Microsoft word - strokewards_restrictedpolicy_oct2011.doc
ANTIBIOTIC PRESCRIBING GUIDELINES FOR THE STROKE WARDS (BERMAN 1, BEESTON, NEWALL AND SEACOLE)
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 Non-pneumonic
as dispersible tablets for enteral tubes)
LRTI/Infective exacerbation COPD If NBM – Piperacillin 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 Aspiration
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 pneumonia Doxycycline PO 100mg BD day 1 then OD for 7 days total (this is available (low/moderate
as dispersible tablets for enteral tubes)
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
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 guideline Mild and penicillin allergy:Doxycycline 100mg BD day 1 then OD for 5 -7 days total Cellulitis 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 immediately
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 APPENDIX 1
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 met. 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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