In this section you will find resources for health professionals about empiric antimicrobial treatment, antimicrobial resistance and Auckland DHB's Antimicrobial Stewardship (AMS) programme.
Resources
Antimicrobial Stewardship Committee
Community Antibiotics Guidance (BPAC) (for adults and children)
SCRIPT App - Antibiotic Treatment Guidelines Available from the App Store and Google Play
| Adults | Paediatrics |
Vancomycin(Auckland DHB intranet only) | |
Cefuroxime, and meropenem dosing guides | |
The antimicrobials highlighted in yellow in the above restricted lists may be exempted pre-approval if one of the relevant listed criteria is met:
- When indicated on the list, a
Aspecial authority number exists for community prescription - Prescription is for an approved indication
- Prescription is by an approved prescriber
There are no exemptions for antimicrobials highlighted in red in the above adult and paediatrics restricted lists.
When pre-approval is required, this will be issued after telephone consultation with a member of the infectious diseases or microbiology teams. These services provide a 24-hour on call service for approvals and clinical advice. Restricted antimicrobials may only be dispensed or administered if the medication chart is completed correctly. All prescriptions should be clearly annotated with:
- the indication (e.g. “CAP”) and
- the planned duration (e.g. “x3/7”) and
- name of approver (e.g. App’d Dr Handy) or
- relevant exemption (e.g. “CHEM/123456789/July 2016 or “TB SMO, Dr Nisbet”).
Should the approved agent be required after hours, supplies can be obtained through the usual routes.
Adult Empirical Antimicrobial Treatment Guidelines
Sepsis | CNS | OPHTHALMOLOGY | EAR, NOSE AND THROAT |
RESPIRATORY TRACT | CARDIOTHORACIC | SKIN AND SOFT TISSUE | BONE AND JOINT |
GASTROINTESTINAL TRACT | GENITO-URINARY TRACT |
Note the following colour-coded key for the table below:
- Red Penicillin-based
- Yellow Suitable for penicillin rash allergy
- Green Not penicillin based
- Purple Requires pre-approval
Sepsis
Neutropenic sepsis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
Haematology | piperacillin-tazobactam 4.5g IV q6h | Oral therapy not appropriate As above | A minimum of 72 hours to a maximum of 14 days | See full guidelines for advice |
Oncology | cefuroxime 1.5g IV q8h | As above | As above | As above |
Patients colonised with MROs Consult ID | ||||
Community onset sepsis – unknown source. Need to assess MRO risk, travel history, recent inpatient stays, source.
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
Normal host
| flucloxacillin 2g IV q6h | Oral therapy not appropriate | Review at 48 hours. |
|
Compromised host
| amoxicillin-clavulanate 1.2g IV q8h | As above | As above | |
Respiratory tract
Community acquired pneumonia
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment (for all CURB scores) | ||
CURB-65
| Oral treatment only | amoxicillin 500mg po TDS
| 5-7 days in total
| S.pneumoniae or S.aureus (penicillin S) | |
S. aureus (penicillin R) | |||||
CURB65
| Oral treatment only | amoxicillin 500mg po TDS
| 5-7 days in total | S. aureus (methicillin R) | |
H. influenzae (amoxicillin S) | |||||
H. influenzae (amoxicillin R) | |||||
CURB65
| amoxicillin + clavulanic acid 1.2g IV q8h OR, if anaphylaxis with penicillins/cephalosporins: |
| 5-7 days in total | M. pneumoniae or Chlamydophila spp. | |
Legionellaspp. | |||||
Aspiration pneumonia – many are not infective and represent chemical pneumonitis.
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
amoxicillin + clavulanic acid 1.2g IV q8h | amoxicillin + clavulanic acid 625mg po TDS | 5 days |
|
Hospital acquired pneumonia
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
Low Risk | amoxicillin + clavulanic acid 1.2g IV q8h | amoxicillin + clavulanic acid 625mg po TDS | 7 days | |
High Risk | piperacillin-tazobactamID 4.5g IV q8h | amoxicillin + clavulanic acid 625mg po TDS | 7 days |
|
Acute exacerbation of COPD or chronic bronchitis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
IV treatment unnecessary | amoxicillin 500mg po TDS | 5 days | S.pneumoniae M.catarrhalis H.influenzae | |
Acute bronchitis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
No antibiotics required | |||
Influenza
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
No IV treatment available | See end | 5 days | Treatment is an option in critically ill or immunocompromised patients. |
Ear, nose & throat
Sinusitis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
| Uncomplicated: Most patients with sinusitis will not have a bacterial infection. Even for those that do, antibiotics only offer a marginal benefit and symptoms will resolve in most patients in 14 days, without antibiotics. | Consider antibiotics for patients with severe sinusitis symptoms (e.g. purulent nasal discharge, nasal congestion and/or facial pain or pressure) for more than 14 days plus any of the following features: fever, unilateral maxillary sinus tenderness, severe headache, symptoms worsening after initial improvement. amoxicillin 500mg po TDS | 7 days | |
Complicated: | No improvement on amoxicillin then amoxicillin + clavulanic acid 625mg po TDS | 7 days | Pathogens often not identified. |
Otitis media
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
IV treatment is unnecessary | Oral treatment is also usually unnecessary amoxicillin 500mg po TDS or cotrimoxazole 960mg po BD if severe or bilateral disease | 5 days | Pathogens often not identified |
Pharyngitis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
IV treatment is unnecessary | No antibiotics necessary unless at risk of rheumatic fever - Past history of Rh fever Throat swab to guide treatment. penicillinVK 500mg po BD | 10 days | Group A Strep Amoxicillin is avoided due to rash in EBV co-infected patients Other pathogens do not require treatment
| |
Epiglottitis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
amoxicillin-clavulanate 1.2g IV q8h | amoxicillin + clavulanic acid 625mg po TDS | 5 days | H.influenzae |
Tonsillitis (including quinsy and deep neck space infections)
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
benzylpenicillin 1.2g IV q6h± metronidazole 400mg po TDS (equivalent to IV) | penicillinVK 500mg po QDS | 10 days | Group A Strep/ S.milleri group: |
Ophthalmology
Blepharitis
Empiric IV treatment | Empiric treatment | Duration of therapy | Pathogen directed treatment |
IV Treatment is unnecessary | Use of non-pharmaceutical intervention is most helpful including warm compress and cleansing of the eyelid margins chloramphenicol 1% eye ointment topically BD | 5 days | Pathogens often not identified. |
Conjunctivitis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
IV Treatment is unnecessary | Can be viral, bacterial or allergic. Bacterial infection is usually associated with mucopurulent discharge. Most bacterial conjunctivitis is self-limiting and the majority of people improve without treatment, in two to five days. chloramphenicol 0.5% eye drops 1 drop every 4 hours | 7 days | Chlamydia: azithromycin 1g po single dose Viral/allergic: No antibiotic
| |
CNS
Meningitis – phone ID for consult advice if bacterial meningitis or post-neurosurgical meningitis.
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
Treatment should be initiated after blood cultures are taken, and after consultation with infectious diseases dexamethasone* 10mg IV q6h for 4 days *starting before or with the first dose of antimicrobial | Oral therapy not appropriate | Pathogen specific | N.meningitidis H.influenzae S.pneumoniae Listeria | |
Encephalitis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
aciclovir ID 10mg/kg IV q8h | Oral therapy not appropriate | 14 – 21 days | HSV: aciclovirID 10mg/kg IV q8h |
Brain abscess
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
Treatment should be initiated after blood cultures are taken, and after consultation with infectious diseases Unknown source/mastoiditis: Secondary to trauma/neurosurg: | Oral therapy not appropriate (except metronidazole) | 28 days | P.acnes benzylpenicillin S.aureus flucloxacillin S.milleri group benzylpenicillin Anaerobes metronidazole | |
Cardiothoracic
Endocarditis (native valve)
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
Treatment should be initiated after blood cultures are taken, and after consultation with cardiology and infectious diseases * benzylpenicillin 1.2g IV q4h | Oral treatment is inappropriate | As per organism below Advice will be provided from infectious diseases about ongoing therapy | S.aureus (MSSA) S.aureus (MRSA) vancomycin IV as per Vanculator 4 weeks Viridans strep : Enteroccci | |
Skin & soft tissue
Cellulitis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
flucloxacillin 1g IV q6h | flucloxacillin 500mg po QDS | 5 days | MSSA Beta-haemolytic strep MRSA | |
Diabetic foot infection – may need referral if recurrent or fails to settle to exclude underlying osteomyelitis. Evaluate PVD.
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | ||
Mild or early
| flucloxacillin 2g IV q6h | flucloxacillin 500mg po QDS | 14 days | MSSA | flucloxacillin 500mg po QDS |
Beta-haemolytic Strep | penicillinVK 500mg po QDS | ||||
Severe or refractory | amoxicillin + clavulanic acid 1.2g IV q8h or cefuroxime 750mg IV q6h | amoxicillin + clavulanic acid 625mg po TDS | 14 days | MRSA | cotrimoxazole 960mg po BD |
Gram negatives | As per culture results | ||||
Mastitis/breast abscess
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
Conservative management of mastitis to alleviate symptoms and ensure on going breast emptying may be all that is required for treatment. flucloxacillin 1g IV q6h | flucloxacillin 500mg po QDS
| 5 days | MSSA Beta-haemolytic Strep Gram negatives | |
Impetigo
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
IV therapy unnecessary | Less than 3 lesions: Extensive disease: | 5 days | MRSA – cotrimoxazole 960mg po BD |
Boils
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
IV therapy unnecessary | Most lesions may be treated with incision and drainage alone. Antibiotics may be considered if there is fever, surrounding cellulitis or co-morbidity, e.g. diabetes, or if the lesion is in a site associated with complications, e.g. face. flucloxacillin 500mg po QDS | 5 days | MRSA – cotrimoxazole 960mg po BD |
Bites – human & animal
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
IV therapy unnecessary | Clean and debride wound thoroughly and assess the need for tetanus immunisation. amoxicillin + clavulanic acid 625mg po TDS | 7 days | Usually polymicrobial |
Bone & joint
Osteomyelitis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
flucloxacillin 2g IV q6h | Oral therapy not appropriate | 6 weeks – Consult ID | MRSA: vancomycin IV as per vanculator® |
Septic arthritis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
flucloxacillin 2g IV q6h | flucloxacillin 500mg po QDS | 3 weeks with an early oral switch (e.g. 7-10 days) Extend to 4 weeks if S.aureus or slow to settle. | MRSA vancomycin IV as per vanculator® MSSA flucloxacillin Group A strep benzylpenicillin | |
Compound fractures (prophylaxis)
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
amoxicillin + clavulanic acid 1.2g IV q8h | Oral therapy not appropriate | Until surgery or 72 hours, whichever is sooner | Prophylactic polymicrobial cover |
Gastrointestinal tract
Peritonitis, severe diverticulitis, intra-abdominal abscesses
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
amoxicillin 1g IV q6h or cefuroxime 750mg IV q6h | amoxicillin + clavulanic acid 625mg po TDS | 5 days unless undrained | S.milleri penicillin VK Enterococci amoxicillin (+ clavulanic acid) Gram negatives as per culture | |
Biliary tree infections (cholangitis or cholecystitis)
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
amoxicillin 1g IV q6h or cefuroxime 750mg IV q6h | amoxicillin + clavulanic acid 625mg po TDS | 5 days | S.milleri penicillin VK Enterococci amoxicillin (+ clavulanic acid) Gram negatives as per culture | |
Gastroenteritis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
IV Treatment is unnecessary | See for pathogens
| Campylobacter | Most people will recover with symptomatic treatment only. Antibiotics have little impact on the duration and severity of symptoms but eradicate stool carriage. Treatment is indicated for severe or prolonged infection, for pregnant women nearing term and for people who are immunocompromised. Treatment may also be appropriate for food handlers, childcare workers and those caring for immunocompromised patients. erythromycin 400mg po QDS for 5 days | |
Clostridum difficile | metronidazole 400mg po TDS for 10 days | |||
Giardia | Metronidazole 2g po daily for 3 days | |||
Oral/mucocutaneous candidiasis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
IV treatment is unnecessary | Immunocompetent | Nystatin topical q2-3h | 7 days |
|
Immunocompromised
| As above. If no response consider fluconazole ID 800mg as a single dose. | |||
H.pylori eradication
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
IV treatment is unnecessary | amoxicillin 1g po BD ( or metronidazole 400mg po BD) | 7 days | If treatment failure on standard regimens: |
Genito-urinary tract
Cystitis (lower UTI)
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | |
IV treatment is unnecessary | nitrofurantoin 100mg po QDS | 5 days | MSSA flucloxacillin 500mg po QDS Group B Strep penicillin VK 500mg po QDS Gram negative as per culture but refer trimethoprim 300mg po aily and nitrofurantoin over beta-lactams. ESBL fosfomycinID 3g po single dose | |
Pyelonephritis (severe upper UTI)
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment | ||
Uncomplicated
| gentamicin 5mg/kg IV q24h | trimethoprim 300mg po daily
| 10 days | MSSA flucloxacillin 500mg po QDS | |
Group B strep penicillinVK 500mg po QDS | |||||
Complicated
| gentamicin 5mg/kg IV q24h | 10 days | Gram negatives as per culture but prefer trimethoprim over beta-lactams. | ||
ESBL fosfomycinID 3g po q72h (2 doses) | |||||
PID/endometritis/cervicitis
Empiric IV treatment | Empiric po treatment | Duration of therapy | Pathogen directed treatment |
ceftriaxone 1g IV single dose | 14 days | - | |
Antimicrobial Stewardship Committee
Auckland DHB has a multi-disciplinary committee that ensures a rational, appropriate and cost effective approach to the use of antimicrobials. The committee meets every two months and the minutes will be posted here following ratification at the subsequent meeting. Any questions regarding the committee or antimicrobial use at Auckland DHB please contact either the chair or secretary.
Current committee members:
| Rupert Handy (chair) | Service Clinical Director Adult Infectious Diseases |
| Eamon Duffy (sec) | Lead Antimicrobial Stewardship pharmacist |
| Catherine Jackson | Public Health physician |
| Emma Best | Infectious Diseases paediatrican |
| Joshua Freeman | Clinical Microbiologist |
| Lesley Voss | Clinical Lead Paediatric Infectious Disease |
| Margaret Johnston | Nurse Specialist Liver Transplant |
| Nigel Patton | Haematologist |
| Sally Roberts | Clinical Lead Clinical Microbiology |
| Stephen Ritchie | Infectious disease physician |
| Stephen Streat | Intensivist and Clinical Director Organ Donation New Zealand |
| - | Antimicrobial Stewardship pharmacist |
| - | Surgical representative |
| Advanced trainees in infectious diseases or microbiology also attend |
Minutes and Terms of Reference (Please note that due to sensitive information and particular cases discussed, these are internal access only.)
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2013 |
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2014 | ||||||
2015 |
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2016 | October | December |