Empirical Antimicrobial Prescribing Guidelines for Adults 2012 INTRA-ABDOMINAL INFECTIONS Condition
Useful information
First line
Bacterial Gastroenteritis
Fluid replacement essential. Send stool samples.
Antibiotic therapy is not usually indicated as it only reduces diarrhoea by 1-2 days and can cause resistance.
Bacillary Dysentery Cholecystitis
Cholangitis
Spontaneous Bacterial Peritonitis
Second line
Duration
If the patient is systemically unwell, or if Salmonella / Shigella are suspected: discuss with cons microbiologist and report to the Health Protection Unit (HPU) on 0845 055 2022 Calculous or acalculous inflammation of the Gallbladder Likely to be caused by coliforms and enterococci. A positive Murphy’s sign has a specificity of 79%–96% for acute cholecystitis. Biliary sepsis with abnormal liver function. Usually occurs in patients with biliary obstruction. Can present with the triad of jaundice, rigors and fever but not exclusively. In addition to Enterobacteriaecae, pneumococci is a major cause.
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Co-amoxiclav IV 1.2g 8hourly PLUS Gentamicin* IV 5mg/Kg STAT CONSIDER continuing Gentamicin 24hourly based on clinical condition, culture results and/or clinical response
Piperacillin/ ¥ Tazobactam IV infusion 4.5g 8hourly PLUS Gentamicin* IV 5mg/Kg 24hourly
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Co-trimoxazole IV / PO 960mg 12hourly PLUS Metronidazole IV 500mg 8hourly (or 400mg PO 8hourly) PLUS Gentamicin* IV 5mg/Kg STAT CONSIDER continuing Gentamicin 24hourly based on clinical condition, culture results and/or clinical response #
Co-trimoxazole IV / PO 960mg 12hourly
7 days
7 days
PLUS Metronidazole IV 500mg 8hourly (or 400mg PO 8hourly) PLUS Gentamicin* IV 5mg/Kg 24hourly
Piperacillin/ ¥ Tazobactam IV infusion 4.5g 8hourly alone
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Co-trimoxazole IV / PO 960mg 12hourly PLUS Metronidazole IV 500mg 8hourly (or 400mg PO 8hourly)
7 - 14 days
3rd Line: Moxifloxacin¥ Q PO 400mg 24hourly
* See Gentamicin guidelines. Dosing based on Ideal Body Weight. Monitoring is required ¥ Significant risk of C difficile # Co-trimoxazole: monitor patients for bone marrow toxicity, Stevens-Johnson syndrome and grey syndrome. If treatment continues beyond two weeks – consider calcium folinate therapy and discuss with a Microbiologist Q May cause QT prolongation: avoid if patient has other risk factors (inc. drugs that prolong QT interval) Produced by the Antimicrobial Management Team. These guidelines are not comprehensive – consult a Microbiologist if advice required. For dosing in renal / hepatic failure, seek advice from a pharmacist Page 1 of 5
Empirical Antimicrobial Prescribing Guidelines for Adults 2012 INTRA-ABDOMINAL INFECTIONS Condition
Useful information
First line
Second line
Duration
Peritonitis
If known or suspected MRSA/ESBL or AmpC carrier then treat accordingly – see guidance in other parts of this document
Piperacillin/ Tazobactam¥ IV infusion 4.5g 8hourly
True penicillin allergy Co-trimoxazole# IV 960mg 12hourly PLUS Metronidazole IV 500mg 8hourly CONSIDER adding Gentamicin* IV 5mg/Kg 24hourly
Review daily
Can be managed in the community under close monitoring
Co-amoxiclav¥ PO 625mg 8hourly
Co-trimoxazole# IV / PO 960mg 12hourly PLUS Metronidazole IV 500mg 8hourly (or 400mg PO 8hourly)
Caused by Salmonella typhi / paratyphi. Discuss with the microbiologist. Report to HPU 0845 055 2022
Campylobacter
Liver Abscess (Not Amoebic)
For amoebic liver abscess please discuss with Consultant Microbiologist
If patient is septic, discuss with microbiologist: Consider Ceftriaxone¥ IV 2–4g 24hourly
Azithromycin PO 1g on day 1 then 500mg 24hourly for 6 days (ie 7days in total)
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Usually resolves spontaneously. Antibiotics only required if immunocompromised or severe (severe abdominal pain, fever, bloody diarrhoea)
Azithromycin PO 500mg 24hourly
Ciprofloxacin PO 500mg 12hourly
Discuss with Gastroenterologist or Microbiologist.
Co-amoxiclav¥ IV 1.2g 8hourly alone
Co-trimoxazole IV 960mg 12hourly
Aspirate if accessible.
Review IV daily
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3 - 5 days
Review IV daily
PLUS Metronidazole IV 500mg 8hourly
* See Gentamicin guidelines. Dosing based on Ideal Body Weight. Monitoring is required ¥ Significant risk of C difficile # Co-trimoxazole: monitor patients for bone marrow toxicity, Stevens-Johnson syndrome and grey syndrome. If treatment continues beyond two weeks – consider calcium folinate therapy and discuss with a Microbiologist Q May cause QT prolongation: avoid if patient has other risk factors (inc. drugs that prolong QT interval) Produced by the Antimicrobial Management Team. These guidelines are not comprehensive – consult a Microbiologist if advice required. For dosing in renal / hepatic failure, seek advice from a pharmacist Page 2 of 5
Empirical Antimicrobial Prescribing Guidelines for Adults 2012 INTRA-ABDOMINAL INFECTIONS Condition
Useful information
First line
Second line
Neutropenic enterocolitis “typhlitis”
Surgical resection might be required.
Piperacillin/ Tazobactam¥ IV infusion 4.5g 8hourly
Meropenem IV 1-2g 8hourly
Protective isolation required
PLUS Gentamicin* IV 5mg/Kg 24hourly PLUS Metronidazole IV 500mg 8hourly
Duration Review IV daily
PLUS Metronidazole IV 500mg 8hourly True Penicillin allergy ¥ Ciprofloxacin IV 400mg 12hourly (or PO 750mg 12hourly) PLUS Gentamicin* IV 5mg/Kg 24hourly PLUS Metronidazole IV 500mg 8hourly
Eradication of Helicobacter pylori
Threadworms
Eradication is beneficial in Duodenal Ulcer, Gastric Ulcer and low grade MALTOMA, but NOT in GastroOesophageal Reflux Disease. Triple treatment attains >90% eradication. Treat household contacts. Advise morning wash and hand hygiene.
Omeprazole PO 20mg 12hourly PLUS Amoxicillin PO 500mg 8hourly PLUS Metronidazole PO 400mg 8hourly
Omeprazole PO 20mg 12hourly
10 days
PLUS Metronidazole PO 400mg 12hourly PLUS Clarithromycin PO 250mg 12 hourly
Mebendazole PO 100mg STAT (single dose) Repeat therapy after 2-3 weeks if re-infection occurs.
* See Gentamicin guidelines. Dosing based on Ideal Body Weight. Monitoring is required ¥ Significant risk of C difficile # Co-trimoxazole: monitor patients for bone marrow toxicity, Stevens-Johnson syndrome and grey syndrome. If treatment continues beyond two weeks – consider calcium folinate therapy and discuss with a Microbiologist Q May cause QT prolongation: avoid if patient has other risk factors (inc. drugs that prolong QT interval) Produced by the Antimicrobial Management Team. These guidelines are not comprehensive – consult a Microbiologist if advice required. For dosing in renal / hepatic failure, seek advice from a pharmacist Page 3 of 5
Empirical Antimicrobial Prescribing Guidelines for Adults 2012 INTRA-ABDOMINAL INFECTIONS Condition Diarrhoea caused by Clostridium difficile Send liquid stool for toxin test before starting therapy. Wash your hands: alcohol gel is ineffective against C difficile spores
Useful information
First line
Second line
If there is clinical suspicion of infection, start treatment and isolate the patient.
Mild / Moderate • ≤ 3 loose stools/day • WCC normal Metronidazole PO 400mg 8hourly for 14 days
Moderate • 4-6 loose stools/day • WCC < 15 Vancomycin PO 125mg 6hourly for 10-14 days
Severe/ fulminant infection
Severe/ fulminant infection
Severe: • WCC > 15 • Rise in creatinine • Severe colitis • Partial ileus Vancomycin PO 250500mg 6hourly (check random levels)
If concurrent antibiotics are required to treat a different infection then use:
Control risk factors: review antibiotic therapy and need for PPI. Keep patient well hydrated and avoid antimotility and promotility agents eg. loperamide, codeine, metoclopramide. Vancomycin injection may be given orally Vancomycin is not usually absorbed via the GIT therefore measurable levels may indicate that dose adjustment is required to prevent toxicity (maintain levels below 10mg/L)
CONSIDER ADDING Metronidazole IV 500mg 8hourly Contact microbiologist or gastro-enterologist and lower GI surgeons to discuss additional therapy and/or IV immunoglobulin – see protocol
Duration
Vancomycin PO 250500mg 6hourly for 2 weeks (check random levels) FOLLOWED BY Rifaximin PO 200-400mg 12hourly for 2weeks OR after discussion with a Cons Microbiologist Fidaxomicin PO 200mg 12hourly for 10days (available in UK from Sept 2012)
Intracolonic Vancomycin (enema) may be an effective adjunctive therapy: 500mg in 250ml Sodium Chloride 0.9% via flexiseal device 4-12hourly. Clamp device for 60min and then release. (Check random levels daily) Relapse Vancomycin PO 125-500mg 6hourly for 14days
* See Gentamicin guidelines. Dosing based on Ideal Body Weight. Monitoring is required ¥ Significant risk of C difficile # Co-trimoxazole: monitor patients for bone marrow toxicity, Stevens-Johnson syndrome and grey syndrome. If treatment continues beyond two weeks – consider calcium folinate therapy and discuss with a Microbiologist Q May cause QT prolongation: avoid if patient has other risk factors (inc. drugs that prolong QT interval) Produced by the Antimicrobial Management Team. These guidelines are not comprehensive – consult a Microbiologist if advice required. For dosing in renal / hepatic failure, seek advice from a pharmacist Page 4 of 5
Empirical Antimicrobial Prescribing Guidelines for Adults 2012
Produced by the Antimicrobial Management Team. These guidelines are not comprehensive – consult a Microbiologist if more advice required. For dosing in renal / hepatic failure, seek advice from a pharmacist. Page 5 of 5
