  • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
  • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
    • i.e. Less than 70 mmHg from 1 month up to 1 year
    • Less than (70 mmHg + [2 x age]) from 1 to 10 years
    • Less than 90 mmHg from 11 to 17 years
TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Carbuncle

Is the patient a child or adult?

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Carbuncle

Is the patient a child or adult?

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Carbuncle

Is the patient a child or adult?

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Child carbuncle antibiotic treatment

Most carbuncles will require only excision and drainage with no antibiotic treatment. If antibiotic treatment is necessary while awaiting the results of cultures and susceptibility, use:

Cephalexin 12.5 mg/kg (up to 500 mg) orally, 6-hourly for 5 days

OR If compliance is unlikely with QID dosing and the infection is mild

Cephalexin 25 mg/kg orally (up to 1 g) orally, 12-hourly




TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Adult carbuncle antibiotic treatment

Most carbuncles will require only excision and drainage with no antibiotic treatment. If antibiotic treatment is necessary while awaiting the results of cultures and susceptibility, use:

Cephalexin 500 mg orally, 6-hourly for 5 days

OR If compliance is unlikely with QID dosing and the infection is mild

Cephalexin 1 g orally 12-hourly



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Child carbuncle antibiotic treatment

Most carbuncles will require only excision and drainage with no antibiotic treatment. If antibiotic treatment is necessary while awaiting the results of cultures and susceptibility, use:

Trimethoprim+sulfamethoxazole for child (6 weeks or older) 4+20 mg/kg (up to 160+800 mg) orally, 12-hourly for 5 days



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Adult carbuncle antibiotic treatment

Most carbuncles will require only excision and drainage with no antibiotic treatment. If antibiotic treatment is necessary while awaiting the results of cultures and susceptibility, use:

Clindamycin 450 mg orally, 8-hourly for 5 days

OR

Trimethoprim+sulfamethoxazole 160+800 mg orally, 12-hourly for 5 days


Code for clindamycin is: 5car
This code is valid for FIVE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past five days. Please annotate when IFD are to be contacted on eMMa and in patient notes



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Child carbuncle antibiotic treatment

Most carbuncles will require only excision and drainage with no antibiotic treatment. If antibiotic treatment is necessary while awaiting the results of cultures and susceptibility, use:

Flucloxacillin 12.5 mg/kg (up to 500 mg) orally, 6-hourly for 5 days.



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Adult carbuncle antibiotic treatment

Most carbuncles require excision and drainage with no antibiotic treatment. If antibiotic treatment is necessary while awaiting the results of cultures and susceptibility, use:

Dicloxacillin 500 mg orally, 6-hourly for 5 days.



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitic Carbuncle/Abscess

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


History of penicillin allergy or adverse reaction

No penicillin allergy

Immediate or delayed non-severe penicillin hypersensitivity

Immediate or delayed severe penicillin hypersensitivity


Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
  • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • OR
  • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

OR

2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
  • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
  • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
  • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

OR

3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
  • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
  • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
    • i.e. Less than 70 mmHg from 1 month up to 1 year
    • Less than (70 mmHg + [2 x age]) from 1 to 10 years
    • Less than 90 mmHg from 11 to 17 years
TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitic Carbuncle/Abscess

Would you class the cellulitis as mild/moderate or severe?


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitic Carbuncle/Abscess

Would you class the cellulitis/abscess as mild/moderate or severe?


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitic Carbuncle/Abscess

Is the patient an adult or a child?

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitic Carbuncle/Abscess

Would you class the cellulitis/abscess as mild/moderate or severe?


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitic Carbuncle/Abscess

Does the patient have a history of previous nmMRSA colonisation?


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitic Carbuncle/Abscess

Is the patient an adult or a child?

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitic Carbuncle/Abscess

Does the patient have a history of previous nmMRSA colonisation?


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitic Carbuncle/Abscess

Does the patient have a history of previous nmMRSA colonisation?


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitic Carbuncle/Abscess

Does the patient have a history of previous nmMRSA colonisation?


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Mild/moderate cellulitis treatment

Mild/moderate cellulitis from carbuncle with nonsevere penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility use:

Cephalexin 500 mg (child 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 days

OR, If compliance is unlikely with QID dosing and the infection is mild

Cephalexin 1 g (child 25 mg/kg up to 1 g) orally, 12-hourly for 5 days



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Mild/moderate cellulitis treatment

Mild/moderate cellulitis from carbuncle with life threatening penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

Clindamycin 450 mg orally, 8-hourly for 5 days

OR,

Trimethoprim+sulfamethoxazole 160+800 mg orally, 12-hourly for 5 days


Code for clindamycin is: 5cac
This code is valid for FIVE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past five days. Please annotate when IFD are to be contacted on eMMa and in patient notes



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Mild/moderate cellulitis treatment

Mild/moderate cellulitis from carbuncle with life threatening penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

Trimethoprim+sulfamethoxazole for child (6 weeks or older) 4+20 mg/kg (up to 160+800 mg) orally, 12-hourly for 5 days



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Mild/Moderate cellulitis treatment

Mild/Moderate cellulitis from carbuncle with no penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

Dicloxacillin 500 mg (child flucloxacillin 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 to 10 days.


OR, If compliance is unlikely with QID dosing and the infection is mild

Cephalexin 1 g (child 25 mg/kg up to 1 g) orally, 12-hourly for 5 to 10 days



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Severe abscess/cellulitis treatment

For empirical therapy in a patient with mild penicillin allergy; while awaiting the results of cultures and susceptibility testing, use:

Cefazolin 2 g (child 50 mg/kg up to 2 g) IV, 8-hourly until systemic features improve then switch to oral



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Severe abscess/cellulitis treatment

For empirical therapy in a patient with no penicillin allergy, while awaiting the results of cultures and susceptibility use:

Flucloxacillin 2 g (child 50 mg/kg up to 2 g) IV, 6-hourly until systemic features improve then switch to oral



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Mild cellulitis treatment

Mild cellulitis from a carbuncle in an adult at risk of nmMRSA or with nonsevere penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

Clindamycin 450 mg orally, 8-hourly for 5 days

OR

Trimethoprim/sulfamethoxazole 160/800 mg orally, 12-hourly for 5 days


Code for clindamycin is: 5cac
This code is valid for FIVE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past five days. Please annotate when IFD are to be contacted on eMMa and in patient notes



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Mild/moderate cellulitis treatment

Mild/moderate cellulitis from a carbuncle in a child at risk of nmMRSA or with nonsevere penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

Trimethoprim/sulfamethoxazole for child (6 weeks or older) 4+20 mg/kg (up to 160+800 mg) orally, 12-hourly for 5 to 10 days



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Severe abscess/cellulitis treatment

Severe cellulitis/abscess in a patient at risk of nmMRSA can be treated with:

Cefazolin 2 g (child 50 mg/kg up to 2 g) IV, 8-hourly.

AND

Vancomycin as per nomograms below or use the vancomycin empiric dose calculator for adults


Code for vancomycin is: 2cac
This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes


Vancomycin Dosing in Paediatrics

Age Starting Dose
(use actual body weight)
Dosing
frequency
Timing of first
trough concentration
Neonates < 30 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 18-hourly Before the second dose
postnatal age
14 days or older
15 mg/kg 12-hourly Before the third dose
Neonates 30 to 36 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 12-hourly Before the third dose
postnatal age
14 days or older
15 mg/kg 8-hourly Before the fourth dose
Neonates 37 to 44 weeks
postmenstrual age (NB1)
postnatal age
0 to 7 days
15 mg/kg 12-hourly Before the third dose
postnatal age
7 days or older
15 mg/kg 8-hourly Before the fourth dose
Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
  • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
  • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer
over(1)
< 40 Call IFD Call IFD Call IFD ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call IFD Call IFD Call IFD ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Man Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


References:

See the vancomycin adults and children ≥ 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017
See the vancomycin children < 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Severe cellulitis treatment

Severe cellulitis/abscess in patients at risk of nmMRSA with penicillin hypersensitivity can be treated with vancomycin:

As a single agent use vancomycin as per nomograms below or use the vancomycin empiric dose calculator for adults


Code for vancomycin is: 2cac
This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



Vancomycin Dosing in Paediatrics

Age Starting Dose
(use actual body weight)
Dosing
frequency
Timing of first
trough concentration
Neonates < 30 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 18-hourly Before the second dose
postnatal age
14 days or older
15 mg/kg 12-hourly Before the third dose
Neonates 30 to 36 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 12-hourly Before the third dose
postnatal age
14 days or older
15 mg/kg 8-hourly Before the fourth dose
Neonates 37 to 44 weeks
postmenstrual age (NB1)
postnatal age
0 to 7 days
15 mg/kg 12-hourly Before the third dose
postnatal age
7 days or older
15 mg/kg 8-hourly Before the fourth dose
Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
  • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
  • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer over(1)
< 40 Call IFD Call IFD Call IFD ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call IFD Call IFD Call IFD ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


References:

See the vancomycin adults and children ≥ 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017
See the vancomycin children < 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Severe cellulitis treatment in a patient with a history of nmMRSA without penicillin allergy

Severe cellulitis/abscess in adult patients at risk of nmMRSA should be treated with:

Cefazolin 2 g (child 50 mg/kg up to 2 g) IV, 8-hourly.

AND

Vancomycin, as per nomograms below or use the vancomycin empiric dose calculator for adults


Code for vancomycin is: 2cac
This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



Vancomycin Dosing in Paediatrics

Age Starting Dose
(use actual body weight)
Dosing
frequency
Timing of first
trough concentration
Neonates < 30 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 18-hourly Before the second dose
postnatal age
14 days or older
15 mg/kg 12-hourly Before the third dose
Neonates 30 to 36 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 12-hourly Before the third dose
postnatal age
14 days or older
15 mg/kg 8-hourly Before the fourth dose
Neonates 37 to 44 weeks
postmenstrual age (NB1)
postnatal age
0 to 7 days
15 mg/kg 12-hourly Before the third dose
postnatal age
7 days or older
15 mg/kg 8-hourly Before the fourth dose
Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
  • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
  • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer over(1)
< 40 Call IFD Call IFD Call IFD ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call IFD Call IFD Call IFD ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


References:

See the vancomycin adults and children ≥ 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017
See the vancomycin children < 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitis

Is there a purulent focus for infection such as an abscess or carbuncle?

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitis

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


History of penicillin allergy or adverse reaction

No penicillin allergy

Immediate or delayed non-severe penicillin hypersensitivity

Immediate or delayed severe penicillin hypersensitivity


Minor penicillin allergy

Anaphylaxis/severe reaction

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
  • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • OR
  • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

OR

2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
  • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
  • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
  • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

OR

3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
  • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
  • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
    • i.e. Less than 70 mmHg from 1 month up to 1 year
    • Less than (70 mmHg + [2 x age]) from 1 to 10 years
    • Less than 90 mmHg from 11 to 17 years
TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitis

Would you class the cellulitis as mild/moderate or severe?


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitis

Would you class the cellulitis as mild/moderate or severe?


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitis

Is the patient an adult or a child?

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitis

Would you class the cellulitis/abscess as mild/moderate or severe?


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitis

Are there suggestive signs of S.pyogenes? (eg, erysipelas or rapid progression with no associated wound or ulcer) (i.e. erysipelas? or rapid progression)


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitis treatment

For mild/moderate cellulitis in a patient with penicillin hypersensitivity (nonsevere) use as a single agent:

Cephalexin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 to 10 days


OR,If compliance is unlikely with QID dosing and the infection is mild

Cephalexin 1000 mg (child: 25 mg/kg up to 1 g), 12-hourly for 5 to 10 days



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitis treatment

For mild/moderate cellulitis in an adult with immediate (life threatening) penicillin hypersensitivity use as a single agent:

Clindamycin 450 mg orally, 8-hourly for 5 to 10 days


Code for clindamycin is: 5cel
This code is valid for FIVE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past five days. Please annotate when IFD are to be contacted on eMMa and in patient notes



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Mild cellulitis treatment

Mild cellulitis in a child with immediate (life threatening) penicillin hypersensitivity is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

Trimethoprim/sulfamethoxazole for child (6 weeks or older) 4+20 mg/kg (up to 160+800 mg) orally, 12-hourly for 5 to 10 days



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitis treatment

For mild/moderate cellulitis in a patient with signs of S.pyogenes use as a single agent:

Phenoxymethylpenicillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 to 10 days

OR

Procaine penicillin 1.5 g (child: 50 mg/kg up to 1.5 g) IM, daily for at least 3 days



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Cellulitis treatment

For mild/moderate cellulitis in a patient without signs of S.pyogenes use as a single agent:

Dicloxacillin 500 mg (child: Flucloxacillin 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 to 10 days



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Severe cellulitis treatment

For empirical therapy of severe cellulitis in an adult with mild penicillin allergy; while awaiting the results of cultures and susceptibility testing, use:

Cefazolin 2 g (child: 50 mg/kg up to 2 g) IV, 8-hourly

Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Severe cellulitis treatment

For empirical treatment of severe cellulitis in a patient with life threatening penicillin hypersensitivity use either vancomycin or clindamycin.

Vancomycin as per nomograms below or use the vancomycin empiric dose calculator for adults

OR

Clindamycin 600 mg (child: 15 mg/kg up to 600 mg) IV, 8-hourly


Code for clindamycin or vancomycin is: 2cel
This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



Vancomycin Dosing in Paediatrics

Age Starting Dose
(use actual body weight)
Dosing
frequency
Timing of first
trough concentration
Neonates < 30 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 18-hourly Before the second dose
postnatal age
14 days or older
15 mg/kg 12-hourly Before the third dose
Neonates 30 to 36 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 12-hourly Before the third dose
postnatal age
14 days or older
15 mg/kg 8-hourly Before the fourth dose
Neonates 37 to 44 weeks
postmenstrual age (NB1)
postnatal age
0 to 7 days
15 mg/kg 12-hourly Before the third dose
postnatal age
7 days or older
15 mg/kg 8-hourly Before the fourth dose
Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
  • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
  • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer over(1)
< 40 Call IFD Call IFD Call IFD ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call IFD Call IFD Call IFD ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


References:

See the vancomycin adults and children ≥ 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017
See the vancomycin children < 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Severe cellulitis treatment

For empirical therapy in a patient with no penicillin allergy, while awaiting the results of cultures and susceptibility use:

Flucloxacillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly

Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Dog, Cat or Human Bite

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


History of penicillin allergy or adverse reaction

No penicillin allergy

Minor penicillin allergy

Anaphylaxis/severe reaction

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
  • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • OR
  • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

OR

2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
  • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
  • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
  • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

OR

3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
  • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
  • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
    • i.e. Less than 70 mmHg from 1 month up to 1 year
    • Less than (70 mmHg + [2 x age]) from 1 to 10 years
    • Less than 90 mmHg from 11 to 17 years
TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Dog, Cat or Human Bite

How severe is the infection? Prophylactic antibiotic therapy may not be required if there is no established infection. (see list below for details on when antibiotic prophylaxis is required)


Antibiotic prophylaxis is required for bites and fist injuries with a high risk of infection such as:
TEAMS - Top End Antimicrobial Stewardship

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Dog, cat or human bite treatment

For patients that have an infection not involving deeper structures and can tolerate penicillins, use:

Amoxicillin+clavulanic acid 875+125 mg (child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12-hourly for 5 days

OR if oral absorption is likely to be impared (i.e. following trauma)

Amoxicillin+clavulanic acid intravenously until oral therapy tolerated or for 5 days (adjust dosing frequency for patients with renal impairment)

adult:   1.2 g IV, 8-hourly
child younger than 3 months and less than 4kg:   25 + 5 mg/kg IV, 12-hourly
child younger than 3 months and 4kg or more, or 3 months or older:   25 + 5 mg/kg (up to 1.2 g) IV, 8-hourly

AND if the patient is at increased risk of methicillin-resistant Staphylococcus aureus (MRSA) infection ADD

Vancomycin as per nomograms below or use the vancomycin empiric dose calculator for adults


Code for IV amoxicillin+clavulanic acid is: 5bit
This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.


Code for vancomycin is: 2bit
This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.



Vancomycin Dosing in Paediatrics

Age Starting Dose
(use actual body weight)
Dosing
frequency
Timing of first
trough concentration
Neonates < 30 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 18-hourly Before the second dose
postnatal age
14 days or older
15 mg/kg 12-hourly Before the third dose
Neonates 30 to 36 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 12-hourly Before the third dose
postnatal age
14 days or older
15 mg/kg 8-hourly Before the fourth dose
Neonates 37 to 44 weeks
postmenstrual age (NB1)
postnatal age
0 to 7 days
15 mg/kg 12-hourly Before the third dose
postnatal age
7 days or older
15 mg/kg 8-hourly Before the fourth dose
Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
  • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
  • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer
over(1)
< 40 Call infectious diseases Call infectious diseases Call infectious diseases ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call infectious diseases Call infectious diseases Call infectious diseases ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Dog, Cat or Human Bite

How severe is the infection? Prophylactic antibiotic therapy may not be required if there is no established infection. (See below for details on when antibiotic prophylaxis is required)


Antibiotic prophylaxis is required for bites and fist injuries with a high risk of infection, such as:
TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Dog, Cat or Human Bite

How severe is the infection? Prophylactic antibiotic therapy may not be required if there is no established infection. (See below for details on when antibiotic prophylaxis is required)


Antibiotic prophylaxis is required for bites and fist injuries with a high risk of infection, such as:
TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Dog, cat or human bite treatment

For patients with a penicillin allergy use:

Metronidazole 400 mg (child 1 month or older: 10 mg/kg up to 400 mg) orally, 12-hourly for 5 days

AND EITHER

Doxycycline (adult) 100mg orally, 12-hourly for 5 days

Child 8 years or older and less than 26 kg:   50 mg
Child 8 years or older and 26 to 35 kg:   75 mg
Child 8 years or older and more than 35 kg:   100 mg

OR

Trimethoprim+sulfamethoxazole 160+800 mg (child 6 weeks or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly for 5 days



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Dog, cat or human bite prophylaxis

For patients without a penicillin allergy, use:

Amoxicillin+clavulanic acid 875+125 mg (child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12-hourly for 3 days

OR if oral absorption is likely to be impared (i.e. following trauma)

Amoxicillin+clavulanic acid intravenously until oral therapy is tolerated or for 3 days (adjust frequency for patients with renal impairment)

adult:   1.2 g IV, 8-hourly
child younger than 3 months and less than 4kg:   25 + 5 mg/kg IV, 12-hourly
child younger than 3 months and 4kg or more, or 3 months or older:   25 + 5 mg/kg (up to 1.2 g) IV, 8-hourly

OR if the patient is at increased risk of methicillin-resistant Staphylococcus aureus (MRSA) infection, in place of the regimen above, use:

Metronidazole 400 mg (child 1 month or older: 10 mg/kg up to 400 mg) orally, 12-hourly for 3 days

AND EITHER

Doxycycline (adult) 100mg orally, 12-hourly for 3 days

Child 8 years or older and less than 26 kg:   50 mg
Child 8 years or older and 26 to 35 kg:   75 mg
Child 8 years or older and more than 35 kg:   100 mg

OR

Trimethoprim+sulfamethoxazole 160+800 mg (child 6 weeks or older: 4+20 mg/kg (up to 160+800 mg) orally, 12-hourly for 3 days


Code for IV amoxicillin+clavulanic acid is: 3bit
This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.



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TEAMS - Top End AntiMicrobial Stewardship

For patients with a penicillin allergy use:

Metronidazole 400 mg (child 1 month or older: 10 mg/kg up to 400 mg) orally, 12-hourly for 3 days

AND EITHER

Doxycycline orally, 12-hourly for 3 days

Adult:   100 mg
Child 8 years or older and less than 26 kg:   50 mg
Child 8 years or older and 26 to 35 kg:   75 mg
Child 8 years or older and more than 35 kg:   100 mg

OR

Trimethoprim+sulfamethoxazole 160+800 mg (child 6 weeks or older: 4+20 mg/kg )up to 160+800 mg) orally* 12-hourly for 3 days



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Dog, cat or human bite prophylaxis

For patients with a penicillin allergy use:

Metronidazole 400 mg (child 1 month or older: 10 mg/kg up to 400 mg) orally, 12-hourly for 3 days

AND EITHER

Doxycycline (adult) 100mg orally, 12-hourly for 3 days

Child 8 years or older and less than 26 kg:   50 mg
Child 8 years or older and 26 to 35 kg:   75 mg
Child 8 years or older and more than 35 kg:   100 mg

OR

Trimethoprim+sulfamethoxazole 160+800 mg (child 6 weeks or older: 4+20 mg/kg )up to 160+800 mg) orally* 12-hourly for 3 days



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Dog, cat or human bite treatment

For patients that do not have a penicillin allergy use:

Amoxicillin+clavulanic acid intravenously (adjust dosing frequency for patients with renal impairment)

Adult:   1.2 g IV, 8-hourly **if the bone is infected, increase to 6-hourly**
Child younger than 3 months and less than 4kg:   25 + 5 mg/kg IV, 12-hourly
Child younger than 3 months and 4kg or more, or 3 months or older:   25 + 5 mg/kg (up to 1.2 g) IV, 8-hourly **if the bone is infected, increase to 6-hourly**

AND if the patient is at increased risk of methicillin-resistant Staphylococcus aureus (MRSA) infection ADD

Vancomycin as per nomograms below or use the vancomycin empiric dose calculator for adults


Code for IV amoxicillin+clavulanic acid is: 5bit
This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.


Code for vancomycin is: 2bit
This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.



Vancomycin Dosing in Paediatrics

Age Starting Dose
(use actual body weight)
Dosing
frequency
Timing of first
trough concentration
Neonates < 30 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 18-hourly Before the second dose
postnatal age
14 days or older
15 mg/kg 12-hourly Before the third dose
Neonates 30 to 36 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 12-hourly Before the third dose
postnatal age
14 days or older
15 mg/kg 8-hourly Before the fourth dose
Neonates 37 to 44 weeks
postmenstrual age (NB1)
postnatal age
0 to 7 days
15 mg/kg 12-hourly Before the third dose
postnatal age
7 days or older
15 mg/kg 8-hourly Before the fourth dose
Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
  • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
  • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer
over(1)
< 40 Call infectious diseases Call infectious diseases Call infectious diseases ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call infectious diseases Call infectious diseases Call infectious diseases ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Dog, cat or human bite treatment

For patients with a penicillin allergy give:

Ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) IV, 12-hourly

AND

Clindamycin 600 mg (child: 15 mg/kg up to 600 mg) IV, 8-hourly

OR if the patient is at an increased risk of MRSA infection, in place of the regimen above give:

Ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) IV, 12-hourly

AND

Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly

AND

Vancomycin as per nomograms below or use the vancomycin empiric dose calculator for adults


Code for IV ciprofloxacin and clindamycin is: 3bit
This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.


Code for vancomycin is: 2bit
This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.


Vancomycin Dosing in Paediatrics

Age Starting Dose
(use actual body weight)
Dosing
frequency
Timing of first
trough concentration
Neonates < 30 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 18-hourly Before the second dose
postnatal age
14 days or older
15 mg/kg 12-hourly Before the third dose
Neonates 30 to 36 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 12-hourly Before the third dose
postnatal age
14 days or older
15 mg/kg 8-hourly Before the fourth dose
Neonates 37 to 44 weeks
postmenstrual age (NB1)
postnatal age
0 to 7 days
15 mg/kg 12-hourly Before the third dose
postnatal age
7 days or older
15 mg/kg 8-hourly Before the fourth dose
Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
  • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
  • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer
over(1)
< 40 Call infectious diseases Call infectious diseases Call infectious diseases ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call infectious diseases Call infectious diseases Call infectious diseases ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Dog, cat or human bite treatment

In a patient with severe infection with a severe penicillin allergy:

Please contact IFD for advice.


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TEAMS - Top End AntiMicrobial Stewardship

Periorbital cellulitis

What type of cellulitis does the patient have? (see table below)

Classification of eye cellulitis


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TEAMS - Top End AntiMicrobial Stewardship

Periorbital cellulitis

Is the patient severely ill? (i.e. periorbital cellulitis is the primary reason for hospitalisation)


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TEAMS - Top End AntiMicrobial Stewardship

Periorbital cellulitis

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


History of penicillin allergy or adverse reaction

No penicillin allergy

Immediate or delayed non-severe penicillin hypersensitivity

Immediate or delayed severe penicillin hypersensitivity


Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
  • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • OR
  • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

OR

2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
  • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
  • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
  • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

OR

3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
  • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
  • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
    • i.e. Less than 70 mmHg from 1 month up to 1 year
    • Less than (70 mmHg + [2 x age]) from 1 to 10 years
    • Less than 90 mmHg from 11 to 17 years
TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Periorbital cellulitis treatment

For patients that do not have a penicillin allergy use:

Dicloxacillin 500 mg (child: flucloxacillin 12.5 mg/kg up to 500 mg) orally, 6-hourly for 7 days.



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TEAMS - Top End AntiMicrobial Stewardship

Periorbital cellulitis treatment

For patients with a non-severe penicillin allergy (unless the allergy involved amoxicillin or ampicillin) use:

Cephalexin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 7 days.



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Periorbital cellulitis treatment

For patients with a penicillin allergy, use:

Clindamycin 450 mg (child: 15 mg/kg up to 450 mg) orally, 8-hourly for 7 days.


Code for oral clindamycin is: 7per
This code is valid for SEVEN days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past one week. Please annotate when IFD are to be contacted on eMMa and in patient notes



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Periorbital cellulitis

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


History of penicillin allergy or adverse reaction

No penicillin allergy

Immediate or delayed non-severe penicillin hypersensitivity

Immediate or delayed severe penicillin hypersensitivity


Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
  • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • OR
  • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

OR

2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
  • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
  • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
  • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

OR

3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
  • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
  • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
    • i.e. Less than 70 mmHg from 1 month up to 1 year
    • Less than (70 mmHg + [2 x age]) from 1 to 10 years
    • Less than 90 mmHg from 11 to 17 years
TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Orbital or severe periorbital cellulitis treatment

For patients that do not have a penicillin allergy, use:

Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) IV, daily

AND

Flucloxacillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly


Code for ceftriaxone is: 3per
This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Orbital or severe periorbital cellulitis treatment

For patients with a nonsevere penicillin allergy, use:

Cefotaxime 2 g (child: 50 mg/kg up to 2 g) IV, 8-hourly


Code for cefotaxime is: 3cli
This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Orbital or severe periorbital cellulitis treatment

For patients with a severe penicillin allergy, use:


Ciprofloxacin 400 mg (child: 10 mg/kg up to 400 mg) IV, 12-hourly

AND

Vancomycin IV, as per nomograms below or use the vancomycin empiric dose calculator for adults


Code for ciprofloxacin and vancomycin is: 3cli
This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



Vancomycin Dosing in Paediatrics

Age Starting Dose
(use actual body weight)
Dosing
frequency
Timing of first
trough concentration
Neonates < 30 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 18-hourly Before the second dose
postnatal age
14 days or older
15 mg/kg 12-hourly Before the third dose
Neonates 30 to 36 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 12-hourly Before the third dose
postnatal age
14 days or older
15 mg/kg 8-hourly Before the fourth dose
Neonates 37 to 44 weeks
postmenstrual age (NB1)
postnatal age
0 to 7 days
15 mg/kg 12-hourly Before the third dose
postnatal age
7 days or older
15 mg/kg 8-hourly Before the fourth dose
Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
  • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
  • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer
over(1)
< 40 Call IFD Call IFD Call IFD ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call IFD Call IFD Call IFD ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot infection

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


History of penicillin allergy or adverse reaction

No penicillin allergy

Immediate or delayed non-severe penicillin hypersensitivity

Immediate or delayed severe penicillin hypersensitivity


Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
  • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • OR
  • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

OR

2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
  • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
  • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
  • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
  • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

OR

3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
  • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
  • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
    • i.e. Less than 70 mmHg from 1 month up to 1 year
    • Less than (70 mmHg + [2 x age]) from 1 to 10 years
    • Less than 90 mmHg from 11 to 17 years
TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot infection

How severe is the infection? (see table below)

Classification of diabetic foot infection

Severity Features
Uninfected
  • Wound lacking purulence or any manifestation of inflammation
Mild
  • Presence of 2 or more manifestations of inflammation (purulence, or erythema, pain, tenderness,warmth, or induration)
  • Extent of cellulitis/erythema: 0.5 - 2cm around ulcer, and infection is limited to the skin or superficial subcutaneous tissues
  • No other local complications or systemic illness.
Moderate
  • Infection (as above) in a patient who is systemically well and metabolically stable, but which has greater than 1 of the following characteristics:
    • cellulitis > 2 cm, lymphangitic streaking, spread beneath the superficial fascia, deeptissue abscess, gangrene and involvement of muscle, tendon, joint or bone.
Severe
  • Infection in a patient with systemic toxicity or metabolic instability
    • eg. Fever, chills, tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, severe hyperglycaemia, renal impairment
  • Any osteomyelitis, systemic toxicity, bacteraemia, gangrene, ulceration to deep tissues, severe cellulitis

References:

See diabetic foot infection management guideline on PCG

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot infection

How severe is the infection? (see table below)

Classification of diabetic foot infection

Severity Features
Uninfected
  • Wound lacking purulence or any manifestation of inflammation
Mild
  • Presence of 2 or more manifestations of inflammation (purulence, or erythema, pain, tenderness, warmth, or induration)
  • Extent of cellulitis/erythema: 0.5 - 2cm around ulcer, and infection is limited to the skin or superficial subcutaneous tissues
  • No other local complications or systemic illness.
Moderate
  • Infection (as above) in a patient who is systemically well and metabolically stable, but which has greater than 1 of the following characteristics:
    • cellulitis > 2 cm, lymphangitic streaking, spread beneath the superficial fascia, deeptissue abscess, gangrene and involvement of muscle, tendon, joint or bone.
Severe
  • Infection in a patient with systemic toxicity or metabolic instability
    • eg. Fever, chills, tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, severe hyperglycaemia, renal impairment
  • Any osteomyelitis, systemic toxicity, bacteraemia, gangrene, ulceration to deep tissues, severe cellulitis
TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot infection

How severe is the infection? (see table below)

Classification of diabetic foot infection

Severity Features
Uninfected
  • Wound lacking purulence or any manifestation of inflammation
Mild
  • Presence of 2 or more manifestations of inflammation (purulence, or erythema, pain, tenderness, warmth, or induration)
  • Extent of cellulitis/erythema: 0.5 - 2cm around ulcer, and infection is limited to the skin or superficial subcutaneous tissues
  • No other local complications or systemic illness.
Moderate
  • Infection (as above) in a patient who is systemically well and metabolically stable, but which has greater than 1 of the following characteristics:
    • cellulitis > 2 cm, lymphangitic streaking, spread beneath the superficial fascia, deeptissue abscess, gangrene and involvement of muscle, tendon, joint or bone.
Severe
  • Infection in a patient with systemic toxicity or metabolic instability
    • eg. Fever, chills, tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, severe hyperglycaemia, renal impairment
  • Any osteomyelitis, systemic toxicity, bacteraemia, gangrene, ulceration to deep tissues, severe cellulitis
TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot treatment

For mild diabetic foot infection in a patient with non-severe penicillin allergy (unless the allergy was to amoxicillin or ampicillin), use:

Cephalexin 500 mg orally, 6-hourly for 1-2 weeks

AND

Metronidazole 400 mg orally, 12-hourly for 1-2 weeks



References:

See the RDH diabetic foot infection management guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on diabetic foot infection, initial approval date 14/10/2014, cited 7/4/2017

References:

See diabetic foot infection management guideline on PCG

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot treatment

For mild diabetic foot infection in a patient with a severe penicillin allergy:

Ciprofloxacin 500 mg orally, 12-hourly for 1-2 weeks

AND

Clindamycin 450 mg orally, 8-hourly for 1-2 weeks


Code for ciprofloxacin and clindamycin is: 7dfi
This code is valid for SEVEN days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past one week. Please annotate when IFD are to be contacted on eMMa and patient notes



References:

See diabetic foot infection management guideline on PCG

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot treatment

For moderate diabetic foot infection in a patient with a severe penicillin allergy:

Ciprofloxacin 500 mg orally, 12-hourly for 1-2 weeks

AND

Clindamycin 450 mg orally, 8-hourly for 1-2 weeks

if the patient is also high risk for infection with methicillin-resistant S. aureus (MRSA), ADD

Vancomycin IV (until culture results return), using the nomogram below or the vancomycin empiric dose calculator for adults


Code for ciprofloxacin and clindamycin is: 7dfi
This code is valid for SEVEN days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past one week. Please annotate when IFD are to be contacted on eMMa and patient notes

Code for vancomycin is: 2dfi
This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.




Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer
over(1)
< 40 Call infectious diseases Call infectious diseases Call infectious diseases ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call infectious diseases Call infectious diseases Call infectious diseases ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

References:

See diabetic foot infection management guideline on PCG

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot treatment

For mild diabetic foot infection in a patient without a penicillin allergy:

Amoxicillin 875 mg+Clavulanic acid 125 mg orally, 12-hourly for 1-2 weeks

OR

Cephalexin 500 mg orally, 6-hourly for 1-2 weeks

AND

  Metronidazole 400 mg orally, 12-hourly for 1-2 weeks.



References:

See diabetic foot infection management guideline on PCG

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot infection

Are there systemic signs of sepsis, or is MRSA suspected?

Signs of Sepsis

SIRS response: ≥2 of: AND presence of refractory hypotension or hypoperfusion

Temp <36 or >38

Heart rate > 90

Resp Rate > 20

WCC > 12.0 or < 4.0

Hypotension:

  • systolic BP< 90 mmHg OR 40 mmHg below premorbid BP AFTER at least 500 mL fluid challenge.

Hypoperfusion:

  • Lactate ≥4 mmol/L OR Bicarbonate <16mmol/L

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot infection

Are there systemic signs of sepsis, or is MRSA suspected?

Signs of Sepsis

SIRS response: ≥2 of: AND presence of refractory hypotension or hypoperfusion

Temp <36 or >38

Heart rate > 90

Resp Rate > 20

WCC > 12.0 or < 4.0

Hypotension:

  • systolic BP< 90 mmHg OR 40 mmHg below premorbid BP AFTER at least 500 mL fluid challenge.

Hypoperfusion:

  • Lactate ≥4 mmol/L OR Bicarbonate <16mmol/L

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot treatment

For severe diabetic foot infection in patient with a penicillin allergy, use:



Ciprofloxacin 400 mg IV, 12-hourly

AND

Vancomycin IV (until culture results available) give loading dose and maintenance dose using nomogram below or the vancomycin empiric dose calculator for adults

AND

Clindamycin 900 mg IV, 8-hourly.


Code for ciprofloxacin, vancomycin and clindamycin (IV) is: 2dfi
This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer
over(1)
< 40 Call IFD Call IFD Call IFD ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call IFD Call IFD Call IFD ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


References:

See diabetic foot infection management guideline on PCG

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot treatment

For moderate diabetic foot infection in a patient with a non-severe penicillin allergy, use:

Cefazolin 2 g IV, q8h (adjust dosing frequency in renal impairment)

AND

Metronidazole 500 mg IV, 12-hourly

if the patient is also high risk for infection with MRSA, ADD

Vancomycin IV (until culture results return), using the nomogram below or the vancomycin empiric dose calculator for adults


Code for vancomycin is: 2dfi
This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.




Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer
over(1)
< 40 Call infectious diseases Call infectious diseases Call infectious diseases ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call infectious diseases Call infectious diseases Call infectious diseases ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

References:

See diabetic foot infection management guideline on PCG

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot treatment

For moderate/severe diabetic foot in patient at risk of MRSA use:

Amoxicillin+clavulanic acid intravenously (adjust dosing frequency for patients with renal impairment):

Adult:   1.2 g IV, 8-hourly
OR if the bone is infected:   1.2 g IV, 6-hourly

AND

Vancomycin IV, as per nomogram below (until culture results return) or use the vancomycin empiric dose calculator for adults


Code for IV amoxicillin+clavulanic acid is: 7dfi
This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 2 weeks. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.


Code for vancomycin is: 2dfi
This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.



Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer
over(1)
< 40 Call infectious diseases Call infectious diseases Call infectious diseases ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call infectious diseases Call infectious diseases Call infectious diseases ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

References:

See diabetic foot infection management guideline on PCG

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot treatment

If Pseudomonas aeruginosa infection is not suspected (eg no recent evidence of colonisation or infection with P. aeruginosa), for moderate diabetic foot infection in a patient without a penicillin allergy, use:

Amoxicillin+clavulanic acid intravenously (review dosing frequency in patients with renal impairment):

Adult:   1.2 g IV, 8-hourly
or, if the bone is infected:   1.2 g IV, 6-hourly

    if the patient is also high risk for infection with MRSA, ADD

Vancomycin IV (until culture results return), using the nomogram below or the vancomycin empiric dose calculator for adults


Code for IV amoxicillin+clavulanic acid is: 7dfi
This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 1 week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.


Code for vancomycin is: 2dfi
This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.




Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer
over(1)
< 40 Call infectious diseases Call infectious diseases Call infectious diseases ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call infectious diseases Call infectious diseases Call infectious diseases ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

References:

See diabetic foot infection management guideline on PCG

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Diabetic foot treatment

For severe diabetic foot infection in patient without a penicillin allergy, use:

Piperacillin and tazobactam 4.5 g IV, 6-hourly

AND

Vancomycin IV, with a loading dose of 25-30 mg/kg then as per nomogram below (until culture results return) or use the vancomycin empiric dose calculator for adults


Code for piperacillin-tazobactam is: 5dfi
This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 2 weeks. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.


Code for vancomycin is: 2dfi
This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.



Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer
over(1)
< 40 Call infectious diseases Call infectious diseases Call infectious diseases ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call infectious diseases Call infectious diseases Call infectious diseases ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

References:

See diabetic foot infection management guideline on PCG

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Display dosing nomograms for

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Code Verifier

Enter the TEAMS code, date prescribed, and antibiotic to check validity and expiry date:



TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Gentamicin dosing nomogram

Gentamicin dose should be based on adjusted body weight for patients with actual body weight more than 20% over ideal weight.
Contact pharmacy for dose recommendation in morbidly obese patients.

Initial Paediatric Gentamicin Dosing (Age < 12 years)

Age Initial dose
(for children with renal impairment, see text below)
Dosing
frequency
Maximum number
of empirical doses
Neonates <30 weeks
postmenstrual age
5 mg/kg 48-hourly 2 doses
(at 0 and 48 hours)
neonates 30 to 34
weeks postmenstrual age
5 mg/kg 36-hourly 2 doses
(at 0 and 36 hours)
neonates 35 weeks
postmenstrual age or older
5 mg/kg 24-hourly 3 doses
(at 0, 24 and 48 hours)
infants (1 month or older)
and children (up to 10 years old)
7.5 mg/kg (max 320 mg) 24-hourly 3 doses
(at 0, 24 and 48 hours)
children 10 years and older 6 mg/kg (max 560 mg)
increase to 7 mg/kg if critically unwell (max 560 mg)
24-hourly 3 doses
(at 0, 24 and 48 hours)

Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

Creatinine clearance
(mL/min)
Initial
dose
Dosing
frequency
Maximum number
of empirical doses
More than
60 mL/min
4 to 5 mg/kg 24-hourly 3 doses
(at 0, 24 and 48 hours)
40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
(at 0 and 36 hours)
less than
40 mL/min
4mg/kg Single dose, then seek expert advice


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Vancomycin dosing nomograms

Vancomycin dosing should be based on weight and renal function for adult patients or age and weight for neonates and children:


Vancomycin Dosing in Paediatrics

Age Starting Dose
(use actual body weight)
Dosing
frequency
Timing of first
trough concentration
Neonates < 30 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 18-hourly Before the second dose
postnatal age
14 days or older
15 mg/kg 12-hourly Before the third dose
Neonates 30 to 36 weeks
postmenstrual age (NB1)
postnatal age
0 to 14 days
15 mg/kg 12-hourly Before the third dose
postnatal age
14 days or older
15 mg/kg 8-hourly Before the fourth dose
Neonates 37 to 44 weeks
postmenstrual age (NB1)
postnatal age
0 to 7 days
15 mg/kg 12-hourly Before the third dose
postnatal age
7 days or older
15 mg/kg 8-hourly Before the fourth dose
Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
  • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
  • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

Vancomycin Dosing in Adults

Actual body
weight (kg)
CrClr
< 20 mL/min
CrClr
20-60 mL/min
CrClr
> 60 mL/min
Administer
over(1)
< 40 Call IFD Call IFD Call IFD ---
40-49 750 mg
48 hly
750 mg
24 hly
750 mg
12 hly
1 hr
15 min
50-64 1000 mg
48 hly
1000 mg
24 hly
1000 mg
12 hly
1 hr
40 min
65-79 1250 mg
48 hly
1250 mg
24 hly
1250 mg
12 hly
2 hrs
5 min
80-94 1500 mg
48 hly
1500 mg
24 hly
1500 mg
12 hly
2 hrs
30 min
95-110 1750 mg
48 hly
1750 mg
24 hly
1750 mg
12 hly
3 hrs
> 110 Call IFD Call IFD Call IFD ---
Timing of 1st
trough level(2)
48 hrs after
the 1st dose(3)
Before the
3rd dose
Before the
4th dose
---
  1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
  2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
  3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Adult vancomycin dose calculator

Enter the patients actual body weight to calculate the vancomycin loading dose

Vancomycin dose: mg


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Adult vancomycin dose calculator

Enter the patient details to calculate the vancomycin loading and maintenance dose:



Vancomycin loading dose (optional): mg

Vancomycin maintenance dose: mg, -


This patient has a Cockcroft Gault calculated creatinine clearance of: mL/min


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Adult creatinine clearance calculator

Cockcroft Gault Creatinine Clearance Calculator for >12 years only:


Enter the patient details to calculate the creatinine clearance:

Creatinine Clearance:0 mL/min


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Gentamicin AUC calculator

Enter the patient details to calculate the gentamicin area under the curve:

Infusion Start Time HH:MM (24 hour format) Infusion End Time HH:MM (24 hour format)
Time of first (peak) level HH:MM (24 hour format) Time of second (trough) level HH:MM (24 hour format)
First (peak) concentration (mg/L) Second (trough) concentration (mg/L)
Calculated AUC: 0 mg/L/hr


K Value: 0


Predicted Peak: 0 mg/L


Predicted Trough: 0 mg/L


Recommended dose: 0 mg


TEAMS - Top End AntiMicrobial Stewardship

TEAMS - Top End AntiMicrobial Stewardship

Tuberculosis dose calculator

Standard course tuberculosis medication dosage calculator:


Enter the patient details to display recommended doses for standard TB treatment:


Isoniazid dose: 0 mg.


Rifampicin dose: 0 mg.


Ethambutol dose: 0 mg.


Pyrazinamide dose: 0 mg.


Pyridoxine dose: 0 mg.



  • Doses have been calculated based on weight and rounded to a practical dose for the preparations available in Australia
  • A loading dose of vancomycin may be considered to help achieve a therapeutic concentration more quickly, particularly in patients with serious infections who are critically ill. However, there are no strong clinical data to show that this approach improves outcomes.
  • Adjust dosage of ethambutol in patients with kidney impairment, or consider an alternative drug.
  • TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Antibiotic half lives for surgery



    Antibiotic Average Half-Life (in Normal Adult Patient) Elapsed Time before Second Dose Required
    Benzylpenicillin 0.3 – 0.8 hours 1 hours
    Flucloxacillin 0.75 – 1.5 hours 3 hours
    Cefazolin 1.8 hours 4 hours
    Clindamycin 2 - 4 hours 6 hours
    Ciprofloxacin 4 hours 8 hours ☸
    Vancomycin 4 – 6 hours 12 hours ☸
    Metronidazole 6 - 8 hours 12 hours ☸
    Teicoplanin 70 – 100 hours Not required
    Gentamicin 2 hours - NB: despite having a short half-life a second dose of gentamicin should never be given within 24 hours due to the potential for nephrotoxicity and ototoxicity with this agent If the operation is expected to be extended then a higher initial dose (up to 5 mg/kg) gentamicin should be given. No second dose to be given.
    • ☸ Typically patients with poor renal function won’t require a second dose as there will be higher levels of antibiotic remaining in their system. Young fit patients are more likely to require a second dose as they will clear the drug more quickly. Patients with significant blood loss during surgery will also require a second dose.

    References:

    See the surgical antibiotic prophylaxis TEHS guidelines on the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline for surgical prophylaxis, initial approval date 10/03/2016

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Oral Equivalents Table



    Oral Alternatives to Intravenous Medicines
    Intravenous Oral
    Antimicrobial Agent and Usual Adult Dose Daily Cost Antimicrobial Agent and Usual Adult Dose Daily Cost
    Ampicillin 1-2g Q6H $4.79 - $9.58 amoxicillin 500mg-1g Q8H 16c-49c
    Azithromycin 500mg Daily $5.67 Azithromycin 500mg Daily $2.69
    Roxithromycin 300mg Daily 57c
    Benzyl penicillin 1.2g Q6H $24.34 amoxicillin 500mg-1 gm Q8H 16c-49c
    Ceftriaxone 1-2g Daily 88c For COAD exacerbation - amoxicillin 500mg oral Q8H (∂) 16c
    For Community Acquired Pneumonia - amoxicillin 1g Q8H (∂) 49c
    For Hospital Acquired or Aspiration Pneumonia,
    Abdominal Sepsis and UTI
    - amoxicillin+clavulanic acid 875mg/125mg Q12H (∂)(∅)
    40c
    Cefazolin 1-2g Q8H $4.35 Cephalexin 500mg Q6H 30c
    Ciprofloxacin 200-400mg Q12H $15.92 Ciprofloxacin 500-750mg Q12H 23c – 98c
    Flucloxacillin 1g Q6H $5.41 - $10.82 Dicloxacillin 500mg Q6H $1.20
    Fluconazole 200-400mg Daily $3.45 - $6.90 Fluconazole 200mg-400mg Daily (∑) 65c - $1.30
    Clindamycin 600-900mg Q8H $81 - $162 Clindamycin 300-600mg oral Q8H (∑) $1.99 - $3.98
    Metronidazole 500mg Q12H $3.69 Metronidazole 400mg Q8H – Q12H (∑) 41c
    Piperacillin / Tazobactam 4.5g Q8H $25.69 Amoxicillin+clavulanic acid 875mg/125mg oral Q12H (∅) 40c
    Ensure patient does not have penicillin allergy before changing
    No direct oral alternative. Check microbiology and site of infection to guide choice of agent
    Agents with excellent oral bioavailability (90% or higher)
    • When switching from an IV to oral route, it is not always possible or necessary to use the same antimicrobial drug. The oral switch is an opportunity to review current therapy in light of new microbiological results and/or a revised diagnosis, and change therapy to suit. Some possible IV to oral switches are given below in table 1

    References:

    See the Antimicrobial Switch to Oral TEHS guidelines on the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline, initial approval date 23/07/2014

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gentamicin empiric dose calculator



    Enter the patient details to calculate the gentamicin loading dose:

    Gentamicin dose weight used (Adjusted body weight is used if patient over 120% of IBW): 0 Kg

    Creatinine clearance calculated for this dose: 0 mL/min


    Gentamicin dose: 0 mg to 0 mg


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Epiglottitis

    Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


    History of penicillin allergy or adverse reaction

    No penicillin allergy

    Immediate or delayed non-severe penicillin hypersensitivity

    Immediate or delayed severe penicillin hypersensitivity


    Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

    1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
    • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • OR
    • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

    OR

    2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
    • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
    • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
    • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

    OR

    3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
    • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
    • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
      • i.e. Less than 70 mmHg from 1 month up to 1 year
      • Less than (70 mmHg + [2 x age]) from 1 to 10 years
      • Less than 90 mmHg from 11 to 17 years
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Epiglottitis

    Epiglottitis treatment:

    Ceftriaxone 1 g (child 1 month or older: 50 mg/kg up to 1 g) IV, daily for 5 days

    OR, if child < 1 month old

    Cefotaxime 50 mg/kg IV, 8-hourly for 5 days

    AND consider the addition of:

    Dexamethasone 10 mg (child: 0.15 mg/kg up to 10 mg) IV, as a single dose; repeat at 24 hours if required.


    Code for ceftriaxone or cefotaxime is: 5epg
    This code is valid for FIVE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 5 days. Please annotate when IFD are to be contacted on eMMa and in patient notes




    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Epiglottitis treatment

    For epiglottitis in a patient with life threatening penicillin hypersensitivity:

    Moxifloxacin 400 mg (child 1 month or older: 10 mg/kg up to 400mg g) IV, daily

    AND consider the addition of:

    Dexamethasone 10 mg (child: 0.15 mg/kg up to 10 mg) IV, as a single dose; repeat at 24 hours if required.


    Code for moxifloxacin is: 5epg
    This code is valid for FIVE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 5 days. Please annotate when IFD are to be contacted on eMMa and in patient notes




    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


    History of penicillin allergy or adverse reaction

    No penicillin allergy

    Immediate or delayed non-severe penicillin hypersensitivity

    Immediate or delayed severe penicillin hypersensitivity


    Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

    1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
    • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • OR
    • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

    OR

    2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
    • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
    • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
    • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

    OR

    3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
    • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
    • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
      • i.e. Less than 70 mmHg from 1 month up to 1 year
      • Less than (70 mmHg + [2 x age]) from 1 to 10 years
      • Less than 90 mmHg from 11 to 17 years
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Is the patient an adult or child?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Is the patient an adult or child?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Is the patient an adult or child?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Does the patient have severe sepsis?


    Signs of Sepsis:

    SIRS response: ≥2 of: AND presence of refractory hypotension or hypoperfusion

    Temp <36 or >38

    Heart rate > 90

    Resp Rate > 20

    WCC > 12.0 or < 4.0

    Hypotension:

    • systolic BP< 90 mmHg OR 40 mmHg below premorbid BP AFTER at least 500 mL fluid challenge.

    Hypoperfusion:

    • Lactate ≥4 mmol/L OR Bicarbonate <16mmol/L
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Does the patient have severe sepsis?


    Signs of Sepsis:

    SIRS response: ≥2 of: AND presence of refractory hypotension or hypoperfusion

    Temp <36 or >38

    Heart rate > 90

    Resp Rate > 20

    WCC > 12.0 or < 4.0

    Hypotension:

    • systolic BP< 90 mmHg OR 40 mmHg below premorbid BP AFTER at least 500 mL fluid challenge.

    Hypoperfusion:

    • Lactate ≥4 mmol/L OR Bicarbonate <16mmol/L
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Does the patient have severe sepsis?


    Signs of Sepsis:

    SIRS response: ≥2 of: AND presence of refractory hypotension or hypoperfusion

    Temp <36 or >38

    Heart rate > 90

    Resp Rate > 20

    WCC > 12.0 or < 4.0

    Hypotension:

    • systolic BP< 90 mmHg OR 40 mmHg below premorbid BP AFTER at least 500 mL fluid challenge.

    Hypoperfusion:

    • Lactate ≥4 mmol/L OR Bicarbonate <16mmol/L
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Does the patient have any risk factors for MRSA? (See below)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Does the patient have any risk factors for MRSA? (See below)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Does the patient have severe sepsis?


    Signs of Sepsis:

    SIRS response: ≥2 of: AND presence of refractory hypotension or hypoperfusion

    Temp <36 or >38

    Heart rate > 90

    Resp Rate > 20

    WCC > 12.0 or < 4.0

    Hypotension:

    • systolic BP< 90 mmHg OR 40 mmHg below premorbid BP AFTER at least 500 mL fluid challenge.

    Hypoperfusion:

    • Lactate ≥4 mmol/L OR Bicarbonate <16mmol/L
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Does the patient have severe sepsis?


    Signs of Sepsis:

    SIRS response: ≥2 of: AND presence of refractory hypotension or hypoperfusion

    Temp <36 or >38

    Heart rate > 90

    Resp Rate > 20

    WCC > 12.0 or < 4.0

    Hypotension:

    • systolic BP< 90 mmHg OR 40 mmHg below premorbid BP AFTER at least 500 mL fluid challenge.

    Hypoperfusion:

    • Lactate ≥4 mmol/L OR Bicarbonate <16mmol/L
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Does the patient have severe sepsis?


    Signs of Sepsis:

    SIRS response: ≥2 of: AND presence of refractory hypotension or hypoperfusion

    Temp <36 or >38

    Heart rate > 90

    Resp Rate > 20

    WCC > 12.0 or < 4.0

    Hypotension:

    • systolic BP< 90 mmHg OR 40 mmHg below premorbid BP AFTER at least 500 mL fluid challenge.

    Hypoperfusion:

    • Lactate ≥4 mmol/L OR Bicarbonate <16mmol/L
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Is the patient being treated during the wet or dry season?


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Is the patient being treated during the wet or dry season?


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Is the patient being treated during the wet or dry season?


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia

    Is the patient being treated during the wet or dry season?


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For febrile neutropnia, use:

    Meropenem 1 g IV, 8-hourly

    AND

    Vancomycin loading dose of 25 to 30 mg/kg IV

    THEN

    Vancomycin IV, as per nomograms below or use the vancomycin empiric dose calculator for adults


    Code for meropenem and vancomycin is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Vancomycin Dosing in Adults

    Actual body
    weight (kg)
    CrClr
    < 20 mL/min
    CrClr
    20-60 mL/min
    CrClr
    > 60 mL/min
    Administer
    over(1)
    < 40 Call IFD Call IFD Call IFD ---
    40-49 750 mg
    48 hly
    750 mg
    24 hly
    750 mg
    12 hly
    1 hr
    15 min
    50-64 1000 mg
    48 hly
    1000 mg
    24 hly
    1000 mg
    12 hly
    1 hr
    40 min
    65-79 1250 mg
    48 hly
    1250 mg
    24 hly
    1250 mg
    12 hly
    2 hrs
    5 min
    80-94 1500 mg
    48 hly
    1500 mg
    24 hly
    1500 mg
    12 hly
    2 hrs
    30 min
    95-110 1750 mg
    48 hly
    1750 mg
    24 hly
    1750 mg
    12 hly
    3 hrs
    > 110 Call IFD Call IFD Call IFD ---
    Timing of 1st
    trough level(2)
    48 hrs after
    the 1st dose(3)
    Before the
    3rd dose
    Before the
    4th dose
    ---
    1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
    2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
    3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


    References:

    See the RDH febrile neutropenia management pathway from the PGC - TEHS Adult febrile neutropenia Guideline.
    See the vancomycin adults and children ≥ 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    Septic paediatric patient with mild or no penicillin allergy in wet season:

    Meropenem 20 mg/kg (to a maximum of 1 g) IV, 8-hourly

    AND

    A vancomycin loading dose of 25 mg/kg IV

    THEN

    Vancomycin IV, as per the nomogram below


    Code for meropenem and vancomycin is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Vancomycin Dosing in Paediatrics

    Age Starting Dose
    (use actual body weight)
    Dosing
    frequency
    Timing of first
    trough concentration
    Neonates < 30 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 14 days
    15 mg/kg 18-hourly Before the second dose
    postnatal age
    14 days or older
    15 mg/kg 12-hourly Before the third dose
    Neonates 30 to 36 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 14 days
    15 mg/kg 12-hourly Before the third dose
    postnatal age
    14 days or older
    15 mg/kg 8-hourly Before the fourth dose
    Neonates 37 to 44 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 7 days
    15 mg/kg 12-hourly Before the third dose
    postnatal age
    7 days or older
    15 mg/kg 8-hourly Before the fourth dose
    Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
    • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
    • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

    1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
    2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
    3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


    References:

    See the RDH febrile neutropenia management pathway from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on febrile neutropenia, initial approval date 14/10/2014, cited 7/4/2017
    See the vancomycin children < 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients with a mild penicillin allergy use:

    Gentamicin IV, dosed as per nomograms below or use the gentamicin empiric dose calculator for adults

    AND

    Ceftazidime 2 g IV, 8-hourly

    AND

    Vancomycin loading dose of 25 to 30 mg/kg IV

    THEN

    Vancomycin IV, as per nomograms below or use the vancomycin empiric dose calculator for adults

    AND if an abdominal or perineal source of infection is suspected ADD

    Metronidazole 500 mg IV, 12-hourly


    Code for vancomycin and ceftazidime is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes


    Code for gentamicin is: 2feb
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Gentamicin/Tobramycin Dosing (age > 12 years)

    Creatinine clearance
    (mL/min)
    Initial
    dose
    Dosing
    frequency
    Maximum number
    of empirical doses
    More than
    60 mL/min
    4 to 5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    less than
    40 mL/min
    4mg/kg Single dose, then seek expert advice

    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)


    Vancomycin Dosing in Adults

    Actual body
    weight (kg)
    CrClr
    < 20 mL/min
    CrClr
    20-60 mL/min
    CrClr
    > 60 mL/min
    Administer
    over(1)
    < 40 Call IFD Call IFD Call IFD ---
    40-49 750 mg
    48 hly
    750 mg
    24 hly
    750 mg
    12 hly
    1 hr
    15 min
    50-64 1000 mg
    48 hly
    1000 mg
    24 hly
    1000 mg
    12 hly
    1 hr
    40 min
    65-79 1250 mg
    48 hly
    1250 mg
    24 hly
    1250 mg
    12 hly
    2 hrs
    5 min
    80-94 1500 mg
    48 hly
    1500 mg
    24 hly
    1500 mg
    12 hly
    2 hrs
    30 min
    95-110 1750 mg
    48 hly
    1750 mg
    24 hly
    1750 mg
    12 hly
    3 hrs
    > 110 Call IFD Call IFD Call IFD ---
    Timing of 1st
    trough level(2)
    48 hrs after
    the 1st dose(3)
    Before the
    3rd dose
    Before the
    4th dose
    ---
    1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
    2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
    3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


    References:

    See the RDH febrile neutropenia management pathway from the PGC - TEHS Adult febrile neutropenia Guideline.
    See the vancomycin adults and children ≥ 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients with a mild penicillin allergy give:

    Ceftazidime 2 g IV, 8-hourly

    AND

    Vancomycin loading dose of 25 mg/kg IV

    THEN

    Vancomycin IV, as per nomogram below or use the vancomycin empiric dose calculator for adults

    AND if an abdomino-perineal infection is suspected ADD

    Metronidazole 500 mg IV, 12-hourly


    Code for ceftazidime and vancomycin is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Vancomycin Dosing in Adults

    Actual body
    weight (kg)
    CrClr
    < 20 mL/min
    CrClr
    20-60 mL/min
    CrClr
    > 60 mL/min
    Administer
    over(1)
    < 40 Call IFD Call IFD Call IFD ---
    40-49 750 mg
    48 hly
    750 mg
    24 hly
    750 mg
    12 hly
    1 hr
    15 min
    50-64 1000 mg
    48 hly
    1000 mg
    24 hly
    1000 mg
    12 hly
    1 hr
    40 min
    65-79 1250 mg
    48 hly
    1250 mg
    24 hly
    1250 mg
    12 hly
    2 hrs
    5 min
    80-94 1500 mg
    48 hly
    1500 mg
    24 hly
    1500 mg
    12 hly
    2 hrs
    30 min
    95-110 1750 mg
    48 hly
    1750 mg
    24 hly
    1750 mg
    12 hly
    3 hrs
    > 110 Call IFD Call IFD Call IFD ---
    Timing of 1st
    trough level(2)
    48 hrs after
    the 1st dose(3)
    Before the
    3rd dose
    Before the
    4th dose
    ---
    1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
    2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
    3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


    References:

    See the RDH febrile neutropenia management pathway from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on febrile neutropenia, initial approval date 14/10/2014, cited 7/4/2017
    See the vancomycin adults and children ≥ 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    If paediatric patient with a mild penicillin allergy give:

    Ceftazidime 50 mg/kg (up to 2 g) IV, 8-hourly

    AND

    A vancomycin loading dose of 25 mg/kg IV

    THEN

    Vancomycin IV, as per the nomogram below

    AND if an abdomino-perineal infection is suspected ADD

    Metronidazole for child 1 month or older: 12.5 mg/kg (up to 500 mg) IV, 12-hourly


    Code for ceftazidime and vancomycin is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Vancomycin Dosing in Paediatrics

    Age Starting Dose
    (use actual body weight)
    Dosing
    frequency
    Timing of first
    trough concentration
    Neonates < 30 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 14 days
    15 mg/kg 18-hourly Before the second dose
    postnatal age
    14 days or older
    15 mg/kg 12-hourly Before the third dose
    Neonates 30 to 36 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 14 days
    15 mg/kg 12-hourly Before the third dose
    postnatal age
    14 days or older
    15 mg/kg 8-hourly Before the fourth dose
    Neonates 37 to 44 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 7 days
    15 mg/kg 12-hourly Before the third dose
    postnatal age
    7 days or older
    15 mg/kg 8-hourly Before the fourth dose
    Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
    • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
    • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years
    1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
    2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
    3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


    References:

    See the RDH febrile neutropenia management pathway from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on febrile neutropenia, initial approval date 14/10/2014, cited 7/4/2017
    See the vancomycin children < 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients with a mild penicillin allergy use:

    A vancomycin loading dose of 25 to 30 mg/kg IV

    THEN

    Vancomycin IV, as per nomogram below

    AND

    Gentamicin IV, dosed as per nomogram below

    AND

    Ceftazidime 50 mg/kg up to 2 g IV, 8-hourly

    AND if an abdomino-perineal infection is suspected ADD

    Metronidazole for child 1 month or older: 12.5 mg/kg (up to 500 mg) IV, 12-hourly


    Code for vancomycin and ceftazidime is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes


    Code for gentamicin is: 2feb
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)


    Vancomycin Dosing in Paediatrics

    Age Starting Dose
    (use actual body weight)
    Dosing
    frequency
    Timing of first
    trough concentration
    Neonates < 30 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 14 days
    15 mg/kg 18-hourly Before the second dose
    postnatal age
    14 days or older
    15 mg/kg 12-hourly Before the third dose
    Neonates 30 to 36 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 14 days
    15 mg/kg 12-hourly Before the third dose
    postnatal age
    14 days or older
    15 mg/kg 8-hourly Before the fourth dose
    Neonates 37 to 44 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 7 days
    15 mg/kg 12-hourly Before the third dose
    postnatal age
    7 days or older
    15 mg/kg 8-hourly Before the fourth dose
    Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
    • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
    • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

    References:

    See the RDH febrile neutropenia management pathway from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on febrile neutropenia, initial approval date 14/10/2014, cited 7/4/2017
    See the vancomycin children < 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients with a severe penicillin allergy use meropenem very cautiously. Please ensure patient is in a critical care area before administering:

    Meropenem 1 g IV, 8-hourly given cautiously in a critical care area to monitor for reaction

    AND

    Vancomycin loading dose of 25 to 30 mg/kg IV

    THEN

    Vancomycin IV, as per nomogram below or use the vancomycin empiric dose calculator for adults


    Code for meropenem and vancomycin is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Vancomycin Dosing in Adults

    Actual body
    weight (kg)
    CrClr
    < 20 mL/min
    CrClr
    20-60 mL/min
    CrClr
    > 60 mL/min
    Administer
    over(1)
    < 40 Call IFD Call IFD Call IFD ---
    40-49 750 mg
    48 hly
    750 mg
    24 hly
    750 mg
    12 hly
    1 hr
    15 min
    50-64 1000 mg
    48 hly
    1000 mg
    24 hly
    1000 mg
    12 hly
    1 hr
    40 min
    65-79 1250 mg
    48 hly
    1250 mg
    24 hly
    1250 mg
    12 hly
    2 hrs
    5 min
    80-94 1500 mg
    48 hly
    1500 mg
    24 hly
    1500 mg
    12 hly
    2 hrs
    30 min
    95-110 1750 mg
    48 hly
    1750 mg
    24 hly
    1750 mg
    12 hly
    3 hrs
    > 110 Call IFD Call IFD Call IFD ---
    Timing of 1st
    trough level(2)
    48 hrs after
    the 1st dose(3)
    Before the
    3rd dose
    Before the
    4th dose
    ---
    1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
    2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
    3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


    References:

    See the RDH febrile neutropenia management pathway from the PGC - TEHS Adult febrile neutropenia Guideline.
    See the vancomycin adults and children ≥ 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients with a severe penicillin allergy use meropenem very cautiously. Please ensure patient is in a critical care area before administering:

    Meropenem 20 mg/kg (to a maximum of 1 g) IV, 8-hourly given cautiously in a critical care area to monitor for reaction

    AND

    A vancomycin loading dose of 25 to 30 mg/kg IV

    THEN

    Vancomycin IV, as per nomogram below;


    Code for meropenem and vancomycin is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Vancomycin Dosing in Paediatrics

    Age Starting Dose
    (use actual body weight)
    Dosing
    frequency
    Timing of first
    trough concentration
    Neonates < 30 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 14 days
    15 mg/kg 18-hourly Before the second dose
    postnatal age
    14 days or older
    15 mg/kg 12-hourly Before the third dose
    Neonates 30 to 36 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 14 days
    15 mg/kg 12-hourly Before the third dose
    postnatal age
    14 days or older
    15 mg/kg 8-hourly Before the fourth dose
    Neonates 37 to 44 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 7 days
    15 mg/kg 12-hourly Before the third dose
    postnatal age
    7 days or older
    15 mg/kg 8-hourly Before the fourth dose
    Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
    • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
    • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years
    1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
    2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
    3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


    References:

    See the RDH febrile neutropenia management pathway from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on febrile neutropenia, initial approval date 14/10/2014, cited 7/4/2017
    See the vancomycin children < 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients with a severe penicillin allergy give:

    Ciprofloxacin 400 mg IV, 8-hourly

    AND

    Vancomycin IV, as per nomograms below or use the vancomycin empiric dose calculator for adults


    AND if an abdomino-perineal infection is suspected ADD

    Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly


    Code for ciprofloxacin and vancomycin is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Vancomycin Dosing in Adults

    Actual body
    weight (kg)
    CrClr
    < 20 mL/min
    CrClr
    20-60 mL/min
    CrClr
    > 60 mL/min
    Administer
    over(1)
    < 40 Call IFD Call IFD Call IFD ---
    40-49 750 mg
    48 hly
    750 mg
    24 hly
    750 mg
    12 hly
    1 hr
    15 min
    50-64 1000 mg
    48 hly
    1000 mg
    24 hly
    1000 mg
    12 hly
    1 hr
    40 min
    65-79 1250 mg
    48 hly
    1250 mg
    24 hly
    1250 mg
    12 hly
    2 hrs
    5 min
    80-94 1500 mg
    48 hly
    1500 mg
    24 hly
    1500 mg
    12 hly
    2 hrs
    30 min
    95-110 1750 mg
    48 hly
    1750 mg
    24 hly
    1750 mg
    12 hly
    3 hrs
    > 110 Call IFD Call IFD Call IFD ---
    Timing of 1st
    trough level(2)
    48 hrs after
    the 1st dose(3)
    Before the
    3rd dose
    Before the
    4th dose
    ---
    1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
    2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
    3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


    References:

    See the RDH febrile neutropenia management pathway from the PGC - TEHS Adult febrile neutropenia Guideline.
    See the vancomycin adults and children ≥ 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients with a severe penicillin allergy but is not showing signs of sepsis:

    Please contact IFD for advice

    A decision must be made on whether the patient should be initiated on a carbapenem or cephalosporin depening on severity of previous penicillin reaction and current clinical state



    References:

    See the RDH febrile neutropenia management pathway from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on febrile neutropenia, initial approval date 14/10/2014, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients that do not have a penicillin allergy use:

    A vancomycin loading dose of 25 to 30 mg/kg IV

    THEN

    Vancomycin IV, as per nomogram below or use the vancomycin empiric dose calculator for adults

    AND

    Gentamicin IV, dosed as per nomogram below or use the gentamicin empiric dose calculator for adults

    AND

    Piperacillin/tazobactam 4.5 g IV, 6-hourly


    Code for vancomycin and piperacillin is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes


    Code for gentamicin is: 2feb
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Gentamicin/Tobramycin Dosing (age > 12 years)

    Creatinine clearance
    (mL/min)
    Initial
    dose
    Dosing
    frequency
    Maximum number
    of empirical doses
    More than
    60 mL/min
    4 to 5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    less than
    40 mL/min
    4mg/kg Single dose, then seek expert advice

    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)


    Vancomycin Dosing in Adults

    Actual body
    weight (kg)
    CrClr
    < 20 mL/min
    CrClr
    20-60 mL/min
    CrClr
    > 60 mL/min
    Administer
    over(1)
    < 40 Call IFD Call IFD Call IFD ---
    40-49 750 mg
    48 hly
    750 mg
    24 hly
    750 mg
    12 hly
    1 hr
    15 min
    50-64 1000 mg
    48 hly
    1000 mg
    24 hly
    1000 mg
    12 hly
    1 hr
    40 min
    65-79 1250 mg
    48 hly
    1250 mg
    24 hly
    1250 mg
    12 hly
    2 hrs
    5 min
    80-94 1500 mg
    48 hly
    1500 mg
    24 hly
    1500 mg
    12 hly
    2 hrs
    30 min
    95-110 1750 mg
    48 hly
    1750 mg
    24 hly
    1750 mg
    12 hly
    3 hrs
    > 110 Call IFD Call IFD Call IFD ---
    Timing of 1st
    trough level(2)
    48 hrs after
    the 1st dose(3)
    Before the
    3rd dose
    Before the
    4th dose
    ---
    1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
    2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
    3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


    References:

    See the RDH febrile neutropenia management pathway from the PGC - TEHS Adult febrile neutropenia Guideline.
    See the vancomycin adults and children ≥ 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients that do not have a penicillin allergy use:

    A vancomycin loading dose of 25 to 30 mg/kg IV

    THEN

    Vancomycin IV, as per nomogram below

    AND

    Gentamicin IV, dosed as per nomogram below

    AND

    Piperacillin/tazobactam 100 mg/kg (dosed on piperacillin component only) up to 4 g IV, 6-hourly


    Code for vancomycin and piperacillin is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes


    Code for gentamicin is: 2feb
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)


    Vancomycin Dosing in Paediatrics

    Age Starting Dose
    (use actual body weight)
    Dosing
    frequency
    Timing of first
    trough concentration
    Neonates < 30 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 14 days
    15 mg/kg 18-hourly Before the second dose
    postnatal age
    14 days or older
    15 mg/kg 12-hourly Before the third dose
    Neonates 30 to 36 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 14 days
    15 mg/kg 12-hourly Before the third dose
    postnatal age
    14 days or older
    15 mg/kg 8-hourly Before the fourth dose
    Neonates 37 to 44 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 7 days
    15 mg/kg 12-hourly Before the third dose
    postnatal age
    7 days or older
    15 mg/kg 8-hourly Before the fourth dose
    Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
    • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
    • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

    References:

    See the RDH febrile neutropenia management pathway from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on febrile neutropenia, initial approval date 14/10/2014, cited 7/4/2017
    See the vancomycin children < 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients that do not have a penicillin allergy give:

    Piperacillin/tazobactam 4.5 g IV, 6-hourly

    AND

    Vancomycin IV, as per nomogram below or use the vancomycin empiric dose calculator for adults


    Code for piperacillin-tazobactam is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes


    Code for vancomycin is: 2feb
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Vancomycin Dosing in Adults

    Actual body
    weight (kg)
    CrClr
    < 20 mL/min
    CrClr
    20-60 mL/min
    CrClr
    > 60 mL/min
    Administer
    over(1)
    < 40 Call IFD Call IFD Call IFD ---
    40-49 750 mg
    48 hly
    750 mg
    24 hly
    750 mg
    12 hly
    1 hr
    15 min
    50-64 1000 mg
    48 hly
    1000 mg
    24 hly
    1000 mg
    12 hly
    1 hr
    40 min
    65-79 1250 mg
    48 hly
    1250 mg
    24 hly
    1250 mg
    12 hly
    2 hrs
    5 min
    80-94 1500 mg
    48 hly
    1500 mg
    24 hly
    1500 mg
    12 hly
    2 hrs
    30 min
    95-110 1750 mg
    48 hly
    1750 mg
    24 hly
    1750 mg
    12 hly
    3 hrs
    > 110 Call IFD Call IFD Call IFD ---
    Timing of 1st
    trough level(2)
    48 hrs after
    the 1st dose(3)
    Before the
    3rd dose
    Before the
    4th dose
    ---
    1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Man Syndrome
    2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
    3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


    References:

    See the RDH febrile neutropenia management pathway from the PGC - TEHS Adult Febrile Neuropenia Guideline.
    See the vancomycin adults and children ≥ 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring.

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients that do not have a penicillin allergy give:

    Piperacillin/tazobactam 100 mg/kg (up to 4 g dosed on piperacillin component only) IV, 6-hourly

    AND

    Vancomycin IV, as per nomogram below


    Code for piperacillin and vancomycin is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Vancomycin Dosing in Paediatrics

    Age Starting Dose
    (use actual body weight)
    Dosing
    frequency
    Timing of first
    trough concentration
    Neonates < 30 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 14 days
    15 mg/kg 18-hourly Before the second dose
    postnatal age
    14 days or older
    15 mg/kg 12-hourly Before the third dose
    Neonates 30 to 36 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 14 days
    15 mg/kg 12-hourly Before the third dose
    postnatal age
    14 days or older
    15 mg/kg 8-hourly Before the fourth dose
    Neonates 37 to 44 weeks
    postmenstrual age (NB1)
    postnatal age
    0 to 7 days
    15 mg/kg 12-hourly Before the third dose
    postnatal age
    7 days or older
    15 mg/kg 8-hourly Before the fourth dose
    Infants and children (NB2) 15 mg/kg up to 750 mg 6-hourly Before the fifth dose
    • NB1- Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
    • NB2- Local NT data support using 6-hourly dosing in all children up to 12 years

    1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Man Syndrome
    2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
    3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known


    References:

    See the RDH febrile neutropenia management pathway from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on febrile neutropenia, initial approval date 14/10/2014, cited 7/4/2017
    See the vancomycin children < 12 years NT guideline from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on vancomycin dosing and monitoring, initial approval date 07/09/2015, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients that do not have a penicillin allergy give:

    Piperacillin/tazobactam 4.5 g IV, 6-hourly


    Code for piperacillin-tazobactam is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    References:

    See the RDH febrile neutropenia management pathway from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on febrile neutropenia, initial approval date 14/10/2014, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Febrile neutropenia treatment

    For patients that do not have a penicillin allergy give:

    Piperacillin/tazobactam 100 mg/kg (up to 4 g dosed on piperacillin component only) IV, 6-hourly


    Code for piperacillin-tazobactam is: 3feb
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    References:

    See the RDH febrile neutropenia management pathway from the PGC - Royal Darwin Hospital, Darwin, Australia, clinical practice guideline on febrile neutropenia, initial approval date 14/10/2014, cited 7/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis

    Does the patient have features of severe disease? (See below)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis

    Is the patient immunocompromised?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis

    Can the patient tolerate oral antibiotics? (See below)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis

    Low risk gastroenteritis:

    Antimicrobial treatment for gastroenteritis is unlikely to be required



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis

    Is the patient an adult or child?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis

    Is the patient an adult or child?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis

    Does the patient have risk factors for enterohaemorrhagic E.coli? (See below)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis

    Can the patient tolerate oral antibiotics? (See below)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis

    Can the patient tolerate oral antibiotics? (See below)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis

    Has the patient had a severe reaction or anaphylaxis to a penicillin antibiotic or do they have a cephalosporin allergy? (See below)


    Diagnostic Criteria for Penicillin Allergy:

    Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

    1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
    • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • OR
    • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

    OR

    2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
    • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
    • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
    • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

    OR

    3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
    • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
    • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
      • i.e. Less than 70 mmHg from 1 month up to 1 year
      • Less than (70 mmHg + [2 x age]) from 1 to 10 years
      • Less than 90 mmHg from 11 to 17 years
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis

    Has the patient had a severe reaction or anaphylaxis to a penicillin antibiotic or do they have a cephalosporin allergy? (See below)


    Diagnostic Criteria for Penicillin Allergy:

    Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

    1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
    • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • OR
    • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

    OR

    2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
    • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
    • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
    • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

    OR

    3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
    • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
    • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
      • i.e. Less than 70 mmHg from 1 month up to 1 year
      • Less than (70 mmHg + [2 x age]) from 1 to 10 years
      • Less than 90 mmHg from 11 to 17 years
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis

    Has the patient had a Severe reaction or anaphylaxis to a penicillin antibiotic or do they have a cephalosporin allergy? (See below)


    Diagnostic Criteria for Penicillin Allergy:

    Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

    1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
    • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • OR
    • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

    OR

    2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
    • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
    • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
    • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

    OR

    3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
    • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
    • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
      • i.e. Less than 70 mmHg from 1 month up to 1 year
      • Less than (70 mmHg + [2 x age]) from 1 to 10 years
      • Less than 90 mmHg from 11 to 17 years
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis treatment

    If the patient can tolerate oral therapy give:

    Azithromycin 10mg/kg (up to 500mg), daily for 3 days


    Code for azithromycin is: 3gas
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis treatment

    If the patient cannot tolerate oral therapy give:

    Ceftriaxone 2g IV, daily for 3 days


    Code for ceftriaxone is: 3gas
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis treatment

    If the patient can tolerate oral therapy give:

    Ciprofloxacin 500mg orally, 12-hourly for 3 days

    OR,

    Norfloxacin 400mg orally, 12-hourly for 3 days

    OR, if the infection was likely to be acquired in a region where quinolone resistance is common (eg South or Southeast Asia)

    Azithromycin 500mg orally, daily for 3 days


    Code for ciprofloxacin, norfloxacin or azithromycin is: 3gas
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis treatment

    If the patient can tolerate oral therapy and bacterial infection is suspected consider giving:

    Ciprofloxacin 500mg orally, 12-hourly for 3 days (see below if treating a child)

    OR,

    Norfloxacin 400mg orally, 12-hourly for 3 days (see below if treating a child)

    OR, if patient is a child, or the infection was likely to be acquired in a region where quinolone resistance is common (eg South or Southeast Asia)

    Azithromycin 500mg (child: 10mg/kg) orally, daily for 3 days


    Code for ciprofloxacin, norfloxacin or azithromycin is: 3gas
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis treatment

    If the patient cannot tolerate oral therapy give:

    ADULT or CHILD >2 months old: Ceftriaxone 2g (child 50mg/kg up to 2g), IV daily for 3 days


    CHILD <2 months old: Cefotaxime 50mg/kg, IV 8-hourly for 3 days


    Code for ceftriaxone or cefotaxime is: 3gas
    This code is valid for THREE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 72 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis treatment

    If the patient has a history of penicillin anaphylaxis and cannot tolerate oral medications:


    Please contact IFD for advice



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Gastroenteritis treatment

    If the patient has risk factors for enterohaemorrhagic E.coli then antibiotic therapy is not recommended:


    Please contact IFD for advice



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Influenza

    If the patient has signs of influenza like illness:

    Diagnostic criteria for influenza:

    1. Fever ≥ 38°c or definite history of fever, AND
    2. Cough and/or sore throat, in the absence of any other explanation for symptoms

    Treat with:

    Oseltamivir 75 mg (child dose as per nomogram below) orally, 12-hourly

    Continue treatment for up to FIVE days or until viral PCR swabs return negative


    Code for oseltamivir is: 5flu
    This code is valid for FIVE days only, starting from the first day of treatment for this condition. IFD must be contacted if treatment is to continue past 5 days. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Oseltamivir dosing in children 1-13 years of age

    Body weight Dosage
    <15Kg 30 mg orally twice daily for FIVE days
    15Kg-23Kg 45 mg orally twice daily for FIVE days
    23Kg-40kg 60 mg orally twice daily for FIVE days
    >40kg 75 mg orally twice daily for FIVE days

    References:

    See the NT hospitals influenza management guideline from the PGC - Northern Territory, Australia, clinical practice guideline on influenza infection, initial approval date 14/10/2014, cited 28/4/2017

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Intra-abdominal infection

    What type of infection is suspected/confirmed?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis

    Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


    History of penicillin allergy or adverse reaction

    No penicillin allergy

    Immediate or delayed non-severe penicillin hypersensitivity

    Immediate or delayed severe penicillin hypersensitivity


    Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

    1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
    • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • OR
    • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

    OR

    2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
    • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
    • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
    • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

    OR

    3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
    • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
    • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
      • i.e. Less than 70 mmHg from 1 month up to 1 year
      • Less than (70 mmHg + [2 x age]) from 1 to 10 years
      • Less than 90 mmHg from 11 to 17 years
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis

    Has an appendicectomy been performed?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis

    Was the appendix ruptured or was there an appendiceal abscess?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical appendicitis treatment

    If the patient has a mild penicillin allergy cover with:

    Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 1 g) IV, daily until surgery

    AND

    Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly until surgery


    Then, after surgery is performed, if a perforation or abscess was uncovered, consider step down to oral after initial improvement:

    Trimethoprim+Sulfamethoxazole 160+800 mg (child 6 weeks or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly

    AND

    Metronidazole 400 mg (child 1 month or older: 10 mg/kg up to 400 mg) orally, 12-hourly


    Code for ceftriaxone is: 2int
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis treatment post surgery

    If the patient has a mild penicillin allergy and the appendix was ruptured or an appendiceal abscess was uncovered treat with:


    Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 1 g) IV, daily until patient's clinical condition improves

    AND

    Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly until patient's clinical condition improves


    then, after clinical condition improves, step down to oral:

    Trimethoprim+Sulfamethoxazole 160+800 mg (child 6 weeks or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly

    AND

    Metronidazole 400 mg (child 1 month or older: 10 mg/kg up to 400 mg) orally, 12-hourly


    Code for ceftriaxone is: 2int
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis treatment post surgery

    If the appendix was not perforated and no appendiceal abscess was uncovered:

    No further antibiotic therapy should be necessary


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis

    Has an appendicectomy been performed?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis

    Was the appendix ruptured or was there an appendiceal abscess?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis

    Is gentamicin contraindicated in this patient? (See below for contraindications)

    Aminoglycoside Contraindications and Precautions

    Contraindications Precautions
    History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
    History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
    Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
    Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
    Advanced liver disease
    Advanced age (eg 80 years or older), depending on calculated renal function
    Use of concomitant drugs that cause nephrotoxicity or ototoxicity

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis

    Is gentamicin contraindicated in this patient? (See below for contraindications)

    Aminoglycoside Contraindications and Precautions

    Contraindications Precautions
    History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
    History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
    Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
    Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
    Advanced liver disease
    Advanced age (eg 80 years or older), depending on calculated renal function
    Use of concomitant drugs that cause nephrotoxicity or ototoxicity

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical appendicitis treatment

    If the patient has a severe penicillin allergy treat with:

    Gentamicin IV, dosed as per nomograms below or use the gentamicin empiric dose calculator for adults

    AND

    Clindamycin 600 mg (child: 15 mg/kg up to 600 mg) IV, 8-hourly until surgery

    then, after surgery is performed, if perforation or abscess was uncovered, consider step down to oral after initial improvement:

    Trimethoprim+Sulfamethoxazole 160+800 mg (child 6 weeks or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly

    AND

    Metronidazole 400 mg (child 1 month or older: 10 mg/kg up to 400 mg) orally, 12-hourly


    Code for clindamycin and gentamicin is: 2int
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)

    Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

    Creatinine clearance
    (mL/min)
    Initial
    dose
    Dosing
    frequency
    Maximum number
    of empirical doses
    More than
    60 mL/min
    4 to 5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    less than
    40 mL/min
    4mg/kg Single dose, then seek expert advice


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis treatment post surgery

    If the patient has a severe penicillin allergy and the appendix was ruptured or had an appendiceal abscess treat with:

    Gentamicin IV, as per nomograms below or use the gentamicin empiric dose calculator for adults

    AND

    Clindamycin 600 mg (child: 15 mg/kg up to 600 mg) IV, 8-hourly until patients clinical condition improves


    then, after clinical condition improves, step down to oral:


    Trimethoprim+Sulfamethoxazole 160+800 mg (child 6 weeks or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly

    AND

    Metronidazole 400 mg (child 1 month or older: 10 mg/kg up to 400 mg) orally, 12-hourly



    Code for clindamycin and gentamicin is: 2int
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)

    Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

    Creatinine clearance
    (mL/min)
    Initial
    dose
    Dosing
    frequency
    Maximum number
    of empirical doses
    More than
    60 mL/min
    4 to 5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    less than
    40 mL/min
    4mg/kg Single dose, then seek expert advice


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis treatment post surgery

    If the patient has a contraindication to gentamicin and a severe penicillin allergy:

    Please contact IFD for advice


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis

    Has an appendicectomy been performed?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis

    Was the appendix ruptured or was there an appendiceal abscess?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis

    Is gentamicin contraindicated in this patient? (See below for contraindications)

    Aminoglycoside Contraindications and Precautions

    Contraindications Precautions
    History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
    History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
    Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
    Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
    Advanced liver disease
    Advanced age (eg 80 years or older), depending on calculated renal function
    Use of concomitant drugs that cause nephrotoxicity or ototoxicity

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis

    Is gentamicin contraindicated in this patient? (See below for contraindications)

    Aminoglycoside Contraindications and Precautions

    Contraindications Precautions
    History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
    History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
    Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
    Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
    Advanced liver disease
    Advanced age (eg 80 years or older), depending on calculated renal function
    Use of concomitant drugs that cause nephrotoxicity or ototoxicity

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical appendicitis treatment

    If the patient tolerates penicillin treat with:

    Gentamicin IV, dosed as per nomograms below or use the gentamicin empiric dose calculator for adults

    AND

    Ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly until surgery

    AND

    Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly until surgery


    then, after surgery is performed, if perforation or abscess was uncovered then consider step down to oral after initial improvement:

    Amoxicillin+clavulanic acid 875+125 mg (child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12-hourly


    Code for gentamicin is: 2int
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)

    Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

    Creatinine clearance
    (mL/min)
    Initial
    dose
    Dosing
    frequency
    Maximum number
    of empirical doses
    More than
    60 mL/min
    4 to 5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    less than
    40 mL/min
    4mg/kg Single dose, then seek expert advice


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Appendicitis treatment post surgery

    If the patient tolerates penicillin but not gentamicin and the appendix was ruptured or the patient has an appendiceal abscess treat with:

    Amoxicillin+clavulanic acid intravenously (adjust frequency based on renal function)

    adult:   1.2 g IV, 8-hourly **increase to 6-hourly for an abscess**
    child younger than 3 months and less than 4kg:   25 + 5 mg/kg IV, 12-hourly
    child younger than 3 months and 4kg or more, or 3 months or older:   25 + 5 mg/kg (up to 1.2 g IV, 8-hourly) **increase to 6-hourly for abscess**

    OR

    Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 1 g) IV, daily

    AND

    Metronidazole 500 mg (child 1 month or older: 7.5 mg/kg up to 500 mg) IV, 12-hourly


    then, after clinical condition improves, step down to oral:

    Amoxicillin+clavulanic acid 875+125 mg (child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12-hourly


    Code for IV amoxicillin+clavulanate or ceftriaxone is: 2int
    This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical appendicitis treatment

    If the patient tolerates penicillin but not gentamicin treat with:

    Amoxicillin+clavulanic acid intravenously (adjust frequency based on renal function)

    adult:   1.2 g IV, 8-hourly (increase to 6-hourly if there is an abscess)
    child younger than 3 months and less than 4kg:   25 + 5 mg/kg IV, 12-hourly
    child younger than 3 months and 4kg or more, or 3 months or older:   25 + 5 mg/kg (up to 1.2 g) IV, 8-hourly (increase to 6-hourly if there is an abscess)

    OR

    Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 1 g) IV, daily

    AND

    Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly


    Then, after surgery either cease antibiotics, or if perforation or abscess was uncovered, consider step down to oral after initial improvement:

    Amoxicillin+clavulanic acid 875+125 mg (child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12-hourly


    Code for IV amoxicillin+clavulanate is: 2inb
    This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

    Code for ceftriaxone is: 2inb
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical appendicitis treatment

    If the patient tolerates penicillin and gentamicin give:

    Gentamicin IV, dosed as per nomograms below or use the gentamicin empiric dose calculator for adults

    AND

    Ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly

    AND

    Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly until clinical condition improves


    Then, after clinical condition improves switch to oral:

    Amoxicillin+clavulanic acid 875+125 mg (child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12-hourly


    Code for gentamicin is: 2int
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Gentamicin/Tobramycin Dosing (age > 12 years)

    Creatinine clearance
    (mL/min)
    Initial
    dose
    Dosing
    frequency
    Maximum number
    of empirical doses
    More than
    60 mL/min
    4 to 5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    less than
    40 mL/min
    4mg/kg Single dose, then seek expert advice

    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Cholecystitis

    Are you treating calculous or acalculous cholecystitis?


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Calculous Cholecystitis

    Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


    History of penicillin allergy or adverse reaction

    No penicillin allergy

    Immediate or delayed non-severe penicillin hypersensitivity

    Immediate or delayed severe penicillin hypersensitivity


    Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

    1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
    • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • OR
    • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

    OR

    2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
    • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
    • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
    • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

    OR

    3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
    • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
    • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
      • i.e. Less than 70 mmHg from 1 month up to 1 year
      • Less than (70 mmHg + [2 x age]) from 1 to 10 years
      • Less than 90 mmHg from 11 to 17 years
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Calculous Cholecystitis

    Has a cholecystectomy been performed?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical cholecystitis treatment intolerant of gentamicin or penicillin

    If the patient has a mild penicillin allergy or does not tolerate gentamicin treat empirically with:


    Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) IV, daily until surgery or until clinical improvement then switch to oral

    Once the patient's condition has improved, change to:


    Trimethoprim+sulfamethoxazole 160+800 mg (child 6 weeks or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly


    Code for ceftriaxone is: 2inb
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    cholecystitis treatment post surgery

    Treatment post cholecystectomy should normally be ceased within 24 hours. If a further dose of surgical prophylaxis is deemed necessary give:

    Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) IV, as a single dose


    Code for ceftriaxone is: 1ina
    This code is valid for ONE day only. Starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 24 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Calculous Cholecystitis

    Has a cholecystectomy been performed?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Cholecystitis

    Is gentamicin contraindicated in this patient? (See below for contraindications)

    Aminoglycoside Contraindications and Precautions

    Contraindications Precautions
    History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
    History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
    Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
    Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
    Advanced liver disease
    Advanced age (eg 80 years or older), depending on calculated renal function
    Use of concomitant drugs that cause nephrotoxicity or ototoxicity

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Calculous Cholecystitis

    Is gentamicin contraindicated in this patient? (See below for contraindications)

    Aminoglycoside Contraindications and Precautions

    Contraindications Precautions
    History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
    History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
    Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
    Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
    Advanced liver disease
    Advanced age (eg 80 years or older), depending on calculated renal function
    Use of concomitant drugs that cause nephrotoxicity or ototoxicity

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical cholecystitis treatment

    If the patient has a severe penicillin allergy cover with:

    Gentamicin IV, dosed as per nomograms below or use the gentamicin empiric dose calculator for adults

    Then, after clinical improvement or after 72 hours consider step down to oral:

    Trimethoprim+Sulfamethoxazole 160+800 mg (child 6 weeks or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly to make up a maximum of 7 days total treatment or until cholecystectomy


    Code for gentamicin is: 2int
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Gentamicin/Tobramycin Dosing (age > 12 years)

    Creatinine clearance
    (mL/min)
    Initial
    dose
    Dosing
    frequency
    Maximum number
    of empirical doses
    More than
    60 mL/min
    4 to 5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    less than
    40 mL/min
    4mg/kg Single dose, then seek expert advice

    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Cholecystitis treatment post surgery

    Following cholecystectomy antibiotic treatment should cease within 24 hours as the source of the infection has been removed. If a further dose of surgical prophylaxis is deemed necessary give:

    Gentamicin IV, as a single dose as the per nomogram below


    Code for gentamicin is: 1ina
    This code is valid for ONE days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 24 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Gentamicin/Tobramycin Dosing (age > 12 years)

    Creatinine clearance
    (mL/min)
    Initial
    dose
    Dosing
    frequency
    Maximum number
    of empirical doses
    More than
    60 mL/min
    4 to 5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    less than
    40 mL/min
    4mg/kg Single dose, then seek expert advice

    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical cholecystitis treatment

    If the patient has a contraindication to gentamicin and a severe penicillin allergy:

    Please contact IFD for advice



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Cholecysitis

    Has a cholecystectomy been performed?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Calculous Cholecystitis

    Is gentamicin contraindicated in this patient? (See below for contraindications)

    Aminoglycoside Contraindications and Precautions

    Contraindications Precautions
    History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
    History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
    Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
    Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
    Advanced liver disease
    Advanced age (eg 80 years or older), depending on calculated renal function
    Use of concomitant drugs that cause nephrotoxicity or ototoxicity

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Calculous Cholecystitis

    Is gentamicin contraindicated in this patient? (See below for contraindications)

    Aminoglycoside Contraindications and Precautions

    Contraindications Precautions
    History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
    History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
    Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
    Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
    Advanced liver disease
    Advanced age (eg 80 years or older), depending on calculated renal function
    Use of concomitant drugs that cause nephrotoxicity or ototoxicity

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Cholecystitis treatment post surgery

    Following cholecystectomy antibiotic treatment should cease within 24 hours as the source of the infection has been removed. If a further dose of surgical prophylaxis is deemed necessary give:

    Ongoing antibiotic treatment should normally be continued for a maximum of 24 hours only:

    Amoxicillin+clavulanic acid intravenously (adjust frequency for patients with renal impairment)

    adult:   1.2 g IV, 8-hourly
    child younger than 3 months and less than 4kg:   25 + 5 mg/kg IV, 12-hourly
    child younger than 3 months and 4kg or more, or 3 months or older:   25 + 5 mg/kg (up to 1.2 g) IV, 8-hourly


    Code for IV amoxicillin+clavulanic acid is: 1ina
    This code is valid for ONE day only. Starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 24 hours. NB: gentamicin should only be given empirically for the first 48 hours, please check patient has not received any previous doses of gentamicin



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical cholecystitis treatment

    Following cholecystectomy antibiotic treatment should cease within 24 hours as the source of the infection has been removed. If a further dose of surgical prophylaxis is deemed necessary give:

    Gentamicin 4-5 mg/kg IV, as a single dose only

    AND

    Ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly for 24 hours


    Code for gentamicin is: 1ina
    This code is valid for ONE dose only. IFD must be contacted if IV treatment is to continue past a single post-operative dose. NB: gentamicin should only be given empirically for the first 48 hours, please check patient has not received any previous doses of gentamicin



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical calculous cholecystitis treatment

    If the patient tolerates penicillin cover with:

    Gentamicin IV, dosed as per nomograms below or use the gentamicin empiric dose calculator for adults

    AND

    Ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly until surgery


    Then, after clinical improvement switch to:

    Amoxicillin+clavulanic acid 875+125 mg (child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12-hourly


    Code for gentamicin is: 2int
    This code is valid for ONE dose only. IFD must be contacted if IV treatment is to continue past a single post-operative dose. NB: gentamicin should only be given empirically for the first 48 hours, please check patient has not received any previous doses of gentamicin



    Initial Gentamicin/Tobramycin Dosing (age > 12 years)

    Creatinine clearance
    (mL/min)
    Initial
    dose
    Dosing
    frequency
    Maximum number
    of empirical doses
    More than
    60 mL/min
    4 to 5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    less than
    40 mL/min
    4mg/kg Single dose, then seek expert advice

    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical calculous cholecystitis treatment

    If the patient tolerates penicillin but not gentamicin treat with:

    Amoxicillin+clavulanic acid intravenously (adjust frequency based on renal function)

    adult:   1.2 g IV, 8-hourly **increase to 6-hourly for abscess**
    child younger than 3 months and less than 4kg:   25 + 5 mg/kg IV, 12-hourly
    child younger than 3 months and 4kg or more, or 3 months or older:   25 + 5 mg/kg (up to 1.2 g) IV, 8-hourly **increase to 6-hourly for abscess**

    OR

    Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) IV, daily until surgery or until clinical improvement then switch to oral


    Then, after clinical improvement:

    Amoxicillin+clavulanic acid 875+125 mg (child: child 2 months or older: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12-hourly to make up a maximum of 7 days total treatment (IV and oral)


    Code for IV amoxicillin+clavulanic acid is: 2ina
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Acalculous Cholecystitis

    Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)


    History of penicillin allergy or adverse reaction

    No penicillin allergy

    Immediate or delayed non-severe penicillin hypersensitivity

    Immediate or delayed severe penicillin hypersensitivity


    Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

    1. Acute onset of an illness (minutes to several hours) involving the skin, mucosal tissue, or both (eg, generalised hives, pruritus or flushing, swollen lips-tongue-uvula) and at least one of:
    • Respiratory compromise (eg, dyspnea, wheeze/bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • OR
    • Reduced blood pressure (BP) or associated symptoms and signs of end-organ malperfusion (eg, hypotonia [collapse] syncope, incontinence).

    OR

    2. TWO OR MORE OF THE FOLLOWING that occur rapidly after exposure to penicillin for that patient (within minutes to several hours):
    • Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula).
    • Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced peak expiratory flow, hypoxemia).
    • Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence).
    • Persistent gastrointestinal symptoms and signs (eg, crampy abdominal pain, vomiting).

    OR

    3. Reduced BP after exposure to penicillin in a patient with known penicillin allergy (within minutes to several hours)
    • Reduced BP in adults is defined as a systolic BP of less than 90 mmHg or greater than 30 percent decrease from that person's baseline
    • In infants and children, reduced BP is defined as low systolic BP (age-specific) or greater than 30 percent decrease in systolic BP
      • i.e. Less than 70 mmHg from 1 month up to 1 year
      • Less than (70 mmHg + [2 x age]) from 1 to 10 years
      • Less than 90 mmHg from 11 to 17 years
    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Acalculous Cholecystitis

    Is gentamicin contraindicated in this patient? (See below for contraindications)

    Aminoglycoside Contraindications and Precautions

    Contraindications Precautions
    History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
    History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
    Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
    Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
    Advanced liver disease
    Advanced age (eg 80 years or older), depending on calculated renal function
    Use of concomitant drugs that cause nephrotoxicity or ototoxicity

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Acalculous Cholecystitis

    Has a cholecystectomy been performed?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Acalculous Cholecystitis

    Has a cholecystectomy been performed?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical cholecystitis treatment intolerant of gentamicin and penicillin

    If the patient has a mild penicillin allergy or does not tolerate gentamicin treat empirically with:


    Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) IV, daily until surgery or until clinical improvement then switch to oral

    AND

    Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly

    Once the patient's condition has improved, change to:


    Trimethoprim+sulfamethoxazole 160+800 mg (child 6 weeks or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly


    Code for ceftriaxone is: 2inb
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    cholecystitis treatment post surgery

    Treatment post cholecystectomy should normally be ceased within 24 hours. If a further dose of surgical prophylaxis is deemed necessary give:

    Ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) IV, as a single dose

    AND

    Metronidazole 500 mg (child 1 month or older: 12.5 mg/kg up to 500 mg) IV, 12-hourly


    Code for ceftriaxone is: 1ina
    This code is valid for ONE day only. Starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 24 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Cholecystitis treatment post surgery

    Following cholecystectomy antibiotic treatment should cease within 24 hours as the source of the infection has been removed. If a further dose of surgical prophylaxis is deemed necessary give:

    Gentamicin IV, as a single dose as the per nomogram below or use the gentamicin empiric dose calculator for adults

    AND

    Clindamycin 600 mg (child: 15 mg/kg up to 600 mg) IV, 8-hourly (for up to 24 hours)


    Code for gentamicin and clindamycin is: 1ina
    This code is valid for ONE days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 24 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Gentamicin/Tobramycin Dosing (age > 12 years)

    Creatinine clearance
    (mL/min)
    Initial
    dose
    Dosing
    frequency
    Maximum number
    of empirical doses
    More than
    60 mL/min
    4 to 5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    less than
    40 mL/min
    4mg/kg Single dose, then seek expert advice

    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Emirpical acalculous cholecystitis treatment

    For empirical therapy in patients with a penicillin allergy, use:

    Gentamicin IV, as per nomogram below or use the gentamicin empiric dose calculator for adults

    AND

    Clindamycin 600 mg (child: 15 mg/kg up to 600 mg) IV, 8-hourly


    Code for gentamicin and clindamycin is: 2ina
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Gentamicin/Tobramycin Dosing (age > 12 years)

    Creatinine clearance
    (mL/min)
    Initial
    dose
    Dosing
    frequency
    Maximum number
    of empirical doses
    More than
    60 mL/min
    4 to 5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    less than
    40 mL/min
    4mg/kg Single dose, then seek expert advice

    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly 3 doses
    (at 0, 24 and 48 hours)


    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Acalculous Cholecystitis

    Has a cholecystectomy been performed?

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Cholecystitis

    Is gentamicin contraindicated in this patient? (See below for contraindications)

    Aminoglycoside Contraindications and Precautions

    Contraindications Precautions
    History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
    History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
    Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
    Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
    Advanced liver disease
    Advanced age (eg 80 years or older), depending on calculated renal function
    Use of concomitant drugs that cause nephrotoxicity or ototoxicity

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Acalculous Cholecystitis

    Is gentamicin contraindicated in this patient? (See below for contraindications)

    Aminoglycoside Contraindications and Precautions

    Contraindications Precautions
    History of vestibular or auditory toxicity caused by an aminoglycoside Pre-existing significant auditory impairment (hearing loss or tinnitus)
    History of serious hypersensitivity reaction to an aminoglycoside (rare) Pre-existing vestibular condition (dizziness, vertigo or balance problems)
    Myasthenia gravis Family history (first-degree relative) of auditory toxicity caused by an aminoglycoside
    Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
    Advanced liver disease
    Advanced age (eg 80 years or older), depending on calculated renal function
    Use of concomitant drugs that cause nephrotoxicity or ototoxicity

    TEAMS - Top End AntiMicrobial Stewardship

    TEAMS - Top End AntiMicrobial Stewardship

    Empirical cholecystitis treatment

    If the patient has a severe penicillin allergy cover with:

    Gentamicin IV, dosed as per nomograms below or use the gentamicin empiric dose calculator for adults

    AND

    Clindamycin 600 mg (child: 15 mg/kg up to 600 mg) IV, 8-hourly

    Then, after clinical improvement or after 72 hours consider step down to oral:

    Trimethoprim+Sulfamethoxazole 160+800 mg (child 6 weeks or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly to make up a maximum of 7 days total treatment or until cholecystectomy


    Code for gentamicin and clindamycin is: 2int
    This code is valid for TWO days only, starting from the first day of treatment for this condition. IFD must be contacted if IV treatment is to continue past 48 hours. Please annotate when IFD are to be contacted on eMMa and in patient notes



    Initial Gentamicin/Tobramycin Dosing (age > 12 years)

    Creatinine clearance
    (mL/min)
    Initial
    dose
    Dosing
    frequency
    Maximum number
    of empirical doses
    More than
    60 mL/min
    4 to 5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    40 to 60 mL/min 4 to 5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    less than
    40 mL/min
    4mg/kg Single dose, then seek expert advice

    Initial Paediatric Gentamicin Dosing (Age < 12 years)

    Age Initial dose
    (for children with renal impairment, see text below)
    Dosing
    frequency
    Maximum number
    of empirical doses
    Neonates <30 weeks
    postmenstrual age
    5 mg/kg 48-hourly 2 doses
    (at 0 and 48 hours)
    neonates 30 to 34
    weeks postmenstrual age
    5 mg/kg 36-hourly 2 doses
    (at 0 and 36 hours)
    neonates 35 weeks
    postmenstrual age or older
    5 mg/kg 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    infants (1 month or older)
    and children (up to 10 years old)
    7.5 mg/kg (max 320 mg) 24-hourly 3 doses
    (at 0, 24 and 48 hours)
    children 10 years and older 6 mg/kg (max 560 mg)
    increase to 7 mg/kg if critically unwell (max 560 mg)
    24-hourly