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

• Code checker

• Appendicitis
• Antibiogram TEHS
• Ascending cholangitis
• Carbuncle/Abscess
• Cat bite
• Cellulitis
• Cellulitis of the eye
• Cholecystitis
• Diabetic foot infection
• Diverticulitis
• Dog bite
• Dosing nomograms and calculators
• Epiglottitis
• Febrile neutropenia
• Gastroenteris
• Human bite
• Influenza infection
• Intra-abdominal infection
• Meningitis
• Open (compound) fracture
• Pancreatitis
• Pelvic inflammatory disease
• Peritonitis
• Pneumonia
• Scabies (crusted)
• Severe sepsis
• Shingles
• Surgical prophylaxis
• Urinary tract infection (UTI)
• Vancomycin dose calculator (adult)
• References and acknowledgements

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• Staphylococcus aureus
• Streptococcus pneumoniae
• Enterococcus sp
• Escherichia coli
• Klebsiella pneumoniae
• Proteus mirabilis
• Enterobacter sp
• Salmonella sp
• Pseudomonas aeruginosa
• Acinetobacter baumannii
• Burkholderia pseudomallei

2020 TEHS Staphylococcus aureus susceptibility profile

---

• Based on all isolates received at RDH laboratory in the first 6 months of 2020

2020 TEHS Streptococcus pneumoniae susceptibility profile

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• Based on all isolates received at RDH laboratory in the first 6 months of 2020

2020 TEHS Enterococcus sp susceptibility profile

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• Based on all isolates received at RDH laboratory in the first 6 months of 2020

2020 TEHS Escherichia coli susceptibility profile

---

• Based on all isolates received at RDH laboratory in the first 6 months of 2020

2020 TEHS Klebsiella pneumoniae susceptibility profile

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• Based on all isolates received at RDH laboratory in the first 6 months of 2020

2020 TEHS Proteus mirabilis susceptibility profile

---

• Based on all isolates received at RDH laboratory in the first 6 months of 2020

2020 TEHS Enterobacter sp susceptibility profile

---

• Based on all isolates received at RDH laboratory in the first 6 months of 2020

2020 TEHS Salmonella sp susceptibility profile

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• Based on all isolates received at RDH laboratory in the first 6 months of 2020

2020 TEHS Pseudomonas aeruginosa susceptibility profile

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• Based on all isolates received at RDH laboratory in the first 6 months of 2020

2020 TEHS Acinetobacter sp susceptibility profile

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• Based on all isolates received at RDH laboratory in the first 6 months of 2020

2020 TEHS Burkholderia pseudomallei (melioid) susceptibility profile

---

• Based on all isolates received at RDH laboratory in the first 6 months of 2020

• No penicillin allergy
• Immediate or delayed non-severe penicillin hypersensitivity
• Immediate or delayed severe penicillin hypersensitivity

---

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Immediate or delayed non-severe penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash.
• There is only a 1-2% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin (except if there is a shared side chain; eg cefalexin and amoxicillin), and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a nonsevere reaction to penicillin

Immediate or delayed severe penicillin hypersensitivity

• This includes anaphylaxis (see below) and other severe reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

---

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

OR

OR

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

---

• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

---

• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

For ascending cholangitis in a patient with nonsevere penicillin hypersensitivity:

---

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

• If patient appears septic, treat as per severe sepsis protocol (see homepage)
• Ascending cholangitis is usually caused by enteric gram negative bacilli such as Eschericia.coli, Klebsiella spp and Enterobacter spp. Gram positive bacteria such as Enterococcus may also be implicated. Infrequently it is caused by anaerobic bacteria
• Consider an early switch to oral within 48 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not usually exceed 7 days treatment. Antibiotic therapy should be ceased within 24 hours of uncomplicated cholecystectomy

---

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

Please contact IFD for advice

---

• If patient appears septic, treat as per severe sepsis protocol (see homepage)
• Ascending cholangitis is usually caused by enteric gram negative bacilli such as Eschericia.coli, Klebsiella spp and Enterobacter spp. Gram positive bacteria such as Enterococcus may also be implicated. Infrequently it is caused by anaerobic bacteria
• Consider an early switch to oral within 48 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not usually exceed 7 days treatment. Antibiotic therapy should be ceased within 24 hours of uncomplicated cholecystectomy

---

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

---

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

---

• If patient appears septic, treat as per severe sepsis protocol (see homepage)
• Ascending cholangitis is usually caused by enteric gram negative bacilli such as Eschericia.coli, Klebsiella spp and Enterobacter spp. Gram positive bacteria such as Enterococcus may also be implicated. Infrequently it is caused by anaerobic bacteria
• Consider an early switch to oral within 48 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not usually exceed 7 days treatment. Antibiotic therapy should be ceased within 24 hours of uncomplicated cholecystectomy

---

Initial Paediatric Gentamicin Dosing (Age < 12 years)

Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

---

• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose, use the adult aminoglycoside dose calculator. For morbidly obese patients, seek expert advice.
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR.
• 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)
• Use the Cockcroft gault calculator to calculate renal function for adults if using the nomogram, or use the adult aminoglycoside dose calculator

---

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

---

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

---

• If patient appears septic, treat as per severe sepsis protocol (see homepage)
• Ascending cholangitis is usually caused by enteric gram negative bacilli such as Eschericia.coli, Klebsiella spp and Enterobacter spp. Gram positive bacteria such as Enterococcus may also be implicated. Infrequently it is caused by anaerobic bacteria
• Consider an early switch to oral within 48 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not usually exceed 7 days treatment. Antibiotic therapy should be ceased within 24 hours of uncomplicated cholecystectomy

---

Initial Gentamicin/Tobramycin Dosing (age > 12 years)

---

Initial Paediatric Gentamicin Dosing (Age < 12 years)

---

• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose, use the adult aminoglycoside dose calculator. For morbidly obese patients, seek expert advice.
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate
• Use the Cockcroft gault calculator to calculate renal function for adults if using the nomogram, or use the adult aminoglycoside dose calculator

---

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

---

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

---

• If patient appears septic, treat as per severe sepsis protocol (see homepage)
• Consider an early switch to oral within 48 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not usually exceed 7 days treatment. Antibiotic therapy should be ceased within 24 hours of uncomplicated cholecystectomy
• Ascending cholangitis is usually caused by enteric gram negative bacilli such as Eschericia.coli, Klebsiella spp and Enterobacter spp. Gram positive bacteria such as Enterococcus may also be implicated. Infrequently it is caused by anaerobic bacteria

---

Are there signs of spreading cellulitis or significant systemic features?

• Yes
• No

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

• No penicillin allergy
• Immediate or delayed non-severe penicillin hypersensitivity
• Immediate or delayed severe penicillin hypersensitivity

---

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Immediate or delayed non-severe penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash.
• There is only a 1-2% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin (except if there is a shared side chain; eg cefalexin and amoxicillin), and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a nonsevere reaction to penicillin

Immediate or delayed severe penicillin hypersensitivity

• This includes anaphylaxis (see below) and other severe reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

---

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

OR

OR

Is the patient a child or adult?

• Paediatric patient
• Adult Patient

Is the patient a child or adult?

• Paediatric patient
• Adult Patient

Is the patient a child or adult?

• Paediatric patient
• Adult Patient

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:

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

---

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:

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Most carbuncles can be treated with incision and drainage alone, in addition to incision and drainage ongoing antibiotic treatment is only required if there is spreading cellulitis or systemic symptoms are present

---

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:

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Most carbuncles can be treated with incision and drainage alone, in addition to incision and drainage ongoing antibiotic treatment is only required if there is spreading cellulitis or systemic symptoms are present

---

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:

---

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

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Most carbuncles can be treated with incision and drainage alone, in addition to incision and drainage ongoing antibiotic treatment is only required if there is spreading cellulitis or systemic symptoms are present

---

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:

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Most carbuncles can be treated with incision and drainage alone, in addition to incision and drainage ongoing antibiotic treatment is only required if there is spreading cellulitis or systemic symptoms are present

---

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

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Most carbuncles can be treated with incision and drainage alone, in addition to incision and drainage ongoing antibiotic treatment is only required if there is spreading cellulitis or systemic symptoms are present

---

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

• No penicillin allergy
• Immediate or delayed non-severe penicillin hypersensitivity
• Immediate or delayed severe penicillin hypersensitivity

---

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Immediate or delayed non-severe penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash.
• There is only a 1-2% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin (except if there is a shared side chain; eg cefalexin and amoxicillin), and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a nonsevere reaction to penicillin

Immediate or delayed severe penicillin hypersensitivity

• This includes anaphylaxis (see below) and other severe reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

---

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

OR

OR

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

• Mild/Moderate
• Severe

---

• Choose severe if there are significant systemic features or no improvement in > 48 hours

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

• Mild/Moderate
• Severe

---

• Choose severe if there are significant systemic features or no improvement in > 48 hours

Is the patient an adult or a child?

• Adult
• Child (< 12 years)

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

• Mild/Moderate
• Severe

---

• Choose severe if there are significant systemic features or no improvement in > 48 hours

Does the patient have a history of previous nmMRSA colonisation?

• Yes
• No

---

• Please check the patients previous admission details. Areas with a high level of nmMRSA prevalence include detention centres, army barracks, remote communities and gaols

Is the patient an adult or a child?

• Adult
• Child (< 12 yrs)

Does the patient have a history of previous nmMRSA colonisation?

• Yes
• No

---

• Please check the patients previous admission details. Areas with a high level of nmMRSA prevalence include detention centres, army barracks, remote communities and gaols

Does the patient have a history of previous nmMRSA colonisation?

• Yes
• No

---

• Please check the patients previous admission details. Areas with a high level of nmMRSA prevalence include detention centres, army barracks, remote communities and gaols

Does the patient have a history of previous nmMRSA colonisation?

• Yes
• No

---

• Please check the patients previous admission details. Areas with a high level of nmMRSA prevalence include detention centres, army barracks, remote communities and gaols

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:

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Treatment for 5 days is generally sufficient, but a longer duration of therapy may be required for patients who are slow to respond or have a more severe infection
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

---

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:

---

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

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Treatment for 5 days is generally sufficient, but a longer duration of therapy may be required for patients who are slow to respond or have a more severe infection
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

---

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:

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Treatment for 5 days is generally sufficient, but a longer duration of therapy may be required for patients who are slow to respond or have a more severe infection
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

---

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:

---

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

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

---

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

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)
• For oral regimens see the mild/moderate infection section
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

---

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

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)
• For oral regimens see the mild/moderate infection section
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

---

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:

---

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

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Treatment for 5 days is generally sufficient, but a longer duration of therapy may be required for patients who are slow to respond or have a more severe infection
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

---

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:

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

---

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

---

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

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

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

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

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

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

---

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

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)
• For oral regimens see the mild/moderate infection section
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

---

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

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

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

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

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

---

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

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)
• See the mild/moderate treatment section for nmMRSA for oral step down options
• The mainstay of treatment for carbuncles is incision and drainage. Antibiotic therapy will not be effective unless the collection is drained

---

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

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

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

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

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

• Yes
• No

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

• No penicillin allergy
• Immediate or delayed non-severe penicillin hypersensitivity
• Immediate or delayed severe penicillin hypersensitivity

---

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Immediate or delayed non-severe penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash.
• There is only a 1-2% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin (except if there is a shared side chain; eg cefalexin and amoxicillin), and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a nonsevere reaction to penicillin

Immediate or delayed severe penicillin hypersensitivity

• This includes anaphylaxis (see below) and other severe reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

---

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash.
• There is only a 1-2% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin (except if there is a shared side chain; eg cefalexin and amoxicillin), and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a nonsevere reaction to penicillin

Anaphylaxis/severe reaction

• This includes anaphylaxis (see below) and other severe reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

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

OR

OR

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

• Mild/Moderate
• Severe

---

• Choose severe if there are significant systemic features or no improvement in > 48 hours

• Mild/Moderate
• Severe

• Adult
• Child (< 12 years)

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

• Mild/Moderate
• Severe

---

• Choose severe if there are significant systemic features or no improvement in > 48 hours

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

• Yes
• No

---

• Erysipelas typically presents as a rapidly progressing erythematous skin lesion that has a sharply demarcated, raised edge
• Erysipelas is most common in infants, indigenous patients, young children and older adults.
• Classically, erysipelas involves either facial skin in a butterfly pattern, or the lower legs
• Spontaneous rapid spreading cellulitis is most commonly due to S.pyogenes or another streptococci

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

---

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary

---

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

---

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

---

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary

---

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:

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

---

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

---

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary

---

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

---

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary

---

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

---

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary
• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Vancomycin may also be needed in patients with severe sepsis or septic shock. (see the severe cellulitis treatment in a patient with severe penicillin allergy for the dosing nomogram and approval code if needed)

---

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

---

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

---

• Consider an early switch to oral clindamycin (within 48 hours), clindamycin has excellent oral bioavailability (90% orally bioavailable)
• In addition to treating cellulitis, examine patient for tinea of the feet and treat if necessary
• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

---

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

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

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

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

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

---

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary
• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Vancomycin may also be needed in patients with severe sepsis or septic shock. (see the severe cellulitis treatment in a patient with severe penicillin allergy for the dosing nomogram and approval code if needed). If vancomycin is started, consider changing flucloxacillin to cefazolin IV.

---

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

• No penicillin allergy
• Immediate or delayed non-severe penicillin hypersensitivity
• Immediate or delayed severe penicillin hypersensitivity

---

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control, such as metoclopramide

Minor penicillin allergy

• This includes non-severe reactions such as isolated rash.
• There is only a 1-2% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin (except if there is a shared side chain; eg cefalexin and amoxicillin), and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a nonsevere reaction to penicillin

Anaphylaxis/severe reaction

• This includes anaphylaxis (see below) and other severe reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

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

OR

OR

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)

• No infection established (prophylaxis)
• Established mild infection (not involving deep tissues)
• Established moderate/severe infection

---

Antibiotic prophylaxis is required for bites and fist injuries with a high risk of infection such as:

• Wounds with delayed presentation for washout (8 hours or more)
• Puncture wounds that can not be debrided adequately
• Any wounds on the hands feet or face
• Wounds involving deeper tissues (eg. bones, joints, tendons)
• Wounds in immunocompromised patients
• Wounds that also involve an open fracture (see open fracture section)
• Any cat bite

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

---

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.

---

• In all cases, the patient's tetanus immunisation status must be ascertained
• A longer antibiotic course may be required according to clinical response
• Depending on microbiological findings from wound swab, the usual oral step down for animal or human bites is amoxicillin+clavulanic acid 875/125mg twice daily
• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable.
• For severe and penetrating wounds, total treatment duration is usually 14 days (IV + oral). A longer duration of directed therapy and higher doses may be needed for injuries involving bones, joints or tendons
• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites

---

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

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

---

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

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)

• No infection established (prophylaxis)
• Established mild infection (not involving deep tissues)
• Established moderate/severe infection

---

Antibiotic prophylaxis is required for bites and fist injuries with a high risk of infection, such as:

• Wounds with delayed presentation for washout (8 hours or more)
• Puncture wounds that can not be debrided adequately
• Any wounds on the hands feet or face
• Wounds involving deeper tissues (eg. bones, joints, tendons)
• Wounds in immunocompromised patients
• Wounds that also involve an open fracture (see open fracture section)
• Any cat 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)

• No infection established (prophylaxis)
• Established mild infection (not involving deep tissues)
• Established moderate/severe infection

---

Antibiotic prophylaxis is required for bites and fist injuries with a high risk of infection, such as:

• Wounds with delayed presentation for washout (8 hours or more)
• Puncture wounds that can not be debrided adequately
• Any wounds on the hands feet or face
• Wounds involving deeper tissues (eg. bones, joints, tendons)
• Wounds in immunocompromised patients
• Wounds that also involve an open fracture (see open fracture section)
• Any cat bite

For patients with a penicillin allergy use:

---

• A longer antibiotic course may be required according to clinical response
• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• For bites and clenched-fist injuries that are not infected, antibiotic therapy is usually not necessary for otherwise healthy individuals if the risk of wound infection is low (e.g. small wounds not involving deeper tissues that present within 8 hours and can be adequately debrided and irrigated). Give presumptive therapy if the risk of wound infection is high
• In all cases, the patient's tetanus immunisation status must be ascertained
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites
• For wounds on the hands, feet or face, or if infection progresses despite antibiotic therapy, consider surgical consultation. Surgical advice may also be sought on the appropriateness of primary versus delayed wound closure

---

For patients without a penicillin allergy, use:

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

---

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.

---

• In all cases, the patient's tetanus immunisation status must be ascertained
• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• For bites and clenched-fist injuries that are not infected, antibiotic therapy is usually not necessary if the risk of wound infection is low (e.g. small wounds not involving deeper tissues that present within 8 hours and can be adequately debrided and irrigated)
.
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites
• For wounds on the hands, feet or face, or if infection progresses despite antibiotic therapy, consider surgical consultation. Surgical advice may also be sought on the appropriateness of primary versus delayed wound closure
• For patients hypersensitive to penicillins who require intravenous or intramuscular therapy, seek expert advice.

---

For patients with a penicillin allergy use:

---

• In all cases, the patient's tetanus immunisation status must be ascertained
• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• For bites and clenched-fist injuries that are not infected, antibiotic therapy is usually not necessary if the risk of wound infection is low (e.g. small wounds not involving deeper tissues that present within 8 hours and can be adequately debrided and irrigated).
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites
• For wounds on the hands, feet or face, or if infection progresses despite antibiotic therapy, consider surgical consultation. Surgical advice may also be sought on the appropriateness of primary versus delayed wound closure
• For patients hypersensitive to penicillins who require intravenous or intramuscular therapy, seek expert advice.

---

For patients with a penicillin allergy use:

---

• In all cases, the patient's tetanus immunisation status must be ascertained
• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• For bites and clenched-fist injuries that are not infected, antibiotic therapy is usually not necessary if the risk of wound infection is low (e.g. small wounds not involving deeper tissues that present within 8 hours and can be adequately debrided and irrigated).
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites
• For wounds on the hands, feet or face, or if infection progresses despite antibiotic therapy, consider surgical consultation. Surgical advice may also be sought on the appropriateness of primary versus delayed wound closure
• For patients hypersensitive to penicillins who require intravenous or intramuscular therapy, seek expert advice.

---

For patients that do not have a penicillin allergy use:

---

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.

---

• In all cases, the patient's tetanus immunisation status must be ascertained
• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• A longer antibiotic course may be required according to clinical response
• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable. Unless directed by microbiological findings, usual step down is amoxicillin+clavulanic acid orally.
• For severe and penetrating wounds, total treatment duration is usually 14 days (IV + oral). A longer duration of directed therapy is needed for injuries involving bones, joints and/or tendons
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites

---

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

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

---

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

For patients with a penicillin allergy give:

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

---

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.

---

• In all cases, the patient's tetanus immunisation status must be ascertained
• The recommended management of clenched fist injuries, and human and animal bites, is thorough cleaning, debridement, irrigation, elevation and immobilisation
• For wounds on the hands, feet or face, or if infection progresses despite antibiotic therapy, consider surgical consultation. Surgical advice may also be sought on the appropriateness of primary versus delayed wound closure
• A longer antibiotic course may be required according to clinical response
• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable. Unless directed by microbiological findings, usual step down is amoxicillin+clavulanic acid orally.
• For severe and penetrating wounds, total treatment duration is usually 14 days (IV + oral). A longer duration of directed therapy is needed for injuries involving bones, joints and/or tendons
• The organisms associated with human bites and clenched fist injuries are Staphylococcus aureus, Eikenella corrodens, Streptococcus species and beta-lactamase–producing anaerobic bacteria
• The organisms associated with animal bites are Pasteurella species, S. aureus, Capnocytophaga canimorsus, Streptococcus species and anaerobic bacteria
• Cat bites have a higher incidence of deep infection than dog bites

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

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

---

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

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

Please contact IFD for advice.

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

• Periorbital (preseptal)
• Orbital (postseptal)

Classification of eye cellulitis

---

• Periorbital (preseptal) cellulitis - is a soft tissue infection of the eyelids, originating anterior to the orbital septum (the anatomical barrier separating the eyelids from the orbit). It is usually caused by local introduction of organisms from trauma or infection of the surrounding skin
• Orbital (postseptal) cellulitis - usually arises from infection (especially untreated) of paranasal sinuses or orbital trauma. It is less common but much more serious than periorbital (preseptal) cellulitis. Clinical symptoms are more pronounced; patients are generally unwell and may have reduced vision, limited or painful extra-ocular movement, or proptosis.

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

• Yes
• No

---

• In severe cases of periorbital cellulitis a CT scan should be performed to exclude sinusitis associated infection and treatment should continue as per orbital cellulitis

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

• No penicillin allergy
• Immediate or delayed non-severe penicillin hypersensitivity
• Immediate or delayed severe penicillin hypersensitivity

---

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Immediate or delayed non-severe penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash.
• There is only a 1-2% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin (except if there is a shared side chain; eg cefalexin and amoxicillin), and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a nonsevere reaction to penicillin

Immediate or delayed severe penicillin hypersensitivity

• This includes anaphylaxis (see below) and other severe reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

---

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

OR

OR

For patients that do not have a penicillin allergy use:

---

• If methicillin-resistant S. aureus (MRSA) is suspected (eg if patient from a gaol, detention centre or community with high MRSA prevalence), seek expert advice.

---

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

---

• If methicillin-resistant S. aureus (MRSA) is suspected (eg if patient from a gaol, detention centre or community with high MRSA prevalence), seek expert advice.

---

For patients with a penicillin allergy, use:

---

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

---

• If methicillin-resistant S. aureus (MRSA) is suspected (eg if patient from a gaol, detention centre or community with high MRSA prevalence), seek expert advice.

---

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

• No penicillin allergy
• Immediate or delayed non-severe penicillin hypersensitivity
• Immediate or delayed severe penicillin hypersensitivity

---

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Immediate or delayed non-severe penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash.
• There is only a 1-2% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin (except if there is a shared side chain; eg cefalexin and amoxicillin), and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a nonsevere reaction to penicillin

Immediate or delayed severe penicillin hypersensitivity

• This includes anaphylaxis (see below) and other severe reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

---

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

OR

OR

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

---

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

---

• In patients with severe disease consider contacting IFD for addition of vancomycin for MRSA cover.
• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable.
• In most cases oral step down therapy should be amoxicillin+clavulanic acid (875+125 mg 12-hourly) for a further 10 days
• If methicillin-resistant S. aureus (MRSA) is suspected (eg if patient from a gaol, detention centre or community with high MRSA prevalence), seek expert advice.
• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing.

---

For patients with a nonsevere penicillin allergy, use:

---

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

---

• In patients with severe disease consider contacting IFD for addition of vancomycin for MRSA cover.
• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable.
• If methicillin-resistant S. aureus (MRSA) is suspected (eg if patient from a gaol, detention centre or community with high MRSA prevalence), seek expert advice.
• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing.

---

For patients with a severe penicillin allergy, use:

---

---

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

---

• In patients with severe disease consider contacting IFD for addition of vancomycin for MRSA cover.
• Modify therapy based on the results of Gram stain, cultures and susceptibility testing. Switch to oral therapy once the patient is stable.
• If methicillin-resistant S. aureus (MRSA) is suspected (eg if patient from a gaol, detention centre or community with high MRSA prevalence), seek expert advice.
• Four-hourly eye observations are advised. If signs worsen, surgical drainage is required, with postoperative antibiotic therapy guided by the results of susceptibility testing.

---

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

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

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

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

• No penicillin allergy
• Immediate or delayed non-severe penicillin hypersensitivity
• Immediate or delayed severe penicillin hypersensitivity

---

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Immediate or delayed non-severe penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash.
• There is only a 1-2% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin (except if there is a shared side chain; eg cefalexin and amoxicillin), and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a nonsevere reaction to penicillin

Immediate or delayed severe penicillin hypersensitivity

• This includes anaphylaxis (see below) and other severe reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

---

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

OR

OR

How severe is the infection? (see table below)

• Mild
• Moderate
• Severe

Classification of diabetic foot infection

How severe is the infection? (see table below)

• Mild
• Moderate
• Severe

Classification of diabetic foot infection

How severe is the infection? (see table below)

• Mild
• Moderate
• Severe

Classification of diabetic foot infection

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

---

• For mild infections usually 1-2 weeks is sufficient; continue antibiotic therapy until infection is resolved but not necessarily until the ulcer is healed.
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required.

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

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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

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• For mild infections usually 1-2 weeks is sufficient; continue antibiotic therapy until infection is resolved but not necessarily until the ulcer is healed.
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations or doses may be required. For infection with Pseudomonas aeruginosa the dose of ciprofloxacin may need to be increased

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

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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.

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• If intravenous therapy is needed, contact IFD or use drugs and codes from the 'severe infection' section
• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a vancomcyin dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state
• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• If Pseudomonas aeruginosa is isolated from cultures of deep tissue specimens change therapy according to sensitivities or contact IFD for advice
• Typically a total duration of 1 to 2 weeks (intravenous + oral) is sufficient for moderate infections, unless deeper tissues are involved in infection

---

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Vancomycin Dosing in Adults

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

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

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• For mild infections usually 1-2 weeks is sufficient; continue antibiotic therapy until infection is resolved but not necessarily until the ulcer is healed.
• In patients with severe renal failure amoxicillin dose may need to be reduced
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required.

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

• Yes
• No

Signs of Sepsis

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• Currently nearly half of all RDH patients are infected or colonised with MRSA (46%). Consult IFD promptly if the patient is not improving, septic, or MRSA is suspected.

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

• Yes
• No

Signs of Sepsis

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• Currently nearly half of all RDH patients are infected or colonised with MRSA (46%). Consult IFD promptly if the patient is not improving, septic, or MRSA is suspected.

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

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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

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• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available;other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa the empirical dosage of ciprofloxacin may need to be modified
• Wherever possible ensure that 2 x blood cultures are taken prior to administration of antibiotics to allow directed therapy
• If septic, door to needle time must be within ONE HOUR of recognition of septic shock
• If septic, repeat fluid bolus every 15 minutes until patient is normotensive.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment and change ongoing resuscitation fluid to Plasmalyte.
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return.
• Ensure urgent baseline bloods are taken following initiation of antibiotics; FBC, UEC, LFTs, Coags, CRP and CaMgP
• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state
• If cultures return sensitive to clindamycin this is often a good alternative to vancomycin with excellent tissue penetration
• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• If Pseudomonas aeruginosa is isolated from cultures of deep tissue specimens then the empirical dose of piperacillin and tazobactam may need to be maintained at 6-hourly dosing for longer.
• Please note clindamycin has excellent oral bioavailability (90% orally bioavailable), consider an early switch to oral if clindamycin is to be used

---

Vancomycin Dosing in Adults

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

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

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

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.

---

---

• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a vancomcyin dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state
• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• If Pseudomonas aeruginosa is isolated from cultures of deep tissue specimens change therapy according to sensitivities or contact IFD for advice.

---

Vancomycin Dosing in Adults

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

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

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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.

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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.

---

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state
• If cultures return sensitive to clindamycin this is often a good alternative to vancomycin with excellent tissue penetration
• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• If Pseudomonas aeruginosa is isolated from cultures of deep tissue specimens then the empirical dose of piperacillin and tazobactam may need to be increased to 6-hourly dosing.

---

Vancomycin Dosing in Adults

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

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:

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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.

---

• If Pseudomonas aeroginosa is suspected, use piperacillin+tazobactam as empirical therapy, see dose and code in severe infection section
• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a vancomcyin dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state
• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• If Pseudomonas aeruginosa is isolated from cultures of deep tissue specimens change therapy according to sensitivities or contact IFD for advice.

---

---

Vancomycin Dosing in Adults

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

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

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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.

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• Adjust dosing frequency in patients with renal impairment.
• If septic, door to needle time must be within ONE HOUR of recognition of septic shock.
• If septic, repeat fluid bolus every 15 minutes until patient is normotensive.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment and change ongoing resuscitation fluid to Plasmalyte.
• Ensure urgent baseline bloods are taken following initiation of antibiotics; FBC, UEC, LFTs, Coags, CRP and CaMgP.
• Watch baseline creatinine closely while treating a patient with pipercilin+tazobactam and vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state.
• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available.

---

Vancomycin Dosing in Adults

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

• Code Checker
• Cockcroft Gault (CrCl) Calculator
• Gentamicin nomogram
• Gentamicin empiric dose calculator
• Surgical prophylaxis antibiotic half-lives nomogram
• Switch to Orals Nomogram
• Vancomycin empiric dose calculator

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

TEAMS CODE:

Date of first dose of antibiotic:

Antibiotic prescribed: Aciclovir IV Aciclovir PO Amoxicillin IV & Clavulanate Azithromycin IV Azithromycin PO Aztreonam Cefotaxime Cefepime Ceftazidime Ceftriaxone Cefuroxime Ciprofloxacin IV Ciprofloxacin PO Clarithromycin Clindamycin IV Clindamycin PO Ivermectin PO Gentamicin Meropenem Moxifloxacin IV Moxifloxacin PO Norfloxacin Oseltamivir Piperacillin/tazobactam Valaciclovir Vancomycin

Check

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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)

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Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

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• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose, use the adult aminoglycoside dose calculator. For morbidly obese patients, seek expert advice.
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR.
• 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)
• Use the Cockcroft gault calculator to calculate renal function for adults if using the nomogram, or use the adult aminoglycoside dose calculator

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

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Vancomycin Dosing in Paediatrics

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Vancomycin Dosing in Adults

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

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

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

Weight (Kg):

Vancomycin dose: mg

Calculate

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• 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.
• Weight-based dosing is recommended for the loading dose, since both volume of distribution and clearance of vancomycin are correlated with actual body weight.
• This calculator is for adult patients only, for paediatric or underweight patients (<36Kg) please seek specialist advice
• This calculator aims for a load of 25 to 30 mg/kg (actual body weight)

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

Gender: Male Female

Age (years):

Approximate height (cm):

Actual weight (kg):

Creatinine:

Calculate

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Vancomycin loading dose (optional): mg

Vancomycin maintenance dose: mg, -

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

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• This calculator must not be used on large muscular patients, it assumes that all weights above IDBW are due to fatty tissue, large muscular patients are likely to be underdosed when using this calculator, please contact IFD for advice with these patients
• This calculator is for use as a guide only. The following patient groups may have altered pharmacokinetics and modified doses may be required. Please contact infectious diseases for advice with the following:
  • critically ill patients with severe sepsis or septic shock
  • patients receiving renal replacement therapy
  • pregnant women
  • patients with ascites or fluid overload
  • morbidly obese or very low body weight patients
• This calculator is not for use in ICU patients (contact the ICU pharmacist or treating physician when dosing in ICU patients)
• This calculator is not for use paediatric patients < 12 years old
• A loading dose of vancomycin should be given to patients with serious infections who are critically ill (eg, severe sepsis)

Cockcroft Gault Creatinine Clearance Calculator for >12 years only:

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Enter the patient details to calculate the creatinine clearance:

Gender: Male Female

Height (cm):

Actual weight (kg):

Age (years):

Creatinine:

Creatinine Clearance:0 mL/min

Calculate Clear

• This calculator is for use as a guide only. The following patient groups may have altered pharmacokinetics and modified doses may be required. Please contact infectious diseases for advice with the following:
  • critically ill patients with severe sepsis or septic shock
  • patients receiving renal replacement therapy
  • pregnant women
  • patients with ascites or fluid overload
  • morbidly obese or very low body weight patients
• This calculator is not for use in critically ill patients with severe sepsis, who may require higher doses
• This calculator is not for use paediatric patients < 12 years old
• 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.
• This calculator aims for a load of 25 to 30 mg/kg (actual body weight)

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

Select the AUC target (normally 80, or 100 for cystic fibrosis) 80 100

Dose of gentamicin (mg)

Infusion Start Time HH:MM (24 hour format)			Infusion End Time HH:MM (24 hour format)
		Day 1 Day 2			Day 1 Day 2

Time of first (peak) level HH:MM (24 hour format)			Time of second (trough) level HH:MM (24 hour format)
		Day 1 Day 2			Day 1 Day 2

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

Calculate

Standard course tuberculosis medication dosage calculator:

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

Intended Dosing Frequency Daily Three times weekly

Weight (kg):

Isoniazid dose: 0 mg.

Rifampicin dose: 0 mg.

Ethambutol dose: 0 mg.

Pyrazinamide dose: 0 mg.

Pyridoxine dose: 0 mg.

Calculate

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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.

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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

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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

• This calculator is for use as a guide only. The following patient groups may have altered pharmacokinetics and modified doses may be required. Please contact infectious diseases for advice with the following:
  • critically ill patients with severe sepsis, septic shock or febrile neutropenia
  • patients receiving renal replacement therapy
  • patients with severe burns
  • patients with cystic fibrosis
  • pregnant women
  • patients with ascites
  • morbidly obese patients
• This calculator is not for use in paediatric patients < 18 years old
• Clinical monitoring for toxicity should be undertaken in all patients, even if AUC monitoring is not required

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Enter the patient details to calculate the gentamicin loading dose:

Gender: - Male Female

Age:

Height (cm):

Actual weight (kg):

Creatinine:

Does the patient have severe sepsis or febrile neutropenia? No Yes

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

Calculate Clear

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

• No penicillin allergy
• Immediate or delayed non-severe penicillin hypersensitivity
• Immediate or delayed severe penicillin hypersensitivity

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History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Immediate or delayed non-severe penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash.
• There is only a 1-2% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin (except if there is a shared side chain; eg cefalexin and amoxicillin), and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a nonsevere reaction to penicillin

Immediate or delayed severe penicillin hypersensitivity

• This includes anaphylaxis (see below) and other severe reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

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

OR

OR

Epiglottitis treatment:

---

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

---

---

• The addition of corticosteroids to reduce airway inflammation is controversial but widespread
• Treatment of acute epiglottitis requires airway maintenance. All patients require intensive monitoring. Seek expert advice from ENT or IFD.

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For epiglottitis in a patient with life threatening penicillin hypersensitivity:

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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

---

---

• The addition of corticosteroids to reduce airway inflammation is controversial but widespread
• Treatment of acute epiglottitis requires airway maintenance. All patients require intensive monitoring. Seek expert advice from ENT or IFD.

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

• No penicillin allergy
• Immediate or delayed non-severe penicillin hypersensitivity
• Immediate or delayed severe penicillin hypersensitivity

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History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Immediate or delayed non-severe penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash.
• There is only a 1-2% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin (except if there is a shared side chain; eg cefalexin and amoxicillin), and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a nonsevere reaction to penicillin

Immediate or delayed severe penicillin hypersensitivity

• This includes anaphylaxis (see below) and other severe reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis

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

OR

OR

Is the patient an adult or child?

• Adult patient
• Paediatric patient