SAASP - Pocket Guide To Antibiotic Prescribing For Adults in SA 2015

A POCKET GUIDE TO ANTIBIOTIC PRESCRIBING

FOR ADULTS IN SOUTH AFRICA, 2015

SEAN WASSERMAN
TOM BOYLES
MARC MENDELSON

ON BEHALF OF THE SOUTH AFRICAN ANTIBIOTIC STEWARDSHIP
PROGRAMME (SAASP)

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Contents

Why do we need this guide? 5
Principles for rational antibiotic prescribing 6
Interpreting test results 11
Correct techniques of microbiological sampling 13
Changing antibiotics 15
Infection prevention 16
Acute upper respiratory tract infection 20
Lower respiratory tract infection 24
Intra-‐abdominal infection 29
Acute diarrhoea 31
Urinary tract infections 35
Sexually transmitted infections 40
Acute meningitis 45
Peripheral line infection 48
Staphylococcus aureus bacteraemia 49
Skin and soft tissue infections 51
Bone and joint infections 56
Prophylaxis 59

A pocket guide to antibiotic prescribing for adults in South Africa 2015
First published 2014
© Sean Wasserman, Tom Boyles, Marc Mendelson
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GLOSSARY

Term Definition
Antibiogram A list of antibiotics to which a cultured bacterium is
susceptible, intermediate or resistant
BC Blood culture
BD Twice daily
Beta-‐lactam antibiotic Antibiotic class containing a beta-‐lactam ring that inhibits
bacterial cell wall synthesis. Includes penicillins,
cephalosporins and carbapenems
CA Community-‐acquired
CAP Community acquired pneumonia
Cleaning solution Antiseptic for hand hygiene, including 0.5% chlorhexidine
in 70% alcohol and iodine-‐based solutions
Community-‐acquired (CA) infection Illness starts prior to, or within 48 hours of admission
CRB-‐65 score A clinical prediction rule for mortality in community-‐
acquired pneumonia. The score is an acronym for
individual risk factors as follows:
Confusion of new onset
Respiratory rate ≥ 30 breaths per minute
Blood pressure < 90 mmHg systolic or < 60 diastolic
65 years or older

A single point is assigned to each risk factor.
CRE Carbapenem resistant Enterobacteriaceae
CXR Chest X-‐ray
eGFR Estimated glomerular filtration rate
ESBL Extended spectrum beta lactamase producing organism
Health care associated infection (HCAI) Any patient with a new infection starting ≥ 48 hours after
admission and was not apparent at the time of admission,
or any catheter or line-‐associated infection irrespective of
time of insertion.
The following factors increase risk:
• Admission to an acute care hospital within 90 days of
the current presentation
• Resident of a nursing home or long-‐term care facility
• Recent intravenous antibiotic therapy, chemotherapy or
wound care within the past 30 days of the current
presentation
• Patients attending a haemodialysis clinic
HCAP Health care associated pneumonia
IPC Infection prevention and control
im Intramuscular injection
iv Intravenous
MRSA Methicillin resistant Staphylococcus aureus
MSSA Methicillin sensitive Staphylococcus aureus
po Per os (oral)
Rx Treatment/therapy
TOE Trans-‐oesophageal echocardiogram
TTE Trans-‐thoracic echocardiogram
VRE Vancomycin resistant enterococci

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Disclaimer
This document is provided as an information resource for all health care workers to
assist in the appropriate prescribing of antibiotics. It attempts to summarise relevant
information for clinicians from South African and International guidelines as well as
reference to textbooks, key publications and expert opinion.

Recommendations change rapidly and opinion can be controversial. The authors do
not warrant that the information contained in this booklet is complete and shall not
be liable for any damages incurred as a result of its use.

Acknowledgements
We would like to acknowledge the following colleagues who provided input during
the editing phase of this book:

Dr Adrian Brink, Prof Alan Karstaedt, Prof Andrew Whitelaw, Prof Andries Gous, Ms
Andriette van Jaarsveld, Prof Andy Parish, Dr Cloete van Vuuren, Dr Colleen
Bamford, Dr Dena van den Bergh, Prof Guy Richards, Prof Gary Maartens, Dr Ivan
Joubert, Dr James Nuttall, Sr Lesley Devenish, Prof Olga Perovic.

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Chapter 1
Why do we need this guide?

The international community sits at the tipping point of a post-‐antibiotic era, where
common bacterial infections are no longer treatable with the antibiotic
armamentarium that exists. In South Africa, the identification of the first case of pan-‐
resistant Klebsiella pneumoniae (Brink et al, J Clin Microbiol. 2013;51(1):369-‐72)
marks a watershed moment and highlights our tip of the antibiotic resistance
‘iceberg’ in this country. Multi-‐drug resistant (MDR)-‐bacterial infections,
predominantly in Gram-‐negative bacteria such as Klebsiella pneumoniae, Escherichia
coli, Pseudomonas aeruginosa and Acinetobacter baumannii are now commonplace
in South African hospitals. Whilst a number of expensive new antibiotics for Gram-‐
positive bacterial infections have been manufactured recently (some of which are
licenced for use in South Africa), no new antibiotics active against Gram-‐negative
infections are expected in the next 10-‐15 years. Hence what we have now, needs
conserving.

The development of antibiotic resistance is a natural phenomenon. Drug-‐resistance
mutations have been found in 30,000-‐year old ice blocks. In addition, bacteria may
acquire antibiotic resistance mechanisms by horizontal gene transfer. There are over
1000 different naturally occurring enzymes that are produced by different bacteria,
which inactivate antibiotics. The overuse of antibiotics is driving the selection of
antibiotic resistance. Given the right circumstances, the resistant bacteria that are
selected out can either colonize a patient (be present, potentially transmissible, but
not cause clinical disease i.e. infection) or cause infection. It follows that the more
antibiotics are used, the greater the likelihood of selecting out antibiotic resistance,
and the broader the spectrum of antibiotic that is used, the greater the number of
different types of resistant bacteria will be selected out. The fact that it is estimated
that half of all antibiotics prescribed in human health are unnecessary e.g. for viral
upper respiratory tract infections, demands our renewed efforts to make antibiotic
prescribing appropriate. When it is indicated, an antibiotic must be the right choice
at the right dose, dosing interval and route, and for the right duration, and when it is
not indicated, that antibiotic must not prescribed.

Rather than be an exhaustive text on infectious diseases, microbiology or clinical
pharmacology, the aim of this guide is to give you the practical information you need
to perform antibiotic stewardship in an algorithmic manner, which mimics the day-‐
to-‐day experience of the prescriber.

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Chapter 2
Principles for rational antibiotic prescribing

1. Decide if an antibiotic is indicated: does the patient have a bacterial
infection?

Targeted refers to specimen from site of infection e.g. urine for cystitis

2. Perform cultures before administering antibiotics in hospitalised
patients or in outpatients with recurrent infections
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This allows de-‐escalation to a narrow spectrum antibiotic once the

antibiogram is available & is a cornerstone of antibiotic stewardship

3. Choose an appropriate empiric antibiotic:
a. Target the most likely pathogen(s) for the site of infection
This can be predicted by understanding the broad groups of pathogens
that most commonly cause infections at various sites:
– Skin and soft tissue: Gram positive cocci
– Urinary tract: Gram negative bacilli
– Intra-‐abdominal: Gram-‐negative, Gram-‐positive and anaerobic
organisms
– See chapters on specific infections for more details
An appropriate empiric antibiotic can then be selected by matching the
narrowest spectrum antibiotic with the likely pathogens. Spectrums of
activity of commonly used antibiotics are shown below

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Gram positive cocci

Clusters Pairs/chains
MSSA MRSA S. pneumoniae E. faecalis E. faecium VRE
Most other
streptococci
Amoxicillin/ampicillin -‐ -‐ + + -‐ -‐
Cloxacillin + -‐ +/-‐ -‐ -‐ -‐
Clindamycin + +/-‐ + -‐ -‐ -‐
Ceftriaxone + -‐ + -‐ -‐ -‐
Co-‐amoxiclav + -‐ + / -‐ -‐
Vancomycin / + / / + -‐
Ertapenem / -‐ / -‐ -‐ -‐
Moxifloxacin / +/-‐ + / +/-‐ -‐
Linezolid / / / / / +
Daptomycin / / / / / /

Gram negative
Bacilli Cocci
E. coli Enterobacter ESBL CRE Salmonella Pseudomonas Neisseria
Klebsiella spp. spp. spp. meningitidis
spp.
Amoxicillin/ampicillin -‐ -‐ -‐ -‐ / -‐ +/-‐
Penicillin -‐ -‐ -‐ -‐ / -‐ +/-‐
Cotrimoxazole* +/-‐ +/-‐ +/-‐ -‐ +/-‐ -‐ -‐
Ceftriaxone + -‐ -‐ -‐ + -‐ +
Co-‐amoxiclav + -‐ -‐ -‐ / -‐ /
Ciprofloxacin + + +/-‐ +/-‐ + + /
Aminoglycosides + + +/-‐ +/-‐ -‐ + -‐
Cefepime / + -‐ -‐ / + /
Piptazobactam / +/-‐ -‐ -‐ / + /
Ertapenem / + + -‐ / -‐ /
Imipenem / / / +/-‐ / + /
Meropenem / / / +/-‐ / + /
*Associated with much higher rates of toxicity than other antibiotics. Avoid using if a suitable
alternative with a similarly narrow spectrum of activity is available

+ usually susceptible: recommended first line therapy while awaiting antibiogram
-‐ frequent resistance or poor clinical efficacy: do not use
+/-‐ variable susceptibility: only use with antibiogram result
/ usually susceptible but not first choice: do not use unless there is a compelling reason (e.g.
allergy, toxicity or resistance to first line drug or better outcomes for a particular site of infection)

b. Assess likelihood of antibiotic resistance
Risk factors include known colonisation with a resistant pathogen, HCAI,
recent antibiotic exposure. Local resistance patterns inform prescribing.

c. Review potential contraindications
Allergy:
Clinicians should differentiate an immediate type 1 IgE mediated
hypersensitivity reaction from other less dangerous types of
hypersensitivity. Classical signs of type 1 hypersensitivity are anaphylaxis,
angioedema, urticarial rash, and bronchospasm. If a type I
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hypersensitivity reaction to penicillin has occurred, then all β-‐lactam

antibiotics should be avoided, unless there is no alternative drug available
when penicillin desensitisation can be attempted as an inpatient.
Patients with other types of hypersensitivity reactions, usually a
maculopapular rash to amoxicillin, should avoid all penicillins but may
tolerate other β-‐lactam antibiotics like cephalosporins. The 1st generation
cephalosporins should be avoided as they have a higher risk of cross-‐
reactivity with penicillin, but this risk is much lower for second-‐ or third-‐
generation cephalosporins reported to be only 0.1%.
If the previous reaction to penicillin was a maculopapular rash, it is
relatively safe to use 2nd/3rd generation cephalosporins and use would
depend on the patient’s social circumstances and access to follow-‐up.
However, in patients with a remote history of a rash on penicillin it is
often difficult to differentiate a maculopapular rash from an urticarial
rash – all β-‐lactam antibiotics should be avoided if urticaria occurred on
penicillins as this is a type 1 reaction. In this setting, skin testing before
using a cephalosporin is recommended, as a positive reaction to penicillin
indicates type 1 hypersensitivity.

Toxicity:
Antibiotics can cause direct dose-‐dependent toxicity and should be
avoided in patients at high risk of developing organ damage with a
specific agent. For example, do not use aminoglycosides in patients with
renal impairment or hearing loss.

d. Choose drug with adequate target tissue penetration
CSF Lung Soft tissue Urinary tract
Ampicillin Good (in high doses) Good Good Good
Cloxacillin Inadequate data Fair Good No data
Clindamycin Poor No data Good No data
Co-‐amoxiclav Poor Good Good Fair
Ceftriaxone Good (in high doses) Good Good Good
Aminoglycosides Poor Poor Fair Good (if normal GFR)
Ciprofloxacin Good (in high doses) Good Good Good
Co-‐trimoxazole Good Good Good Good
Ertapenem Poor Good Good Good
Meropenem Good (in high doses) Good Good Good
Imipenem Good* Good Good Good
Vancomycin Poor Fair Poor Good
Linezolid Good Good Good Good
Daptomycin Poor Poor Good Good
*Associated with higher risk of seizures

e. Aim for a single drug with the desired spectrum of activity
Monotherapy is preferred unless combination therapy is required for
synergy (e.g. endocarditis) or extended spectrum beyond what can be
obtained with a single drug (e.g. atypical pathogens in severe CAP).

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4. Ensure correct dose and route of administration

The oral/enteral route is preferred whenever possible for patients
with mild to moderate infections. Intravenous antibiotics should be
reserved for severe infection or for certain sites such as the CSF,
bacteraemia, endocarditis, bone and joint infections.
Oral absorption (%) Comments
Penicillin VK Moderate Take without food
Amoxicillin Good
Flucloxacillin Good Take on empty stomach
Clindamycin Good
Co-‐amoxiclav Good
Ciprofloxacin Good Do not give via NGT or with antacids
Doxycycline Excellent Take with food, do not co-‐administer with antacids
Azithromycin Poor Take without food
Metronidazole Excellent
Co-‐trimoxazole Good
Linezolid Excellent

5. Start the appropriate antibiotic rapidly in severe infections
Mortality increases by 8% for every hour antibiotic administration is delayed in
septic shock1

6. Practice early and effective source control
Search for and remove any persistent foci of infection

7. Evaluate antibiotic appropriateness every day

1
Kumar et al. Crit Care Med. 2006 Jun;34(6):1589-‐96.
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Chapter 3
Interpreting test results

Non culture-‐based tests
Non culture-‐based tests such as urinary dipstick, peripheral white cell count (WCC),
and C-‐reactive protein (CRP) confirm the presence of inflammation when positive
but do not differentiate bacterial from non-‐bacterial causes. However, presence of
nitrites on urine dipstick, high neutrophil count with left-‐shift and CRP >100 mg/ml
all suggest bacterial infection. Negative results are generally good at excluding
inflammation and therefore bacterial infection.

Procalcitonin (PCT) is more specific for bacterial infection than CRP or WCC but 10
times more expensive. There is high quality evidence for its use in a limited number
of infections and its use should be limited to these indications. Specifically, low PCT
safely excludes bacterial infection such that antibiotics can be withheld in meningitis,
and acute exacerbations of chronic obstructive pulmonary disease (see later sections
for details). PCT has no value in differentiating bacterial infection from tuberculosis
and has very limited value in sepsis. Its price generally excludes its use in serial
measurement to determine when to stop, although some evidence in ICU settings
alone, exist.

Cultures

Does this positive culture represent infection, colonisation or contamination?

Infection = the presence of one or more microorganisms with an inflammatory
response

Colonisation = the presence of microorganisms without significant inflammation.

Contamination = A culture that contains a microorganism(s) that did not originate
from the intended anatomical site

Sterile sites
Normally sterile sites are CSF, lungs (below the glottis), urinary tract, biliary tract,
and blood. Bacteria cultured from these sites are likely to be causing infection but
still sometimes represent colonisation or contamination.

Finding bacteria in a sterile site is abnormal but may represent infection, or
contamination. Organisms colonizing skin such as coagulase-‐negative staphylococci
may cause contamination of sterile sites. Colonisation of urinary tract can occur
without causing infection. If the organism corresponds with the clinical scenario
then this should be considered to be causing infection

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Non-‐sterile sites
Non-‐sterile specimens include sputum (as it must pass through the mouth), pus
swabs from skin, GI tract and vagina. Specimens from these sites are expected to
culture bacteria (unless growth is inhibited by laboratory techniques). Interpretation
therefore depends on the organism(s) being compatible with the clinical scenario.

Cultures from non-‐sterile sites are often much harder to interpret and usually of
less value.

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Chapter 4
Correct techniques of microbiological sampling

Optimal sampling is very important to increase yields and decrease contamination
rates (see boxes below). Surgical specimens from abnormal structures such as
abscesses should usually be collected at the time of operation. Once surgical drains
are placed they quickly become colonised with skin and environmental bacteria and
culture results are not interpretable. Pus swabs collected outside of theatre are
discouraged, as it is extremely rare for them to yield information that will change
patient management.

Box 1. Correct technique for collecting mid-‐stream urine specimens
Instructions for collection of urine specimens
Females
• Wash your hands
• Clean the vulva front to back with sterile gauze and sterile water
• Spread labia with fingers
• Void and collect urine mid-‐flow

Males
• Wash your hands
• Retract foreskin and wash glans with sterile gauze and sterile water
• Void and collect urine mid-‐flow

Box 2. Correct technique for collecting urine specimens from a catheter

• Use aseptic technique with sterile gloves
and apron
• Clamp tubing just distal to sampling port
• Wait for urine to collect above clamp
• Wipe sampling port with cleaning
solution
• Remove urine with a small gauge sterile
needle and syringe
Transfer ufrine
Box 3• – Technique to sterile
or taking container
a pus swab
• Clean p ort a gain
• Unclamp tubing

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Box 3. Correct technique for performing a pus swab

1. Wounds with slough, necrotic tissue, or dried exudate should first be debrided
2. Wash the wound with sterile saline
3. If the wound is dry moisten the tip of the swab with sterile saline

4. Move swab tip across the wound surface in a zig-‐zag motion at the same time as

being rotated between the fingers

5. Apply gentle pressure to release fluid from the base of the wound

6. Aim to include as much of the area of the wound as possible but avoid intact skin

around the wound
7. Document clinical information on laboratory request form
8. Transfer to laboratory as soon as possible

Box 4. Correct technique for performing a blood culture
1. Verify the patient’s identity and obtain verbal consent.
2. Assemble the correct materials required for blood culture:
• blood culture bottle(s)
• syringe (10 ml or more)
• needle (22 gauge or more)
• sterile gloves
• tourniquet
• adhesive strip
• Cleaning solution*
• sterile pack containing cotton/gauze swabs, sterile paper x2 and waste bag
• patient labels
• sharps waste disposal bin
3. Apply tourniquet and select a suitable vein
4. Wash hands and apply sterile gloves
5. Clean the puncture site with cleaning solution using aseptic technique and allow 30
seconds for the disinfectant to dry
6. Place green sterile cover with opening over site for blood culture
7. Collect 10ml of blood per bottle from adults
8. Release tourniquet and remove needle
9. If not using the vacutainer system, disinfect the top of the blood culture bottle before
inoculating blood
10. Do not change needles between blood sample collection and inoculation of blood
culture bottle
11. Always fill blood culture bottle before filling vials for other tests
12. Label the blood culture bottle making sure not to cover the bar code label or the
bottom of the bottle
13. Complete a laboratory request form in full
14. If there is a delay in getting the sample to the laboratory, do not refrigerate the
bottle; rather leave it at room temperature
15. Document in the notes, the date and time that the blood culture was taken

*Chlorhexidine-‐alcohol is recommended, but if using povidone iodine, it must be left to dry
for at least 1 minute prior to performing culture
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Chapter 5
Changing Antibiotics

Once antibiotics have been initiated the decision to change or stop therapy depends
on the patient’s clinical response and culture results (see algorithm).

Abx = Antibiotics, BSA = Broad spectrum antibiotics
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Chapter 6
Infection prevention

The most important tools to prevent spread of infection are hand hygiene and
contact precautions. Correct management of IV lines and urinary catheters are
essential for reducing hospital-‐acquired infections.

Hand hygiene
WHEN:

HOW:
Use alcohol-‐based solutions for routine hand decontamination.

Indications for soap and water:
• Hands visibly dirty
• Hands contaminated with body

fluids
• After using the restroom or eating
• Exposure Clostridium difficile

Indications for gloves:
• Patient interactions that involve
exposure to blood, mucous
membranes or non-‐intact skin
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• Suspected or proven C. difficile
Always wash hands after glove use

Contact precautions

These should be implemented for any patient infected by or colonised with a drug-‐
resistant bacterial pathogen other than tuberculosis (which requires airborne
precautions to prevent small droplet spread). Contact precautions involve the
following:
1. Clear signage indicating that contact precautions are in place
2. Patient preferably placed in isolation
3. Hand disinfection prior to patient contact
4. Mandatory use of apron and gloves when entering the patient’s room, before
any contact with the patient or their surroundings and during examination
5. Remove apron first, followed by gloves
6. Hand disinfection after disposal of apron and gloves (use soap and water for C.
difficile exposure)
7. Contact precautions remain in place even after treatment with antibiotics and for
every hospital or nursing care re-‐admission for a period of 6 months. For patients
with C. difficile associated diarrhoea contact precautions can be withdrawn after
completion of treatment and resolution of diarrhoea.

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Management of peripheral IV lines

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Management of urinary catheters

Every time you see a patient you should be asking the
questions:
1. Can I stop or de-‐escalate antibiotics?
2. Can I remove this urinary catheter?
3. Can I remove this IV line?

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Chapter 7
Acute Upper Respiratory Tract Infection

Over-‐prescribing of antibiotics for upper respiratory tract infection (URTI) is a major
driver of bacterial resistance in the community. URTI comprises three clinical
syndromes depending on the site of infection; pharyngotonsillitis (sore throat), acute
otitis media, and acute bacterial sinusitis.

Acute pharyngotonsillitis (sore throat)

Typical appearance of viral pharyngitis

Typical appearance of bacterial pharyngitis

Definition
• Acute inflammation of the pharyngeal wall and tonsils.

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Likely pathogens
• Commonly respiratory viruses and Epstein-‐Barr virus. Around 5-‐30% caused
by group A β-‐haemolytic streptococci (GABHS) (S. pyogenes).
• Viral and bacterial acute pharyngitis are self-‐limiting, including those caused
by GABHS, hence, the primary reason for considering antibiotic therapy is to
prevent Acute Rheumatic Fever (ARF)

Clinical features
• Sore throat
• It is possible to differentiate bacterial from viral causes on clinical grounds.

Penicillin allergy
Azithromycin 500 mg po daily for 3 days

Acute otitis media

Definition
Acute inflammation of the middle ear

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Typical appearance of acute otitis media

Likely pathogens
• Haemophilus influenza, Streptococcus pneumoniae, Moraxella catarrhalis

Clinical features
• Ear pain and decreased hearing
• Reddened and bulging tympanic membrane, which may be draining pus.

Tests
• None required

Treatments
• Initially analgesics and decongestants only
• Antibiotics if febrile or symptoms do not settle within 48 hrs

First line
Amoxicillin 1g po 8-‐hourly for 5 days
Alternative in beta-‐lactam allergic patients

Acute bacterial sinusitis
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Definition-‐ Acute bacterial infection of para-‐nasal sinuses

Likely pathogens-‐ Haemophilus influenzae, Streptococcus pneumoniae, Moraxella
catarrhalis

Clinical features
• Often preceded by a viral URTI
• Fever, facial tenderness, dental tenderness, nasal discharge, nasal
congestion and anosmia.

Tests
• Usually none
• If failure of initial therapy a CT scan, fibre-‐optic endoscopy with aspiration
and culture of pus may be necessary

Treatments
• Symptomatic treatment: paracetamol, decongestant, nasal steroids perform
better than antibiotics
• Antibiotics should be prescribed if any of the following are present-‐
o Symptoms lasting > 10 days
o Fever >39oC
o Purulent discharge
o Facial pain
o Biphasic illness with sinusitis following typical viral URTI

First line
Amoxicillin 1g 8 hourly for 5 days po
Alternative for beta-‐lactam allergy
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Chapter 8
Lower Respiratory Tract Infection

Acute bronchitis
Definition
Self-‐limited inflammatory process involving large and mid-‐sized airways

Common aetiologies
• Respiratory viruses (> 90%)
– Influenza
– Parainfluenza 3
– Respiratory syncytial virus
– Human metapneumovirus
• Non-‐viral (<10%)
– Suspect if prolonged cough, longer incubation period, local outbreaks
§ Mycoplasma pneumoniae
§ Chlamydia pneumoniae
§ Bordetella pertussis
– No association with S. pneumoniae or H. influenzae in patients
without evidence of underlying lung disease

Tests
No investigations are required in the vast majority of cases:
• Gram stain not recommended
• Nasopharyngeal swab for influenza PCR not recommended for uncomplicated
influenza-‐like illness

Diagnosis and management

*Chest X-‐rays are not necessarily indicated for all patients with acute bronchitis and
should be performed only if likely to influence management

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Acute Exacerbation of COPD (AECOPD)

Definition
Acute increase in baseline dyspnoea, cough and/or sputum above the normal day-‐
to-‐day variations, requiring a change in medication. Up to 80% of AECOPD have an
infectious aetiology.

Common aetiologies
• Viral (up to 50%) – more common in winter months
– Rhinoviruses
– Parainfluenza
– Coronavirus
– Influenza (in non-‐vaccinated)
– RSV
• Bacterial
– H. influenzae
– S. pneumoniae
– M. catarrhalis
– Enterobacteriaceae (frequent hospitalisation and antibiotic use)
• Atypical bacteria are not implicated in AECOPD

Tests

Moderate Severe
Mild (Requiring hospitalisation) (Requiring high
care/ICU)
– Sputum culture not – Sputum culture if – Sputum culture
routine frequent admissions or – Blood culture if
– CRP or PCT (if available) poor response to pyrexial
o Withhold antibiotics – Nasopharyngeal
antibiotics if – CRP or PCT (if available) swab for influenza
negative o Withhold PCR if in flu season
antibiotics if
negative

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Prevention
• Annual influenza vaccine recommended for all patients with COPD
• Pneumococcal polysaccharide (PPSV23) vaccine is recommended for all
individuals over 65 years of age and anyone with COPD
• Antiviral chemoprophylaxis is not recommended

Pneumonia

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Definition
Pneumonia is acute infection of lung parenchyma distal to the terminal bronchiole
and causes consolidation.

Common aetiologies of community acquired or health care associated pneumonia
CAP HCAP
Agent Comments Increased risk for infection with
S. pneumoniae Most common cause MDR pathogens
H. influenzae More common in COPD
Tuberculosis More common in HIV – Similar organisms to CAP
‘Atypical organisms’ Not cultured o Uncommonly
– M. pneumoniae No specific clinical/ legionella or viruses
– Chlamydophilia radiological features – Gram negative bacilli
– Legionella spp. Suspect if risk factors or o P. aeruginosa
non-‐response to beta-‐ o A. baumanii
lactams o Enterobacteriaciae
Oral anaerobes Risk factors: alcoholism, – S. a ureus (including MRSA)
aspiration, lung abscess
P. jirovecii HIV, bilateral infiltrates,
desaturation on minimal
exertion, poor response
to beta-‐lactams
Respiratory viruses Seasonal
Risk factors: pregnancy,
elderly, co-‐morbidities

Tests
CAP HCAP
Only perform if likely to influence empiric Always send specimens prior to
management decisions initiation of empiric antibiotics

Mild (CRB-‐65 score ≤ 2) In all cases
• Sputum culture and Xpert MTB/Rif if • Blood culture
failed outpatient Abx therapy • Sputum Gram stain and
culture
Severe (CRB-‐65 ≥ 3) or co-‐morbidities*
• Sputum Gram stain and culture
• Blood culture
• Sputum for P. jirovecii DFAT if HIV +ve
• Urine Legionella antigen testing
• NP swab for influenza PCR if flu season
NP = Nasopharyngeal, DFAT = direct fluorescent antibody test
* Chronic cardio-‐pulmonary disease, alcoholics, immune suppression (excluding HIV), CKD, cirrhosis

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Special circumstances

2. Health care associated pneumonia
– Send blood and sputum cultures prior to initiating broad spectrum
antibiotics
– Consult microbiologist or infectious diseases specialist about choice of
appropriate empiric antibiotic

3. Penicillin allergy
– Moxifloxacin 400 mg po/iv daily or levofloxacin 500mg po 12-‐hourly
(750mg iv 12-‐hourly in severe pneumonia)

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Chapter 9
Intra-‐abdominal infection

Definitions and causes
Infections in the abdomen can be divided into the following main groups:
1. Infections of the biliary system, including cholecystitis and cholangitis
2. Infections of the bowel, including appendicitis and diverticulitis
3. Intra-‐abdominal collections or abscesses
4. Peritonitis, including bowel perforations and spontaneous bacterial
peritonitis (SBP) related to liver disease

Common aetiologies
Empiric antibiotic therapy for community-‐acquired intra-‐abdominal infections should
cover all of the following organisms:
• Enteric gram-‐negative bacilli: E. coli, K. pneumoniae
• Anaerobic organisms
• Enteric streptococci

Other possible causes in health care-‐associated infections or severely ill patients
include:
• Enterococci
• Candida
• MRSA

Tests
Most cases will require abdominal imaging (either ultrasound or CT), unless there is
a clear indication for urgent laparotomy.
• Blood culture is recommended for patients with sepsis syndrome and
suspected intra-‐abdominal infection.
• Culture of infected material is generally not helpful but is recommended in
the following situations:
o HCAI
o SBP
o Infections with incomplete source control (e.g. inability to clear liver
abscess)
o Re-‐do laparotomies

1. Spontaneous bacterial peritonitis
Diagnosis:
• Ascitic fluid aspirate with WCC > 250 cells/mm3
• Positive ascitic fluid culture (low sensitivity; high specificity if sample taken
properly)

Management:
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• Ceftriaxone 1 g IV daily for 5 days

• Add ampicillin 1 g QID in the following situations only:
– Cholestatic liver disease
– Fulminant liver failure (encephalopathy with coma)
– Not responding to ceftriaxone after 48 hours

2. Most other intra-‐abdominal infections

Alternative antibiotic regimens
• Co-‐amoxiclav unavailable:
o Ampicillin 1 g iv 6 hourly PLUS gentamicin 6 mg/kg/day PLUS
metronidazole 500 mg iv 8-‐HOURLY
OR
o Ceftriaxone 1 g daily PLUS metronidazole 500 mg 8-‐hourly
• Severe Penicillin allergy:
o Ciprofloxacin 400 mg iv 8-‐hourly PLUS metronidazole 500 mg iv 8-‐hourly

30 | P a g e

Chapter 10
Acute diarrhoea

Definition
Diarrhoea for < 2 weeks duration

Likely pathogens-‐
• Viruses (norovirus, rotavirus, adenoviruses, astrovirus),
• Bacteria (Salmonella, Campylobacter, Shigella, Enterotoxigenic E. coli, C.
difficile) and bacterial toxins
• Protozoa (Cryptosporidium, Giardia, Cyclospora, Entamoeba)

Clinical features
• Stool taking the shape of its container > 3 times per day
• Blood in stool
• Fever

History
• Food exposure
• Illness among close contacts
• Recent travel
• HIV status
• Recent antibiotics

Tests (see algorithm)
The vast majority of episodes of diarrhoea DO NOT require antibiotics. Mild cases
are usually self-‐limiting and require symptomatic treatment only. Moderate to
severe cases require investigation +/-‐ hospitalisation.

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Treatments
• Empiric:
o Ciprofloxacin 500 mg po 12-‐hourly for 3 days pending results of
culture and sensitivity
o If bloody diarrhoea add empiric metronidazole 500 mg iv 8-‐hourly (or
400 mg po 8-‐hourly) for 5 days
• Definitive:
o Based on culture results
• Clostridium difficile toxin or molecular test positive:
o See algorithm
o Resolution of symptoms generally occurs within 5-‐7 days, but it is not
unusual for symptoms to persist for the first 3-‐5 days
o 25% of patients with C. difficile will relapse

32 | P a g e

Management of C. difficile diarrhoea

33 | P a g e

Chapter 11
Urinary tract infections

Uncomplicated UTI

Definition
‘Uncomplicated’ refers to either a lower urinary tract infection or upper urinary tract
infection (pyelonephritis) in non-‐pregnant women with structurally and
neurologically normal genitourinary tracts. Acute uncomplicated cystitis is defined
as:
• Symptomatic bladder infection characterised by a clinical syndrome of
frequency, urgency, dysuria or suprapubic pain

Common aetiologies

Pathogens Common contaminants of urine cultures
• Enterobacteriaceae • Candida species
– E. coli (most common) • Enterococcus spp.
– K. pneumoniae • Gardnerella vaginalis
– Enterobacter spp. • Mycoplasma hominus
– Proteus spp. • Ureaplasma urealyticum
• Coagulase negative staphylococci
– S. saprophyticus
• Group B streptococcus
• Enterococcus spp.

Tests
– Urine culture only for:
o Reinfection, persistent or recurrent cystitis
o Symptoms with negative dipstick
– Do not perform follow-‐up cultures if symptoms have resolved
– Do not perform screening cultures in asymptomatic diabetics, elderly or patients
with indwelling urinary catheters

The diagnosis of urinary tract infection requires the presence of compatible
symptoms plus bacteriuria (bacteria in the urine) or indirect evidence of infection,
such as:
• Urine dipstick leucocyte esterase or nitrite positive
• Urine microscopy showing > 1+ leucocytes
Asymptomatic bacteriuria (a positive urine culture from patients without symptoms
referable to the urinary tract) should not be treated, except in pregnant women and
prior to invasive urological procedures.
34 | P a g e

Pyelonephritis

35 | P a g e

Complicated UTI

Definitions
A symptomatic urinary tract infection in:
• Individuals with functional or structural abnormalities of the genitourinary
tract
• Men
• Pregnant women
• Patients with indwelling urinary catheters

Common infectious aetiologies
Caused by the same pathogens as uncomplicated UTIs. Infections in patients with
indwelling urinary catheters more likely to be caused by drug resistant organisms.

Tests
Perform urine cultures in all of the above patient groups presenting with symptoms
of UTI. In catheterised patients urine specimens should be obtained after catheter
removal from a freshly placed catheter or voided midstream sample.
If fever/symptoms persist > 48 hours:
– Perform blood culture (in case of resistant bacteria)
– Image the urinary tract and abdomen to exclude collections

36 | P a g e

Catheter-‐associated UTI

NB: non-‐specific signs of CA-‐UTI include fever or rigors, altered mental state and
unexplained lethargy

37 | P a g e

UTI in men

UTI in pregnancy

i. Asymptomatic bacteriuria

Pregnant women with asymptomatic bacteriuria are at increased risk of
developing pyelonephritis. Therefore all pregnant women should be screened
for bacteriuria.

Diagnosis:
• Any culture showing ≥ 103 cfu/ml of a single organism (or any E. coli)
in an asymptomatic pregnant woman

Management:
• Appropriate oral antibiotic for 5 days (see below)
• Perform follow-‐up urine culture to confirm sterility

ii. Cystitis and pyelonephritis

Diagnosis:
• As per uncomplicated UTI guidelines
38 | P a g e

• Always send urine culture

Management:

Ciprofloxacin is contraindicated in pregnancy. Therefore the following
empiric antibiotics should be used, with de-‐escalation to narrower spectrum
antibiotics once organism and sensitivities available:
• Cystitis or mild pyelonephritis:
– Coamoxiclav 1 g po 12-‐hourly before the 3rd trimester.
Cefuroxime 250 mg po 8-‐hourly is preferred in the 3rd
trimester due to decreased risk of necrotizing enterocolitis
– Duration 5 days for cystitis, 14 days for pyelonephritis
• Severe pyelonephritis
– Treat as per uncomplicated UTI guidelines

39 | P a g e

Chapter 12
Sexually transmitted infections

Vaginal discharge

Definitions
Vaginal and occasionally cervical infection characterised by discharge, itching or
odour.

Common aetiologies
• Bacterial vaginosis (BV): replacement of normal flora by polymicrobial
overgrowth
• Trichomoniasis: T. vaginalis
• Candidiasis: Candida albicans
• Cervicitis: C. trachomatis and N. gonorrhoeae

Tests
No tests are necessary to confirm specific causes at the initial presentation.
For recurrent or persistent symptoms, attempt to confirm diagnosis by office tests:
• Bacterial vaginosis
– Clue cells on microscopy
– pH of vaginal fluid > 4.5
– Whiff test: fishy odour after addition of KOH to vaginal fluid
• Trichomoniasis
– Wet prep slide to visualise motile organisms (sensitivity 70%)
• Candidiasis
– Wet prep slide with KOH demonstrating yeasts and pseudohyphae

40 | P a g e


Penicillin allergy (severe)
Omit ceftriaxone and increase azithromycin: 2 g po single dose

41 | P a g e

Urethritis

Definition
Urethral inflammation from infectious and non-‐infectious causes

Common aetiologies
• Gonococcal urethritis (N. gonorrhoeae)
• Non-‐gonococcal urethritis (NGU)
– Chlamydia (C. trachomatis)
• Non-‐chlamydial NGU: usually no pathogen found

Tests
Usually requires no special investigations.

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Genital ulcer syndrome (GUS)

Definition
New genital, anal or perianal lesion after recent sexual activity.

Common aetiologies
Sexually transmitted
• HSV and syphilis most common
• H. ducreyi (chancroid)
• C. trachomatis (LGV)

Non-‐sexually transmitted
43 | P a g e

• Infectious: folliculitis, candida, tuberculosis

• Non-‐infectious: trauma, malignancy, eczema, psoriasis, contact dermatitis
(latex allergy), aphthous ulcers

Diagnosis
It is not possible to distinguish the causes on clinical grounds alone. Do not diagnose
a venereal cause of GUS if no sexual activity in the past 3 months (except for
reactivated HSV).

Recurrent Herpes simplex reactivation
Painless Primary syphilis
Lymphogranuloma venerum (LGV)
Painful Herpes simplex (HSV)
Chancroid
Lymphadenopathy Syphilis
HSV
LGV (massive, often unilateral)
Chancroid

Tests
Usually requires no investigations.

Management
44 | P a g e

Chapter 13
Acute meningitis

Definition
• Acute inflammation of the meninges of <7 days duration.

Likely pathogens
• Common – Various bacteria, viruses. TB meningitis can present acutely. Rare
-‐ fungi, protozoa and helminths
• Common bacterial pathogens are Streptococcus pneumoniae, Neisseria
meningitidis, Haemophilus influenzae and Listeria monocytogenes (in
immunocompromised and elderly patients).

Clinical features
• Any 2 of the 4 cardinal features; headache, fever > 37.5oC, neck stiffness and
altered mental status
• Supporting features are photophobia, blanching or purpuric rash and
vomiting

Tests
• See algorithm for lumbar puncture and CT brain

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Management
General principles:
• Patients with suspected bacterial meningitis should receive ceftriaxone 2 g iv
immediately. The dose for continued treatment is 2 g iv 12-‐hourly
• Penicillin allergy is not a contra-‐indication to use of ceftriaxone, unless the
allergy was life threatening
• Blood culture and lumbar puncture should be performed before
administration of antibiotics ONLY if this does not cause significant delay
• If bacterial meningitis is strongly suspected on the basis of clinical and CSF
findings and all cultures are negative give ceftriaxone for 10 days
• Steroids are not recommended

Specific therapy:
• S pneumoniae: duration 10 days
– If MIC unknown or > 0.1 microg/ml: ceftriaxone 2 g iv 12-‐hourly
– If MIC < 0.1 microg/ml: penicilin G 4 mU ivi 4-‐hourly or ampicillin 2 g
iv 4-‐hourly
• N meningitidis: duration 7 days
– Ceftriaxone 2 g iv 12-‐hourly
• L monocytogenes: duration 21 days
– Ampicillin 2 g iv 4-‐hourly
• Gram-‐negative infection: duration 21 days
– Community-‐acquired: cefepime 2 g iv 8-‐hourly or ceftazidime 2 g iv 8-‐
hourly
– Health care associated: meropenem 2 g iv 8-‐hourly
46 | P a g e

47 | P a g e

Chapter 14
Peripheral line sepsis

Peripheral line-‐related infections increase morbidity, mortality, antibiotic usage and
length of stay. PREVENTION BY EARLY REMOVAL OF LINES IS THE KEY
INTERVENTION. By definition these are healthcare associated infections (HCAI) with
a high risk of resistant pathogens.
Likely pathogens
Staphylococcus aureus (MSSA/MRSA), Coagulase negative staphylococci,
Streptococcus spp.


48 | P a g e

Chapter 15
Staphylococcus aureus bacteraemia

Staphylococcus aureus (S. aureus) bloodstream infection carries a high mortality
rate. It is commonly introduced by vascular line infections or other health-‐care
associated interventions, but can result from invasive S. aureus at any site. S. aureus
bacteraemia can disseminate to any organ including heart valves, bone and lungs,
and therefore requires prolonged intravenous therapy with higher doses of
appropriate antibiotics.
Definitions and dosing
Methicillin sensitive S. aureus (MSSA)
• Sensitive to anti-‐staphylococcal beta-‐lactam antibiotics
• Cloxacillin is the treatment of choice:
– Initial dose 2 g 6 hourly IV
– Use 3 g 6 hourly for endocarditis, prosthetic heart valves or other

endovascular material, meningitis and osteomyelitis
Methicillin resistant S. aureus (MRSA)
• Resistant to beta-‐lactam antibiotics
• Vancomycin is the treatment of choice:
– Loading dose 25 – 30 mg/kg slow infusion
– Thereafter 15-‐20 mg/kg BD (will require lower doses and/or less

frequent intervals in renal impairment)
– Measure trough levels before the 4th dose and aim for a target of 15 –
20 mg/L
49 | P a g e

Management

Clinical features of complicated S. aureus bacteraemia include persistent fever, bone
pain, new murmur or peripheral manifestations of endocarditis or focal neurological
signs. Patients with these problems require directed investigations for source control
and should be discussed with an infectious diseases specialist.

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Chapter 16
Skin and soft tissue infections

Cellulitis

Definition
Acute infection involving skin and subcutaneous tissue
• Commonly precipitated by minor trauma or underlying skin lesion

Diagnosis (Image: http://treatmentofcellulitis.net)
Clinical only:
• Redness, tenderness, local heat, non-‐raised edges

Differentiate from:
Infections Non-‐infectious
Erysipelas DVT
Necrotising fasciitis Insect bites
Gas gangrene Fixed drug reaction

Common aetiologies
• Streptococci (usually S. pyogenes)
• S. aureus

Tests
None recommended
• Blood cultures are rarely positive and not generally helpful unless extensive
or severe infection.
• Superficial pus swabs are not helpful and should NOT be performed

51 | P a g e

Management

Cutaneous abscess

Definition
Deep inflammatory nodule extending into subcutaneous tissue that develops from
preceding folliculitis

Common aetiologies
S. aureus

Tests
None

Management
All cases require surgical drainage.

Uncomplicated cases
• No antibiotics required

Complicated cases (surrounding cellulitis, located on face, systemic symptoms)
• Flucloxacillin 500 mg po 6-‐hourly for 5 days or co-‐amoxiclav 1g po 12-‐hourly
• In penicillin allergy use clindamycin 450 mg po 8 hourly

52 | P a g e

Diabetic foot

Definition
Chronic foot infections in diabetics
• Mild: limited to skin/superficial subcutaneous tissue < 2 cm beyond ulcer
margin
• Moderate: cellulitis > 2 cm, deep fascial involvement, gangrene, abscess,
osteomyelitis
• Severe: systemic complications

Common aetiologies
• Mild infections or previously untreated
– S. aureus
– Streptococci
• Chronic lesions or previously treated
– Above plus
– Enterobacteriaceae
• Chronic, refractory or prolonged broad spectrum antibiotics
– Above plus
– Pseudomonas
– Anaerobes
– Enterococci

Tests
None required in mild or previously untreated infections. Tissue cultures are
recommended in all other scenarios. It is essential to clean and debride the lesion
before obtaining specimens for culture. Blood cultures should be performed in
severe infections.

53 | P a g e


Penicillin allergy:
• Mild/moderate infections:
Clindamycin 450 mg po 8-‐hourly (add ciprofloxacin 500mg po 12-‐hourly if
requires admission)
• Severe infections:
Clindamycin 600 mg iv 8-‐hourly PLUS ciprofloxacin 400 mg iv 8-‐hourly

Wound management
Optimal wound care is essential. Surgical consultation is recommended for the
following problems:
• Deep abscess
• Bone or joint involvement
• Crepitus
• Gangrene
• Necrotising fasciitis
• Severe vascular insufficiency

54 | P a g e

Necrotising fasciitis

Definition (image: http://medicatoz.com/news/view?id=57)
Acute severe infection involving subcutaneous soft tissues including the fascial
layers. Usually precipitated by trauma, surgery, peri-‐rectal abscess, bedsores or
bowel perforation.

Common aetiologies
Usually polymicrobial infections:
• Streptococci
• Enterobacteriaceae
• Anaerobes

Tests
Blood cultures and surgical tissue specimens.

Necrotising fasciitis is commonly associated with systemic toxicity manifested by
fever, leukocytosis and possibly organ dysfunction. It rapidly progresses to
cutaneous gangrene. Management involves the following:
1. Early and aggressive surgical debridement
2. Co-‐amoxiclav 1.2 g IV continued until clinical resolution

Alternative antibiotic regimens
• If co-‐amoxiclav unavailable: ampicillin 1 g 6-‐hourly PLUS metronidazole 500 mg
8-‐hourly PLUS gentamicin 6 mg/kg/day, all iv
• For refractory infections and in penicillin allergy: clindamycin 600 mg 8-‐hourly
PLUS ciprofloxacin 400 mg 8-‐hourly, both iv

55 | P a g e

Chapter 17
Bone and joint infections

SEPTIC ARTHRITIS

Definition
Bacterial joint infection, usually due to haematogenous spread.

Common aetiologies
• Non-‐gonococcal
o S aureus most common
o Streptococcus spp. (S pyogenes, S pneumoniae, S agalactiae)
o Gram-‐negative organisms (elderly, immunocompromised,
comorbidities)
• N gonorrhoeae

Tests
In all cases:
• Joint aspirate BEFORE ANTIBIOTICS
o Cell count plus differential: high neutrophil count in most cases
o Gram stain and culture
o Microscopy for crystals
• Plain X-‐ray


56 | P a g e

OSTEOMYELITIS

Definition
Bacterial infection of bone due to contiguous spread from soft tissues,
haematogenous seeding, or direct inoculation.

Common aetiologies
• Common
– S aureus
– Coagulase-‐negative staphylococci
• Occasional
– Streptococci
– Enterococci
– Gram-‐negative bacilli
• Other
– M tuberculosis
– Fungal infections

Tests
• Always send specimens for culture
– Deep tissue specimen: open surgical procedure or guided needle
aspiration
– Blood culture
• Imaging
– Plain X-‐ray in all cases
– May require other modalities such as bone scan, CT or MRI
• CRP may be useful to monitor response to therapy

57 | P a g e

Notes:
• May need to continue IV therapy for 6 weeks or longer
• Do not add rifampicin in cases without foreign material
• Consider tuberculosis if culture-‐negative or no clinical improvement
• Vancomycin is used for health care-‐associated osteomyelitis or confirmed
MRSA (loading dose 23 – 30 mg/kg followed by 15 – 20 mg/kg 12-‐hourly;
maintain trough levels 15 – 20 mg/mL)
• See Chapter 18 for management of open fractures
• Infections associated with prosthetic material should be discussed with an
expert

58 | P a g e

Chapter 18
Prophylaxis

Surgery
Surgical prophylaxis aims to prevent infection following a predictable exposure to
bacteria. Antibiotics are only required during exposure and a single dose taken pre-‐
operatively is usually sufficient. A repeat dose should only be given if surgery is
prolonged or there is massive blood loss. Choice of antibiotic depends on which
bacteria are likely to be introduced by the operation, usually normal colonisers of
skin or bowel. Examples are given below but refer to local policies for guidance.

Type of surgery Prophylaxis
Cardiothoracic Cefazolin 2g iv
Upper GI
Neurosurgery
Orthopaedic (elective non-‐trauma)
Lower limb amputation Cefazolin 2g iv
Colorectal Plus
Biliary Metronidazole 500mg iv
Pelvic
ENT
Ophthalmic Chloramphenicol 0.5% drops
ERCP with obstruction Ciprofloxacin 500mg po 2h prior to the
procedure or cefuroxime 1.5g iv or
PIP/TZ 4.5g iv, both 1h prior to the
procedure
Surgery for the implantation of any Cefazolin 2g iv or cefuroxime 1.5g iv or
permanent prosthetic material vancomycin 1g iv as single dose
Penetrating abdominal trauma or open Cefazolin 2g iv + metronidazole 500mg IV
fracture and second dose if procedure > 3h

Head injuries
Closed head injuries with non-‐penetrating wounds do not require antibiotic
prophylaxis even if there is a CSF leak. Compound depressed skull fractures and
penetrating spinal cord injuries do require prophylaxis/pre-‐emptive treatment e.g.
ceftriaxone plus metronidazole for 5 days.

Open long bone fractures
If early (< 5 hours) washout and debridement, provide prophylaxis with cefazolin 1g
iv 12-‐hourly for 48 hours only. If long delay to washout or significant contamination,
treat with coamoxiclav 1.2 g ivi 12-‐hourly for 5 days.

Infective endocarditis
The evidence base is weak and guidelines are largely based on expert opinion, which
differs between countries and region. In general only those at the highest risk of
59 | P a g e

infective endocarditis should be offered prophylaxis and then only when the risk of
bacteraemia from the procedure is high.

Conditions requiring prophylaxis
• Significant congenital or acquired cardiac abnormalities
• Prosthetic valves or valvular repair utilising prosthetic material
• Previous infective endocarditis

Procedures requiring prophylaxis
• Dental procedures involving manipulations if the gingival or perapical region
of the teeth or perforating the oral mucosa.

Examples of regimens are given in the table.

Procedure Regimen Alternative
Dental, oral or upper Amoxicillin 3g po Clindamycin 600mg iv
respiratory tract
Genitourinary, Ampicillin 2g iv Vancomycin 1g iv
gastrointestinal or Plus gentamicin 1.5mg/kg Plus gentamicin 1.5mg/kg
biliary

Rheumatic fever
• Secondary prophylaxis should be prescribed for all patients following
rheumatic fever to prevent recurrences

Duration
• Without carditis 5 years after last attack or 21 years (whichever is longer)
• With mild carditis 10 years after last attack or 21 years (whichever is longer)
• With carditis and residual heart disease 10 years or until age 40 (whichever is
longer). Sometimes life-‐long prophylaxis.

Regimen
• Benzathine penicillin 1.2MU IM every 3-‐4 weeks or penicillin V 250mg po 12-‐
hourly. If penicillin allergic azithromycin 250mg daily.

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A POCKET GUIDE TO ANTIBIOTIC PRESCRIBING

This allows de-­‐escalation to a narrow spectrum antibiotic once the

Gram positive cocci

hypersensitivity reaction to penicillin has occurred, then all β-­‐lactam

4. Ensure correct dose and route of administration

Box 3. Correct technique for performing a pus swab

Management of peripheral IV lines

Management of urinary catheters

Acute Exacerbation of COPD (AECOPD)

Diagnosis and management

• Ceftriaxone 1 g IV daily for 5 days

Management of C. difficile diarrhoea

UTI in men

• Always send urine culture

Diagnosis and management

• Infectious: folliculitis, candida, tuberculosis

Definitions and dosing

Methicillin sensitive S. aureus (MSSA)

• Sensitive to anti-­‐staphylococcal beta-­‐lactam antibiotics

• Cloxacillin is the treatment of choice:

– Initial dose 2 g 6 hourly IV

– Use 3 g 6 hourly for endocarditis, prosthetic heart valves or other

Methicillin resistant S. aureus (MRSA)

• Resistant to beta-­‐lactam antibiotics

• Vancomycin is the treatment of choice:

– Loading dose 25 – 30 mg/kg slow infusion

– Thereafter 15-­‐20 mg/kg BD (will require lower doses and/or less

Diagnosis and management

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This allows de-‐escalation to a narrow spectrum antibiotic once the

hypersensitivity reaction to penicillin has occurred, then all β-‐lactam

• Sensitive to anti-‐staphylococcal beta-‐lactam antibiotics

• Resistant to beta-‐lactam antibiotics

– Thereafter 15-‐20 mg/kg BD (will require lower doses and/or less