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Only proceed if the patient has confirmed febrile neutropenia as per the definition below:

• Febrile neutropenia is defined as temperature ≥ 38.3°C (or temperature ≥38.0°C on two occasions) in the setting of absolute neutrophil count (ANC) <1x10⁹ cells/L or predicted ANC <1x10⁹ cells/L during the next 48 hours
• Consider infection in any unwell patient with neutropenia because fever may not be present, particularly if the patient is elderly or taking corticosteroids

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 this patient been colonised with, or recently infected with multi-drug resistant Gram negative bacteria?

• Yes
• No

• If a patient only has risk factors for infection with a multidrug-resistant Gram-negative bacterium click 'no', unless known to be colonised or recently infected with a resistant bacterium

Has this patient been colonised with, or recently infected with multi-drug resistant Gram negative bacteria?

• Yes
• No

• If a patient only has risk factors for infection with a multidrug-resistant Gram-negative bacterium click 'no', unless known to be colonised or recently infected with a resistant bacterium

Does the patient have systemic compromise (hypotension, hypoxia or organ dysfunction) or signs of severe sepsis? (See below)

• Yes
• No

Signs of Sepsis:

• See the Therapeutic Guidelines for more advice on managing a septic patient
• If yes to the above contact the haematologist or ID physician for review of this patient

Is the patient at risk of methicillin-resistant Staphylococcus aureus (MRSA) infection? Do they have a CVC infection or gram positive organisms on blood cultures?

• Yes
• No

• Risk factors for MRSA infection include;
  • residence in an area with a high prevalence of MRSA )eg Northern Territory; remote communities in northern Queensland; regions north of metropolitan Perth in Western Australia, especially the Kimberly and Pilbara(
  • known or suspected to be colonised with methicillin-resistant Staphylococcus aureus (MRSA)
  • previous colonisation or infection with MRSA, particularly if recent or associated with the current episode of care
  • frequent stays, or a current prolonged stay, in a hospital with a high prevalence of MRSA, particularly if associated with antibiotic exposure or recent surgery
  • residence in an aged-care facility with a high prevalence of MRSA, particularly if the patient has had multiple courses of antibiotics
  • an intravascular catheter-related infection in a unit with a significant incidence of MRSA infection

Is the patient at risk of methicillin-resistant Staphylococcus aureus (MRSA) infection? Do they have a CVC infection or gram positive organisms on blood cultures?

• Yes
• No

• Risk factors for MRSA infection include;
  • residence in an area with a high prevalence of MRSA )eg Northern Territory; remote communities in northern Queensland; regions north of metropolitan Perth in Western Australia, especially the Kimberly and Pilbara(
  • known or suspected to be colonised with methicillin-resistant Staphylococcus aureus (MRSA)
  • previous colonisation or infection with MRSA, particularly if recent or associated with the current episode of care
  • frequent stays, or a current prolonged stay, in a hospital with a high prevalence of MRSA, particularly if associated with antibiotic exposure or recent surgery
  • residence in an aged-care facility with a high prevalence of MRSA, particularly if the patient has had multiple courses of antibiotics
  • an intravascular catheter-related infection in a unit with a significant incidence of MRSA infection

Is the patient at risk of methicillin-resistant Staphylococcus aureus (MRSA) infection? Do they have a CVC infection or gram positive organisms on blood cultures?

• Yes
• No

• Risk factors for MRSA infection include;
  • residence in an area with a high prevalence of MRSA )eg Northern Territory; remote communities in northern Queensland; regions north of metropolitan Perth in Western Australia, especially the Kimberly and Pilbara(
  • known or suspected to be colonised with methicillin-resistant Staphylococcus aureus (MRSA)
  • previous colonisation or infection with MRSA, particularly if recent or associated with the current episode of care
  • frequent stays, or a current prolonged stay, in a hospital with a high prevalence of MRSA, particularly if associated with antibiotic exposure or recent surgery
  • residence in an aged-care facility with a high prevalence of MRSA, particularly if the patient has had multiple courses of antibiotics
  • an intravascular catheter-related infection in a unit with a significant incidence of MRSA infection

Does the patient have systemic compromise (hypotension, hypoxia or organ dysfunction) or signs of severe sepsis? (See below)

• Yes
• No

Signs of Sepsis:

• See the Therapeutic Guidelines for more advice on managing a septic patient
• If yes to the above contact the haematologist or ID physician for review of this patient

Does the patient have systemic compromise (hypotension, hypoxia or organ dysfunction) or signs of severe sepsis? (See below)

• Yes
• No

Signs of Sepsis:

• See the Therapeutic Guidelines for more advice on managing a septic patient
• If yes to the above contact the haematologist or ID physician for review of this patient

Does the patient have systemic compromise (hypotension, hypoxia or organ dysfunction) or signs of severe sepsis? (See below)

• Yes
• No

Signs of Sepsis:

• See the Therapeutic Guidelines for more advice on managing a septic patient
• If yes to the above contact the haematologist or ID physician for review of this patient

Does the patient have systemic compromise (hypotension, hypoxia or organ dysfunction) or signs of severe sepsis? (See below)

• Yes
• No

Signs of Sepsis:

• See the Therapeutic Guidelines for more advice on managing a septic patient
• If yes to the above contact the haematologist or ID physician for review of this patient

If patient is likely to have an MDR gram negative infection or has a penicillin allergy and is at risk of MRSA use:

Code for meropenem and vancomycin is: 3feb

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.

• 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
• Beta-lactam antibiotics have better treatment outcomes if given as extended (4 hour) infusions in patients with febrile neutropenia
• Take blood cultures as soon as possible, preferably before antibiotics are administered and consider line removal
• In the absence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after a 48 hour afebrile period despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L

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 vancomycin dosing recommendations on the Therapeutic Guidelines

If patient has a penicillin allergy and has signs of sepsis or systemic compromise give:

Code for aztreonam and vancomycin is: 3feb

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.

• It is important to give the other antibiotics before vancomycin because vancomycin has a long infusion time
• Please note aztreonam shares a side chain with ceftazidime. If patient has a known ceftazidime allergy contact infectious diseases for advice
• Beta-lactam antibiotics have better treatment outcomes if given as extended (4 hour) infusions in patients with febrile neutropenia
• Take blood cultures as soon as possible, preferably before antibiotics are administered and consider line removal
• In the absence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• If the results of susceptibility testing are not available by 72 hours and empirical intravenous therapy is still required, seek expert advice; empirical gentamicin dosing should not continue beyond 48 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after a 48 hour afebrile period despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L

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)

• 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)

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
• Use the Cockcroft gault calculator to calculate renal function for adults if using the nomogram, or use the adult aminoglycoside dose calculator

References:

See the section on Febrile Neutropenia in the Therapeutic Guidelines

If patient has a penicillin allergy but is not septic give:

Code for aztreonam and vancomycin is: 3feb

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.

• It is important to give the other antibiotics before vancomycin because vancomycin has a long infusion time
• Please note aztreonam shares a side chain with ceftazidime. If patient has a known ceftazidime allergy contact infectious diseases for advice
• Beta-lactam antibiotics have better treatment outcomes if given as extended (4 hour) infusions in patients with febrile neutropenia
• Take blood cultures as soon as possible, preferably before antibiotics are administered and consider line removal
• In the absence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• If the results of susceptibility testing are not available by 72 hours and empirical intravenous therapy is still required, seek expert advice; empirical gentamicin dosing should not continue beyond 48 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after a 48 hour afebrile period despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L

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 the section on Febrile Neutropenia in the Therapeutic Guidelines

If patient is likely to have an MDR gram negative infection or has a penicillin allergy and is at risk of MRSA use:

Code for meropenem is: 3feb

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.

• It is important to give the other antibiotics before vancomycin because vancomycin has a long infusion time
• Beta-lactam antibiotics have better treatment outcomes if given as extended (4 hour) infusions in patients with febrile neutropenia
• Take blood cultures as soon as possible, preferably before antibiotics are administered and consider line removal
• In the absence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after a 48 hour afebrile period despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L

References:

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

If patient is likely to have an MDR gram negative infection or has a penicillin allergy and is at risk of MRSA consider:

Code for meropenem is: 3feb

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.

• 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
• Beta-lactam antibiotics have better treatment outcomes if given as extended (4 hour) infusions in patients with febrile neutropenia
• Take blood cultures as soon as possible, preferably before antibiotics are administered and consider line removal
• In the absence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after a 48 hour afebrile period despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L

References:

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

If patient has no penicillin allergy and is showing signs of sepsis use:

Code for vancomycin and piperacillin is: 3feb

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 gentamicin is: 2feb

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.

• It is important to give the other antibiotics before vancomycin as it has a long infusion time
• Beta-lactam antibiotics have better treatment outcomes if given as extended (4 hour) infusions in patients with febrile neutropenia
• Take blood cultures as soon as possible, preferably before antibiotics are administered and consider line removal
• In the absence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• If the results of susceptibility testing are not available by 72 hours and empirical intravenous therapy is still required, seek expert advice; empirical gentamicin dosing should not continue beyond 48 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after a 48 hour afebrile period despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L

Initial Paediatric Gentamicin 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)

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
• Use the Cockcroft gault calculator to calculate renal function for adults if using the nomogram, or use the adult aminoglycoside dose calculator

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 febrile neutropenia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy and is at risk of MRSA infection use:

Code for vancomycin and piperacillin is: 3feb

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 gentamicin is: 2feb

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.

• It is important to give the piperacillin+tazobactam before the vancomycin as it has the shortest infusion time
• Beta-lactam antibiotics have better treatment outcomes if given as extended (4 hour) infusions in patients with febrile neutropenia
• Take blood cultures as soon as possible, preferably before antibiotics are administered and consider line removal
• In the absence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after a 48 hour afebrile period despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L

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 febrile neutropenia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy use:

Code for piperacillin is: 3feb

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.

• Beta-lactam antibiotics have better treatment outcomes if given as extended (4 hour) infusions in patients with febrile neutropenia
• Take blood cultures as soon as possible, preferably before antibiotics are administered and consider line removal
• In the absence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after a 48 hour afebrile period despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L

References:

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

If patient has delayed penicillin hypersensitivity and is showing signs of sepsis use:

Code for vancomycin and cefepime is: 3feb

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 gentamicin is: 2feb

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.

• It is important to give the other antibiotics before vancomycin as vancomycin has a long infusion time
• Beta-lactam antibiotics have better treatment outcomes if given as extended (4 hour) infusions in patients with febrile neutropenia
• Take blood cultures as soon as possible, preferably before antibiotics are administered and consider line removal
• In the absence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• If the results of susceptibility testing are not available by 72 hours and empirical intravenous therapy is still required, seek expert advice; empirical gentamicin dosing should not continue beyond 48 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after a 48 hour afebrile period despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L

Initial Paediatric Gentamicin 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)

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
• Use the Cockcroft gault calculator to calculate renal function for adults if using the nomogram, or use the adult aminoglycoside dose calculator

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 febrile neutropenia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has delayed hypersenitivity to penicillin use:

Code for vancomycin and cefepime is: 3feb

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.

• It is important to give cefepime before vancomycin as vancomycin has a long infusion time
• Beta-lactam antibiotics have better treatment outcomes if given as extended (4 hour) infusions in patients with febrile neutropenia
• Take blood cultures as soon as possible, preferably before antibiotics are administered and consider line removal
• In the absence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after a 48 hour afebrile period despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L

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 febrile neutropenia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If patient has no penicillin allergy use:

Code for cefepime is: 3feb

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.

• Beta-lactam antibiotics have better treatment outcomes if given as extended (4 hour) infusions in patients with febrile neutropenia
• Take blood cultures as soon as possible, preferably before antibiotics are administered and consider line removal
• In the absence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after a 48 hour afebrile period despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L

References:

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

If patient has a severe penicillin allergy but is showing signs of sepsis:

Contact infectious diseases but do not delay antibiotics. If patient does not have an allergy to meropenem give cautiously in a critical care area and monitor frequently for signs of reaction

Code for meropenem and vancomycin is: 3feb

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.

• 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
• Beta-lactam antibiotics have better treatment outcomes if given as extended (4 hour) infusions in patients with febrile neutropenia
• Take blood cultures as soon as possible, preferably before antibiotics are administered and consider line removal
• In the absence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after a 48 hour afebrile period despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L

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 febrile neutropenia - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

How old is the patient?

• 2 months or younger
• Adult or child > 2 months

Does the patient have a penicillin allergy?

• Yes
• 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

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

OR

OR

Is Listeria cover required? (See below for listeria risk factors)

• Listeria suspected
• Listeria not suspected

• Patient groups with risk factors for listeria infection include adults over 50 years of age, patients with a history of hazardous alcohol consumption, immunosuppression and pregnant or debilitated patients

Is Listeria cover required? (See below for listeria risk factors)

• Listeria suspected
• Listeria not suspected

• Patient groups with risk factors for listeria infection include adults over 50 years of age, patients with a history of hazardous alcohol consumption, immunosuppression and pregnant or debilitated patients

Is Listeria cover required? (See below for listeria risk factors)

• Listeria suspected
• Listeria not suspected

• Patient groups with risk factors for listeria infection include adults over 50 years of age, patients with a history of hazardous alcohol consumption, immunosuppression and pregnant or debilitated patients

Meningitis should initially be treated empirically with:

AND

AND, if patient meets any criteria outlined below ADD:

Code for ceftriaxone and vancomycin (if it is required) is: 2men

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.

• Add vancomycin if Gram-positive diplococci are seen on Gram stain, if pneumococcal antigen assay of CSF is positive, or if the patient has known or suspected otitis media or sinusitis, or has been recently treated with a beta lactam
• There is no evidence of any net benefit if dexamethasone is given after a patient has received antibiotic therapy
• 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

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 meningitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Meningitis should initially be treated empirically with:

AND

AND, if patient meets any criteria outlined below ADD:

Code for ceftriaxone and vancomycin (if it is required) is: 2men

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.

• Add vancomycin if Gram-positive diplococci are seen on Gram stain, if pneumococcal antigen assay of CSF is positive, or if the patient has known or suspected otitis media or sinusitis, or has been recently treated with a beta lactam
• Patients older than 50 years, immunocompromised patients, patients with a history of alcohol abuse or pregnant or debilitated patients are likely to need Listeria cover. The above regimen does not cover Listeria
• There is no evidence of any net benefit if dexamethasone is given after a patient has received antibiotic therapy
• 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

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 meningitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Meningitis should initially be treated empirically with:

AND

Code for moxifloxacin iv is: 2men

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.

• please contact ID to discuss allergy status as benefits of beta-lactam treatment may outweigh risks of potential allergy
• Add vancomycin if Gram-positive diplococci are seen on Gram stain, if pneumococcal antigen assay of CSF is positive, or if the patient has known or suspected otitis media or sinusitis, or has been recently treated with a beta lactam
• There is no evidence of any net benefit if dexamethasone is given after a patient has received antibiotic therapy
• 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

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 meningitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Meningitis should initially be treated empirically with:

Code for moxifloxacin iv is: 2men

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.

• Add vancomycin if Gram-positive diplococci are seen on Gram stain, if pneumococcal antigen assay of CSF is positive, or if the patient has known or suspected otitis media or sinusitis, or has been recently treated with a beta lactam
• Patients older than 50 years, immunocompromised patients, patients with a history of alcohol abuse or pregnant or debilitated patients are likely to need Listeria cover. The above regimen does not cover Listeria
• There is no evidence of any net benefit if dexamethasone is given after a patient has received antibiotic therapy
• 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

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 meningitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Meningitis should initially be treated empirically with:

AND

AND, if patient meets any criteria outlined below ADD:

Code for ceftriaxone and vancomycin (if it is required) is: 2men

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.

• Add vancomycin if Gram-positive diplococci are seen on Gram stain, if pneumococcal antigen assay of CSF is positive, or if the patient has known or suspected otitis media or sinusitis, or has been recently treated with a beta lactam
• There is no evidence of any net benefit if dexamethasone is given after a patient has received antibiotic therapy
• 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

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 meningitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Meningitis should initially be treated empirically with:

AND

Code for ceftriaxone (and vancomycin if required) is: 2men

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.

• Add vancomycin if Gram-positive diplococci are seen on Gram stain, if pneumococcal antigen assay of CSF is positive, or if the patient has known or suspected otitis media or sinusitis, or has been recently treated with a beta lactam
• There is no evidence of any net benefit if dexamethasone is given after a patient has received antibiotic therapy
• 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

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 meningitis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

In a child < 2 months meningitis should initially be treated empirically with:

Code for cefotaxime and aciclovir iv is: 2men

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.

• Herpes encephalitis should be suspected if focal neurological signs and symptoms are present including seizures, behavioural changes, focal neurological deficits and coma, or if the patient has had recent contact with a person known to be infected with herpes
• There is insufficient evidence to support the use of dexamethasone in children < 2 months of age
• 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

References:

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

In a child < 2 months presenting with meningitis with a penicillin allergy:

Please contact infectious diseases for advice. Treatment is complex in patient's with penicillin hypersensitivity

How old is your patient?

• Adult Patient
• Child < 2 months
• Child >= 2 months

• Please contact infectious diseases for advice if treating a neonatal patient as dosing is complex

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

Is the source known?

• Source UNKNOWN
• Community acquired pneumonia
• Hospital acquired pneumonia
• Biliary or gastrointestinal infection
• Bone or joint infection
• Cellulitis or necrotising skin or soft tissue infection
• Chorioamnionitis (intra-amniotic infection)
• Diabetic foot infection
• Intravascular device
• Pelvic inflammatory disease
• Postpartum endometritis
• Surgical site infection
• Urinary tract infection

Is the source known?

• Source UNKNOWN
• Community acquired pneumonia
• Hospital acquired pneumonia
• Biliary or gastrointestinal infection
• Bone or joint infection
• Cellulitis or necrotising skin or soft tissue infection
• Chorioamnionitis (intra-amniotic infection)
• Diabetic foot infection
• Intravascular device
• Pelvic inflammatory disease
• Postpartum endometritis
• Surgical site infection
• Urinary tract infection

Is the source known?

• Source UNKNOWN
• Community acquired pneumonia
• Hospital acquired pneumonia
• Biliary or gastrointestinal infection
• Bone or joint infection
• Cellulitis or necrotising skin or soft tissue infection
• Chorioamnionitis (intra-amniotic infection)
• Diabetic foot infection
• Intravascular device
• Pelvic inflammatory disease
• Postpartum endometritis
• Surgical site infection
• Urinary tract infection

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

Was sepsis sourced in the community or from within a hospital?

• Hospital sourced
• Community sourced

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• 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

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• 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

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• 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

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• 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

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• 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

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• 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

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• 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

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• 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

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• 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

Was sepsis sourced in the community or from within a hospital?

• Hospital sourced
• Community sourced

Was sepsis sourced in the community or from within a hospital?

• Hospital sourced
• Community sourced

• If there is concern around gentamicin contraindications for this patient please contact infectious diseases for advice

• 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

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• 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

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• 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

Is gentamicin contraindicated in this patient? (See below)

• No gentamicin contraindications
• 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

Sepsis treatment when source unknown:

Code for ceftriaxone, gentamicin and vancomycin is: 2sep

This code is valid for TWO 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.

• 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
• Typical features of N. meningitidis infection include fever, meningitis symptoms and a nonblanching, purpuric rash. Leg pain, cold extremities and abnormal skin colour may also occur. Increasingly, N. meningitidis infection has an atypical presentation—gastrointestinal symptoms may predominate, as well as other nonspecific features. Purpuric rash and meningitis symptoms may be absent
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

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 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
• 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 sepsis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Sepsis treatment when source unknown:

Code for ceftriaxone, gentamicin and vancomycin is: 2sep

This code is valid for TWO 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.

• Typical features of N. meningitidis infection include fever, meningitis symptoms and a nonblanching, purpuric rash. Leg pain, cold extremities and abnormal skin colour may also occur. Increasingly, N. meningitidis infection has an atypical presentation—gastrointestinal symptoms may predominate, as well as other nonspecific features. Purpuric rash and meningitis symptoms may be absent
• Risk factors for MRSA infection include: residence in a gaol or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

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 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
• Use the Cockcroft gault calculator to calculate renal function for adults if using the nomogram, or use the adult aminoglycoside dose calculator

References:

References:

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

Sepsis treatment when source unknown:

Code for IV ciprofloxacin, gentamicin, meropenem and vancomycin is: 2sep

This code is valid for TWO 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.

• 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
• Typical features of N. meningitidis infection include fever, meningitis symptoms and a nonblanching, purpuric rash. Leg pain, cold extremities and abnormal skin colour may also occur. Increasingly, N. meningitidis infection has an atypical presentation—gastrointestinal symptoms may predominate, as well as other nonspecific features. Purpuric rash and meningitis symptoms may be absent
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Risk factors for MRSA infection include: residence in a gaol or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

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 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
• 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 severe sepsis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Hospital acquired sepsis treatment when source unknown, or community acquired sepsis when gentamicin contraindicated:

Code for piperacillin+tazobactam or cefepime or meropenem and vancomycin is: 2sep

This code is valid for TWO 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.

• 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
• Infectious diseases should be involved as soon as possible with all hospital acquired sepsis cases as a wide range of organisms could be causing the infection which may not be covered by the above regimen
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Risk factors for MRSA infection include: residence in a gaol or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

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 severe sepsis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Community acquired sepsis treatment when source unknown and gentamicin contraindicated:

Code for cefepime, meropenem and vancomycin is: 2sep

This code is valid for TWO 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.

• 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
• Infectious diseases should be involved as soon as possible with all hospital acquired sepsis cases as a wide range of organisms could be causing the infection which may not be covered by the above regimen
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Risk factors for MRSA infection include: residence in a gaol or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

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 severe sepsis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Hospital acquired sepsis treatment when source unknown:

Code for gentamicin and vancomycin is: 2sep

This code is valid for TWO 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.

• Infectious diseases should be involved as soon as possible with all hospital acquired sepsis cases as a wide range of organisms could be causing the infection which may not be covered by the above regimen
• 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
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Risk factors for MRSA infection include: residence in a gaol or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

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 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
• 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 severe sepsis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Hospital acquired sepsis treatment when source unknown:

Code for gentamicin and vancomycin is: 2sep

This code is valid for TWO 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.

• 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
• Infectious diseases should be involved as soon as possible with all hospital acquired sepsis cases as a wide range of organisms could be causing the infection which may not be covered by the above regimen
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Risk factors for MRSA infection include: residence in a gaol or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

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 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
• 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 severe sepsis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Severe sepsis treatment in neonate:

Code for gentamicin and vancomycin is: 2sep

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 the patient only has a single IV line it is important to give gentamicin then benzylpenicillin before vancomycin as they have the shortest infusion time
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Risk factors for MRSA infection include: residence in a gaol or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

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)

References:

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

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

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 the patient tolerates penicillin but not gentamicin, prior to release of culture results treat empirically with:

Code for piperacillin+tazobactam is: 2sep

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.

• As with all intra-abdominal infections, IV therapy can be rapidly switched to oral therapy if patient is improving (generally within the first 48 hours after intiating IV therapy)
• Empirical antifungal therapy is not normally required, however consider antifungal therapy if yeasts are uncovered from deep surgical site samples
• When available, the results of susceptibility testing should always guide treatment
• Peritonitis is usually a polymicrobial infection with aerobic and anaerobic bowel flora. Peritonitis from a perforated viscus normally requires surgery
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

References:

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

If the patient tolerates penicillin cover with:

Code for gentamicin is: 2sep

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.

• If further IV treatment is required after 72 hours of empirical treatment with gentamicin, change patient to piperacillin and tazobactam 4/0.5g (100 mg/kg piperacillin for child) 8-hourly until clinically improved as for patients not tolerant of gentamicin
• As with all intra-abdominal infections, IV therapy can be rapidly switched to oral therapy if patient is improving (generally within the first 48 hours after intiating IV therapy)
• Empirical antifungal therapy is not normally required, however consider antifungal therapy if yeasts are uncovered from deep surgical site samples
• When available, the results of susceptibility testing should always guide treatment
• Peritonitis is usually a polymicrobial infection with aerobic and anaerobic bowel flora. Peritonitis from a perforated viscus normally requires surgery
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

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 peritonitis due to perforated viscus - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

Sepsis treatment from biliary source:

Code for IV clindamycin and gentamicin is: 2sep

This code is valid for TWO 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.

• If further IV treatment is required after 72 hours of empirical treatment contact infectious diseases
• As with all intra-abdominal infections, IV therapy can be rapidly switched to oral therapy if patient is improving (generally within the first 48 hours after intiating IV therapy)
• Empirical antifungal therapy is not normally required, however consider antifungal therapy if yeasts are uncovered from deep surgical site samples
• When available, the results of susceptibility testing should always guide treatment
• Peritonitis is usually a polymicrobial infection with aerobic and anaerobic bowel flora. Peritonitis from a perforated viscus normally requires surgery
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

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
• Use the Cockcroft gault calculator to calculate renal function for adults if using the nomogram, or use the adult aminoglycoside dose calculator

• Please contact infectious diseases within 48 hours of initiating therapy with vancomycin
• 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 sepsis - Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2019.

If gentamicin is contraindicated:

• When available, the results of susceptibility testing should always guide treatment
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Consider addition of an echinocandin for yeast cover if sepsis is sourced from TPN, an intra-abdominal infection or patient requires ICU admission. Contact infectious diseases for advice as soon as possible (as with all sepsis cases)

Sepsis treatment from bone source with no penicillin allergy:

Code for gentamicin and vancomycin is: 2sep

This code is valid for TWO 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.

• 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
• 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.
• If patient is not normotensive after administration of > 3L of fluid, move the patient to the resuscitation room ASAP if in ED, inform the supervising medical officer (senior emergency doctor or registrar/consultant if on a ward), refer for urgent ICU assessment. Please see the severe sepsis treatment notes in the Therapeutic Guidelines for more details
• Risk factors for MRSA infection include: residence in a gaol or detention centre, indigenous heritage, previous MRSA colonisation and line associated infection
• Please contact infectious diseases within 24 hours to rationalise antibiotics once blood culture results return

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 Gentamicin/Tobramycin Dosing (age > 12 years)