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Antimicrobial Guidelines
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Bone and Joint
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Acute Osteomyelitis and Septic Arthritis
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- Take diagnostic samples before starting antimicrobials unless the patient has severe sepsis or acute neurological deficits.
- Follow empiric guidelines for non-vertebral osteomyelitis, and consult Infections Diseases (ID) for vertebral disease.
- Consult ID for treatment duration and follow-on oral agents, if appropriate (oral agents no longer specified).
- For patients on flucloxacillin or cefazolin, add vancomycin for cover against methicillin-resistant S. aureus (MRSA) if risk factors exist:
- known recent MRSA-positive,
- household contact with known recent MRSA-positive,
- recent admission to any overseas healthcare facility,
- residence overseas.
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Cardiovascular System
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Bacterial Endocarditis Treatment
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- Native valve: benzylpenicillin empiric dose increased to IV 2.4 g 4-hourly to cover more resistant streptococci.
- Prosthetic valves, implantable cardiac devices, hospital-acquired: empiric regimen now includes flucloxacillin with vancomycin and gentamicin for better activity against staphylococci.
- All regimens involve high-doses of renally-cleared agents. Consider dose reduction in renal impairment.
- Consult with ID for treatment duration (2–6 weeks depending on organism and type of valve in situ), and tailoring of treatment against susceptibilities.
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Central Nervous System
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Meningitis - Adults
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- Treatment duration is now specified for various pathogens.
- Clinical risk factors for resistant S. pneumoniae (requiring addition of vancomycin to empiric treatment), e.g. known or suspected otitis media or sinusitis, are now emphasised.
- For severe penicillin allergy, moxifloxacin IV is now first-line. Ciprofloxacin plus vancomycin [± trimethoprim+sulfamethoxazole for listeria] (all IV) is second-line and may be given if delays are anticipated with moxifloxacin access.
- Ceftriaxone dose for N. meningitidis in patients with mild penicillin allergy has been increased to IV 2 g 12-hourly.
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Ear, Nose, and Throat
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Acute Epiglottitis and Deep Neck Space Infections
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- For acute epiglottis, anaerobic cover is not needed unless other structures involved (refer deep neck space guideline).
- Only IV treatment options given (oral follow-ons removed).
- Empiric treatment in severe penicillin allergy has changed to ciprofloxacin IV plus vancomycin IV (was clindamycin IV) for acute epiglottis, with metronidazole IV added for deep neck space infections.
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Tonsillopharyngitis (was 'pharyngitis')
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- Cefalexin added as an option for mild penicillin allergy.
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Chronic Rhinosinusitis (was 'chronic sinusitis')
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- Content updated to reflect inflammatory aetiology.
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MRSA
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Decolonisation protocol
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- Octenidine 0.3% wash has replaced triclosan as an alternative to chlorhexidine 4% solution in cases of intolerance or sensitive skin.
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Surgical prophylaxis
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- Add vancomycin to standard antimicrobials for surgical prophylaxis if patient is MRSA colonised, or has prior MRSA colonisation and their current status is unknown.
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MRSA Bacteraemia
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- Duration of treatment should be at least 2 weeks of IV antimicrobials, and ID should be consulted in all cases.
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Skin and Soft Tissue
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Infected Bite Wounds (Animal and Human) (was 'Bites – human and animal')
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- For mild infections in patients with mild penicillin allergy, use oral metronidazole (was clindamycin) and either trimethoprim+sulfamethoxazole or doxycycline.
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Cellulitis - Simple and Erysipelas
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- Advice to consider referral for home IV antimicrobials now removed as oral dosing strategies can often be deployed.
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Infected Ulcers (e.g. diabetic, vascular, pressure) (was 'Cellulitis – complicated/ulcers')
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- Initial text altered to indicate that antimicrobials should only be used if clear signs of infection.
- For mild or moderate infections in patients with severe penicillin allergy, treatment is now with ciprofloxacin PO (was gentamicin IV) and clindamycin PO.
- For severe infections, empiric treatment is with piperacillin+tazobactam, meropenem in mild penicillin allergy, and ID consultation for severe allergy.
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Necrotising Soft Tissue Infections
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- Empiric treatment now divided into limb (flucloxacillin and clindamycin) and abdominal/peritoneal (piperacillin+tazobactam and clindamycin) infections.
- Clindamycin dose is reduced to IV 600 mg 8-hourly, and flucloxacillin IV increased to IV 2 g 4-hourly.
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Varicella Zoster
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Now divided into uncomplicated and complicated disease, with definitions for complicated disease (e.g. severely immunocompromised, ophthalmic involvement) given.
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Universal changes (throughout guidelines)
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- Clindamycin IV and PO dosing is now three times daily.
- Clindamycin is > 90% orally available so IV dosing is not routinely recommended for milder infections e.g. cellulitis.
- PHARMAC restrictions are now accessed via the buttons under drug listing ( not as separate bullet points).
- Costings no longer listed for recommended dosing regimen.
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