General changes

Introduction

• Updated.

Style

• Route of administrations abbreviations changed to uppercase.

Pharmacology Guidelines

Adverse Drug Reaction (ADR) Reporting Guidelines

• Updated.

Antimicrobial Guidelines

Download the Antimicrobial Stewardship Bulletin PDF for this release.

Universal change

• Cefuroxime tablets are not funded for most indications in the community. Liaise with hospital pharmacy for supply on discharge.

Sepsis (was called "Septicaemia")

• Empiric antimicrobial recommendations for sepsis without apparent source are now stratified by renal function (to guide gentamicin use) and penicillin allergy.
• Do not add metronidazole for suspected intra-abdominal source to regimens that contain amoxicillin+clavulanic acid, piperacillin+tazobactam or meropenem, as the beta-lactams have sufficient anaerobic cover.
• Gentamicin dose is now IV 7 mg/kg ideal body weight (rounded down to the nearest half vial i.e., 40 mg) for patients with an eGFR ≥ 20 mL/min. This aims to optimise peak concentrations for maximal bacterial kill. Give only one dose empirically, with susceptibility results guiding subsequent antimicrobial choices. If further doses are being considered, discuss antimicrobial choice with ID/Micro and seek advice on dosing/monitoring from your ward pharmacist.

Respiratory

Hospital-acquired Pneumonia (HAP)

• Empiric antimicrobial therapy is based on HAP severity and risk factors (now defined in the guideline) for multidrug-resistant gram-negative bacilli (MDR-GNB).
• HAP is severe if there is at least one of: rapid progression of infiltrates, severe sepsis/septic shock or need for intubation.

Aspiration Pneumonia

• Empiric recommendations are now divided into hospital-acquired and community-acquired aspiration pneumonia. Mild to moderate disease may not require antimicrobials.

Influenza

• Give patients who have started oseltamivir in hospital the rest of their course to take home (it is not funded in the community).

Infective Exacerbation of COPD

• Antimicrobial use only to be considered for infective exacerbations, defined as increase in sputum purulence together with increase in sputum volume and/or dyspnoea.

Urinary Tract Infections

• Risk factors for MDR-GNB are now given with guidance for empiric treatment.
• High local resistance of Escherichia coli to trimethoprim (~24%) has resulted in changes to the following two empiric guidelines:

Uncomplicated Acute Lower Urinary Tract Infections

• Recommended empiric treatment is (in order of preference) nitrofurantoin, cefalexin, or trimethoprim.
• ESBL-producing E. coli are usually susceptible to nitrofurantoin. Fosfomycin or pivmecillinam are alternatives if susceptibility is proven and usual oral agents are not suitable (liaise with hospital pharmacy for supply on discharge).

Acute Pyelonephritis or Complicated Urinary Tract Infection

• Recommended empiric treatment for non-pregnant patients without renal failure is now gentamicin IV 5 mg/kg ideal body weight then (in order of preference) oral amoxicillin+clavulanic acid, cefalexin, or ciprofloxacin. Adjust treatment, if required, when susceptibilities are available.
• Trimethoprim may be used after IV antimicrobial therapy if susceptibility is proven.
• Treatment duration is usually 10 days with a beta-lactam-based regimen, or 7 days with a ciprofloxacin-based regimen. Longer courses may be considered for patients slow to respond.
• Cystitis in men is "complicated" and should be treated as for non-pregnant women with cystitis but for a longer 7 day course.