Greater Glasgow and Clyde Medicines

Infection Management Guideline Changes Jan 2021

Updated GGC Infection Management Guideline (IMG) and Intravenous Oral Switch Therapy (IVOST) Guideline for adults January 2021

Updates to the GGC Infection Management Guideline (IMG) and IVOST guideline (on StaffNet) reflect a review of evidence including:

  • increasing resistance in Gram negative organisms to co-amoxiclav and temocillin
  • the support of oral (over intravenous) therapy and shorter course (5 day) treatment particularly in lower respiratory tract infections
  • promotion of patient centered care by informing the patient and recording on the Kardex the indication and planned duration of treatment

Please review the updated IMG and IVOST guidance for detailed recommendations. The main changes include:

  1. Temocillin removed from routine guidance: Following concerns of increasing resistance patterns and expenditure, temocillin is now a “protected” antibiotic for use only on recommendation by microbiology or an infection disease physician. Advice on alternatives to gentamicin in reduced renal function is included in the IMG and information on what to prescribe after 4 days of gentamicin is now available (see separate guidance on StaffNet here).

     

  2. Co-trimoxazole (IV or oral) included more widely: Indicated in the updated IMG for “uncertain lower respiratory tract infection (LRTI)/ urinary tract infection (UTI)”, hospital acquired pneumonia (HAP), spontaneous bacterial peritonitis (SBP) and mild skin/soft tissue infection (SSTI) in patients with true penicillin/beta-lactam allergy. In the IVOST guidance, co-trimoxazole is first line for
    • urinary sepsis / pyelonephritis
    • HAP
    • SBP (if not receiving co-trimoxazole as prophylaxis)
    Note: Microbiology reports may not include co-trimoxazole sensitivities however trimethoprim sensitive organisms are co-trimoxazole sensitive. Click here for further information on co-trimoxazole prescribing, administration and monitoring.

     

  3. Metronidazole: No longer recommended in combination with amoxicillin in aspiration pneumonia (amoxicillin is effective against oral/upper gastrointestinal anaerobes). For other metronidazole indications the oral route is preferred unless sepsis or oral route compromised (80-100% oral bioavailability).

     

  4. Gentamicin: Remains first choice for up to a maximum of 4 days when severe infection with Gram negative organisms is suspected:
    • as monotherapy in urinary sepsis
    • with amoxicillin in undifferentiated sepsis
    • with amoxicillin and metronidazole in intra-abdominal sepsis.

Review all IV antibiotics daily and record a review date.

(Note, if viewing table on a mobile device, switch to landscape)

Indication Change to guidance Note
All Temocillin no longer routinely recommended Increasing resistance and expenditure
Where metronidazole is stated Oral route preferred.
Use IV if oral route compromised or sepsis
80-100% bioavailability
Uncertain LRTI/UTI (non-severe) Oral co-trimoxazole added as possible monotherapy 1st line agent. Treatment with separate agents for UTI and LRTI removed.
Non-severe HAP Oral co-trimoxazole added as possible 1st line agent Change in 1st line agent
Severe HAP IV co-trimoxazole
(or if allergy to co-trimoxazole: IV co-amoxiclav 1.2g 8 hourly)
+ IV gentamicin
Duration 5 days (total IV/oral)
Change in 1st line agent and reduction in duration
Aspiration pneumonia Metronidazole not recommended in combination with amoxicillin Change in 1st line agent
Mild soft tissue infection Oral co-trimoxazole added as option for patients with true penicillin/beta-lactam allergy Change in 2nd line agent
Moderate/Severe cellulitis

If rapidly progressing add:
IV clindamycin 600mg 6 hourly


Duration changed from 7 days to 7-10 days (IV/oral)

Additional information
Necrotising Fasciitis

IV clindamycin increased to 1.2g 6 hourly


IV flucloxacillin 2g reduced to 6 hourly

Dose adjustments
Non-severe Clostridium difficile (CDI) infection Do NOT use metronidazole suspension. 

Increased awareness rather than change. See CDI guidelines (on StaffNet).

Metronidazole suspension contains the pro-drug metronidazole benzoate that requires activation via gastric enzymes. In diarrhoea there is a risk of reduced exposure to gastric enzymes and thus reduced efficacy. The full GGC CDI guidelines contain information on how to treat patients who are unable to swallow tablets/capsules and those with enteral feeding tubes.

Intra-abdominal sepsis If eGFR < 20 ml/min/1.73m2
IV piperacillin/tazobactam 4.5g 12 hourly
Additional information
Spontaneous Bacterial Peritonitis

If not receiving co-trimoxazole prophylaxis:
IV/oral co-trimoxazole


If receiving co-trimoxazole prophylaxis:
IV co-amoxiclav or (if true penicillin/beta lactam allergy)

oral/IV ciprofloxacin + IV vancomycin

Change in 1st line agent
Decompensated Chronic Liver Disease with sepsis of unknown source

IV piperacillin/tazobactam 4.5g 8 hourly


or if true penicillin/beta-lactam allergy
Oral /IV ciprofloxacin 500mg/400mg 12 hourly
+ IV vancomycin


Duration 7 days (IV/oral)

New Section
Suspected prostatitis Oral ciprofloxacin/trimethoprim
Duration 14 days
Duration reduction
Diabetic foot infection Only add IV gentamicin if the patient has sepsis Additional information
Sepsis – Source unknown IV amoxicillin dose reduced to 1g 8 hourly Dose reduction
Native valve endocarditis

IV flucloxacillin dose weight based

2g 6 hourly if < 85kg

2g 4 hourly if ≥ 85kg

Additional information
Neutropenic Sepsis - Standard risk

Removed ceftazidime and aztreonam options.

IV vancomycin added if MRSA or line infection.

Full guideline available on StaffNet
Neutropenic Sepsis - High Risk Changes as above plus: IV ciprofloxacin (if true penicillin/beta lactam allergy) dose changed from 12 to 8 hourly Full guideline available on StaffNet
Neutropenic Sepsis - Critical Risk

 

Removed from IMG poster. Please refer to full guideline.

Full guideline available on StaffNet

 

Published 11/01/2021. Medicines Update blogs are correct at the time of publication.