Sassoon General Hospital & BJGMC, Pune
ANTIBIOTIC POLICY
Sassoon Hospital
&
BJGMC
Pune
2014-15
FOREWORD
It gives me immense pleasure to present this handbook on Antimicrobial Policy for Sassoon Hospital, Pune. I sincerely appreciate the efforts of team who have worked to make this policy a reality.
It is less than a century since antibiotic therapy became available to humanity. However, widespread and indiscriminate use of antibiotics has resulted in microorganisms developing resistance to them, so much so, that now the antibiotic resistance has reached alarming proportion. This antibiotic policy will ensure rational use of antibiotics in Sassoon Hospital and help us contribute to minimizing the menace of antibiotic resistance.
Dr A.S. Chandanwale
Dean
B.J. Govt. Medical College &
Sassoon Hospital, Pune
Index
Foreword 3
Introduction 5
General Guidelines 6
MEDICINE 7-9
SURGERY 10-15
PEDIATRICS 16-17
ENT 18
NEONATAL INFECTIONS 19-20
OBST. & GYNAEC. 21-22
ORTHOPEDICS 23-24
DERMATOLOGY 25-26
CVTS 27
OPHTHALMOLOGY 28-30
Contributors 31
Steps of Hand-washing 32
INTRODUCTION
The emergence and spread of antibiotic resistance is becoming a global public health concern. The widespread use of antibiotics both inside and outside of medicine has contributed largely to this phenomenon. The large volume of antibiotics prescribed in health care settings is a major cause of concern and bacteria once exposed to antibiotics have the capacity to adapt and develop resistance by various mechanisms. All newly introduced antimicrobial agents have only a limited ‘virginity’ before the specter of resistance emerges. The current situation is that there are very few newer antibiotics in the pipeline as it is no longer cost effective for the pharmaceutical industry to develop newer antimicrobials.
Antimicrobial resistance in hospitals hampers the control of infectious diseases and threatens a return to the pre-antibiotic era. It also increases the costs of health care and jeopardizes health-care gains to society
Thus, this antibiotic policy was developed by the staff of B.J. Government Medical College & Sassoon general Hospitals, Pune as an effort to rationalize the use of antibiotics in the hospital keeping in mind the current sensitivity patterns of hospital bacteria and availability in our drug store. It is planned that the policy will be renewed regularly based on the feedback of the clinicians, the availability of drugs in the hospital and the drug sensitivity pattern of the hospital pathogens. I would like to reiterate that these are guidelines only and the interpretation and application of these guidelines is the responsibility of the clinician. A review of the current guidelines will be planned based on the experiences of the clinicians and the problems faced by them.
Formulation & implementation of an antibiotic policy is a first step in implementing the rationale use of antibiotics. It is also a step towards controlling the spread of antimicrobial resistance in our hospital. However it cannot be a short cut to appropriate infection control practices especially hand washing.
An antibiotic policy can only succeed if there is willingness and ownership of every single doctor in the hospital. Please ensure that samples for culture and sensitivity are sent before onset of therapy, so that data regarding antimicrobial spectrum of pathogens from various sites stays updated and is available to you so you can plan therapy better
GENERAL GUIDELINES
1. Clinical samples for microbiologic culture and sensitivity must ALWAYS be sent, before starting empiric therapy.
2. Empiric treatment can be started as per policy guidelines and clinical judgment
3. Step down or step up of treatment can be done based on the antibiotic sensitivity report. In case of no clinical response, consult microbiologist and pharmacologist.
4. Various factors associated with drug metabolism must be taken into account while prescribing treatment
· Hypersensitivity(Patient MUST be questioned about drug allergies in past)
· Renal function
· Drug interactions
5. Irrational drug combinations must be avoided.
6. Colistin, Carbapenems and linezolid are reserve drugs only and should be prescribed only after culture sensitivity report demonstrating sensitivity exclusively to these drugs.
7. Therapy monitoring: Need of antibiotic must be reviewed on daily basis. Most common infections usually need antibiotics for not more than 7 days. IV antibiotics should be switched to oral within 24-48 hours, based on clinical improvement and microbiology antibiotic sensitivity pattern.
8. Antibiotics should not be used as a substitute for appropriate infection control procedures.
ANTIBIOTIC POLICY
MEDICINE DEPARTMENT
Clinical condition / Empirical therapy / RemarksCommunity acquired Pneumonia
Mild(Not hospitalized) / Oral Doxycycline100 mg 12 hourly X 7days /Oral Azithromycin 500 mg OD 3 days / Use oral drugs
Moderate(Hospitalised, Not in ICU) / Inj Levofloxacin
750 mg IV 6 hourly X 7-10days/
Oral Azithromycin 500 mg OD 3 days / Use injectables. Switch to oral as early as possible
Severe (ICU) / Levofloxacin 750 mg IV 6 hourly X 7-10 days
OR
Moxifloxacin 400 mg IV 24 hourly / -Use injectables. Switch to oral as early as possible
Hospital Acquired Pneumonia / Amikacin15mg/kg 6 hourly +IIIrd generation cephalosporins Cefotaxime 1–2 g IV 8 hourly , Ceftriaxone 2 g IV qd) / -Escalate/descalte after culture sensitivity report
-Stop antibiotics after 5 days of clinical response
VAP / Vancomycin 15 mg/kg, up to 1 g IV, 12 hourly + Imipenem/Meropenem 500 mg IV 6 hourly or 1 g IV 8 hourly / -Escalate/deescalate after culture sensitivity report
-Stop antibiotics after 5 days of clinical response
Clinical condition / Empirical therapy / Remarks
Acute meningitis / Vancomycin 15 mg/kg IV 8hourly+ Ceftriaxone 2 gIV 12hourly/Cefotaxime 2 g IV 6hourlyfor 10-14 days+ Dexamethasone 0.15mg/kg X 4 days
Chronic meningitis / Culture is mandatory prior to starting therapy
Clinical condition / Empirical therapy
Gastroenteritis
Mild diarrhoea < 3 unformed stools with min symptoms / Ciprofloxacin 500 mg/ Norfloxacin 400mg orally 12 hourly) + Metronidazole 250 mg 8 hourly for 3 days
Moderate diarrhoea > 4 < 6 / Ciprofloxacin 500 mg/ Norfloxacin 400mg orally 12 hourly) for 3 -5 days + Metronidazole 250 mg 8 hourly for 5 days
Severe diarrhoea > 6 with > temp. tenesmus / Ciprofloxacin500 mg/ / Norfloxacin 400mg orally 12 hourly for 3 -5 days + Metronidazole 250 mg 8 hourly for 5 days
Cholera like watery diarrhoea / Doxycycline 300 mg orally x 1 day
Clostridium difficile associated diarrhoea / Oral Metronidazole 400 mg orally tds X 10-14 days OR
Oral Vancomycin (125mg 6 hourly ) X 10-14 days
Clinical condition / Empirical therapy / Remarks
Oesophagitis / Fluconazole 200 -400 mg daily/
Injection Amphotericin B / Use fluconazole only if candidial oesophagitis is suspected
Duodenal/gastric ulcer / Omeprazole(20 mg 12 hourly) + Clarithromycin(250 or 500 mg 12 hourly)+Metronidazole(500 mg 12 hourly) for 14 days
Clinical condition / Empirical therapy / Remarks
Blood stream infections
1) CRBSI / Vancomycin(15mg/kg IV 12 hourly)+ Third generation cephalosporins (Ceftazidime 2 gm IV 8 hourly,Cefoperazone) for 4-6 weeks
2) Native valve endocarditis / Vancomycin(15mg/kg IV 12 hourly) + Gentamicin( 1mg /kg IM or IV 8 hourly) for 4-6 week
3) Prosthetic valve endocarditis / Vancomycin (15mg/kg IV 12 hourly)+ Gentamicin( 1mg /kg IM or IV 8 hourly) for 4-6 weeks / Cardiothoracic surgery consultation
Clinical condition / Empirical therapy / Remarks
Urinary tract infection
Community acquired / Cotimoxazole DS 12 hourly for 3 days /Nitrofurantoin 100 mg orally 12 hourly for 5 days
Catheter associated / Gentamicin( 1mg /kg IM or IV 8 hourly)
+
Imipenem(500 mg IV 6 hourly) x 7-14 days
Pyelonephritis / Uncomplicated: Oral Ciprofloxacin 500 mg BD
Complicated: Piperacillin with Tazobactam 3.375 IV 6 hourly/ Imipenem 500 mg IV 6 hourly or 1 g IV 8 hourly
Clinical condition / Empirical therapy / Remarks
Fever of unknown origin(PUO) / Cefotaxime (2g IV every 4-6 hourly)
Clinical condition / Empirical therapy / Remarks
Diabetic foot Mild (No systemic symptoms, Localised cellulitis / 1. Cloxacillin 500 - 1000
mild (localized mg orally6 hourly × 7-10 days
2.Cefazolin 1 gm i.v. 8 hourly
symptoms) /Cephalexin 500 mg
orally6 hourly × 7-10 day
+ Metronidazole IV500 mg 8 hourly
Diabetic foot –moderate to severe (Limb threatening-severe cellulits/gangrene/SIRS) / Cefazolin 1 gm i.v. 8 hourly+ Gentamicin 5mg/kg i.v once daily
OR
Ciprofloxacin 400 mg IV 12 hourly+ Metronidazole IV500 mg 8 hourly / Surgery consultation if intervention needed
SURGERY DEPARTMENT
Ulcer without inflammation / No antibacterial therapy
Ulcer with<2 cm of sup inflamation / Oral Cotrimoxazole DS 12 hourly /Tetracycline 500 mg 12 hourly
Ulcer with > 2 cm of inflammation / · Oral Cotrimoxazole DS 12 hourly
· Gentamicin Gentamicin 5mg/kg i.v once daily / Piperacillin with Tazobactam 3.375 IV 6 hourly +Metronidazole IV500 mg 8 hourly
GIT
Cholecystitis / Ciprofloxacin 400 mg IV 12 hourly / Gentamicin 5mg/kg i.v once daily + Metronidazole IV 500 mg 8 hourly
If severe, Piperacillin with Tazobactam 3.375 IV 6 hourly /Imipenem 500 mg IV 6 hourly /Doripenem 500 mg 8 hourly /Meropenem 1 g IV 24 hourly + Metronidazole IV500 mg 8 hourly
Cholangitis / Same as above
Biliary sepsis / Same as above
Oesophagitis / Fluconazole 200 -400 mg daily or Amphotercin B 0.5 mg/kg daily)
Duodenal/Gastric ulcer / Omeprazole(20 mg 12 hourly) +Clarithromycin (250 or 500 mg 12 hourly)+Metronidazole(500 mg 12 hourly) for 14 days
Diverticulitis
Perirectal abscess
Peritonitis / OPD: MILD /DRAINED PERIRECTAL ABCESS: Cotimoxazole bid/Levo 750 mg 24hourly+ Metro 500 mg 6hourly: All orally FOR 7-10 DAYS
IPD:MILD –MODERATE: Piperacillin-Tazobactam 3.375.g IV 6hourly/4.5 g IV 8hourly/Ticarcillin-Clavulinic acid 3.1 g IV 6 hourly/Ertapenem 1 g IV 24 hourly/Moxi 400 mg IV 24 hourly
SEVERE LIFE THREATENING: Imipenem 500 mg IV 6 hourly/Meropenem 1 g IV 8 hourly/Doripenem 500 mg 8 hourly
UTI
Catheter associated / Mild: Nitrofurantoin 100 mg 12 hourly/Cotrimoxazole DS 12 hourly
Severe: Amikacin 15mg/kg 6 hourly /Gentamicin 5mg/kg i.v once daily / Ciprofloxacin 400 mg IV 12 hourly / IIIrd generation cephalosporin/ Piperacillin- Tazobactam 3.375 IV 6 hourly
Perinephric abscess / Vancomycin 15mg/kg IV 12 hourly + IIIrd generation cephalosporin/ Piperacillin with Tazobactam 3.375 IV 6 hourly
Start with Vancomycin 15mg/kg IV 12 hourly. Descalate to Cloxacillin 250 mg oral 6 hourly
Prostatitis / Cotrimoxazole DS 12 hourly / Ciprofloxacin IV: 400 mg IV every 12 hours
Oral: 500 mg oral 12 hourly / Ofloxacin 300 mg orally 12 hourly
Clinical condition / Empirical therapy / Remarks
Skin and soft tissue infections
Cellulitis / Oral regimens:
Cotimoxazole 1-2 DS tablets orally 12 hourly + Amoxycillin 500 mg orally 8 hourly
Doxycycline 100 mg orally 12 hourly
Parenteral regimens
Clindamycin 600 mg IV 8 hourly
If spreading, Vancomycin 15mg/kg IV 12 hourly.
Cutaneous abscess / Oral regimens:
Cotimoxazole 1-2 DS tablets orally 12 hourly + Cloxacillin 500 mg orally 6 hourly
Doxycycline 100 mg orally 12 hourly
Parenteral regimens
Clindamycin 600 mg IV 8 hourly
If spreading, Vancomycin 15mg/kg IV 12 hourly.
Diabetic foot with extensive inflammation and systemic toxicity / Vancomycin 15mg/kg IV 12 hourly. + Piperacillin with Tazobactam 3.375 IV 6 hourly + Metronidazole IV500 mg 8 hourly
Descalate
Clinical condition / Empirical therapy
SSI
For clean procedures(Orthopaedic joint replacements, open reduction of closed fractures, Vascular procedures, craniotomy, breast & hernia surgery) / Cloxacillin 1-2g IV 4 hourly
PCN allergy: Clindamycin 600 mg IV 8 hourly
For clean contaminated procedures(GI/GU procedures, oropharyngesl & OBGY ) / Piperacillin with Tazobactam 3.375 IV 6 hourly /Gentamicin 5mg/kg i.v once daily +Metronidazole IV500 mg 8 hourly
In deep fascia involvement / Clindamycin 600 mg IV 8 hourly +Metronidazole IV500 mg 8 hourly
Necrotising fascitis / Clindamycin 600 mg IV 8 hourly +Metronidazole IV500 mg 8 hourly
Clinical condition / Empirical therapy / Remarks
CNS
Brain abscess
Primary / Meropenem 1 g IV 8 hourly +Metronidazole IV500 mg 8 hourly
Postsurgical / Vancomycin 15mg/kg IV 12 hourly.+Meropenem 1 g IV 8 hourly +Metronidazole IV 500 mg 8 hourly/
Preop prophylaxis (Recommended)
Urologic surgeryTransrectal prostate biopsy / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV500 mg 8 hourly with or without Gentamicin 5mg/kg i.v once daily
Transurethral surgery(eg. TURP, TURBT, ureteroscopy, cystouretoscopy, lithotripsy) / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Nephrectomy or radial prostectomy / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Radial cystectomy, Cystoprostectomy or Anterior exenteration / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV500 mg 8 hourly with or without Gentamicin 5mg/kg i.v once daily
Head and Neck Surgery
Major procedure with incision of oral or pharyngeal or sinus mucosa / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or Clindamycin 600 mg IV 8 hourly
Major Neck dissection or Parotid dissection / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM or Clindamycin 600 mg IV 8 hourly
Thyroid/Parathyroid surgery / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Amikacin15mg/kg 6 hourly
Tonsillectomy / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Amikacin15mg/kg 6 hourly
Neurosurgery
Craniotomy (including shunt placement) / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Spinal fusion / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Laminectomy / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
General surgery
Inguinal hernia repair / Uncomplicated with mesh: Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Complicated, recurrent, remergent: Metronidazole IV 500 mg 8 hourly + (Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM)
PEG / Ampicillin +Gentamicin +Metronidazole ORPCN allergy: Clindamycin ±Gentamicin
Gastrectomy/Hepatectomy/cholecystectomy / Metronidazole IV 500 mg 8 hourly +(Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM
Small bowel or colon surgery / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV 500 mg 8 hourly
Whipple procedure or pancreatectomy / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV 500 mg 8 hourly
Appendectomy(uncomplicated),if complicated and perforated treated as secondary peritonitis / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV 500 mg 8 hourly
Penetrating abdominal trauma / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV 500 mg 8 hourly
Mastectomy / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV 500 mg 8 hourly
Mastectomy with lymph node dissection / Ceftriaxone/Cefotaxime 1 to 2 g/day IV or IM + Metronidazole IV 500 mg 8 hourly
Post op prophylaxis