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Antimicrobial Stewardship (AMS)

Antimicrobial Stewardship (AMS)

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)

NZ STI Guidelines()
NextDose ()

SCRIPT App - Antibiotic Treatment Guidelines Available from the App Store()() and Google Play()()

Adults	Paediatrics
Empirical Treatment Guidelines	Starship Clinical Guidelines()
Surgical Prophylaxis [PDF, 224 KB]	Surgical Prophylaxis [PDF, 213 KB]
Aminoglycoside flowchart [PDF, 126 KB]	Aminoglycosides()
Vancomycin()(Auckland DHB intranet only) The calculator is now located within Concerto	Vancomycin()
Cefuroxime [PDF, 683 KB], and meropenem [PDF, 211 KB] dosing guides
Penicillin allergy assessment tool (Monochrome [PDF, 248 KB])
Adult restricted list [PDF, 93 KB] *	Paediatric restricted list [PDF, 92 KB] *

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 special 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 ± gentamicin 5mg/kg IV q24h	Oral therapy not appropriate	A minimum of 72 hours to a maximum of 14 days	See full guidelines for advice
Oncology	cefuroxime 1.5g IV q8h ± gentamicin 5mg/kg IV q24h	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

Non-neutropenic host

cefuroxime 750mg IV q6h
+ gentamicin 5mg/kg IV q24h

Oral therapy not appropriate

Review at 48 hours.
5 days for culture negative sepsis.

Respiratory tract
Community acquired pneumonia

Empiric IV treatment		Empiric po treatment	Duration of therapy	Pathogen directed treatment (for all CURB scores)
CURB-65 0-1	Oral treatment only	amoxicillin 500mg po TDS OR doxycycline 200mg po BD on day 1 then 100mg po BD	5 days in total	S.pneumoniae or S.aureus (penicillin S) benzylpenicillin 600mg IV q6h → penicillin V 500mg oral QDS
				S. aureus (penicillin R) flucloxacillin 2g IV q6h → 500mg oral QDS
CURB65 2:	Oral treatment only	amoxicillin 500mg po TDS + doxycycline 100mg po BD	5 days in total	S. aureus (methicillin R) vancomycin (as per Vanculator) → oral as per sensitivities
				H. influenzae (amoxicillin S) amoxicillin 1g IV q6h → 500mg oral TDS
				H. influenzae (amoxicillin R) amoxicillin + clavulanic acid 1.2g IV q8h → 625mg oral TDS
CURB65 3-5:	amoxicillin + clavulanic acid 1.2g IV q8h + clarithromycin 500mg IV q12h OR, if anaphylaxis with penicillins/cephalosporins: discuss with ID		5 days in total	M. pneumoniae or Chlamydophila* spp.* clarithromycin 500mg IV q12h → roxithromycin 300mg oral daily
				Legionella spp. ciprofloxacin ^ID400mg IV q8h → 750mg oral BD

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-tazobactam^ID 4.5g IV q8h + gentamicin 5mg/kg IV q24h	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
or doxycycline 200mg BD on day 1 then 100mg BD

5 days

S.pneumoniae
penicillin VK 500mg po QDS

M.catarrhalis
trimethoprim 300mg po daily

H.influenzae
amoxicillin 500mg po TDS

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. oseltamivir^ID 75mg po BD

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
or doxycycline 200mg on day 1 then 100mg daily

7 days

Complicated:
amoxicillin + clavulanic acid 1.2g IV q8h

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
-          Maori/Pacific ethnicity
- Aged 3 – 30
-          With: fever, cervical nodes, tonsillar swelling

Throat swab to guide treatment.

penicillin VK 500mg po BD
or erythromycin 400mg po BD
or benzathine benzylpenicillin 900mg IM single dose

10 days

Group A Strep
penicillin VK 500mg po BD

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 or cefuroxime 750mg IV q6h	amoxicillin + clavulanic acid 625mg po TDS	5 days	H.influenzae amoxicillin 500mg po TDS

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 BD (equivalent to IV)	penicillin VK 500mg po QDS ± metronidazole 400mg po BD	10 days	Group A Strep/S.milleri group: penicillin VK 500mg po QDS

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
+ chloramphenicol 1% eye ointment at night

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
+ ceftriaxone 2g IV q12h
+ vancomycin as per Vanculator
± benzylpenicillin 2.4g IV q4h (if >50yo or pregnant or immunosuppressed)

*starting before or with the first dose of antimicrobial

Oral therapy not appropriate

Pathogen specific

N.meningitidis
benpenicillin 1.2g IV q4h for 3 days

H.influenzae
amoxicillin 2g IV q4h for 7 days

S.pneumoniae
benzylpenicillin 2.4g IV q4h for 10 days

Listeria
benpen/amox/cotrim for 14 days

Encephalitis

Empiric IV treatment	Empiric po treatment	Duration of therapy	Pathogen directed treatment
aciclovir^ID 10mg/kg IV q8h + dexamethasone* 10mg IV q6h for 4 days + ceftriaxone 2g IV q12h + benzylpenicillin 1.2g IV q4h + vancomycin as per Vanculator	Oral therapy not appropriate	14 – 21 days	HSV: aciclovir^ID10mg/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:
amoxicillin 2g IV q4h
+metronidazole 400mg po BD

Secondary to trauma/neurosurg:
amoxicillin 2g IV q4h
+metronidazole 400mg po BD
+ flucloxacillin 2g IV q4h

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
+ gentamicin 3mg/kg IV q24h

(*flucloxacillin 2g IV q4h should be used instead of penicillin if staphylococcal sepsis suspected e.g. IV drug user)

Oral treatment is inappropriate

As per organism below

Advice will be provided from infectious diseases about ongoing therapy

S.aureus (MSSA)
flucloxacillin 2g IV q4h 4 weeks

S.aureus (MRSA) vancomycin IV as per Vanculator 4 weeks

Viridans strep:
benzylpenicillin 1.2g IV q4h 4 weeks or with gentamicin 3mg/kg IV q24h for 2 weeks

Enteroccci
benzylpenicillin 2.4g IV q4-6h
+ gentamicin 3mg/kg IV q24h for 4 weeks

Skin & soft tissue

Cellulitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

flucloxacillin 1g IV q6h
(no need to add benzylpenicillin)
or
cefazolin 1g IV q8h if intolerant

flucloxacillin 500mg po QDS
or cefalexin 500mg po QDS

5 days

MSSA
flucloxacillin 500mg po QDS

Beta-haemolytic strep
penicillin VK 500mg po QDS

MRSA
cotrimoxazole 960mg po BD

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
No sepsis	Not required	amoxicillin + clavulanic acid 625mg po TDS or cefalexin 500mg po QDS + metronidazole 400mg po BD	5 days	MSSA	flucloxacillin 500mg po QDS
				Beta-haemolytic Strep	penicillin VK 500mg po QDS
With sepsis	amoxicillin + clavulanic acid 1.2g IV q8h or cefuroxime 750mg IV q6h + metronidazole 400mg po BD	amoxicillin + clavulanic acid 625mg po TDS or cefalexin 500mg po QDS + metronidazole 400mg po BD	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
or cefazolin 1g IV q8h if intolerant

flucloxacillin 500mg po QDS

5 days

MSSA
flucloxacillin 500mg po QDS

Beta-haemolytic Strep
penicillin VK 500mg po QDS

Gram negatives
amoxicillin + clavulanic acid 625mg po TDS

Impetigo

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV therapy unnecessary

Less than 3 lesions:
hydrogen peroxide 1% cream applied BD

Extensive disease:
penicillin VK 500mg po QDS
or flucloxacillin 500mg po QDS

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
or
doxycycline 200mg on day 1 then 100mg po BD
+ metronidazole 400mg po BD

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 Consider oral switch	MRSA: vancomycin IV as per vanculator®

Septic arthritis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

flucloxacillin 2g IV q6h

Oral therapy not appropriate

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

Gastrointestinal tract

Peritonitis, severe diverticulitis, intra-abdominal abscesses

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

amoxicillin 1g IV q6h
+ gentamicin 5mg/kg IV q24h
+ metronidazole 400mg po BD

or cefuroxime 750mg IV q6h
+ metronidazole 400mg po BD

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
+gentamicin 5mg/kg IV q24h

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 or vancomycin^ID 125mg po QDS for 14 days if no response to 2 courses of metronidazole
			Giardia	Metronidazole 2g po daily for 3 days or 400mg po TDS for 7 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) + clarithromycin 500mg BD + omeprazole 40mg BD	14 days	If treatment failure on standard regimens: amoxicillin 1g po BD + tetracycline 250-500mg po QDS + omeprazole 40mg po BD + bismuth 120mg po QDS

Genito-urinary tract

Cystitis (lower UTI)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV treatment is unnecessary

nitrofurantoin MR 100mg po BD

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 daily and nitrofurantoin over beta-lactams.

ESBL fosfomycin^ID 3g po single dose
or pivemecillinam^ID 400mg load then 200mg po TDS

Pyelonephritis (severe upper UTI)

Empiric IV treatment		Empiric po treatment	Duration of therapy	Pathogen directed treatment
Uncomplicated	gentamicin 5mg/kg IV q24h or cefuroxime 750mg IV q8h	trimethoprim 300mg po daily	10 days	MSSA flucloxacillin 500mg po QDS
				Group B strep penicillin VK 500mg po QDS
Complicated	gentamicin 5mg/kg IV q24h + amoxicillin 1g IV q6h		10 days	Gram negatives as per culture but prefer trimethoprim over beta-lactams.
ESBL colonised	amikacin[^ID] 15mg/kg IV q24h or meropenem[^ID] 500mg IV q8h		10 days	ESBL E.coli fosfomycin[^ID] 3g po daily

PID/endometritis/cervicitis

Empiric IV treatment	Empiric po treatment	Duration of therapy	Pathogen directed treatment
ceftriaxone 1g IV single dose + doxycycline 100mg po BD + metronidazole 400mg po BD		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. 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
	Public Health physician
Emma Best	Infectious Diseases paediatrician
Matthew Blakiston	Clinical Microbiologist
Lesley Voss	Clinical Lead Paediatric Infectious Disease
Margaret Johnston	Nurse Specialist Liver Transplant
Claire Hemmaway	Haematologist
Stephen Ritchie	Infectious disease physician
Craig Hourigan	Intensivist
Natasha Pool	Antimicrobial Stewardship pharmacist
Markus Schamm	Transplant Surgeon
	Advanced trainees in infectious diseases or microbiology also attend

Terms of Reference()

Antimicrobial Stewardship (AMS)

Resources

Adult Empirical Antimicrobial Treatment Guidelines

Sepsis

Neutropenic sepsis

Community onset sepsis – unknown source. Need to assess MRO risk, travel history, recent inpatient stays, source.

Respiratory tractCommunity acquired pneumonia

Aspiration pneumonia – many are not infective and represent chemical pneumonitis.

Hospital acquired pneumonia

Acute exacerbation of COPD or chronic bronchitis

Acute bronchitis

Influenza

Ear, nose & throat

Sinusitis

Otitis media

Pharyngitis

Epiglottitis

Tonsillitis (including quinsy and deep neck space infections)

Ophthalmology

Blepharitis

Conjunctivitis

CNS

Meningitis – phone ID for consult advice if bacterial meningitis or post-neurosurgical meningitis.

Encephalitis

Brain abscess

Cardiothoracic

Endocarditis (native valve)

Skin & soft tissue

Cellulitis

Diabetic foot infection – may need referral if recurrent or fails to settle to exclude underlying osteomyelitis. Evaluate PVD.

Mastitis/breast abscess

Impetigo

Boils

Bites – human & animal

Bone & joint

Osteomyelitis

Septic arthritis

Gastrointestinal tract

Peritonitis, severe diverticulitis, intra-abdominal abscesses

Biliary tree infections (cholangitis or cholecystitis)

Gastroenteritis

Oral/mucocutaneous candidiasis

H.pylori eradication

Genito-urinary tract

Cystitis (lower UTI)

Pyelonephritis (severe upper UTI)

PID/endometritis/cervicitis

Antimicrobial Stewardship Committee

Current committee members:

Respiratory tract
Community acquired pneumonia