Guideline for the Empirical Treatment of Infections in Adults

Guideline for the Empirical Treatment of Infections in Adults

1. Guideline for the Empirical Treatment of Infections in Adults Dr. Tarek Abd -Elkader Aboulmagd Infectious Diseases Consultant

2. Decision to prescribe clinical evidence of bacterial infection patient is gravely ill and sepsis is part of the differential diagnosis

3. Decision to prescribe If the clinical picture is not clear and the patient is stable , it may be possible to wait , monitor the patient clinically and review with laboratory results.

4. Decision to prescribe

5. Decision to prescribe

6. Minimising the use of broad-spectrum antibiotics To reduce: C. difficile infection MRSA prevalence

7. Minimising the use of broad-spectrum antibiotics Clinicians should avoid the use of cephalosporins , quinolones , broad-spectrum penicillins (including amoxicillin) and clindamycin unless there are clear clinical indications for their use.

8. Documentation

9. Review of antibiotic treatment To: 1. Stop antibiotics if there is no evidence of infection 2. Switch IV to Oral 3. Change antibiotics – ideally to a narrower spectrum – or broader if required 4. Continue and review again after a further 24 hours

10. Review of antibiotic treatment Treatment with antibiotics should not continue beyond 7 days (IV and oral) unless recommended by a local guideline or microbiologist.

11. Intravenous or oral therapy Intravenous ( IV ) therapy should only be used for: patients with severe infections, patients who have a focus of infection requiring high doses of antibiotics, patients who are unable to take or absorb oral antibiotics, when there are no alternative suitable oral agents.

12. Intravenous or oral therapy Oral switch criteria are: temperature < 37.5 °C for 24 hours signs and symptoms of infection are improving inflammatory markers are decreasing patient able to tolerate oral food and fluids absence of on-going or potential problem of absorption oral formulation or suitable oral alternative is available

13. Using this guideline Do not use Gentamicin for more than 7 days Penicillin allergy - patients with a history of anaphylaxis, urticarial rash or a rash immediately after penicillin administration (type 1 allergy) should not receive a penicillin, cephalosporin or other beta- lactam antibiotic.

14. Using this guideline MRSA - If LOS > five days, or colonised or is at risk with MRSA colonisation , consider using Vancomycin or Teicoplanin .

15. Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: Sepsis (antibiotics should be initiated within 1 hour of diagnosis) Infection Antibiotic Treatment IV Option Community-acquired sepsis of unknown origin, meningitis not suspected Co- amoxiclav 1.2g tds & Gentamicin 5mg/kg od +/- Metronidazole 500mg tds if anaerobic infection suspected Penicillin allergy: Teicoplanin 600mg 12 hourly for first 3 doses then 600mg od & Gentamicin 5mg/kg od +/- Metronidazole 500mg tds if anaerobic infection suspected

16. Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: CNS Infections Infection Antibiotic Treatment IV Option Suspected Bacterial Meningitis Ceftriaxone 4g od Add Amoxicillin 2g 4 hourly if patient >50 years old or if immunocompromised or pregnant Discuss with Microbiology if recent travel abroad or penicillin allergy

17. Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: CNS Infections Infection Antibiotic Treatment IV Option Suspected HSV encephalopathy Aciclovir 10mg/kg tds Dose reduction required if eGFR <50 Treat for 14-21 days CSF should be sent for viral PCR

18. Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: Genitourinary Infection Antibiotic Treatment Total Duration Additional Comments Uncomplicated UTI in women Trimethoprim 200mg po bd 3 days Nitrofurantoin is contra-indicated in patients with eGFR <20ml/min and may be ineffective if eGFR 20-60ml/min Discuss with Microbiology if there is high risk of, or previous infection/ colonisation with a VRE , ESBL producing isolate, or other multi-resistant organism If recent Trimethoprim use or known Trimethoprim resistant isolate: Co- amoxiclav 625mg po tds Penicillin allergy: Nitrofurantoin 50mg po qds

19. Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: Genitourinary Infection Antibiotic Treatment Total Duration Additional Comments UTI in men Trimethoprim 200mg po bd 7 days If recent Trimethoprim use or known Trimethoprim resistant isolate: Co- amoxiclav 625mg po tds Penicillin allergy: Nitrofurantoin 50mg po qds Mild UTI in pregnancy Cefalexin 500mg po bd 7 days Repeat UA 7 days after completion of antibiotics as test of cure

20. Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: Genitourinary Infection IV treatment: Oral treatment: Total Duration Additional Comments Pyelonephritis Co- amoxiclav 1.2g tds & single dose of Gentamicin 5mg/kg Co- amoxiclav 625mg tds 10-14 days Discuss with Microbiology if there is high risk of, or previous infection/ colonisation with a VRE, ESBL producing isolate, or other multi-resistant organism Review oral switch with culture results and clinical progress Penicillin allergy : Ciprofloxacin 500mg po bd & single dose of Gentamicin 5mg/kg iv Penicillin allergy: Ciprofloxacin 500mg bd (7 days treatment only required if ciprofloxacin used) 7 days

21. Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: Genitourinary Infection IV treatment: Oral treatment: Total Duration Additional Comments Urinary Catheter Infection (Urinary symptoms, fever, sepsis, ↑ inflammatory markers). Amoxicillin1g tds & Gentamicin 5mg/kg od Oral treatment not recommended for empirical treatment 7 days Discuss with previously infection/ colonisation with a VRE, ESBL or other multi-resistant organism Consider catheter change Penicillin allergy: Gentamicin 5mg/kg once daily & single dose of Vancomycin 1g

22. Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: Genitourinary Infection Antibiotic Treatment Total Duration Additional Comments Epididymo-orchitis STI suspected Ceftriaxone 500mg im single dose & Doxycycline 100mg po bd for 14 days OR If likely due to chlamydia or other non- gonococcal organisms: Doxycycline 100mg po bd or Ofloxacin 200mg po bd OR If severe epididymo-orchitis or features of bacteraemia , Ceftriaxone 1g iv od & Gentamicin 5mg/kg iv od for 3-5 days until fever subsides, and then review with culture OR Ofloxacin 200mg po bd 14 days

23. Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: Genitourinary Infection Antibiotic Treatment Total Duration Additional Comments Epididymo-orchitis STI not suspected If systemically well Ciprofloxacin 500mg po bd If severe epididymo-orchitis or features suggestive of bacteraemia , Ceftriaxone 1g iv od & Gentamicin 5mg/kg iv od for 3-5 days until fever subsides, and then review with culture results 10 days Bacterial Prostatitis STI not suspected Ciprofloxacin 500mg po bd 28 days Review with culture results

24. Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: Infective Endocarditis (IE) Infection Antibiotic Treatment IV Option Infective Endocarditis : indolent presentation Amoxicillin 2g iv 4 hourly & Gentamicin 1mg/kg (ideal body weight) iv bd It is preferable to wait for blood culture results before commencing treatment

25. Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: Infective Endocarditis (IE) Infection Antibiotic Treatment IV Option Infective Endocarditis : acute presentation (or indolent presentation with penicillin allergy) with no risk factors for multi-resistant bacteria Vancomycin iv 15 to 20 mg/kg IV every 8 to 12 hours & Gentamicin 1mg/kg (ideal body weight) iv bd. If eGFR <45 use Ciprofloxacin 750mg po bd / 400mg iv bd 12 hourly instead of Gentamicin

26. Empirical Treatment Guidelines Adult Empirical Treatment Guidelines: Infective Endocarditis (IE) Infection Antibiotic Treatment IV Option Infective Endocarditis : prosthetic heart valve or suspected MRSA Vancomycin 15 to 20 mg/kg IV every 8 to 12 hours & Gentamicin 1mg/kg ideal body weight 12 hourly & rifampicin 300-600mg 12 hourly po /iv (use lower dose of rifampicin if severe renal impairment)

27. Empirical Treatment Guidelines

28. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Non-severe exacerbations of COPD Treat as low severity Community Acquired Pneumonia 5 days Low severity CAP (0 - 1) Amoxicillin 1g tds Amoxicillin 500mg tds 5 days Use IV only if unable to swallow or absorb orally If there is a high clinical suspicion of pneumonia caused by atypical pathogens (including legionella ) add Clarithromycin 500mg bd to Amoxicillin Penicillin allergy or recent Amoxicillin: Clarithromycin 500mg po /iv bd Penicillin allergy or recent Amoxicillin: Doxycycline 200mg on day 1 then 100mg od OR continue Clarithromycin 500mg bd if switching from IV

29. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Moderate severity CAP (2) Amoxicillin 1g tds & Clarithromycin 500mg po /iv bd Amoxicillin 500mg tds & Clarithromycin 500mg bd 7-10 days Treat with Co- amoxiclav 1.2g iv tds instead of Amoxicillin if recent Amoxicillin use in the community Send urine for legionella antigen Penicillin allergy: Vancomycin dosed according to local guidelines & Clarithromycin 500mg po /iv bd Penicillin allergy: Doxycycline 200mg day 1 and then 100mg od OR continue Clarithromycin 500mg bd if switching from IV

30. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments High severity CAP (≥ 3) Use iv treatment initially Co- amoxiclav 1.2g tds & Clarithromycin 500mg iv bd Follow on from iv treatment: Co- amoxiclav 625mg tds & Clarithromycin 500mg bd 7 - 10 days If MRSA pneumonia suspected add iv Vancomycin Send urine for legionella antigen and pneumococcal antigen Penicillin allergy: Vancomycin dosed according to local guidelines & Clarithromycin 500mg iv bd (if pre-existing chest disease, consider using Ciprofloxacin in place of Clarithromycin ) Follow on from iv treatment if Penicillin allergy: Doxycycline 200mg on day 1 then 100mg od

31. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Aspiration pneumonia (inpatient < 48 hours) Co- amoxiclav 1.2g tds Amoxicillin 500mg po tds 5-10 days in the first 48 hours post aspiration, the patient may present with chemical pneumonitis for which antibiotics are not indicated If suspected lung abscess , necrotising pneumonia or patient very unwell , discuss with Microbiology Penicillin allergy: Clarithromycin 500mg po /iv BD & Metronidazole po /iv tds

32. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Aspiration pneumonia (inpatient >48 hours) Co- amoxiclav 1.2g tds Co- amoxiclav 625mg tds 5-10 days As before Penicillin allergy: Clarithromycin 500mg po /iv BD & Metronidazole po /iv tds

33. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Infective exacerbation of bronchiectasis , Cystic Fibrosis or other suppurative lung condition Discuss with Respiratory/ Microbiology According to clinical response Empirical therapy depends upon culture results. Two agents may be required.

34. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments CAP pregnancy or breast feeding Cefuroxime 1.5g tds & Clarithromycin 500mg po / iv bd Amoxicillin 500mg tds & Clarithromycin 500mg bd 5 -10 days Send urine for legionella antigen Treat with Co- amoxiclav 625mg po tds instead of Amoxicillin if recent Amoxicillin use in the community Penicillin allergy: Discuss with Microbiology Penicillin allergy: Clarithromycin 500mg bd Discuss with Microbiology if concerns

35. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments HAP (Hospital < 5 days and no previous antibiotics) Co- amoxiclav 1.2g tds Co- amoxiclav 625mg tds 7 - 10 days Add Vancomycin iv dosed according to local guidelines if MRSA suspected Send legionella urinary antigen and discuss with Microbiology if any history suggestive of legionella If not responding to therapy, discuss with Microbiology Penicillin allergy: Vancomycin iv dosed according to local guidelines & Ciprofloxacin po 500mg bd (or 400mg iv bd if oral route not appropriate) Penicillin allergy: Discuss with Microbiology

36. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments HAP (Hospital > 5 days or previous Co- amoxiclav ) Piperacillin - tazobactam 4.5g tds Discuss with Microbiology 7 - 10 days Add Vancomycin iv dosed according to local guidelines if MRSA suspected or patient very unwell Send urine for legionella antigen If not responding to therapy, discuss with Microbiology Penicillin allergy: Vancomycin iv dosed according to local guidelines & Ciprofloxacin po 500mg bd (or 400mg iv bd if oral route not appropriate)

37. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Tonsillitis/ Quinsy Benzylpenicillin 1.2g qds Penicillin V 500mg qds 10 days Consider infectious mononucleosis Add Metronidazole 500mg iv tds if quinsy Penicillin allergy: Clarithromycin 500mg bd Penicillin allergy: Clarithromycin 500mg po bd

38. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Epiglottitis Ceftriaxone 2g iv od Follow on from iv treatment: Co- amoxiclav 625mg tds 10-14 days Add Metronidazole 500mg iv tds if abscess Penicillin allergy: Discuss with Microbiology

39. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Acute sinusitis Co- amoxiclav 1.2g tds Co- amoxiclav 625mg tds OR Doxycycline 200mg on day 1 then 100mg od 5-7 days Use iv only if unable to swallow or absorb po antibiotic Penicillin allergy: Doxycycline 200mg po on day 1 then 100mg po od

40. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Acute sinusitis Co- amoxiclav 1.2g tds Co- amoxiclav 625mg tds OR Doxycycline 200mg on day 1 then 100mg od 5-7 days Use iv only if unable to swallow or absorb po antibiotic Penicillin allergy: Doxycycline 200mg po on day 1 then 100mg po od

41. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Acute severe otitis externa Flucloxacillin 1g qds Flucloxacillin 500mg qds According to clinical response Penicillin allergy or MRSA suspected: Vancomycin iv dosed according to local guidelines Penicillin allergy: Doxycycline 200mg on day 1 then 100mg od

42. Adult Empirical Treatment Guidelines: Respiratory Tract Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Invasive otitis externa Piperacillin-tazobactam 4.5g tds & Gentamicin 5mg/kg iv od Discuss with Microbiology According to clinical response Add Teicoplanin 600mg iv 12 hourly for first 3 doses then 600mg iv od if MRSA isolated or suspected Penicillin allergy: Discuss with Microbiology

43. Adult Empirical Treatment Guidelines: Bone and Joint Infection Antibiotic Treatment IV Option Total Duration Additional Comments Always try to take appropriate specimens for culture prior to antibiotic therapy Septic arthritis native joint Flucloxacillin 2g iv qds & Gentamicin 5mg/kg iv od Consider gonorrhoea Please discuss with Microbiology within 1 week Treatment usually requires 2 weeks iv then 4 weeks oral antibiotics If MRSA isolated or suspected, discuss with Microbiology Rationalise therapy based on results of deep tissue culture results Penicillin allergy: Vancomycin iv dosed according to local guidelines & Ciprofloxacin 750mg po bd

44. Adult Empirical Treatment Guidelines: Bone and Joint Infection Antibiotic Treatment IV Option Total Duration Additional Comments Acute osteomyelitis Flucloxacillin 2g iv qds & Gentamicin 5mg/kg iv od Please discuss with Microbiology within 1 week Chronic osteomyelitis Discuss individual case with Microbiology

45. Adult Empirical Treatment Guidelines: Bone and Joint Infection Antibiotic Treatment IV Option Total Duration Additional Comments Diabetic foot with possible underlying osteomyelitis If sepsis, Piperacillin-tazobactam 4.5g iv tds . Add Vancomycin iv dosed according to local guidelines if MRSA is suspected Penicillin allergy: Discuss with Microbiology If MRO suspected, discuss with Microbiology If not septic, discuss with Microbiology communicate with Diabetic Foot Team Penicillin allergy: Discuss with Microbiology

46. Adult Empirical Treatment Guidelines: Bone and Joint Infection Antibiotic Treatment IV Option Total Duration Additional Comments Suspected prosthetic joint infection Vancomycin iv dosed according to local guidelines. Add Piperacillin-tazobactam 4.5g iv tds if previous or suspected infection with Gram negative organisms or patient septic or sinus present Continue antibiotics until culture results are available, then review treatment with Microbiology Penicillin allergy: Discuss with Microbiology

47. Adult Empirical Treatment Guidelines: Skin and Soft Tissue Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Human or animal bite Co- amoxiclav 1.2g tds Co- amoxiclav 625mg tds 7 days Check tetanus status and discuss with Microbiology if human bite or concern regarding rabies Penicillin allergy: Ciprofloxacin 400mg iv bd & Clindamycin 600mg iv qds Penicillin allergy: Ciprofloxacin 500-750mg bd & Clindamycin 300-450mg qds

48. Adult Empirical Treatment Guidelines: Skin and Soft Tissue Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Cellulitis Flucloxacillin 1g qds Flucloxacillin 500mg qds 5 - 7 days Only if severe consider adding Clindamycin 300-450mg po qds to Flucloxacillin / Vancomycin (substitute if on Doxycycline ) Penicillin allergy or MRSA suspected: Vancomycin iv dosed according to local guidelines Penicillin allergy: Doxycycline 200mg po on day 1 then 100mg po od

49. Adult Empirical Treatment Guidelines: Skin and Soft Tissue Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Bursitis Flucloxacillin 1g qds Flucloxacillin 500mg qds 7 days Penicillin allergy or MRSA suspected: Vancomycin iv dosed according to local guidelines Penicillin allergy: Doxycycline 200mg po on day 1 then 100mg po od

50. Adult Empirical Treatment Guidelines: Skin and Soft Tissue Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Mastitis Flucloxacillin 1g qds OR consider Co- amoxiclav 1.2g tds if breastfeeding, post- operative or recent Flucloxacillin Flucloxacillin 500mg qds OR consider Co- amoxiclav 625mg tds if breastfeeding, post -operative or recent Flucloxacillin 5-7days Penicillin allergy or MRSA suspected: Vancomycin iv dosed according to local guidelines Penicillin allergy or MRSA suspected: Discuss with Microbiology

51. Adult Empirical Treatment Guidelines: Skin and Soft Tissue Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Moderate-severe cellulitis in association with diabetes or post GI surgery Co- amoxiclav 1.2g tds If severe consider adding Clindamycin 300-450mg po qds Co- amoxiclav 625mg tds 7 -10 days If MRSA is suspected add Vancomycin iv dosed according to local guidelines communicate with Diabetic Foot Team Penicillin allergy: Clindamycin 600mg iv qds & Ciprofloxacin 750mg po bd (or 400mg iv bd if oral route not appropriate) Penicillin allergy: Discuss with Microbiology

52. Adult Empirical Treatment Guidelines: Skin and Soft Tissue Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Necrotising Fasciitis Meropenem 1g tds & Clindamycin 600mg iv qds & Metronidazole 500mg tds & single dose Gentamicin 5mg/kg Not appropriate According to clinical response If suspected get an URGENT surgical opinion and discuss with a Microbiologist If MRSA is suspected add Vancomycin iv dosed according to local guidelines

53. Adult Empirical Treatment Guidelines: Skin and Soft Tissue Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Severe pre septal and orbital cellulitis Ceftriaxone 2g bd Discuss with Microbiology According to clinical response Discuss with Microbiology, Ophthalmology and ENT Consider urgent imaging

54. Adult Empirical Treatment Guidelines: Skin and Soft Tissue Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Cellulitis surrounding ulcer or pressure sore Flucloxacillin 1g qds +/- Metronidazole 500mg tds Flucloxacillin 500mg qds +/- Metronidazole 400mg tds OR Co- amoxiclav 625mg tds According to clinical response Consider possibility of a deep seated infection and referral to Tissue Viability Penicillin allergy or MRSA suspected: Vancomycin iv dosed according to local guidelines +/- Metronidazole 500mg tds Penicillin allergy or MRSA suspected: Doxycycline 200mg on day 1 then 100mg od +/- Metronidazole 400mg tds

55. Adult Empirical Treatment Guidelines: Skin and Soft Tissue Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Ulcer or pressure sore with no evidence of cellulitis Pressure relief and topical wound care should be adequate

56. Adult Empirical Treatment Guidelines: Intra-abdominal Infections Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Appendicitis, diverticulitis or peritonitis Amoxicillin 1g tds & Metronidazole 500mg tds & Gentamicin 5mg/kg od OR If eGFR <45, treat with Piperacillin-tazobactam 4.5g tds & Metronidazole 500mg iv tds Co- amoxiclav 625mg tds & Metronidazole 400mg tds 5 - 7 days Continue IV for 5-7 days if peritoneal contamination Review with culture results prior to switching to oral therapy Penicillin allergy: Teicoplanin 600mg 12 hourly for 3 doses then 600mg od & Metronidazole 500mg tds & Gentamicin 5mg/kg od OR If eGFR <45, discuss with Microbiology Penicillin allergy: Ciprofloxacin 500 mg bd & Metronidazole 400mg tds

57. Adult Empirical Treatment Guidelines: Intra-abdominal Infections Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Cholecystitis and Cholangitis Amoxicillin 1g tds & Metronidazole 500mg tds & Gentamicin 5mg/kg od OR If eGFR <45, treat with Piperacillin-tazobactam 4.5g iv tds & Metronidazole 500mg iv tds Co- amoxiclav 625mg tds & Metronidazole 400mg tds 7 days Penicillin allergy: Teicoplanin 600mg 12 hourly for 3 doses then 600mg od & Metronidazole 500mg tds & Gentamicin 5mg/kg od OR If eGFR <45, discuss with Microbiology Penicillin allergy: Ciprofloxacin 500 mg bd & Metronidazole 400mg tds

58. Adult Empirical Treatment Guidelines: Intra-abdominal Infections Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Severe Pancreatitis with infected necrosis Piperacillin / tazobactam 4.5g tds & Metronidazole 500mg iv tds Not appropriate 7 days Add Gentamicin 5mg/ kg od if septic Note: Infected necrosis is rare in the first week. Infection is presumed when there is extraluminal gas in the pancreatic and/or peripancreatic tissues or when Fine-Needle Aspiration is positive for bacteria and / or fungi on Gram stain and culture. Penicillin allergy: Discuss with Microbiology

59. Adult Empirical Treatment Guidelines: Intra-abdominal Infections Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Spontaneous Bacterial Peritonitis Piperacillin / tazobactam 4.5g iv tds Be guided by culture results 5-7 days Penicillin allergy: Discuss with Microbiology

60. Adult Empirical Treatment Guidelines: Intra-abdominal Infections Infection Antibiotic Treatment IV Option Antibiotic Treatment Oral Option Total Duration Additional Comments Variceal haemorrhage with cirrhosis Piperacillin / tazobactam 4.5g iv tds 5-7 days Penicillin allergy: Teicoplanin 600mg 12 hourly for 3 doses then 600mg od & Gentamicin 5mg/kg od OR If eGFR <45, discuss with Microbiology