Microsoft word - strokewards_restrictedpolicy_oct2011.doc


Annette Clarkson Senior pharmacist antimicrobials and infection control Dr Vivienne Weston Consultant microbiologist Date on which guideline must be reviewed (this should be one to Explicit definition of patient group to which it applies (e.g. inclusion Applies to: Adult stroke patients on stroke wards This guideline minimises the use of (co-amoxiclav, cefuroxime and quinolones) which have been implicated with C.difficile infection. Addition of diagnostic indicators for aspiration pneumonia. Further oral options added. Sepsis section updated to include advice on ESBL. Statement of the evidence base of the guideline – has the guideline Moore, JPEN J Parenter Enteral Nutr 2002 26: S69 Recommended clinical best practice from the Stroke Consultants NUH meta analysis of randomised controlled trials at least one randomised controlled trial at least one well-designed controlled study without randomisation at least one other type of well-designed quasi-experimental study well –designed non-experimental descriptive studies (i.e. comparative / correlation and case studies) expert committee reports or opinions and / or clinical experiences of respected authorities recommended best practise based on the clinical experience of the guideline developer Doctors and nursing staff covering stroke wards and pharmacists This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The
interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in
doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

This antibiotic policy minimises the use of quinolones (levofloxacin and ciprofloxacin), co-amoxiclav and cefuroxime which have been implicated in Clostridium difficile infection. This guideline lists alternative narrow spectrum agents for those infections where alternatives are required to the current Trust guideline in order to minimise the use of broad spectrum agents (co-amoxiclav, cefuroxime, quinolones). If the infection is not listed below then treatment should be prescribed in conjunction with the Trust antibiotic guideline which currently contains a narrow spectrum agent. These guidelines can be found on the antibiotic website. For further advice on the infections listed below, refer to the relevant full guideline, available on the antibiotic website http://nuhnet/diagnostics_clinical_support/antibiotics. This contains all information on diagnosis, appropriate tests and duration of therapy. Previous MRSA infection / colonisation
Inpatient stay for longer than 7 days in the last six months
Patient with long term in-dwelling catheter or central line
Admitted from a Nursing Home or Residential Home with long term breaks in the skin
For patients with complicated infection or resistant organisms, please contact the duty medical microbiologist on 61163. Doxycycline PO 100mg BD day 1 then OD for 5 days total (this is available
as dispersible tablets for enteral tubes) LRTI/Infective
exacerbation COPD

If NBMPiperacillin tazobactam IV 4.5g tds. If penicillin allergic and NBM
For aspiration pneumonia, please see further prescribing information in
appendix 1.

Non severe: PO Doxycycline 100mg bd day 1 then od plus metronidazole
po 400mg tds (dispersible tablets and syrup available for enteral tubes) pneumonia/HAP
Severe/NBM not penicllin allergic: IV Piperacillin Tazobactam 4.5g tds
Severe/NBM and penicillin allergic speak with microbiology Community acquired

Doxycycline PO 100mg BD day 1 then OD for 7 days total (this is available
as dispersible tablets for enteral tubes) CURB65 0-2)
IV Piperacillin Tazobactam 4.5g tds plus IV Clarithromycin 500mg BD
Community acquired
pneumonia (high

Converting to PO Doxycycline 100mg bd day 1 then od. Total course IV and
severity CURB65 >3 oral 7-10 days
Uncomplicated UTI

Trimethoprim or nitrofurantoin as per Trust guideline. If both agents
(urosepsis see below)
unsuitable seek advice from microbiology. IV Piperacillin Tazobactam 4.5g tds plus if sepsis not responding to fluid
bolus add a single dose of gentamicin IV 5mg/kg (max 500mg) reduce dose
if renal impairment- see antibiotic website Sepsis of unknown
origin, bilary/abdo
Non severe Penicillin allergy OR If patient is at risk of a multi resistant gram sepsis/urosepsis
negative (see antibiotic website under sepsis for risk factors): Meropenem IV 1g tds
Contact microbiology if patient has a severe penicillin allergy.
Mild/severe and no penicllin allergy: Flucloxacillin as per Trust
Mild and penicillin allergy: Doxycycline 100mg BD day 1 then
OD for 5 -7 days total
Severe disease and penicillin allergy: IV Clindamycin 600mg qds
converting to PO doxycycline 200mg immediately then 100mg od
once clinically improved. Total duration 5-7 days.
If suspect necrotising fasciitis contact duty medical microbiologist
Remove the cannula
Doxycycline PO 100mg BD for one day then OD for 6 days
Monitor cannula site closely to check response to treatment
Cannula site infection
Any signs of severe infection, or spreading cellulitis: Vancomycin IV
1g BD and monitor levels (if CrCl<50ml/min or >65 years reduce frequency to 1g OD). If CrCl<20ml/min refer to antibiotic website for dosing, monitor levels. PEG insertion
Teicoplanin 400mg IV (slow injection over 1 min) pre procedure

Aspiration pneumonia is the most important acute complication of stroke related
dysphagia and these patients have a higher mortality.
Risk factors for pneumonia in stroke patients are:
• decreased level of consciousness • mechanical ventilation • multiple strokes • vertebrobasilar stroke • dysphagia • abnormal chest x-ray on admission A recent audit showed that more than half of patients admitted with a stroke were labelled as having an aspiration pneumonia, on review the diagnosis was found to be incorrect. It was found that there was a low threshold for diagnosing aspiration pneumonia and not differentiating clearly between hypostatic crepitations and frank aspiration pneumonia. Patients should not be labelled with this diagnosis unless the index of suspicion is high. The unnecessary diagnosis of aspiration pneumonia leads to a false increase in the incidence and prevalence of aspiration pneumonia and the inappropriate use of antibiotics (with risks of C difficile and resistance). There are no internationally accepted guidelines for diagnosis of aspiration pneumonia but the following criteria can be taken into account: 1. new or progressive pulmonary infiltrate
2. fever (>38°C)
3. leukocytosis (>10,000/mm3)
4. positive blood or sputum cultures with the same microorganism
5. No other source of infection but the lung

Pneumonia is considered definite when criteria 1 + 2 or criteria 2 + 3 + 4 + 5 are
It is considered probable when criteria 2+3+4 or criteria 2+5 with the addition of 3 or
4 are met


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