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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 Te Whatu Ora | Te Toka Tumai Auckland's Antimicrobial Stewardship (AMS) programme.

Resources

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()(Te Whatu Ora \| Te Toka Tumai Auckland 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, 266 KB] *	Paediatric restricted list [PDF, 222 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 Empiric Antibiotic Treatment Guidelines

Sepsis

e.g. neutropenic sepsis

Respiratory tract

e.g. CAP

Ear, nose and throat

e.g. pharyngitis

Ophthalmology

e.g. conjunctivitis

Central nervous system

e.g. meningitis

Cardiothoracic

e.g. endocarditis

Skin and soft tissue

e.g. cellulitis

Bone and joint

e.g. septic arthritis

Gastrointestinal

e.g. cholangitis

Genitourinary tract

e.g. pyelonephritis

Sepsis If patients are colonised with ESBL-E or other MRO call Infectious Disease service
Neutropenic sepsis
	FIRST	ALTERNATIVE
Haematology	piperacillin-tazobactam 4.5g IV q6h AND gentamicin 5mg/kg IV q24h	cefepime 2g IV q8h AND gentamicin 5mg/kg IV q24h
Oncology	cefuroxime 1.5g IV q8h AND gentamicin 5mg/kg IV q24h	ceftriaxone 2g IV q24h
Non-neutropenic sepsis
	FIRST	ALTERNATIVE
Community onset sepsis – unknown source. Assess MRO risk, travel history, recent inpatient stay	5 days total if no source found cefuroxime 750mg IV q6h AND gentamicin 5mg/kg IV q24h	5 days total if no source found clindamycin 600mg IV q8h AND gentamicin 5mg/kg IV q24h

Respiratory tract
Community acquired pneumonia
	FIRST	ALTERNATIVE
CURB65 0 – 1	5 days total amoxicillin 500mg po TDS	5 days total doxycycline 200mg po BD on day 1 then 100mg po BD
CURB65 2	5 days total amoxicillin 500mg po TDS AND doxycycline 100mg po BD	5 days total doxycycline 200mg po BD on day 1 then 100mg po BD
CURB65 3 – 5	5 days total amoxicillin + clavulanic acid 1.2g IV q8h for 1 or 2 days AND azithromycin 500mg po daily ------ THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS AND azithromycin 500mg po daily	5 days total clarithromycin 500mg IV q12h for 1 or 2 days THEN complete 5 days total with azithromycin 500mg po daily
Pathogen specific regimens
	FIRST
S.pneumoniae or S.aureus (PSSA)	benzylpenicillin 1.2g IV q6h THEN penicillin V 500mg po QDS
S. aureus (MSSA)	flucloxacillin 2g IV q6h THEN flucloxacillin 1g po TDS
H. influenzae (amoxicillin S)	amoxicillin 1g IV q6h THEN amoxicillin 1g po TDS
H. influenzae (amoxicillin R)	amoxicillin + clavulanic acid 1.2g IV q8h THEN amoxicillin + clavulanic acid 625mg po TDS AND amoxicillin 500mg po TDS
M.pneumoniae or Chlamydophila spp.	clarithromycin 500mg IV q12h THEN azithromycin 500mg po daily
Legionella spp.	ciprofloxacin 400mg IV q8h THEN ciprofloxacin 750mg oral BD
Aspiration pneumonia
	FIRST	ALTERNATIVE
Many are not infective and represent chemical pneumonitis	5 days total amoxicillin + clavulanic acid 1.2g IV q8h for 1 or 2 days THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS	5 days total cefuroxime 750mg IV q8h THEN complete 5 days total with doxycycline 200mg po BD on day 1 then 100mg po BD
Hospital acquired pneumonia
Infection caused by more resistant Gram-negatives is increased by ICU ventilation, thoracic surgery or course of broad-spectrum antibiotic during this admission
	FIRST	ALTERNATIVE
Low risk of resistant Gram-negative infection	5 days total amoxicillin + clavulanic acid 1.2g IV q8h for 1 or 2 days THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS	5 days total cefuroxime 750mg IV q8h THEN complete 5 days total with doxycycline 200mg po BD on day 1 then 100mg po BD
High risk of resistant Gram-negative infection	5 days total piperacillin-tazobactam 4.5g IV q6h for 1 or 2 days AND gentamicin 5mg/kg IV q24h ------ THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS	5 days total ceftazidime 2g IV q8h for 1 or 2 days THEN complete 5 days total with co-trimoxazole 960mg po BD
Acute exacerbation of COPD or chronic bronchitis
	FIRST	ALTERNATIVE
Acute bronchitis does not require antibiotics	5 days total amoxicillin 500mg po TDS	5 days total doxycycline 200mg po BD on day 1 then 100mg po BD
Influenza
	FIRST
Immunocompromised or critically unwell	5 days total oseltamivir 75mg po BD

Ear, nose & throat
Sinusitis 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.
	FIRST	ALTERNATIVE
Uncomplicated	7 days total amoxicillin 500mg po TDS	7 days total doxycycline 200mg on day 1 then 100mg daily
Complicated	7 days total amoxicillin + clavulanic acid 1.2g IV q8h for 1 or 2 days THEN complete 7 days total with amoxicillin + clavulanic acid 625mg po TDS	7 days total cefuroxime 750mg IV q6h for 1 or 2 days THEN complete 7 days total with cefalexin 1g po TDS
Otitis media
	FIRST	ALTERNATIVE
Severe or bilateral disease	5 days total amoxicillin 500mg po TDS	5 days total co-trimoxazole 960mg po BD
Pharyngitis
	FIRST	ALTERNATIVE
If at risk of rheumatic fever i.e. - Past history of Rh fever - Māori/Pacific ethnicity - Aged under 30 with fever, cervical nodes or tonsillar swelling	10 days total penicillin V 500mg po BD Note: amoxicillin is avoided due to rash in EBV co-infected patients	10 days total erythromycin 400mg po BD
Epiglottitis
	FIRST	ALTERNATIVE
	5 days total amoxicillin + clavulanic acid 1.2g IV q8h for 1 or 2 days THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS	5 days total cefuroxime 750mg IV q6h for 1 or 2 days THEN complete 5 days total with cefalexin 1g po TDS
Tonsillitis (including quinsy and deep neck space infections)
	FIRST	ALTERNATIVE
	10 days total benzylpenicillin 1.2g IV q6h for 1 or 2 days AND metronidazole 400mg po BD ----- THEN complete 10 days total with penicillin V 500mg po QDS AND metronidazole 400mg po BD	10 days total cefazolin 1g IV q8h for 1 or 2 days AND metronidazole 400mg po BD ----- THEN complete 10 days total with cefalexin 1g po TDS AND metronidazole 400mg po BD

Ophthalmology
Blepharitis
	FIRST
	5 days total chloramphenicol 1% eye ointment topically BD	Use of non-pharmaceutical intervention is most helpful including warm compress and cleansing of the eyelid margins
Conjunctivitis 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
	FIRST
	7 days total chloramphenicol 0.5% eye drops 1 drop every 4 hours AND chloramphenicol 1% eye ointment at night

Central nervous system
Meningitis Call Infectious Disease if concern for bacterial meningitis or post-neurosurgical meningitis Treatment should be initiated after blood cultures are taken, and after consultation with infectious diseases
	FIRST	ALTERNATIVE
If patient over 50 years old, pregnant or immunosuppressed	Administer in this order: dexamethasone* 10mg IV q6h for 4 days AND ceftriaxone 2g IV q12h AND benzylpenicillin 2.4g IV q4h AND vancomycin as per vanculator	Administer in this order: dexamethasone* 10mg IV q6h for 4 days AND ceftriaxone 2g IV q12h AND co-trimoxazole 960mg IV q6h AND vancomycin as per vanculator
All other patients	Administer in this order: dexamethasone* 10mg IV q6h for 4 days AND ceftriaxone 2g IV q12h AND vancomycin as per vanculator *starting before or with the first dose of antimicrobial	Administer in this order: dexamethasone* 10mg IV q6h for 4 days AND ceftriaxone 2g IV q12h AND vancomycin as per vanculator *starting before or with the first dose of antimicrobial
Meningitis pathogen specific regimens
	THEN	ALTERNATIVE THEN
N.meningitidis	3 days total benzylpenicillin 1.2g IV q4h	3 days total ceftriaxone 2g IV q12h
H.influenzae	7 days total amoxicillin 2g IV q4h	7 days total ceftriaxone 2g IV q12h
S.pneumoniae	10 days total benzylpenicillin 2.4g IV q4h	10 days total ceftriaxone 2g IV q12h
Listeria spp.	14 days total benzylpenicillin 2.4g IV q4h	14 days total co-trimoxazole 960mg IV q6h
Encephalitis Treatment should be initiated after blood cultures are taken, and after consultation with infectious diseases
	FIRST	ALTERNATIVE
Antibiotics for listeria encephalitis and bacterial meningitis are recommended until diagnosis excluded Complete 14 to 21 days of aciclovir if HSV confirmed and bacterial meningitis/encephalitis excluded	dexamethasone* 10mg IV q6h for 4 days AND ceftriaxone 2g IV q12h AND benzylpenicillin 2.4g IV q4h AND aciclovir 10mg/kg IV q8h AND vancomycin as per vanculator *starting before or with the first dose of antimicrobial	dexamethasone* 10mg IV q6h for 4 days AND ceftriaxone 2g IV q12h AND aciclovir 10mg/kg IV q8h AND co-trimoxazole 960mg IV q6h AND vancomycin as per vanculator *starting before or with the first dose of antimicrobial
Brain abscess Treatment should be initiated after blood cultures are taken, and after consultation with infectious diseases
	FIRST	ALTERNATIVE
Community onset	amoxicillin 2g IV q4h AND metronidazole 400mg po BD	ceftriaxone 2g IV q12h AND metronidazole 400mg po BD
Trauma/neurosurgical source	ceftriaxone 2g IV q12h AND vancomycin as per vanculator

Cardiothoracic
Endocarditis (native valve) Treatment should be initiated after blood cultures are taken, and after consultation with cardiology and infectious diseases
	FIRST	ALTERNATIVE
	benzylpenicillin 1.2g IV q4h AND gentamicin 3mg/kg IV q24h Note: flucloxacillin 2g IV q4h should be used instead of penicillin if staphylococcal sepsis suspected e.g. injecting drug user THEN therapy rationalised following cultures with Infectious Disease consult	cefazolin 2g IV q8h AND gentamicin 3mg/kg IV q24h THEN therapy rationalised following cultures with Infectious Disease consult

Skin and soft tissue
Cellulitis
	FIRST	ALTERNATIVE
EWS 0 -1	5 days total flucloxacillin 1g po TDS	5 days total cefalexin 1g po TDS
EWS 2 – 5 or marked systemic symptoms with PVD, inc BSA, BMI or venous insufficiency	5 days total flucloxacillin 1g po TDS AND probenecid 500mg po TDS	5 days total cefalexin 1g po TDS AND probenecid 500mg po TDS
EWS 6 – 7 or RED/BLUE zone vital sign	5 days total flucloxacillin 1g IV q6h for 1 or 2 days THEN complete 5 days total with flucloxacillin 1g po TDS	5 days total cefazolin 1g IV q8h for 1 or 2 days THEN complete 5 days total with cefalexin 1g po TDS
EWS ≥ 8	5 days total flucloxacillin 2g IV q6h for 1 or 2 days AND clindamycin 600mg IV q6h AND gentamicin 5mg/kg IV q24h ----- THEN complete 5 days total with flucloxacillin 1g po TDS	5 days total cefazolin 2g IV q8h for 1 or 2 days AND clindamycin 600mg IV q6h AND gentamicin 5mg/kg IV q24h ----- THEN complete 5 days total with cefalexin 1g po TDS
Diabetic foot infection May need referral if recurrent or fails to settle to exclude underlying osteomyelitis. Evaluate PVD.
	FIRST	ALTERNATIVE
No signs of sepsis	5 days total amoxicillin + clavulanic acid 625mg po TDS	5 days total cefalexin 1g po TDS AND metronidazole 400mg po BD
Signs of sepsis	14 days total amoxicillin + clavulanic acid 1.2g IV q8h for 1 or 2 days THEN complete 14 days total with amoxicillin + clavulanic acid 625mg po TDS	14 days total cefuroxime 750mg IV q6h for 1 or 2 days AND metronidazole 400mg po BD ----- THEN complete 14 days total with cefalexin 1g po TDS AND metronidazole 400mg po BD
Mastitis/breast abscess
	FIRST	ALTERNATIVE
Conservative management of mastitis to alleviate symptoms and ensure on going breast emptying may be all that is required for treatment	5 days total flucloxacillin 1g IV q6h for 1 or 2 days THEN complete 5 days total with flucloxacillin 1g po TDS	5 days total cefazolin 1g IV q8h for 1 or 2 days THEN complete 5 days total with cefalexin 1g po TDS
Impetigo
	FIRST	ALTERNATIVE
Less than 4 lesions	5 days total hydrogen peroxide 1% cream applied BD
4 or more lesions	5 days total penicillin V 500mg po QDS	5 days total erythromycin 400mg po QDS
Boils
Most lesions may be treated with incision and drainage alone. Antibiotics may be considered if there is, surrounding cellulitis.
Bites – human and animal
	FIRST	ALTERNATIVE
Clean and debride wound thoroughly and assess the need for tetanus immunisation	7 days total amoxicillin + clavulanic acid 625mg po TDS	7 days total doxycycline 200mg on day 1 then 100mg po BD AND metronidazole 400mg po BD

Bone and joint infections
Osteomyelitis
	FIRST	ALTERNATIVE
	42 days flucloxacillin 2g IV q6h THEN therapy rationalised following cultures with Infectious Disease consult	42 days cefazolin 2g IV q8h THEN therapy rationalised following cultures with Infectious Disease consult
Septic arthritis
	FIRST	ALTERNATIVE
	21 days flucloxacillin 2g IV q6h THEN therapy rationalised following cultures with Infectious Disease consult	21 days cefazolin 2g IV q8h THEN therapy rationalised following cultures with Infectious Disease consult

Gastrointestinal tract
Peritonitis, severe diverticulitis, intra-abdominal abscesses
	FIRST		ALTERNATIVE
	5 days following drainage amoxicillin 1g IV q6h for 1 or 2 days AND gentamicin 5mg/kg IV q24h AND metronidazole 400mg po BD ----- THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS		5 days following drainage cefuroxime 750mg IV q6h for 1 or 2 days AND metronidazole 400mg po BD ----- THEN complete 5 days total with cefalexin 1g po TDS AND metronidazole 400mg po BD
Biliary tree infections (cholangitis or cholecystitis)
	FIRST		ALTERNATIVE
	5 days total amoxicillin 1g IV q6h for 1 or 2 days AND gentamicin 5mg/kg IV q24h ------ THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS		5 days total cefuroxime 750mg IV q6h for 1 to 2 days THEN complete 5 days total with cefalexin 1g po TDS
Gastroenteritis
	FIRST
C.difficile infection Mild-moderate	10 days total metronidazole 400mg po TDS
C.difficile infection Severe	14 days total vancomycin 125mg po QDS
Giardia	3 days total metronidazole 2g po daily
Campylobacter	5 days total erythromycin 400mg po QDS	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.
Oral/mucocutaneous candidiasis
	FIRST		ALTERNATIVE
Immunocompetent	7 days total nystatin 1mL topical q2-3h		7 days total amphotericin B lozenge 10mg topical QDS
Immunocompromised	7 days total nystatin 1mL topical q2-3h		If no response discuss fluconazole 800mg as a single dose with ID
H.pylori eradication
	FIRST		ALTERNATIVE
	14 days total amoxicillin 1g po BD (or metronidazole 400mg po BD) AND clarithromycin 500mg BD AND omeprazole 40mg BD		If treatment failure on standard regimens: 14 days total amoxicillin 1g po BD AND tetracycline 250mg po QDS AND omeprazole 40mg po BD AND bismuth 120mg po QDS

Genitourinary tract
Cystitis (lower UTI)
	FIRST	ALTERNATIVE
	5 days total nitrofurantoin MR 100mg po BD Note: See SCRIPT for local recommendations about renal dysfunction	ESBL-E fosfomycin 3g po single dose OR pivmecillinam 400mg load then 200mg po TDS for 3 days
Pyelonephritis (severe upper UTI)
	FIRST	ALTERNATIVE
Uncomplicated	7 days total gentamicin 5mg/kg IV q24h for 1 or 2 days ----- THEN rationalise based on cultures and complete 7 days total with for example: co-trimoxazole 960mg po BD	7 days total cefuroxime 750mg IV q8h for 1 or 2 days if gentamicin contra-indicated ----- THEN rationalise based on cultures and complete 7 days total with for example: co-trimoxazole 960mg po BD
Complicated	7 days total gentamicin 5mg/kg IV q24h for 1 or 2 days AND amoxicillin 1g IV q6h ----- THEN rationalise based on cultures and complete 7 days total with for example: co-trimoxazole 960mg po BD	7 days total ceftazidime 1g IV q8h for 1 or 2 days if gentamicin contra-indicated ----- THEN rationalise based on cultures and complete 7 days total with for example: co-trimoxazole 960mg po BD
If ESBL-E colonised discuss these options with Infectious Disease	amikacin 15mg/kg IV q24h for 1 or 2 days ----- THEN rationalise based on cultures and complete 7 days total with for example: fosfomycin 3g po daily	meropenem 500mg IV q6h for 1 or 2 days ----- THEN rationalise based on cultures and complete 7 days total with for example: fosfomycin 3g po daily
PID/endometritis/cervicitis
	FIRST
	14 days total ceftriaxone 1g IV q24h AND doxycycline 100mg po BD AND metronidazole 400mg po BD