Infection Management Guideline Changes Jan 2021
Updated GGC Infection Management Guideline (IMG) and Intravenous Oral Switch Therapy (IVOST) Guideline for adults January 2021
- 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
- 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).
- 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
- SBP (if not receiving co-trimoxazole as prophylaxis)
- 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).
- 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
|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|
If rapidly progressing add:
IV clindamycin increased to 1.2g 6 hourly
|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
|Spontaneous Bacterial Peritonitis||
If not receiving co-trimoxazole prophylaxis:
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
|Suspected prostatitis||Oral ciprofloxacin/trimethoprim
Duration 14 days
|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
|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.