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What type of infection is suspected/confirmed?

• Bronchiectasis
• Infective exacerbation of COPD
• Influenza infection
• Nursing home or aged care facility pneumonia
• Parapneumonic effusion or empyema
• Pneumonia

• Yes, (treat as per pneumonia)
• No, not suggestive of pneumonia

• An exacerbation of bronchiectasis is an acute deterioration of symptoms from the patient’s baseline that usually develops over several days
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Do not treat colonising organisms if the patient is clinically stable.

Has a nose and/or throat swab for viral (flu, RSV etc) NAAT been performed?

• Yes
• No
• I am treating an outpatient

• Viral testing is not indicated for outpatient management

Code for oseltamivir is: 5flu

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Proceed to next question

Code for oseltamivir is: 5flu

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Proceed to next question

• Please perform a nose and/or throat swab for viral NAAT for respiratory viruses
• Consider influenza treatment with oseltamivir (Tamiflu®) whilst awaiting results
• Cease if flu results return not detected

• Yes
• No

• Antibiotics are only indicated for bacterial infection if all three of the following clinical features are present::
• increased sputum volume or change in sputum viscosity
• increased sputum purulence
• increased cough, which may be associated with wheeze, breathlessness or haemoptysis
• Do not use antibiotic therapy unless the patient has clinical features suggestive of bacterial infection
• Consider witholding antibiotics for patients managed in the community
• Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy

How old is the patient?

• Adult patient
• Child (< 12 years old)

How severe is your patient/s clinical status? (see below)

• Severe
• Non-severe

Clinical features of severe exacerbations of bronchiectasis

• Worsening respiratory distress
• Worsening hypoxaemia from the patient’s baseline state
• Acute-onset confusion
• Signs of sepsis or septic shock

How severe is your patient/s clinical status? (see below)

• Severe
• Non-severe

Clinical features of severe exacerbations of bronchiectasis

• Worsening respiratory distress
• Worsening hypoxaemia from the patient’s baseline state
• Acute-onset confusion
• Signs of sepsis or septic shock

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Has your patient been colonised with Pseudomonas aeruginosa on previous microbiology? Or do they have known active Pseudomonas aeruginosa infection?

• Yes
• No

For treatment in a patient with no penicillin allergy use:

• Exacerbations of bronchiectasis can be caused by colonising organisms such as pseudomonas or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Consider influenza treatment with oseltamivir (Tamiflu® ) 75 mg whilst awaiting swab results
• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• If there has been no improvement with the above regimen then consider this regimen with anti-pseudomonal cover. ciprofloxacin 750mg PO, 12 hourly
• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy
• Consider influenza treatment with oseltamivir (Tamiflu®) 75 mg whilst awaiting swab results
• Modify regimen based on sputum culture results. However if patient improving, adjustment is not required even if the cultured isolate is resistant. Call ID if discussion required

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For treatment in a patient with no penicillin allergy use:

• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy
• Consider influenza treatment with oseltamivir (Tamiflu®) 75 mg whilst awaiting swab results
• Modify regimen based on sputum culture results. However if patient improving, adjustment is not required even if the cultured isolate is resistant. Call ID if discussion required

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has your patient been colonised with Pseudomonas aeruginosa on previous microbiology? Or do they have known active Pseudomonas aeruginosa infection?

• Yes
• No

For treatment in a patient with penicillin allergy use:

• Exacerbations of bronchiectasis can be caused by colonising organisms such as pseudomonas or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Consider influenza treatment with oseltamivir (Tamiflu® ) 75 mg whilst awaiting swab results
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy
• Consider influenza treatment with oseltamivir (Tamiflu®) 75 mg whilst awaiting swab results
• Modify regimen based on sputum culture results. However if patient improving, adjustment is not required even if the cultured isolate is resistant. Call ID if discussion required

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For treatment in a patient with penicillin allergy use:

• Exacerbations of bronchiectasis can be caused by colonising organisms such as pseudomonas or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Consider influenza treatment with oseltamivir (Tamiflu® ) 75 mg whilst awaiting swab results
• If there has been no improvement with the above regimen then consider this regimen with anti-pseudomonal cover. ciprofloxacin 750mg PO, 12 hourly
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy
• Consider influenza treatment with oseltamivir (Tamiflu®) 75 mg whilst awaiting swab results
• Modify regimen based on sputum culture results. However if patient improving, adjustment is not required even if the cultured isolate is resistant. Call ID if discussion required

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has your patient been colonised with Pseudomonas aeruginosa on previous microbiology? Or do they have known active Pseudomonas aeruginosa infection?

• Yes
• No

Has your patient been colonised with Pseudomonas aeruginosa on previous microbiology? Or do they have known active Pseudomonas aeruginosa infection?

• Yes
• No

For treatment in a patient with no penicillin allergy or non-severe hypersensitivity and history of pseudomonas use:

Code for piperacillin+tazobactam and gentamicin is: 2bch

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Initial Gentamicin/Tobramycin Dosing (age > 12 years)

• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose. For morbidly obese patients, seek expert advice
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of up to 7mg/kg may be appropriate (depending on renal function). See the Therapeutic Guidelines for more detail
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
• Use the Cockcroft gault calculator to calculate renal function for adults if using the nomogram, or use the adult aminoglycoside dose calculator

• If resistance to ceftazidime is proven or suspected please contact infectious diseases
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy
• Consider influenza treatment with oseltamivir (Tamiflu®) 75 mg whilst awaiting swab results
• Modify regimen based on sputum culture results. However if patient improving, adjustment is not required even if the cultured isolate is resistant. Call ID if discussion required

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For treatment in a patient with no penicillin allergy or non-severe hypersensitivity and history of Pseudomonas aeruginosa use:

Code for ceftazidime and gentamicin is: 2bch

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• If resistance to ceftazidime is proven or suspected please contact infectious diseases
• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Consider influenza treatment with oseltamivir (Tamiflu® ) 75 mg whilst awaiting swab results
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy
• Modify regimen based on sputum culture results. However if patient improving, adjustment is not required even if the cultured isolate is resistant. Call ID if discussion required

Initial Gentamicin/Tobramycin Dosing (age > 12 years)

• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose. For morbidly obese patients, seek expert advice
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of up to 7mg/kg may be appropriate (depending on renal function). See the Therapeutic Guidelines for more detail
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
• Use the Cockcroft gault calculator to calculate renal function for adults if using the nomogram, or use the adult aminoglycoside dose calculator

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For treatment in a patient with no penicillin allergy with no signs of pseudomonas use:

Code for IV amoxicillin+clavulanate is: 10bch

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For treatment in a patient with no penicillin allergy or non-severe hypersensitivity with no signs of pseudomonas use:

Code for ceftriaxone is: 10bch

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has your patient been colonised with Pseudomonas aeruginosa on previous microbiology? Or do they have known active Pseudomonas aeruginosa infection?

• Yes
• No

For treatment in a patient with severe penicillin hypersensitivity and no evidence of Pseudomonas aeruginosa infection use:

Code for moxifloxacin is: 10bch

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has your patient been colonised with Pseudomonas aeruginosa on previous microbiology? Or do they have known active Pseudomonas aeruginosa infection?

• Yes
• No

For treatment in a patient with evidence of Pseudomonas aeruginosa infection use:

Code for ciprofloxacin is: 10bch

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy
• Ciprofloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Ciprofloxacin can be used in children when it is the drug of choice.

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For treatment in a patient with no penicillin allergy use:

• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has your patient been colonised with Pseudomonas aeruginosa on previous microbiology? Or do they have known active Pseudomonas aeruginosa infection?

• Yes
• No

For treatment in a patient with penicillin allergy use:

Code for cefuroxime is: 10bch

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has your patient been colonised with Pseudomonas aeruginosa on previous microbiology? Or do they have known active Pseudomonas aeruginosa infection?

• Yes
• No

For treatment in a patient with penicillin allergy use:

Code for clarithromycin is: 10bch

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has your patient been colonised with Pseudomonas aeruginosa on previous microbiology? Or do they have known active Pseudomonas aeruginosa infection?

• Yes
• No

For treatment in a patient with no penicillin allergy and active Pseudomonas infection, whilst awaiting culture results use:

Code for piperacillin+tazobactam and gentamicin is: 2bch

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy
• If resistance to ceftazidime is proven or suspected contact infectious diseases

Initial Paediatric Gentamicin Dosing (Age < 12 years)

• It is good practice to start gentamicin therapeutic drug monitoring from the first dose if it is expected to be used for more than 72 hours
• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose. For morbidly obese patients, seek expert advice
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
• Wherever possible ensure that 2 x blood cultures are taken prior to administration of antibiotics to allow directed therapy
• Door to needle time must be within ONE HOUR of recognition of septic shock
• Repeat fluid bolus every 15 minutes until patient is normotensive.
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return
• If patient has had a previous reaction to penicillin then contact infectious diseases immediately for treatment advice
• See the Therapeutic Guidelines - Clinical Monitoring for aminoglycoside toxicity section for more information on monitoring for possible aminoglycoside toxicity

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For treatment in a patient with non-severe penicillin hypersensitivity and active Pseudomonas infection, whilst awaiting culture results use:

Code for ceftazidime and gentamicin is: 2bch

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy
• If resistance to ceftazidime is proven or suspected contact infectious diseases

Initial Paediatric Gentamicin Dosing (Age < 12 years)

• It is good practice to start gentamicin therapeutic drug monitoring from the first dose if it is expected to be used for more than 72 hours
• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose. For morbidly obese patients, seek expert advice
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
• Wherever possible ensure that 2 x blood cultures are taken prior to administration of antibiotics to allow directed therapy
• Door to needle time must be within ONE HOUR of recognition of septic shock
• Repeat fluid bolus every 15 minutes until patient is normotensive.
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return
• If patient has had a previous reaction to penicillin then contact infectious diseases immediately for treatment advice
• See the Therapeutic Guidelines - Clinical Monitoring for aminoglycoside toxicity section for more information on monitoring for possible aminoglycoside toxicity

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For treatment in a patient with no penicillin allergy or delayed hypersensitivity use:

Code for IV amoxicillin+clavulanate is: 10bch

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has your patient been colonised with Pseudomonas aeruginosa on previous microbiology? Or do they have known active Pseudomonas aeruginosa infection?

• Yes
• No

For treatment in a patient with delayed penicillin hypersensitivity use:

Code for ceftriaxone or cefotaxime is: 10bch

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy

Initial Paediatric Gentamicin Dosing (Age < 12 years)

• It is good practice to start gentamicin therapeutic drug monitoring from the first dose if it is expected to be used for more than 72 hours
• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose. For morbidly obese patients, seek expert advice
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
• Wherever possible ensure that 2 x blood cultures are taken prior to administration of antibiotics to allow directed therapy
• Door to needle time must be within ONE HOUR of recognition of septic shock
• Repeat fluid bolus every 15 minutes until patient is normotensive.
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return
• If patient has had a previous reaction to penicillin then contact infectious diseases immediately for treatment advice
• See the Therapeutic Guidelines - Clinical Monitoring for aminoglycoside toxicity section for more information on monitoring for possible aminoglycoside toxicity

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has your patient been colonised with Pseudomonas aeruginosa on previous microbiology? Or do they have known active Pseudomonas aeruginosa infection?

• Yes
• No

For treatment in a patient with immediate penicillin hypersensitivity use:

Code for moxifloxacin is: 10bch

This code is valid for TEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past ten days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy
• Moxifloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Moxifloxacin can be used in children when it is the drug of choice.

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For treatment in a patient with immediate severe penicillin hypersensitivity and pseudomonas infection:

Code for meropenem and gentamicin is: 2bch

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• In patients with penicillin hypersensitivity, the rate of immune-mediated cross-reactivity with carbapenems is approximately 1%; therefore, meropenem can be considered in supervised settings. However, in patients with a history of a severe cutaneous adverse reaction (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome / toxic epidermal necrolysis [SJS/TEN], acute generalised exanthematous pustulosis [AGEP]), consider meropenem only in a critical situation when there are limited treatment options
• Duration of therapy is usually 14 days (PO + IV). If clinical response is rapid and no resistant isolates are found, duration may be shortened to 10 days (IV + PO)
• Exacerbations of bronchiectasis can be caused by colonising organisms or infection with a new organism. For this reason, a trial of narrower-spectrum antibiotic therapy is recommended despite previous Pseudomonas aeruginosa growth
• Optimise airway clearance, physical activity and, if appropriate, bronchodilator therapy during exacerbations of bronchiectasis
• In patients with bronchiectasis, the airways are often colonised with organisms such as Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa and Staphylococcus aureus. Exacerbations of bronchiectasis may be caused by colonising organisms or infection with a new organism, including common respiratory viruses
• Many patients with bronchiectasis easily expectorate sputum. Collect a sputum sample for culture in all patients (including patients managed in the community) before starting antibiotic therapy
• Moxifloxacin is not licensed for use in children on the basis of animal studies that showed an adverse effect on cartilage development with quinolone use; however, there are few data from human trials to support this finding. Moxifloxacin can be used in children when it is the drug of choice.
• Consider influenza treatment with oseltamivir (Tamiflu® ) 75 mg whilst awaiting swab results

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Initial Paediatric Gentamicin Dosing (Age < 12 years)

Age		Initial dose	Dosing frequency	Maximum number of empirical doses
Neonates <30 weeks postmenstrual age	postnatal age 0 to 7 days	5 mg/kg	48-hourly	2 doses (at 0 and 48 hours)
	postnatal age 8 to 28 days	4 mg/kg	36-hourly	2 doses (at 0 and 36 hours)
	postnatal age 29 days or older	4 mg/kg	24-hourly	3 doses (at 0, 24 and 48 hours)
neonates 30 to 34 weeks postmenstrual age	postnatal age 0 to 7 days	4.5 mg/kg	36-hourly	2 doses (at 0 and 36 hours)
	postnatal age 8 days and older	4 mg/kg	24-hourly	3 doses (at 0, 24 and 48 hours)
neonates 35 weeks postmenstrual age or older		4 mg/kg	24-hourly	3 doses (at 0, 24 and 48 hours)
infants and children		7.5 mg/kg	24-hourly	3 doses (at 0, 24 and 48 hours)

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Initial Gentamicin/Tobramycin Dosing (age > 12 years)

Creatinine clearance (mL/min)	Initial dose	Dosing frequency	Maximum number of empirical doses
More than 60 mL/min	4 to 5 mg/kg	24-hourly	3 doses (at 0, 24 and 48 hours)
40 to 60 mL/min	4 to 5 mg/kg	36-hourly	2 doses (at 0 and 36 hours)
less than 40 mL/min	4mg/kg	Single dose, then seek expert advice

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• It is good practice to start gentamicin therapeutic drug monitoring from the first dose if it is expected to be used for more than 72 hours
• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose. For morbidly obese patients, seek expert advice
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)
• Wherever possible ensure that 2 x blood cultures are taken prior to administration of antibiotics to allow directed therapy
• Door to needle time must be within ONE HOUR of recognition of septic shock
• Repeat fluid bolus every 15 minutes until patient is normotensive.
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return
• If patient has had a previous reaction to penicillin then contact infectious diseases immediately for treatment advice
• See the Therapeutic Guidelines - Clinical Monitoring for aminoglycoside toxicity section for more information on monitoring for possible aminoglycoside toxicity

References:

See section on bronchiectasis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Has a nose and/or throat swab for viral (flu, RSV etc) NAAT been performed?

• Yes
• No

• Proceed to next question

Code for oseltamivir is: 5flu

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Proceed to next question

• Please perform a nose and/or throat swab for viral NAAT for respiratory viruses
• Consider influenza treatment with oseltamivir (Tamiflu®) 75 mg whilst awaiting results
• 75 mg oseltamivir orally, 12-hourly for 5 days
• Cease if flu results return not detected

Does your patient have chest X-ray changes consistent with pneumonia?

• Yes (treat as pneumonia)
• No

Does your patient have evidence of a bacterial exacerbation? (see below)

• Yes
• No

• Consider bacterial as a cause of COPD exacerbation if the patient has all three of three following clinical features:
• increased sputum volume
• sputum purulence or a change in sputum colour
• Fever
• Do not use antibiotic therapy unless the patient has clinical features suggestive of bacterial infection
• Consider witholding antibiotics for patients managed in the community
• Sputum cultures are not routinely recommended in IECOPD, Gram-negative bacteria, such as Enterobacteriaceae, are sometimes identified by sputum culture in patients with COPD. These are likely to be colonising organisms, reflecting trhe high levels of antibiotic use and the frequency of hospitalisation in these patients. The pathology of Enterobacteriaceae in axaserbations of COPD is uncertain

If no evidence of bacterial infection:

• Antibiotics such as amoxicillin+clavulanate, macrolides and cephalosporins are not recommended for initial therapy because they are not more effective than amoxicillin or doxycycline, and they expose the patient to harms from unnecessary broader-spectrum treatment
• If antibiotics are deemed necessary for another reason, a lack of response to initial antibiotic therapy rarely requires a change to broader-spectrum therapy. Ensure the patient is receiving appropriate inhaled bronchodilator and, where necessary, oral corticosteroid therapy. Viral and noninfective causes of COPD exacerbations are common. Consider other diagnoses such as pneumonia, influenza or heart failure

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Does your patient have severe symptoms or are they requiring ICU or HDU support? (see COPD assessment criteria below)

• Yes (treat as per pneumonia)
• No

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

For treatment in a patient with no penicillin allergy use:

• Other antibiotics such as amoxicillin+clavulanate, macrolides and cephalosporins are not recommended for initial therapy because they are not more effective than amoxicillin or doxycycline, and they expose the patient to harms from unnecessary broader-spectrum treatment
• Lack of response to initial antibiotic therapy rarely requires a change to broader-spectrum therapy. Ensure the patient is receiving appropriate inhaled bronchodilator and, where necessary, oral corticosteroid therapy. Viral and noninfective causes of COPD exacerbations are common. Consider other diagnoses such as pneumonia, influenza or heart failure

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For treatment in a patient with immediate or delayed non-severe or severe penicillin allergy use:

• Other antibiotics such as amoxicillin+clavulanate, macrolides and cephalosporins are not recommended for initial therapy because they are not more effective than amoxicillin or doxycycline, and they expose the patient to harms from unnecessary broader-spectrum treatment
• Lack of response to initial antibiotic therapy rarely requires a change to broader-spectrum therapy. Ensure the patient is receiving appropriate inhaled bronchodilator and, where necessary, oral corticosteroid therapy. Viral and noninfective causes of COPD exacerbations are common. Consider other diagnoses such as pneumonia, influenza or heart failure

References:

See section on cellulitis and erysipelas - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If the patient has signs of influenza like illness:

Diagnostic criteria for influenza:

1. Fever ≥ 38°c or definite history of fever, AND
2. Cough and/or sore throat, in the absence of any other explanation for symptoms

Treat with:

Code for oseltamivir is: 5flu

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 5 days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Patients with proven or suspected influenza should be placed in droplet and contact precautions and in a single room if possible. If single room not possible patients should be cohorted in a 2 bed room (>1 metre apart)
• Do not cohort undiagnosed influenza with confirmed influenza
• See the influenza management guideline for further details on infection control measures
• Patients are considered no longer infectious if 24 hours have elapsed since the resolution of fever, provided either:
• They have received 72 hours of ant-influenza medication, OR
• 7 days have elapsed since onset of respiratory symptoms
• Patients should be vaccinated prior to discharge. See the influenza management guideline for further details on influenza vaccination
• Cease oseltamivir and remove from droplet precautions if influenza swabs return negative or another respiratory virus is identified
• See the Therapeutic Guidelines for dose adjustments if creatinine clearance is <30 mL/min

Oseltamivir dosing in children 1-13 years of age

References:

See the section on Influenza Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

For nursing home or aged care facility acquired pneumonia treat as per community acquired pneumonia

• Continue to Community Acquired Pneumonia Treatment

• Community-acquired pneumonia (CAP) mortality is higher in aged-care facility residents than in the general community. This is largely due to comorbidities and advanced age rather than infection with resistant pathogens
• The spectrum of pathogens identified in aged-care facility residents with pneumonia does not vary greatly from the general community. Streptococcus pneumoniae is the most common pathogen
• Although residents of aged-care facilities are at higher risk of being colonised with multidrug-resistant Gram-negative bacteria such as extended-spectrum beta-lactamase (ESBL)-producing bacteria, these organisms rarely cause CAP
• If sputum samples are taken for Gram stain and culture, interpret with care. The identification of enteric Gram-negative bacilli (eg Klebsiella pneumoniae) in sputum usually reflects colonisation or prior antibiotic use, especially in patients with low- to moderate-severity CAP
• Atypical bacterial pathogens such as Mycoplasma pneumoniae and Chlamydophila (Chlamydia) pneumoniae are uncommon. Therefore, empirical antibiotics for atypical pathogens are not routinely required, but may be considered if atypical bacterial pathogens (especially Legionella species) are suspected on clinical history or risk exposures

References:

See section on CAP in residents of aged-care facilities - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

What type of pneumonia is suspected?

• Aspiration Pneumonia
• Community Acquired Pneumonia
• Hospital Acquired Pneumonia
• Tropically Acquired Community Acquired Pneumonia

• Hospital-acquired pneumonia (HAP) is pneumonia that develops in a patient who has been hospitalised for longer than 48 hours. Most bacterial HAP occurs by 'microaspiration' of bacteria that colonise the oropharynx or upper gastrointestinal tract. Atypical pathogens (eg Legionella) are much less common in HAP than in community-acquired pneumonia

Has the patient had an aspiration event (ie a clear or witnessed episode of aspiration) AND signs of pneumonia (tachypnoea at rest, tachycardia, persistent fever, rigors, hypoxaemia or crackles on auscultation that do not clear with coughing) (See information table below)

• Yes
• No

Only aspiration pneumonia needs antibiotics (Information taken from eTG 2019)

Treat the patient as:

• Community Acquired Pneumonia
• Hospital Acquired Pneumonia

Has the patient shown improvement on empirical CAP or HAP therapy at 48 hours?

• Yes
• No

If the patient is improving on the current regimen:

References:

See the Therapeutic Guidelines - Aspiration Pneumonia section for more information on treatment of aspiration pneumonia

No antibiotics required. Monitor closely

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Has the patient been on amoxicillin+clavulanate, clindamycin, lincomycin, meropenem, moxifloxacin or piperacillin+tazobactam (single doses do not count).

• Yes
• No

Consider the addition of anaerobic cover

• Click here to continue

Please contact infectious diseases for advice

Aspiration pneumonia treatment with no penicillin allergy:

• The duration of therapy for aspiration pneumonia is guided by the setting (eg hospital- or community-acquired pneumonia).
  • For community-acquired aspiration pneumonia, the total duration of therapy is 5 to 7 days (intravenous + oral). If the patient has significantly improved after 2 to 3 days of antibiotic therapy, treat for 5 days. If the clinical response is slow, treat for 7 days.
  • For hospital-acquired aspiration pneumonia, 7 days of therapy (intravenous + oral) is generally adequate
  • Patients with lung abscess, empyema or large parapneumonic effusion complicating aspiration pneumonia require a longer duration of therapy — see Parapneumonic effusion and empyema
  • If the patient is not improving and susceptibility results are not available, seek expert advice.
  • Initial therapy for aspiration pneumonia is the same as empirical therapy for CAP or HAP, which treats most pathogens aspirated from the oropharynx, including oral anaerobes. If the response to empirical therapy is inadequate at 48 hours, reassess the diagnosis before adjusting the antibiotic regimen
  • In rare cases, pneumonia following aspiration may be due to specific anaerobes such as Bacteroides or Prevotella species that are not adequately treated with some empirical regimens for CAP or HAP. These pathogens are more likely in a patient who has severe periodontal disease or putrid sputum. Pneumonia involving anaerobic pathogens can be necrotising or cavitary, and the infection may progress to lung abscess or parapneumonic effusion and empyema. Assess the patient for these complications
  • Antibiotic regimens for CAP and HAP in these guidelines that include amoxicillin+clavulanate, clindamycin, lincomycin, meropenem, moxifloxacin or piperacillin+tazobactam are effective against a broader range of oral anaerobes that cause pneumonia, including Bacteroides or Prevotella species. If the patient is taking one of these drugs and the response is inadequate after 48 hours, seek expert advice

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  References:
  
  See section on aspiration pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

   Home

For aspiration pneumonia treatment with immediate non-severe or delayed non-severe penicillin allergy give:

Code for clindamycin orally and ceftriaxone IV is: 7asp

This code is valid for SEVEN days only. Starting from the first day of treatment for this condition. Infectious diseases must be contacted within 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• The duration of therapy for aspiration pneumonia is guided by the setting (eg hospital- or community-acquired pneumonia).
  • For community-acquired aspiration pneumonia, the total duration of therapy is 5 to 7 days (intravenous + oral). If the patient has significantly improved after 2 to 3 days of antibiotic therapy, treat for 5 days. If the clinical response is slow, treat for 7 days.
  • For hospital-acquired aspiration pneumonia, 7 days of therapy (intravenous + oral) is generally adequate
  • Patients with lung abscess, empyema or large parapneumonic effusion complicating aspiration pneumonia require a longer duration of therapy — see Parapneumonic effusion and empyema
  • If the patient is not improving and susceptibility results are not available, seek expert advice.
  • Initial therapy for aspiration pneumonia is the same as empirical therapy for CAP or HAP, which treats most pathogens aspirated from the oropharynx, including oral anaerobes. If the response to empirical therapy is inadequate at 48 hours, reassess the diagnosis before adjusting the antibiotic regimen
  • In rare cases, pneumonia following aspiration may be due to specific anaerobes such as Bacteroides or Prevotella species that are not adequately treated with some empirical regimens for CAP or HAP. These pathogens are more likely in a patient who has severe periodontal disease or putrid sputum. Pneumonia involving anaerobic pathogens can be necrotising or cavitary, and the infection may progress to lung abscess or parapneumonic effusion and empyema. Assess the patient for these complications
  • Antibiotic regimens for CAP and HAP in these guidelines that include amoxicillin+clavulanate, clindamycin, lincomycin, meropenem, moxifloxacin or piperacillin+tazobactam are effective against a broader range of oral anaerobes that cause pneumonia, including Bacteroides or Prevotella species. If the patient is taking one of these drugs and the response is inadequate after 48 hours, seek expert advice

  ---

  References:
  
  See section on aspiration pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Aspiration pneumonia treatment in a patient with immediate or delayed severe penicillin allergy:

Code for clindamycin IV is: 3asp

This code is valid for THREE days only. Starting from the first day of treatment for this condition. Infectious diseases must be contacted within 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• The duration of therapy for aspiration pneumonia is guided by the setting (eg hospital- or community-acquired pneumonia).
  • For community-acquired aspiration pneumonia, the total duration of therapy is 5 to 7 days (intravenous + oral). If the patient has significantly improved after 2 to 3 days of antibiotic therapy, treat for 5 days. If the clinical response is slow, treat for 7 days.
  • For hospital-acquired aspiration pneumonia, 7 days of therapy (intravenous + oral) is generally adequate
  • Patients with lung abscess, empyema or large parapneumonic effusion complicating aspiration pneumonia require a longer duration of therapy — see Parapneumonic effusion and empyema
  • If the patient is not improving and susceptibility results are not available, seek expert advice.
  • Initial therapy for aspiration pneumonia is the same as empirical therapy for CAP or HAP, which treats most pathogens aspirated from the oropharynx, including oral anaerobes. If the response to empirical therapy is inadequate at 48 hours, reassess the diagnosis before adjusting the antibiotic regimen
  • In rare cases, pneumonia following aspiration may be due to specific anaerobes such as Bacteroides or Prevotella species that are not adequately treated with some empirical regimens for CAP or HAP. These pathogens are more likely in a patient who has severe periodontal disease or putrid sputum. Pneumonia involving anaerobic pathogens can be necrotising or cavitary, and the infection may progress to lung abscess or parapneumonic effusion and empyema. Assess the patient for these complications
  • Antibiotic regimens for CAP and HAP in these guidelines that include amoxicillin+clavulanate, clindamycin, lincomycin, meropenem, moxifloxacin or piperacillin+tazobactam are effective against a broader range of oral anaerobes that cause pneumonia, including Bacteroides or Prevotella species. If the patient is taking one of these drugs and the response is inadequate after 48 hours, seek expert advice

  ---

  References:
  
  See section on aspiration pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

How old is the patient?

• > 15 years of age
• 5 to 15 years old

What is the patients SMARTCOP score?

• Continue to treatment

• If blood lactate concentration is more than 2 mmol/L consider treating as per severe pneumonia protocol

How severe is the pneumonia?

Grade severity based on both clinical impression and SMARTCOP score:

• Mild (smartcop <3)
• Moderate (smartcop 3-4)
• Severe (smartcop ≥5)

• If clinical impression from a medical consultant is that the pneumonia is severe it should always be treated as severe regardless of the SMARTCOP score
• Any patient which meets the criteria for severe sepsis (see infectious diseases severe sepsis protocol for details) or any patients accepted into ICU or transferred to ICU should be treated as severe (ICU)

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Penicillin anaphylaxis

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Penicillin anaphylaxis

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Penicillin anaphylaxis

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Is the patient likely to require atypical cover? (See below for a summary of when to consider atypical cover)

• Yes
• No

• Atypical cover should be considered if atypical pathogens are suspected based on the clinical presentation (i.e. prodrome of > 1 week, a prominent headache, non-productive cough for 5 or more days with bilateral lower zone infiltrates on chest X-ray, diffuse interstitial pneumonitis) or epidemiological clues (contact with known cases of “atypical” pneumonia, or if there is a current outbreak)
• For more information on pneumonia in your area please see your local pneumonia guideline on the intranet

Mild community acquired pneumonia should be treated as an outpatient with oral antibiotic therapy where possible:

Doxycycline 100mg orally, every 12 hours for 5-7 days

Empirical monotherapy is prefered unless there is a risk that follow up within 48 hours will not occur. If so, please see eTG for combination empirical therapy recommendations

• For more information on pneumonia in your area please see your local pneumonia guideline on the intranet
• It is important to use oral agents or a penicillin rather than ceftriaxone where appropriate, as overuse of third-generation cephalosporins within a hospital has been shown to lead to an increased incidence of infection with multi-resistant Gram negative organisms, C.difficile and MRSA
• If the patient has already been treated with doxycycline and monotherapy has failed, contact infectious diseases. Combination treatment with cefuroxime or an alternative agent may be warranted
• For penicillin-susceptible infections, ceftriaxone does not have superior activity against H. influenzae and S. pneumoniae compared to penicillins. Therefore ceftriaxone is not recommended for routine use in empirical treatment of moderate-severity CAP or for directed therapy of S. pneumoniae pneumonia

References:

See the Therapeutic Guidelines - Community Acquired Pneumonia section for more information on treatment of community acquired pneumonia

Mild community acquired pneumonia should be treated as an outpatient with oral antibiotic therapy where possible:

Moxifloxacin 400 mg orally or enterally, daily for 7 days.

Code for moxifloxacin is: 7cap

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• For more information on pneumonia in your area please see your local pneumonia guideline on the intranet
• If compliance with oral antibiotics is unlikely then consider treating as for moderate pneumonia
• It is important to use oral agents or a penicillin rather than ceftriaxone where appropriate, as overuse of third-generation cephalosporins within a hospital has been shown to lead to an increased incidence of infection with multi-resistant Gram negative organisms, C.difficile and MRSA
• For penicillin-susceptible infections, ceftriaxone does not have superior activity against H. influenzae and S. pneumoniae compared to penicillins. Therefore ceftriaxone is not recommended for routine use in empirical treatment of moderate-severity CAP or for directed therapy of S. pneumoniae pneumonia

References:

See the Therapeutic Guidelines - Community Acquired Pneumonia section for more information on treatment of community acquired pneumonia

Mild community acquired pneumonia should be treated as an outpatient with oral antibiotic therapy where possible:

• For more information on pneumonia in your area please see your local pneumonia guideline on the intranet
• It is important to use oral agents or a penicillin rather than ceftriaxone where appropriate, as overuse of third-generation cephalosporins within a hospital has been shown to lead to an increased incidence of infection with multi-resistant Gram negative organisms, C.difficile and MRSA
• For penicillin-susceptible infections, ceftriaxone does not have superior activity against H. influenzae and S. pneumoniae compared to penicillins. Therefore ceftriaxone is not recommended for routine use in empirical treatment of moderate-severity CAP or for directed therapy of S. pneumoniae pneumonia

References:

See the Therapeutic Guidelines - Community Acquired Pneumonia section for more information on treatment of community acquired pneumonia

Mild community acquired pneumonia should be treated as an outpatient with oral antibiotic therapy where possible:

Empirical monotherapy is prefered unless there is a risk that follow up within 48 hours will not occur. If so, please see eTG for combination empirical therapy recommendations

• For more information on pneumonia in your area please see your local pneumonia guideline on the intranet
• For penicillin-susceptible infections, ceftriaxone does not have superior activity against H. influenzae and S. pneumoniae compared to penicillins. Therefore ceftriaxone is not recommended for routine use in empirical treatment of moderate-severity CAP or for directed therapy of S. pneumoniae pneumonia

References:

See the Therapeutic Guidelines - Community Acquired Pneumonia section for more information on treatment of community acquired pneumonia

Community acquired pneumonia taddeeatment:

Code for ceftriaxone is: 3cap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• For more information on pneumonia in your area please see your local pneumonia guideline on the intranet
• It is important to use oral agents or a penicillin rather than ceftriaxone as soon as appropriate, as overuse of third-generation cephalosporins within a hospital has been shown to lead to an increased incidence of infection with multi-resistant Gram negative organisms, C.difficile and MRSA
• Please see the switch to oral guideline on the intranet for details on when the patient can qualify for the IV to oral switch
• Ensure blood cultures, sputum gram stain and cultures are sent to pathology for testing. Please see your local pneumonia guideline on the intranet for a full list of all relevant tests required
• For penicillin-susceptible infections, ceftriaxone does not have superior activity against H. influenzae and S. pneumoniae compared to penicillins. Therefore ceftriaxone is not recommended for routine use in empirical treatment of moderate-severity CAP or for directed therapy of S. pneumoniae pneumonia

References:

See the Therapeutic Guidelines - Community Acquired Pneumonia section for more information on treatment of community acquired pneumonia

Community acquired pneumonia treatment:

Code for ceftriaxone and azithromycin iv is: 3cap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2cap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• For more information on pneumonia in your area please see your local pneumonia guideline on the intranet
• Please see the switch to oral guideline on the intranet for details on when the patient can qualify for the IV to oral switch
• Ensure blood cultures, sputum gram stain and cultures are sent to pathology for testing. Please see your local pneumonia guideline on the intranet for a full list of all relevant tests required
• Usual total treatment duration is 7 days (IV + PO), except for azithromycin which is only required for 3-5 days

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See the Therapeutic Guidelines - Community Acquired Pneumonia section for more information on treatment of community acquired pneumonia

Community acquired pneumonia treatment:

Code for moxifloxacin orally is: 7cap

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past one week. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• For more information on pneumonia in your area please see your local pneumonia guideline on the intranet
• Please see the switch to oral guideline on the intranet for details on when the patient can qualify for the IV to oral switch
• Ensure blood cultures, sputum gram stain and cultures are sent to pathology for testing. Please see your local pneumonia guideline on the intranet for a full list of all relevant tests required

References:

See the Therapeutic Guidelines - Community Acquired Pneumonia section for more information on treatment of community acquired pneumonia

Community acquired pneumonia treatment:

• For more information on pneumonia in your area please see your local pneumonia guideline on the intranet
• Please see the switch to oral guideline on the intranet for details on when the patient can qualify for the IV to oral switch
• Ensure blood cultures, sputum gram stain and cultures are sent to pathology for testing. Please see your local pneumonia guideline on the intranet for a full list of all relevant tests required

References:

See the Therapeutic Guidelines - Community Acquired Pneumonia section for more information on treatment of community acquired pneumonia

Community acquired pneumonia treatment:

• For more information on pneumonia in your area please see your local pneumonia guideline on the intranet
• Please see the switch to oral guideline on the intranet for details on when the patient can qualify for the IV to oral switch
• Ensure blood cultures, sputum gram stain and cultures are sent to pathology for testing. Please see your local pneumonia guideline on the intranet for a full list of all relevant tests required
• It is important to use oral agents or a penicillin rather than ceftriaxone where appropriate, as overuse of third-generation cephalosporins within a hospital has been shown to lead to an increased incidence of infection with multi-resistant Gram negative organisms, C.difficile and MRSA

References:

See the Therapeutic Guidelines - Community Acquired Pneumonia section for more information on treatment of community acquired pneumonia

Community acquired pneumonia treatment:

Code for moxifloxacin iv is: 3cap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2cap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• For more information on pneumonia in your area please see your local pneumonia guideline on the intranet
• Please see the switch to oral guideline on the intranet for details on when the patient can qualify for the IV to oral switch
• Ensure blood cultures, sputum gram stain and cultures are sent to pathology for testing. Please see your local pneumonia guideline on the intranet for a full list of all relevant tests required
• Usual total treatment duration is 7 days (IV + PO), except for azithromycin which is only required for 3-5 days

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

References:

See the Therapeutic Guidelines - Community Acquired Pneumonia section for more information on treatment of community acquired pneumonia

How severe is the pneumonia?

Grade severity based on clinical impression:

• Mild to Moderate
• Severe
• Severe (ICU)

• Any patient which meets the criteria for severe sepsis (see infectious diseases severe sepsis protocol for details) or any patients accepted into ICU or transferred to ICU should be treated as "Severe (ICU)"

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Penicillin anaphylaxis

• Penicillin anaphylaxis is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Penicillin anaphylaxis

• Penicillin anaphylaxis is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Penicillin anaphylaxis

• Penicillin anaphylaxis is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Is Mycoplasma pneumoniae infection suspected? (See below for a summary of Mycoplasma pneumoniae clinical features)

• Yes
• No

• Mycoplasma or other atypical cover should be considered if the patient has a prodrome of > 1 week, a prominent headache, dry cough, diffuse interstitial pneumonitis or epidemiological clues (contact with known cases of “atypical” pneumonia, or if there is a current outbreak)
• Clinical features of Mycoplasma pneumoniae infection include: concurrent pharyngitis, rhinorrhea and ear pain
• Skin rash, joint involvement or symptoms indicative of gastrointestinal tract, CNS or heart disease, can also indicate Mycoplasma pneumoniae infection
• Mycoplasma pneumoniae infection may worsen asthma symptoms and can produce wheezing in children who do not have asthma

Is Mycoplasma pneumoniae infection suspected? (See below for a summary of Mycoplasma pneumoniae clinical features)

• Yes
• No

• Mycoplasma or other atypical cover should be considered if the patient has a prodrome of > 1 week, a prominent headache, dry cough, diffuse interstitial pneumonitis or epidemiological clues (contact with known cases of “atypical” pneumonia, or if there is a current outbreak)
• Clinical features of Mycoplasma pneumoniae infection include: concurrent pharyngitis, rhinorrhea and ear pain
• Skin rash, joint involvement or symptoms indicative of gastrointestinal tract, CNS or heart disease, can also indicate Mycoplasma pneumoniae infection
• Mycoplasma pneumoniae infection may worsen asthma symptoms and can produce wheezing in children who do not have asthma

Is Mycoplasma pneumoniae infection suspected? (See below for a summary of Mycoplasma pneumoniae clinical features)

• Yes
• No

• Mycoplasma or other atypical cover should be considered if the patient has a prodrome of > 1 week, a prominent headache, dry cough, diffuse interstitial pneumonitis or epidemiological clues (contact with known cases of “atypical” pneumonia, or if there is a current outbreak)
• Clinical features of Mycoplasma pneumoniae infection include: concurrent pharyngitis, rhinorrhea and ear pain
• Skin rash, joint involvement or symptoms indicative of gastrointestinal tract, CNS or heart disease, can also indicate Mycoplasma pneumoniae infection
• Mycoplasma pneumoniae infection may worsen asthma symptoms and can produce wheezing in children who do not have asthma

Is Mycoplasma pneumoniae infection suspected? (See below for a summary of Mycoplasma pneumoniae clinical features)

• Yes
• No

• Mycoplasma or other atypical cover should be considered if the patient has a prodrome of > 1 week, a prominent headache, dry cough, diffuse interstitial pneumonitis or epidemiological clues (contact with known cases of “atypical” pneumonia, or if there is a current outbreak)
• Clinical features of Mycoplasma pneumoniae infection include: concurrent pharyngitis, rhinorrhea and ear pain
• Skin rash, joint involvement or symptoms indicative of gastrointestinal tract, CNS or heart disease, can also indicate Mycoplasma pneumoniae infection
• Mycoplasma pneumoniae infection may worsen asthma symptoms and can produce wheezing in children who do not have asthma

Is Mycoplasma pneumoniae infection suspected? (See below for a summary of Mycoplasma pneumoniae clinical features)

• Yes
• No

• Mycoplasma or other atypical cover should be considered if the patient has a prodrome of > 1 week, a prominent headache, dry cough, diffuse interstitial pneumonitis or epidemiological clues (contact with known cases of “atypical” pneumonia, or if there is a current outbreak)
• Clinical features of Mycoplasma pneumoniae infection include: concurrent pharyngitis, rhinorrhea and ear pain
• Skin rash, joint involvement or symptoms indicative of gastrointestinal tract, CNS or heart disease, can also indicate Mycoplasma pneumoniae infection
• Mycoplasma pneumoniae infection may worsen asthma symptoms and can produce wheezing in children who do not have asthma

Mild community acquired pneumonia should be treated with oral antibiotic therapy where possible:

Code for azithromycin orally is: 5cap

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for azithromycin iv is: 2cap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• It is important to use oral agents rather than ceftriaxone or cefotaxime whenever appropriate, as overuse of third-generation cephalosporins within a hospital has been shown to lead to an increased incidence of infection with multi-resistant Gram negative organisms, C.difficile and MRSA

References:

See the CHAMP guidelines - See local protocol for community acquired pneumonia in the CHAMP guidelines

Mild community acquired pneumonia should be treated with oral antibiotic therapy where possible:

Code for azithromycin orally is: 5cap

This code is valid for FIVE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past five days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for azithromycin iv is: 2cap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• It is important to use oral agents rather than ceftriaxone or cefotaxime as soon as appropriate, as overuse of third-generation cephalosporins within a hospital has been shown to lead to an increased incidence of infection with multi-resistant Gram negative organisms, C.difficile and MRSA

References:

See the CHAMP guidelines - See local protocol for community acquired pneumonia in the CHAMP guidelines

Mild community acquired pneumonia should be treated with oral antibiotic therapy where possible. Use:

• Please see the switch to oral guideline on the intranet for details on when to best make the IV to oral switch

References:

See the CHAMP guidelines - See local protocol for community acquired pneumonia in the CHAMP guidelines

For severe community acquired pneumonia in a patient with non-life threatening penicillin allergy empirically treat with:

Code for azithromycin iv and ceftriaxone is: 2cap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Please see the switch to oral guideline on the intranet for details on when the patient can qualify for the IV to oral switch
• Ensure blood cultures, sputum gram stain and cultures and mycoplasma serology are sent to pathology for testing

References:

See the CHAMP guidelines - See local protocol for community acquired pneumonia in the CHAMP guidelines

Severe community acquired pneumonia in a patient with non-life threatening penicillin allergy should be treated with:

Code for ceftriaxone is: 2cap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Please see the switch to oral guideline on the intranet for details on when the patient can qualify for the IV to oral switch
• Ensure blood cultures, sputum gram stain and cultures and mycoplasma serology are sent to pathology for testing

References:

See the CHAMP guidelines - See local protocol for community acquired pneumonia in the CHAMP guidelines

Severe community acquired pneumonia in a patient with life threatening penicillin allergy should be treated with:

Code for vancomycin is: 3cap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Vancomycin Dosing in Paediatrics

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Please see the switch to oral guideline on the intranet for details on when the patient can qualify for the IV to oral switch
• Ensure blood cultures, sputum gram stain and cultures and mycoplasma serology are sent to pathology for testing

References:

See the CHAMP guidelines - See local protocol for community acquired pneumonia in the CHAMP guidelines

Severe community acquired pneumonia in a patient with life threatening penicillin allergy should be treated with:

Code for azithromycin iv and vancomycin is: 2cap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Vancomycin Dosing in Paediatrics

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Please see the switch to oral guideline on the intranet for details on when the patient can qualify for the IV to oral switch
• Ensure blood cultures, sputum gram stain and cultures and mycoplasma serology are sent to pathology for testing

References:

See the CHAMP guidelines - See local protocol for community acquired pneumonia in the CHAMP guidelines

Severe community acquired pneumonia for ICU admission:

Code for vancomycin, meropenem and azithromycin iv is: 2cap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• In patients with penicillin hypersensitivity, the rate of immune-mediated cross-reactivity with carbapenems is approximately 1%; therefore, meropenem can be considered in supervised settings. However, in patients with a history of a severe cutaneous adverse reaction (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome / toxic epidermal necrolysis [SJS/TEN], acute generalised exanthematous pustulosis [AGEP]), consider meropenem only in a critical situation when there are limited treatment options

Vancomycin Dosing in Paediatrics

• Switch to oral therapy when systemic features have improved (see switch to oral guideline on the intranet for details)

Severe community acquired pneumonia for ICU admission:

Code for piperacillin, azithromycin iv and vancomycin is: 2cap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Vancomycin Dosing in Paediatrics

• Switch to oral therapy when systemic features have improved (see switch to oral guideline on the intranet for details)

How severe is the hospital acquired pneumonia? (Please see below for details on how to diagnose high severity HAP)

• Low to moderate severity
• High severity

HAP severity assessment

• septic shock
• respiratory failure, particularly if requiring mechanical ventilation
• rapid progression of infiltrates on chest X-ray

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Non-severe immediate or delayed penicillin hypersensitivity
• Severe immediate or delayed penicillin hypersensitivity

History of penicillin allergy or adverse reaction

No penicillin allergy

• This includes non-severe reactions such as nausea and limited diarrhoea
• Such reactions are frequently not replicable or generalizable to the whole class. It is safe to prescribe penicillin class antibiotics (with the patient’s knowledge), and if required, use strategies for symptom control such as metoclopramide

Non-severe immediate or delayed penicillin hypersensitivity

• This includes non-severe reactions such as isolated rash
• There is only a 2-3% chance of cephalosporin allergy in a patient with a previous IgE mediated allergy to penicillin, and probably even less for other types of allergies. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Severe immediate or delayed penicillin hypersensitivity

• This includes anaphylaxis (see below) BUT DOES NOT INCLUDE other life-threatening reactions such as Stevens-Johnson Syndrome (SJS), Toxic epidermal necrolysis (TEN), Drug reaction with eosinophilia and systemic symptoms (DRESS) or interstitial nephritis. If your patient has a history of these, contact infectious diseases for advice

Penicillin anaphylaxis is highly likely if any ONE of the following is fulfilled:

OR

OR

Does the patient have signs of septic shock? (See below)

• Yes
• No

Signs of Sepsis:

• See the management of severe sepsis section in the Australian Therapeutic Guidelines for more information on identifying a septic patient

Does the patient have signs of septic shock? (See below)

• Yes
• No

Signs of Sepsis:

• See the management of severe sepsis section in the Australian Therapeutic Guidelines for more information on identifying a septic patient

If patient has no penicillin allergy, as a single agent use:

Code for piperacillin+tazobactam is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• Review the patient after 24 to 48 hours: Consider stopping antibiotic treatment if an alternative diagnosis is likely, the patient has improved and blood cultures are negative. Consider de-escalating antibiotic therapy if pneumonia is likely, patient has improved and no MDR pathogens have been isolated from cultures (See eTG guidelines for low-moderate severity HAP)
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• Azithromycin is not required for empirical treatment of HAP or VAP unless Legionella pneumonia is strongly suspected based on clinical presentation and/or risk factors. Infection with Legionella is very uncommon in this setting
• In overweight patients gentamicin should be dosed on adjusted body weight, not actual body weight

• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose. For morbidly obese patients, seek expert advice
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of up to 7mg/kg may be appropriate (depending on renal function). See the Therapeutic Guidelines for more detail
• See the Therapeutic Guidelines - Clinical Monitoring for aminoglycoside toxicity section for more information on monitoring for possible aminoglycoside toxicity

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy and signs of septic shock use:

Code for piperacillin+tazobactam is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin and gentamicin (if required) is: 2hap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• Review the patient after 24 to 48 hours: Consider stopping antibiotic treatment if an alternative diagnosis is likely, the patient has improved and blood cultures are negative. Consider de-escalating antibiotic therapy if pneumonia is likely, patient has improved and no MDR pathogens have been isolated from cultures (See eTG guidelines for low-moderate severity HAP)
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• Azithromycin is not required for empirical treatment of HAP or VAP unless Legionella pneumonia is strongly suspected based on clinical presentation and/or risk factors. Infection with Legionella is very uncommon in this setting
• In overweight patients gentamicin should be dosed on adjusted body weight, not actual body weight

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

Initial Paediatric Gentamicin Dosing (Age < 12 years)

Initial Gentamicin/Tobramycin Dosing Age > 12 Years

• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose. For morbidly obese patients, seek expert advice
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of up to 7mg/kg may be appropriate (depending on renal function). See the Therapeutic Guidelines for more detail
• See the Therapeutic Guidelines - Clinical Monitoring for aminoglycoside toxicity section for more information on monitoring for possible aminoglycoside toxicity

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has mild penicillin allergy and signs of sepsis use:

Code for cefepime is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin and gentamicin is: 2hap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• Review the patient after 24 to 48 hours: Consider stopping antibiotic treatment if an alternative diagnosis is likely, the patient has improved and blood cultures are negative. Consider de-escalating antibiotic therapy if pneumonia is likely, patient has improved and no MDR pathogens have been isolated from cultures (See eTG guidelines for low-moderate severity HAP)
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• Azithromycin is not required for empirical treatment of HAP or VAP unless Legionella pneumonia is strongly suspected based on clinical presentation and/or risk factors. Infection with Legionella is very uncommon in this setting
• In overweight patients gentamicin should be dosed on adjusted body weight, not actual body weight

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

Initial Paediatric Gentamicin Dosing (Age < 12 years)

Initial Gentamicin/Tobramycin Dosing Age > 12 Years

• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose. For morbidly obese patients, seek expert advice
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of up to 7mg/kg may be appropriate (depending on renal function). See the Therapeutic Guidelines for more detail
• See the Therapeutic Guidelines - Clinical Monitoring for aminoglycoside toxicity section for more information on monitoring for possible aminoglycoside toxicity

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy, as a single agent use:

Code for cefepime is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• Review the patient after 24 to 48 hours: Consider stopping antibiotic treatment if an alternative diagnosis is likely, the patient has improved and blood cultures are negative. Consider de-escalating antibiotic therapy if pneumonia is likely, patient has improved and no MDR pathogens have been isolated from cultures (See eTG guidelines for low-moderate severity HAP)
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• Azithromycin is not required for empirical treatment of HAP or VAP unless Legionella pneumonia is strongly suspected based on clinical presentation and/or risk factors. Infection with Legionella is very uncommon in this setting
• In overweight patients gentamicin should be dosed on adjusted body weight, not actual body weight

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has severe penicillin allergy use:

Code for IV ciprofloxacin and meropenem is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2hap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• In patients with penicillin hypersensitivity, the rate of immune-mediated cross-reactivity with carbapenems is approximately 1%; therefore, meropenem can be considered in supervised settings. However, in patients with a history of a severe cutaneous adverse reaction (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome / toxic epidermal necrolysis [SJS/TEN], acute generalised exanthematous pustulosis [AGEP]), consider meropenem only in a critical situation when there are limited treatment options
• If the patient only has a single IV line it is important to give the other antibiotics before vancomycin as it has the longest infusion time
• Review the patient after 24 to 48 hours: Consider stopping antibiotic treatment if an alternative diagnosis is likely, the patient has improved and blood cultures are negative. Consider de-escalating antibiotic therapy if pneumonia is likely, patient has improved and no MDR pathogens have been isolated from cultures (See eTG guidelines for low-moderate severity HAP)
• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• Azithromycin is not required for empirical treatment of HAP or VAP unless Legionella pneumonia is strongly suspected based on clinical presentation and/or risk factors. Infection with Legionella is very uncommon in this setting
• In overweight patients gentamicin should be dosed on adjusted body weight, not actual body weight

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

Initial Paediatric Gentamicin Dosing (Age < 12 years)

Initial Gentamicin/Tobramycin Dosing Age > 12 Years

• If actual body weight is more than 20% over the ideal body weight, use adjusted body weight to calculate the dose. For morbidly obese patients, seek expert advice
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of up to 7mg/kg may be appropriate (depending on renal function). See the Therapeutic Guidelines for more detail
• See the Therapeutic Guidelines - Clinical Monitoring for aminoglycoside toxicity section for more information on monitoring for possible aminoglycoside toxicity

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient tolerates penicillin use as a single agent:

Code for IV Amoxicillin+Clavulanate is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Broader anaerobic cover is not normally required for mild hospital acquired pneumonia
• Review the patient after 24 to 48 hours: Consider stopping antibiotic treatment if an alternative diagnosis is likely, the patient has improved and blood cultures are negative. Consider de-escalating antibiotic therapy if pneumonia is likely, patient has improved and no MDR pathogens have been isolated from cultures (See eTG guidelines for low-moderate severity HAP)
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has immediate nonsevere or delayed nonsevere penicillin allergy use as a single agent:

Code for cefuroxime is: 7hap

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 7 days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for ceftriaxone is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Broader anaerobic cover is not normally required for mild hospital acquired pneumonia
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has severe penicillin allergy use as a single agent:

Code for moxifloxacin orally is: 7hap

This code is valid for SEVEN days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 7 days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for IV moxifloxacin is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• Broader anaerobic cover is not normally required for mild hospital acquired pneumonia
• Review the patient after 24 to 48 hours: Consider stopping antibiotic treatment if an alternative diagnosis is likely, the patient has improved and blood cultures are negative. Consider de-escalating antibiotic therapy if pneumonia is likely, patient has improved and no MDR pathogens have been isolated from cultures (See eTG guidelines for low-moderate severity HAP)
• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient is an adult immediately hypersensitive to penicillin (life threatening reaction) use:

Please contact infectious diseases for treatment options for a child immediately hypersensitive to penicillin

• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• Please note that oral moxifloxacin has excellent bioavailability (>90% orally bioavailable)
• Consider stopping antibiotic treatment after 48 to 72 hours when patients are improving and culture-negative, if an alternative diagnosis is likely
• Azithromycin is not required for empirical treatment of HAP or VAP unless Legionella pneumonia is strongly suspected based on clinical presentation and/or risk factors. Infection with Legionella is very uncommon in this setting

Code for IV Moxifloxacin or PO Moxifloxacin is: 8hap

This code is valid for EIGHT days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if treatment is to continue past eight days. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has penicillin hypersensitivity treatment is complex, please contact infectious diseases for advice

Is gentamicin contraindicated in this patient? (See below for contraindications)

• Gentamicin not contraindicated
• Gentamicin contraindicated

Aminoglycoside Contraindications and Precautions

• A single dose can be used in patients with:
  • Chronic renal impairment (creatinine clearance less than 40 mL/min) or rapidly deteriorating renal function
  • Advanced age (eg 80 years or older), depending on calculated renal function
• If you are unsure whether gentamicin is appropriate for this patient please consult infectious diseases

If patient has not had a life threatening penicillin reaction use:

AND for anaerobic cover

Code for cefepime is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2hap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• Consider stopping antibiotic treatment after 48 to 72 hours when patients are improving and culture-negative, if an alternative diagnosis is likely. Otherwise, if pneumonia is the likely diagnosis, and the patient has clinically improved, and no MDR pathogens are isolated from cultures by 48 to 72 hours, consider de-escalating antibiotic therapy
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• Azithromycin is not required for empirical treatment of HAP or VAP unless Legionella pneumonia is strongly suspected based on clinical presentation and/or risk factors. Infection with Legionella is very uncommon in this setting
• In patients with severe disease who have recently been treated with the above drugs meropenem may be required. Please contact infectious diseases if your patient meets this criteria

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has not had a life threatening penicillin reaction use:

Code for cefepime is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2hap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• Consider stopping antibiotic treatment after 48 to 72 hours when patients are improving and culture-negative, if an alternative diagnosis is likely. Otherwise, if pneumonia is the likely diagnosis, and the patient has clinically improved, and no MDR pathogens are isolated from cultures by 48 to 72 hours, consider de-escalating antibiotic therapy
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• Azithromycin is not required for empirical treatment of HAP or VAP unless Legionella pneumonia is strongly suspected based on clinical presentation and/or risk factors. Infection with Legionella is very uncommon in this setting
• In patients with severe disease who have recently been treated with the above drugs meropenem may be required. Please contact infectious diseases if your patient meets this criteria

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has not had a life threatening penicillin reaction use:

Code for piperacillin+tazobactam is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• infectious diseases should be contacted as soon as possible if staphylococcal pneumonia is suspected as the patient may require MRSA cover
• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• Consider stopping antibiotic treatment after 48 to 72 hours when patients are improving and culture-negative, if an alternative diagnosis is likely. Otherwise, if pneumonia is the likely diagnosis, and the patient has clinically improved, and no MDR pathogens are isolated from cultures by 48 to 72 hours, consider de-escalating antibiotic therapy
• Azithromycin is not required for empirical treatment of HAP or VAP unless Legionella pneumonia is strongly suspected based on clinical presentation and/or risk factors. Infection with Legionella is very uncommon in this setting

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has not had a life threatening penicillin reaction use:

Code for piperacillin+tazobactam is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2hap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• If the patient only has a single IV line it is important to give piperacillin before vancomycin as it has the shortest infusion time
• Consider stopping antibiotic treatment after 48 to 72 hours when patients are improving and culture-negative, if an alternative diagnosis is likely. Otherwise, if pneumonia is the likely diagnosis, and the patient has clinically improved, and no MDR pathogens are isolated from cultures by 48 to 72 hours, consider de-escalating antibiotic therapy
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• Azithromycin is not required for empirical treatment of HAP or VAP unless Legionella pneumonia is strongly suspected based on clinical presentation and/or risk factors. Infection with Legionella is very uncommon in this setting

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has not had a life threatening penicillin reaction use:

Code for piperacillin+tazobactam and IV ciprofloxacin is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin is: 2hap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• Consider stopping antibiotic treatment after 48 to 72 hours when patients are improving and culture-negative, if an alternative diagnosis is likely. Otherwise, if pneumonia is the likely diagnosis, and the patient has clinically improved, and no MDR pathogens are isolated from cultures by 48 to 72 hours, consider de-escalating antibiotic therapy
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• Azithromycin is not required for empirical treatment of HAP or VAP unless Legionella pneumonia is strongly suspected based on clinical presentation and/or risk factors. Infection with Legionella is very uncommon in this setting

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

References:

See section on hospital acquired pneumonia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has not had a life threatening penicillin reaction use:

Code for piperacillin+tazobactam is: 3hap

This code is valid for THREE days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 72 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

Code for vancomycin and gentamicin is: 2hap

This code is valid for TWO days only, starting from the first day of treatment for this condition. Infectious diseases must be contacted if IV treatment is to continue past 48 hours. Please annotate this code on the medication chart and document when infectious diseases are to be contacted in the patient notes.

• This is a guide for empirical treatment only. It is essential to collect blood and, if possible, expectorated sputum for cultures before antibiotics are given
• Consider stopping antibiotic treatment after 48 to 72 hours when patients are improving and culture-negative, if an alternative diagnosis is likely. Otherwise, if pneumonia is the likely diagnosis, and the patient has clinically improved, and no MDR pathogens are isolated from cultures by 48 to 72 hours, consider de-escalating antibiotic therapy
• The usual total duration of therapy is 7 days (intravenous plus oral). Patients with lung abscess, empyema or large parapneumonic effusion require a longer duration of therapy
• Azithromycin is not required for empirical treatment of HAP or VAP unless Legionella pneumonia is strongly suspected based on clinical presentation and/or risk factors. Infection with Legionella is very uncommon in this setting
• In overweight patients gentamicin should be dosed on adjusted body weight, not actual body weight

Vancomycin Dosing in Paediatrics

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10 mg/min to avoid Red Person Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• Please contact infectious diseases for any patient with a body mass index [BMI] of 30 kg/m² or more, dosing is complex in obese patients
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

Initial Paediatric Gentamicin Dosing (Age < 12 years)

Initial Gentamicin/Tobramycin Dosing Age > 12 Years