Please email any recommendations for improvement (big or small) to john.shanks@nt.gov.au

• Antibiogram TEHS
• Ascending cholangitis
• Carbuncle
• Cellulitis
• Diabetic foot infection
• Dosing nomograms and calculators
• Febrile neutropenia
• Intra-abdominal Infection
• Meningitis
• Open (Compound) Fracture
• Pelvic inflammatory disease
• Pneumonia
• Pyelonephritis
• Scabies (crusted)
• Severe sepsis
• Shingles
• Surgical prophylaxis
• Urinary tract infection (UTI)
• References and acknowledgements

• Staph aureus
• Strep pneumoniae
• Enterococcus sp
• E.coli
• Kleb pneumoniae
• Proteus mirabilis
• Enterobacter sp
• Salmonella
• Pseudomonas aeruginosa
• Acinetobacter baumannii
• Burkholderia pseudomallei

TEHS Staphylococcus aureus % susceptible

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TEHS Streptococcus pneumoniae % susceptible

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TEHS Enterococcus faecalis % susceptible

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TEHS Eschericiae coli % susceptible

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TEHS Klebsiella pneumoniae % susceptible

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TEHS Proteus mirabilis % susceptible

---

TEHS Enterobacter sp % susceptible

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TEHS Salmonella sp % susceptible

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TEHS Pseudomonas aeruginosa % susceptible

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TEHS Acinetobacter sp % susceptible

---

TEHS Burkholderia pseudomallei % susceptible

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• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

---

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

For ascending cholangitis in a patient with non-life threatening penicillin hypersensitivity:

Ceftriaxone 1g IV, (child 1 month or older: 50 mg/kg up to 1 g) Daily

OR

Cefotaxime 1 g (child: 50 mg/kg up to 1 g) IV, every 8 hours

Metronidazole 500mg IV, (child 1 month or older: 12.5 mg/kg up to 500mg) 12 hourly

---

Code for cefotaxime is: 2asc

---

• Ascending cholangitis is usually caused by enteric gram negative bacilli such as Eschericia.coli or Enterococcus faecalis, infrequently it is caused by anaerobic bacteria
• Consider an early switch to oral within 48 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not exceed 7 days treatment. Antibiotic therapy should be ceased within 24 hours of cholecystectomy
  • Metronidazole is not normally required unless the patient has a history of biliary obstruction

For ascending cholangitis in a patient with life threatening penicillin hypersensitivity intolerant of gentamicin:

Please contact IFD for advice

---

• Ascending cholangitis is usually caused by enteric gram negative bacilli such as Eschericia.coli or Enterococcus faecalis, infrequently it is caused by anaerobic bacteria
• Consider an early switch to oral within 48 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not exceed 7 days treatment. Antibiotic therapy should be ceased within 24 hours of cholecystectomy

For ascending cholangitis in a patient with life threatening penicillin hypersensitivity use as a single agent:

Gentamicin IV, dosed as per table below
AND if the patient has a history of biliary obstruction ADD

Metronidazole 500mg IV, (child 1 month or older: 12.5 mg/kg up to 500mg) 12 hourly

Please contact IFD for advice for ongoing therapy past 72 hours

---

Initial Paediatric Gentamicin Dosing (Age < 12 years)

Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR.
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)

---

• Ascending cholangitis is usually caused by enteric gram negative bacilli such as Eschericia.coli or Enterococcus faecalis, infrequently it is caused by anaerobic bacteria
• Consider an early switch to oral within 48 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not exceed 7 days treatment. Antibiotic therapy should be ceased within 24 hours of cholecystectomy
• Metronidazole is not normally required unless the patient has a history of biliary obstruction

For ascending cholangitis in a patient who can tolerate penicillin and gentamicin:

Ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly

AND

Gentamicin IV, dosed as per table below
AND if the patient has a history of biliary obstruction ADD

Metronidazole 500mg IV, (child 1 month or older: 12.5 mg/kg up to 500mg) 12 hourly

If IV treatment is required after 72 hours change to ceftriaxone 1g daily +/- metronidazole if biliary obstruction present, or use piperacillin 4g and tazobactam 500mg 8 hourly

---

Initial Gentamicin/Tobramycin Dosing (age > 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate

---

• Ascending cholangitis is usually caused by enteric gram negative bacilli such as Eschericia.coli or Enterococcus faecalis, infrequently it is caused by anaerobic bacteria
• Consider an early switch to oral within 48 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not exceed 7 days treatment. Antibiotic therapy should be ceased within 24 hours of cholecystectomy
• Metronidazole is not normally required unless the patient has a history of biliary obstruction

For ascending cholangitis in a patient tolerant of penicillin but intolerant of gentamicin:

Ceftriaxone 1g IV, (child 1 month or older: 50 mg/kg up to 1 g) Daily

OR

Cefotaxime 1 g (child: 50 mg/kg up to 1 g) IV, every 8 hours

AND if the patient has a history of biliary obstruction ADD

Metronidazole 500mg IV, (child 1 month or older: 12.5 mg/kg up to 500mg) 12 hourly

OR as a single agent (without metronidazole)

Piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) IV, every 8 hours

---

Code for either piperacillin or cefotaxime is: 2asc

---

• Consider an early switch to oral within 48 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not exceed 7 days treatment. Antibiotic therapy should be ceased within 24 hours of cholecystectomy
• Metronidazole is not normally required unless the patient has a history of biliary obstruction

Are there signs of spreading cellulitis or significant systemic features?

• Yes
• No

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

• Penicillin anaphylaxis is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Is the patient a child or adult?

• Paediatric patient
• Adult Patient

Is the patient a child or adult?

• Paediatric patient
• Adult Patient

Is the patient a child or adult?

• Paediatric patient
• Adult Patient

Most carbuncles will require only excision and drainage with no antibiotic treatment. If antibiotic treatment is necessary while awaiting the results of cultures and susceptibility, use:

Cephalexin 12.5 mg/kg (up to 500 mg) orally, 6-hourly for 5 days

OR If compliance is unlikely with QID dosing

Cephalexin 25mg/kg orally 12 hourly

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

Most carbuncles will require only excision and drainage with no antibiotic treatment. If antibiotic treatment is necessary while awaiting the results of cultures and susceptibility, use:

Cephalexin 500 mg orally, 6-hourly for 5 days

OR If compliance is unlikely with QID dosing

Cephalexin 1g orally 12 hourly

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

Most carbuncles will require only excision and drainage with no antibiotic treatment. If antibiotic treatment is necessary while awaiting the results of cultures and susceptibility, use:

Clindamycin 10 mg/kg (up to 450 mg) orally, 8-hourly for 5 days

OR

Trimethoprim+sulfamethoxazole 4+20 mg/kg (up to 160+800 mg) orally, 12-hourly for 5 days

---

Code for clindamycin is: 5car

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

Most carbuncles will require only excision and drainage with no antibiotic treatment. If antibiotic treatment is necessary while awaiting the results of cultures and susceptibility, use:

Clindamycin 450 mg orally, 8-hourly for 5 days

OR

Trimethoprim+sulfamethoxazole 160+800 mg orally, 12-hourly for 5 days

---

Code for clindamycin is: 5car

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

Most carbuncles will require only excision and drainage with no antibiotic treatment. If antibiotic treatment is necessary while awaiting the results of cultures and susceptibility, use:

Flucloxacillin 12.5 mg/kg (up to 500 mg) orally, 6-hourly for 5 days.

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

Most carbuncles will require only excision and drainage with no antibiotic treatment. If antibiotic treatment is necessary while awaiting the results of cultures and susceptibility, use:

Dicloxacillin 500 mg orally, 6-hourly for 5 days.

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

• Penicillin anaphylaxis is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Would you class the cellulitis as mild/moderate or severe?

• Mild/Moderate
• Severe

---

• Choose severe if there are significant systemic features or no improvement in > 48hours

Would you class the cellulitis as mild/moderate or severe?

• Mild/Moderate
• Severe

---

• Choose severe if there are significant systemic features or no improvement in > 48hours

Would you class the cellulitis as mild/moderate or severe?

• Mild/Moderate
• Severe

---

• Choose severe if there are significant systemic features or no improvement in > 48hours

Is the patient from an area with high nMRSA prevalence?

• Low nMRSA risk
• High nMRSA risk

---

• Areas with a high level of nMRSA prevalence include detention centres, army barracks, remote communities and gaols

Is the patient from an area with high nMRSA prevalence?

• Low nMRSA risk
• High nMRSA risk

---

• Areas with a high level of nMRSA prevalence include detention centres, army barracks, remote communities and gaols

Is the patient from an area with high nMRSA prevalence?

• Low nMRSA risk
• High nMRSA risk

---

• Areas with a high level of nMRSA prevalence include detention centres, army barracks, remote communities and gaols

Is the patient from an area with high nMRSA prevalence?

• Low nMRSA risk
• High nMRSA risk

---

• Areas with a high level of nMRSA prevalence include detention centres, army barracks, remote communities and gaols

Mild cellulitis from carbuncle with non-life threatening penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility use:

Cephalexin 500 mg (child 12.5mg/kg up to 500mg) orally, 6-hourly for 5 to 10 days

OR, If compliance is unlikely with QID dosing

Cephalexin 1 g (child 25mg/kg up to 1g) orally, 12-hourly for 5 to 10 days

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

Mild cellulitis from carbuncle with life threatening penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

Clindamycin 450 mg (child 10mg/kg up to 450mg) orally, 8-hourly for 5 to 10 days

---

Code for clindamycin is: 5cac

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

Mild cellulitis from carbuncle with no penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

Dicloxacillin 500 mg (child flucloxacillin 12.5mg/kg up to 500mg) orally, 6-hourly for 5 to 10 days.

OR, If compliance is unlikely with QID dosing

Cephalexin 1 g (child 25mg/kg up to 1g) orally, 12-hourly for 5 to 10 days

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

For empirical therapy in a patient with mild penicillin allergy; while awaiting the results of cultures and susceptibility testing, use:

Cephazolin 2 g (child 50mg/kg up to 2g) IV, 8-hourly until systemic features improve then switch to oral

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)

For empirical therapy in a patient with no penicillin allergy, while awaiting the results of cultures and susceptibility use:

Flucloxacillin 2 g (child 50mg/kg up to 2g) IV, 6-hourly until systemic features improve then switch to oral

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)

Mild cellulitis from a carbuncle in a patient from an nMRSA endemic community or with non-life threatening penicillin allergy is treated with oral antibiotics. For empirical therapy while awaiting the results of cultures and susceptibility testing, use:

Trimethoprim/sulfamethoxazole 160/800mg (child 1 month or older 4/20 mg/kg up to 160/800mg) orally, 12-hourly for 5 to 10 days

OR

Clindamycin 450 mg (child: 10 mg/kg up to 450 mg) orally 8-hourly for 5 to 10 days

---

Code for clindamycin is: 5cac

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

Severe cellulitis from carbuncle in a patient where nMRSA is endemic can be treated with vancomycin and cephazolin:

Cephazolin 2g (child 50mg/kg up to 2g) IV, 8-hourly.

AND,

Vancomycin as per nomograms below;

---

Code for vancomycin is: 2cac

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)

Severe cellulitis from carbuncle in patients where nMRSA is endemic with penicillin hypersensitivity can be treated with vancomycin:

As a single agent use vancomycin as per nomograms below;

---

Code for vancomycin is: 2cac

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)

Severe cellulitis from carbuncle in adult patients where nMRSA is endemic can be treated with vancomycin and flucloxacillin:

Flucloxacillin 2g (child 50mg/kg up to 2g) IV, 6-hourly.

AND,

Vancomycin, as per nomogram below;

---

Code for vancomycin is: 2cac

---

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy
• Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)

Is there a purulent focus for infection such as an abscess or carbuncle?

• Yes, purulent focus present
• No, non-discharging wound

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

• Penicillin anaphylaxis is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Would you class the cellulitis as mild/moderate or severe?

• Mild/Moderate
• Severe

---

• Choose severe if there are significant systemic features or no improvement in >48hours

• Mild/Moderate
• Severe

Would you class the cellulitis as mild/moderate or severe?

• Mild/Moderate
• Severe

---

• Choose severe if there are significant systemic features or no improvement in >48hours

Are there signs of S.pyogenes? (i.e. erysipelas? or rapid progression)

• Yes
• No

---

• Erysipelas typically presents as a rapidly progressing erythematous skin lesion which has a sharply demarcated, raised edge
• Classically, erysipelas involves either facial skin in a butterfly pattern, or the lower legs
• Spontaneous rapid spreading cellulitis is most commonly due to S.pyogenes or another streptococci

For mild/moderate cellulitis in a patient with penicillin hypersensitivity (non-life threatening) use as a single agent:

Cephalexin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 to 10 days

OR,If compliance is unlikely with QID dosing

Cephalexin 1000mg (child:25 mg/kg up to 1g) , 12-hourly for 5 to 10 days

---

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary

For mild/moderate cellulitis in a patient with immediate (life threatening) penicillin hypersensitivity use as a single agent:

Clindamycin 450 mg (child: 10 mg/kg up to 450 mg) orally, 8-hourly for 5 to 10 days

---

Code for clindamycin is: 5cel

---

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary

For mild/moderate cellulitis in a patient with signs of S.pyogenes use as a single agent:

Phenoxymethylpenicillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 to 10 days

OR

Procaine penicillin 1.5 g (child: 50 mg/kg up to 1.5 g) IM, daily for at least 3 days

---

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary

For mild/moderate cellulitis in a patient with signs of S.pyogenes use as a single agent:

Dicloxacillin 500 mg (child: Flucloxacillin 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 to 10 days

---

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary

For empirical therapy of mild to moderate cellulitis in an adult with mild penicillin allergy; while awaiting the results of cultures and susceptibility testing, use:

Cephazolin 2 g IV (child: 50 mg/kg up to 2 g), 8-hourly

Switch to oral therapy when systemic features have improved (see switch to oral guideline on the PGC for details)

---

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary
• As with all skin and soft tissue infections patients with cellulitis can benefit from an early switch to oral within the first 48 hours of treatment
• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

For empirical treatment of severe cellulitis in a patient with life threatening penicillin hypersensitivity use either vancomycin or lincomycin.

Vancomycin as per nomogram below;

OR

Lincomycin 600 mg (child: 15 mg/kg up to 600 mg) IV, 8-hourly.

---

Code for lincomycin or vancomycin is: 2cel

---

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

• Consider an early switch to oral clindamycin (within 48 hours), clindamycin has excellent oral bioavailability (90% orally bioavailable)
• In addition to treating cellulitis, examine patient for tinea of the feet and treat if necessary
• As with all skin and soft tissue infections patients with cellulitis can benefit from an early switch to oral within the first 48 hours of treatment
• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

For empirical therapy in a patient with no penicillin allergy, while awaiting the results of cultures and susceptibility use:

Flucloxacillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly

---

• In addition to treating cellulitis examine patient for tinea of the feet and treat if necessary
• As with all skin and soft tissue infections patients with cellulitis can benefit from an early switch to oral within the first 48 hours of treatment
• This is a guide for empirical treatment only. It is imperative that cultures are taken prior to administration of antibiotics (where possible) for targeted therapy

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

---

• Penicillin anaphylaxis is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

How severe is the infection? (see table below)

• Mild
• Moderate
• Severe

Classification of diabetic foot infection

How severe is the infection? (see table below)

• Mild
• Moderate
• Severe

Classification of diabetic foot infection

How severe is the infection? (see table below)

• Mild
• Moderate
• Severe

Classification of diabetic foot infection

For mild diabetic foot in a patient with non-life-threatening penicillin allergy:

Cephalexin 500mg PO, every 6 hours for 1-2 weeks

AND

Metronidazole 400mg PO, every 12 hours for 1-2 weeks

---

• Treatment may extend up to 4 weeks if slow to resolve
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa ciprofloxacin or piperacillin with tazobactam may be required

For mild diabetic foot in a patient with life-threatening penicillin allergy:

Ciprofloxacin 500mg PO, every 12 hours for 1-2 weeks

AND

Clindamycin 450mg PO, every 8 hours for 1-2 weeks

---

Code for ciprofloxacin and clindamycin is: 7dfi

---

• Treatment may extend up to 4 weeks if slow to resolve
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa the empirical dosage of ciprofloxacin may need to be modified

For mild diabetic foot in a patient with no penicillin allergy:

Amoxycillin 875mg/Clavulanic acid 125mg PO, every 12 hours for 1-2 weeks

OR

Cephalexin 500mg PO, every 6 hours for 1-2 weeks

AND

Metronidazole 400mg PO, every 12 hours for 1-2 weeks.

---

• Treatment may extend up to 4 weeks if slow to resolve
• In patients with severe renal failure amoxycillin dose may need to be reduced
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa ciprofloxacin or piperacillin with tazobactam may be required

Are there systemic signs of sepsis, or is MRSA suspected?

• Yes
• No

Signs of Sepsis

Hypotension:

• systolic BP< 90mmHg OR 40mmHg below premorbid BP AFTER at least 500mL fluid challenge.

Hypoperfusion:

• Lactate >=4 mmol/L OR Bicarbonate <16mmol/L

---

• Currently nearly half of all RDH patients are infected or colonised with MRSA (46%). Consult IFD promptly if the patient is not improving, septic, or MRSA is suspected.

Are there systemic signs of sepsis, or is MRSA suspected?

• Yes
• No

Signs of Sepsis

---

• Currently nearly half of all RDH patients are infected or colonised with MRSA (46%). Consult IFD promptly if the patient is not improving, septic, or MRSA is suspected.

For moderate/severe diabetic foot with potential for MRSA in patient intolerant of penicillin use:

Ciprofloxacin 500mg PO, every 12 hours for 2-4 weeks

AND

Vancomycin IV, dosed as per nomogram below until cultures return

AND

Clindamycin 450mg PO, every 6 hours for 2-4 weeks

OR

Lincomycin 600mg IV, every 8 hours until stable then step down to oral clindamycin 450mg tds

---

Code for ciprofloxacin, vancomycin, clindamycin or lincomycin is: 2dfi

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• Please note clindamycin has excellent oral bioavailability (90% orally bioavailable), consider an early switch to oral if lincomycin is to be used
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa the empirical dosage of ciprofloxacin may need to be modified

For moderate/severe diabetic foot in patient intolerant of penicillin use:

Ciprofloxacin 500mg PO, every 12 hours for 2-4 weeks

AND

Clindamycin 450mg PO, every 6 hours for 2-4 weeks

OR

Lincomycin 600mg IV, every 8 hours until stable then step down to oral clindamycin 450mg tds

---

Code for ciprofloxacin or clindamycin is: 7dfi

---

Code for lincomycin is: 2dfi

---

• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• Please note clindamycin has excellent oral bioavailability (90% orally bioavailable), consider an early switch to oral if lincomycin is to be used
• Depending on the organisms that are isolated from cultures of deep tissue specimens, other antibiotic combinations may be required. For infection with Pseudomonas aeruginosa the empirical dosage of ciprofloxacin may need to be modified

For moderate/severe diabetic foot in patient at risk of MRSA use:

Piperacillin 4g and tazobactam 0.5g IV, every 8 hours until patient meets switch to oral criteria

AND

Vancomycin IV, dosed as per nomogram below until cultures return

---

Code for piperacillin is: 14dfi

---

Code for vancomycin is: 2dfi

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state
• If cultures return sensitive to clindamycin this is often a good alternative to vancomycin with excellent tissue penetration
• This is a guide for empirical therapy only until the results of microbiology and susceptibilities are available
• If Pseudomonas aeruginosa is isolated from cultures of deep tissue specimens then the empirical dose of piperacillin and tazobactam may need to be increased to 6 hourly dosing.
• See the switch to oral protocol on the PGC for details on when to make the switch to oral antibiotics

For mild to moderate diabetic foot in a patient with non-life-threatening penicillin allergy:

Piperacillin 4g and tazobactam 500mg, IV every 8 hours until patient meets switch to oral criteria

---

Code for piperacillin is: 14dfi

---

• Treatment may extend up to 4 weeks if slow to resolve
• If Pseudomonas aeruginosa is isolated from cultures of deep tissue specimens then the empirical dose of piperacillin and tazobactam may need to be increased to 6 hourly dosing.
• See the switch to oral protocol on the PGC for details on when to make the switch to oral antibiotics

• Cockcroft Gault (CrCl) Calculator
• Gentamicin nomogram
• Gentamicin empiric dose calculator
• Vancomycin nomogram
• Vancomycin load calculator
• Vancomycin dose adjustment calculator
• Vancomycin empiric dose calculator

---

Gentamicin dose should be based on ideal body weight for patients with actual body weight more than 20% over ideal weight. Contact pharmacy for dose recommendation in morbidly obese patients.

Initial Paediatric Gentamicin Dosing (Age < 12 years)

---

Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR.
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)

---

Vancomycin dosing should be based on weight and renal function for adult patients or age and weight for neonates and children:

---

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

Enter the patients actual body weight to calculate the vancomycin loading dose

Weight (Kg):

Vancomycin dose: mg

Calculate

---

• Please note this calculator is for testing purposes only, please confirm any dose recommendations with a second source before prescribing treatment
• A loading dose of vancomycin may be considered to help achieve a therapeutic concentration more quickly, particularly in patients with serious infections who are critically ill. However, there are no strong clinical data to show that this approach improves outcomes.
• Weight-based dosing is recommended for the loading dose, since both volume of distribution and clearance of vancomycin are correlated with actual body weight.
• This calculator is for adult patients only, for paediatric or underweight patients (<36Kg) please seek specialist advice
• This calculator aims for a load of 25 to 30 mg/kg (actual body weight)

Enter the patients previous vancomycin level and previous dose to acheive steady state below

Last trough vancomycin level:

Previous dose (in milligrams): milligrams

Previous dosage interval: every 48 hours every 24 hours every 12 hours every 8 hours

Would you rate the infection as complicated (major) or uncomplicated (minor)? Complicated Uncomplicated

Suggested new vancomycin dose:

Calculate

---

• Please note the values from this calculator are to be used as a guide only. This calculator provides a dose which targets a level of 17.5, however there are numerous clinical reasons this would not be an appropriate target. This tool is to be used as a guide only and should never replace clinical judgement
• This tool should not be used in paediatrics, patients with severe sepsis, rapidly changing renal function, on haemodialysis or CRRT or other nephrotoxic medications
• efore changing a dose, please check that the timing of the previous dose was as intended, that the level was taken at the appropriate time and that the patient has had adequate time to reach steady state since the last dose change (see the vancomycin protocol on PGC for details)

Enter the patient details to calculate the gentamicin loading dose:

Gender: Male Female

Height (cm):

Actual weight (kg):

Creatinine clearance: More than 60mL/min 40-60mL/min Less than 40mL/min

Gentamicin dose weight:0 Kg

Gentamicin dose:0 mg to 0 mg

Calculate

---

• This calculator is for use as a guide only. The following patient groups may have altered pharmacokinetics and modified doses may be required. Please contact infectious diseases for advice with the following:
  • critically ill patients with severe sepsis or septic shock
  • patients receiving renal replacement therapy
  • patients with severe burns
  • patients with cystic fibrosis
  • pregnant women
  • patients with ascites
  • morbidly obese patients
• In low body weight patients or patients with an eGFR < 60mL/min it is important to calculate CrCl using the cockcroft gault formula.
• This calculator is not for use in critically ill patients with severe sepsis, who may require a dose of up to 7mg/kg (IDBW if obese or actual body weight if not obese)
• This calculator is not for use paediatric patients < 12 years old

Enter the patient details to calculate the vancomycin maintenance and loading dose:

Gender: Male Female

Body type: Normal frame Heavy frame Light Frame

Height (cm):

Actual weight (kg):

Age (years):

Creatinine:

vancomycin loading dose (optional):0 mg

vancomycin maintenance dose:0 mg, -

Calculate

---

• This calculator must not be used on large muscular patients, it assumes that all weights above IDBW are due to fatty tissue, large muscular patients are likely to be underdosed when using this calculator, please contact IFD for advice with these patients
• This calculator is for use as a guide only. The following patient groups may have altered pharmacokinetics and modified doses may be required. Please contact infectious diseases for advice with the following:
  • critically ill patients with severe sepsis or septic shock
  • patients receiving renal replacement therapy
  • pregnant women
  • patients with ascites or fluid overload
  • morbidly obese or very low body weight patients
• This calculator must not be used on large muscular patients, it assumes that all weights above IDBW are due to fatty tissue, large muscular patients are likely to be underdosed when using this calculator, please contact IFD for advice with these patients
• This calculator is not for use in critically ill patients with severe sepsis, who may require higher doses
• This calculator is not for use paediatric patients < 12 years old
• A loading dose of vancomycin may be considered to help achieve a therapeutic concentration more quickly, particularly in patients with serious infections who are critically ill. However, there are no strong clinical data to show that this approach improves outcomes.

• This calculator aims for a load of 25 to 30 mg/kg (actual body weight)

Cockcroft Gault Creatinine Clearance Calculator for >12 years only:

---

Enter the patient details to calculate the creatinine clearance:

Gender: Male Female

Body type: Normal frame Heavy frame Light Frame

Height (cm):

Actual weight (kg):

Age (years):

Creatinine:

Creatinine Clearance:0 mL/min

Calculate

---

• This calculator is for use as a guide only. The following patient groups may have altered pharmacokinetics and modified doses may be required. Please contact infectious diseases for advice with the following:
  • critically ill patients with severe sepsis or septic shock
  • patients receiving renal replacement therapy
  • pregnant women
  • patients with ascites or fluid overload
  • morbidly obese or very low body weight patients
• This calculator is not for use in critically ill patients with severe sepsis, who may require higher doses
• This calculator is not for use paediatric patients < 12 years old
• A loading dose of vancomycin may be considered to help achieve a therapeutic concentration more quickly, particularly in patients with serious infections who are critically ill. However, there are no strong clinical data to show that this approach improves outcomes.
• This calculator aims for a load of 25 to 30 mg/kg (actual body weight)

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

---

• Penicillin anaphylaxis is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Is the patient an adult or child?

• Adult patient
• Paediatric patient

Is the patient an adult or child?

• Adult patient
• Paediatric patient

Is the patient an adult or child?

• Adult patient
• Paediatric patient

Does the patient have severe sepsis?

• Yes
• No

---

• Any patient with a systolic blood pressure <90 or heart rate > 110 BPM despite having adequate fluid resuscitation should be regarded as having severe sepsis
• Any patient which has been accepted for admission into ICU or HDU should be treated as having severe sepsis

Does the patient have severe sepsis?

• Yes
• No

---

• Any patient with a systolic blood pressure <90 or heart rate > 110 BPM despite having adequate fluid resuscitation should be regarded as having severe sepsis
• Any patient which has been accepted for admission into ICU or HDU should be treated as having severe sepsis

Does the patient have severe sepsis?

• Yes
• No

---

• Any patient with a systolic blood pressure <90 or heart rate > 110 BPM despite having adequate fluid resuscitation should be regarded as having severe sepsis
• Any patient which has been accepted for admission into ICU or HDU should be treated as having severe sepsis

Does the patient have any risk factors for MRSA? (see below)

• Yes
• No

---

• Risk factors include; central or PICC line inflammation, known MRSA colonisation, severe mucositis, haemodynamic compromise BP<90 or HR>110, residence at a gaol or detention centre, or previous ciprofloxacin prophylaxis)

Does the patient have severe sepsis?

• Yes
• No

---

• Any patient with a systolic blood pressure <90 or heart rate > 110 BPM despite having adequate fluid resuscitation should be regarded as having severe sepsis
• Any patient which has been accepted for admission into ICU or HDU should be treated as having severe sepsis

Does the patient have severe sepsis?

• Yes
• No

---

• Any patient with a systolic blood pressure <90 or heart rate > 110 BPM despite having adequate fluid resuscitation should be regarded as having severe sepsis
• Any patient which has been accepted for admission into ICU or HDU should be treated as having severe sepsis

Does the patient have severe sepsis?

• Yes
• No

---

• Any patient with a systolic blood pressure <90 or heart rate > 110 BPM despite having adequate fluid resuscitation should be regarded as having severe sepsis
• Any patient which has been accepted for admission into ICU or HDU should be treated as having severe sepsis

Is the patient being treated during the wet or dry season?

• Wet season
• Dry season

---

• Typically the wet season is from November 1st to April 30th, however this may vary year to year.
• For more information on management of severe sepsis in a patient with febrile neutropenia see the IFD - febrile neutropenia initial management guideline on the PGC

Is the patient being treated during the wet or dry season?

• Wet season
• Dry season

---

• Typically the wet season is from November 1st to April 30th, however this may vary year to year.
• For more information on management of severe sepsis in a patient with febrile neutropenia see the IFD - febrile neutropenia initial management guideline on the PGC

Is the patient being treated during the wet or dry season?

• Wet season
• Dry season

---

• Typically the wet season is from November 1st to April 30th, however this may vary year to year.
• For more information on management of severe sepsis in a patient with febrile neutropenia see the IFD - febrile neutropenia initial management guideline on the PGC

Is the patient being treated during the wet or dry season?

• Wet season
• Dry season

---

• Typically the wet season is from November 1st to April 30th, however this may vary year to year.
• For more information on management of severe sepsis in a patient with febrile neutropenia see the IFD - febrile neutropenia initial management guideline on the PGC

If patient has a mild penicillin allergy use:

Meropenem 1g (child 20mg/Kg to a maximum of 1g) IV, 8 hourly

AND

A vancomycin loading dose of 25mg/Kg IV

THEN

Vancomycin IV, dosed as per nomograms below

---

Code for meropenem and vancomycin is: 3feb

---

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

• In the abscence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after an afebrile period 48 hours despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted.
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L.

If patient has a mild penicillin allergy use:

A vancomycin loading dose of 25mg/Kg IV

THEN

Vancomycin IV, dosed as per nomograms below

AND

Gentamicin IV, dosed as per nomograms below

AND

Ceftazidime 2g IV, 8 hourly

---

Code for vancomycin and ceftazidime is: 3feb

---

Initial Gentamicin/Tobramycin Dosing (age > 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate

---

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

• In the abscence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after an afebrile period 48 hours despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted.
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L.

If patient has a mild penicillin allergy give:

Ceftazidime 2g (child 50mg/Kg up to 2g) IV, 8 hourly

AND

A vancomycin loading dose of 25mg/Kg IV

THEN

Vancomycin IV, dosed as per nomograms below

AND if an abdomino-peritoneal infection is suspected ADD

Metronidazole 500mg (child 12.5mg/Kg up to 500mg) IV, 12 hourly

---

Code for ceftazidime and vancomycin is: 3feb

---

Vancomycin Dosing in Paediatrics

---

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

• In the abscence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after an afebrile period 48 hours despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted.
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L.

If patient has a mild penicillin allergy use:

A vancomycin loading dose of 25mg/Kg IV

THEN

Vancomycin IV, dosed as per nomogram below

AND

Gentamicin IV, dosed as per nomogram below

AND

Ceftazidime 50mg/Kg up to 2g IV, 8 hourly

---

Code for vancomycin and ceftazidime is: 3feb

---

Initial Paediatric Gentamicin Dosing (Age < 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR.
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)

---

Vancomycin Dosing in Paediatrics

---

• In the abscence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call about the patient
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after an afebrile period 48 hours despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted.
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L.

If patient has a severe penicillin allergy use meropenem very cautiously. Please ensure patient is in a critical care area before administering:

Meropenem 1g (child 20mg/Kg to a maximum of 1g) IV, 8 hourly given cautiously in a critical care area to monitor for reaction

AND

A vancomycin loading dose of 25mg/Kg IV

THEN

Vancomycin IV, dosed as per nomograms below

---

Code for meropenem and vancomycin is: 3feb

---

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

• In the abscence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after an afebrile period 48 hours despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted.
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L.

If patient has a severe penicillin allergy give:

Ciprofloxacin 400mg IV, 8 hourly

AND

Vancomycin IV, dosed as per nomograms below

AND if an abdomino-peritoneal infection is suspected ADD

Metronidazole 500mg (child 12.5mg/Kg up to 500mg) IV, 12 hourly

---

Code for ciprofloxacin and vancomycin is: 3feb

---

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

• In the abscence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the haematologist on call about patient admission

The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci

In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia

If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after an afebrile period 48 hours despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted.

If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L.

If patient has a severe penicillin allergy but is not showing signs of sepsis:

Please contact IFD for advice

A decision must be made on whether the patient should be initiated on a carbapenem or cephalosporin depening on severity of previous penicillin reaction and current clinical state

---

• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after an afebrile period 48 hours despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted.
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L.

If patient has no penicillin allergy use:

A vancomycin loading dose of 25mg/Kg IV

THEN

Vancomycin IV, dosed as per nomograms below

AND

Gentamicin IV, dosed as per nomograms below

AND

Piperacillin/tazobactam 4/0.5g IV, 6 hourly

---

Code for vancomycin and piperacillin is: 3feb

---

Initial Gentamicin/Tobramycin Dosing (age > 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate

---

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

• In the abscence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after an afebrile period 48 hours despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted.
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L.

If patient has no penicillin allergy use:

A vancomycin loading dose of 25mg/Kg IV

THEN

Vancomycin IV, dosed as per nomogram below

AND

Gentamicin IV, dosed as per nomogram below

AND

Piperacillin/tazobactam 100mg/Kg (dosed on piperacillin component only) up to 4g IV, 6 hourly

---

Code for vancomycin and ceftazidime is: 3feb

---

Initial Paediatric Gentamicin Dosing (Age < 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR.
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)

---

Vancomycin Dosing in Paediatrics

---

• In the abscence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the ICU consultant and haematologist on call about the patient
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after an afebrile period 48 hours despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted.
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L.

If patient has no penicillin allergy give:

Piperacillin 4/0.5g (child 100mg/Kg up to 4g dosed on piperacillin component only) IV, 6 hourly

AND

Vancomycin IV, dosed as per nomograms below

---

Code for piperacillin is: 3feb

---

Vancomycin Dosing in Adults

1. Vancomycin should be administered at a maximum rate of 10mg/min to avoid Red Man Syndrome
2. "Trough" levels are taken within 60 minutes of the next dose. If a loading dose is given then it is considered the first dose
3. In patients with CrClr < 20 mL/min, the clinical context (e.g haemodialysis) determines whether the next dose is given before the trough concentration is available or withheld until the result is known

---

• Please contact IFD within 48 hours of initiating therapy with vancomycin
• Watch baseline creatinine closely while treating a patient with vancomycin. An increase from baseline creatinine will almost always result in an increase in vancomycin concentration as vancomycin is 40-100% renally cleared. A sudden dramatic increase in creatinine should always prompt an immediate vancomycin level prior to the next dose, witholding the next dose until the level is available.
• If a dose is missed or delayed within 48 hours of taking a level please contact pharmacy for interpretation of trough levels as vancomycin will not have reached steady state

---

• In the abscence of resistant organisms on blood culture vancomycin may be ceased after 48-72 hours
• Please notify the haematologist on call of patient admission
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after an afebrile period 48 hours despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted.
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L.

If patient has no penicillin allergy give:

Piperacillin 4/0.5g (child 100mg/Kg up to 4g dosed on piperacillin component only) IV, 6 hourly

---

Code for piperacillin is: 3feb

---

• Please notify the haematologist on call of patient admission
• The median time to defervescence in patients with febrile neutropenia treated with frontline antibiotics is 3-5 days and thus escalation of antibiotic coverage should not occur prior to this period in the absence of clinical instability, isolation of a resistant organism or emergence of new infective foci
• In the absence of clinical evidence of viral or fungal infection, empiric frontline coverage for these pathogens is not required. Some haematology patients on high dose or T cell suppressing chemotherapy will be on prophylactic Posaconazole and/ or Bactrim and that should be continued during the management of febrile neutropenia
• If the patient has persistent fever of unknown origin for 96 hours or recurrent fevers after an afebrile period 48 hours despite broad spectrum antibacterial therapy then investigation and potential treatment for fungal therapy should be considered and the Infectious Diseases unit consulted.
• If the patient becomes afebrile within 3-5 days of parenteral antibiotic therapy, and no causative organism is isolated it is preferable to stop antibiotic treatment when the neutrophil count recovers to at least 0.5 x 10⁹ cells/L.

What type of infection is suspected/confirmed?

• Appendicitis
• Cholecystitis
• Diverticulitis
• Pancreatitis
• Peritonitis

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

---

• Penicillin anaphylaxis is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Has an appendicectomy been performed?

• Yes
• No

Was the appendix ruptured or was there an appendiceal abscess?

• Yes
• No

If the patient has a mild penicillin allergy cover with:

Ceftriaxone 1 g (child 1 month or older: 50 mg/kg up to 1 g) IV, daily until surgery

AND,

Metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV, every 12 hours until surgery

---

Then, after surgery is performed, if perforation or abscess was uncovered then consider step down to oral after initial improvement:

Trimethoprim+Sulfamethoxazole 160+800 mg (child 1 month or older: 4+20 mg/kg up to 160+800 mg) orally, 12 hourly to make up 7 days total treatment post appendicectomy

AND,

Metronidazole 400 mg (child: 10 mg/kg up to 400 mg) orally, every 12 hours to make up 7 days total treatment post appendicectomy

---

• Following successful surgery IV therapy can be rapidly switched to oral therapy if patient is improving
• If the appendix was not perforated then antibiotic therapy can be discontinued immediately post appendicectomy
• If the appendix was perforated or an appendiceal abscess was uncovered then total treatment duration (IV and oral) should usually only continue for 7 days
• When available the results of susceptibility testing should always guide treatment

If the patient has a mild penicillin allergy and the appendix was ruptured or had an appendiceal abscess treat with:

Ceftriaxone 1 g (child 1 month or older: 50 mg/kg up to 1 g) IV, daily until patients clinical condition improves

AND,

Metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV, every 12 hours until patients clinical condition improves

---

Then, after clinical condition improves, step down to oral:

Trimethoprim+Sulfamethoxazole 160+800 mg (child 1 month or older: 4+20 mg/kg up to 160+800 mg) orally, 12 hourly to make up 7 days total treatment post appendicectomy

AND,

Metronidazole 400 mg (child: 10 mg/kg up to 400 mg) orally, every 12 hours to make up 7 days total treatment post appendicectomy

---

• Following successful surgery IV therapy can be rapidly switched to oral therapy if patient is improving. Please see the switch to oral guideline on the PGC for information on how to identify when to switch to oral
• If the appendix was perforated or an appendiceal abscess was uncovered then total treatment duration (IV and oral) should usually only continue for 7 days
• When available the results of susceptibility testing should always guide treatment

If the appendix was not perforated and no appendiceal abscess was uncovered:

No further antibiotic therapy should be necessary

Has an appendicectomy been performed?

• Yes
• No

Was the appendix ruptured or was there an appendiceal abscess?

• Yes
• No

Is gentamicin contraindicated in this patient? (See below for contraindications)

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

Is gentamicin contraindicated in this patient? (See below for contraindications)

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

If the patient has a severe penicillin allergy cover with:

Gentamicin IV, dosed as per nomograms below

AND,

Lincomycin 600 mg (child: 15 mg/kg up to 600 mg) IV, every 8 hours until surgery

---

Then, after surgery is performed, if perforation or abscess was uncovered then consider a step down to oral after initial improvement:

Trimethoprim+Sulfamethoxazole 160+800 mg (child 1 month or older: 4+20 mg/kg up to 160+800 mg) orally, 12 hourly to make up 7 days total treatment post appendicectomy

AND,

Metronidazole 400 mg (child: 10 mg/kg up to 400 mg) orally, every 12 hours to make up 7 days total treatment post appendicectomy

---

Code for lincomycin is: 2int

---

Initial Paediatric Gentamicin Dosing (Age < 12 years)

Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR.
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)

---

• Following successful surgery IV therapy can be rapidly switched to oral therapy if patient is improving
• If the appendix was not perforated then antibiotic therapy can be discontinued immediately post appendicectomy
• If the appendix was perforated or an appendiceal abscess was uncovered then total treatment duration (IV and oral) should usually only continue for 7 days
• When available the results of susceptibility testing should always guide treatment

If the patient has a severe penicillin allergy and the appendix was ruptured or had an appendiceal abscess treat with:

Gentamicin IV, as per nomograms below

AND,

Lincomycin 600 mg (child: 15 mg/kg up to 600 mg) IV, every 8 hours until patients clinical condition improves

---

Then, after clinical condition improves, step down to oral:

Trimethoprim+Sulfamethoxazole 160+800 mg (child 1 month or older: 4+20 mg/kg up to 160+800 mg) orally, 12 hourly to make up 7 days total treatment post appendicectomy

AND,

Metronidazole 400 mg (child: 10 mg/kg up to 400 mg) orally, every 12 hours to make up 7 days total treatment post appendicectomy

---

Code for lincomycin is: 2int

---

Initial Gentamicin/Tobramycin Dosing (age > 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate

---

• Please note clindamycin has excellent oral bioavailability (90% orally bioavailable), consider an early switch to oral therapy once patients clinical condition has improved
• Following successful surgery IV therapy can be rapidly switched to oral therapy if patient is improving. Please see the switch to oral guideline on the PGC for information on how to identify when to switch to oral
• If the appendix was perforated or an appendiceal abscess was uncovered then total treatment duration (IV and oral) should usually only continue for 7 days
• When available the results of susceptibility testing should always guide treatment

If the patient has a contraindication to gentamicin and a severe penicillin allergy:

Please contact IFD for advice

Has an appendicectomy been performed?

• Yes
• No

Was the appendix ruptured or was there an appendiceal abscess?

• Yes
• No

Is gentamicin contraindicated in this patient? (See below for contraindications)

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

Is gentamicin contraindicated in this patient? (See below for contraindications)

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

If the patient tolerates penicillin cover with:

Gentamicin IV, dosed as per nomograms below

AND,

Ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, every 6 hours until surgery

AND,

Metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV, every 12 hours until surgery

---

Then, after surgery is performed, if perforation or abscess was uncovered then consider step down to oral after initial improvement:

Amoxycillin+clavulanate 875+125 mg (child: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12 hourly to make up 7 days total treatment post appendicectomy

---

Initial Paediatric Gentamicin Dosing (Age < 12 years)

---

Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR.
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)

---

• Following successful surgery IV therapy can be rapidly switched to oral therapy if patient is improving
• If the appendix was not perforated then antibiotic therapy can be discontinued immediately post appendicectomy
• If the appendix was perforated or an appendiceal abscess was uncovered then total treatment duration (IV and oral) should usually only continue for 7 days
• When available the results of susceptibility testing should always guide treatment

If the patient tolerates penicillin but not gentamicin and the appendix was ruptured or had an appendiceal abscess treat with:

Piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) IV, 8 hourly until clinical condition improves

---

Then, after clinical condition improves, step down to oral:

Amoxycillin+clavulanate 875+125 mg (child: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12 hourly to make up 7 days total treatment post appendicectomy

---

Code for piperacillin is: 2int

---

• Following successful surgery IV therapy can be rapidly switched to oral therapy if patient is improving. Please see the switch to oral guideline on the PGC for information on how to identify when to switch to oral
• If the appendix was perforated or an appendiceal abscess was uncovered then total treatment duration (IV and oral) should usually only continue for 7 days
• When available the results of susceptibility testing should always guide treatment

If the patient has a contraindication to gentamicin and a severe penicillin allergy:

Please contact IFD for advice

If the patient tolerates penicillin but not gentamicin cover with:

Piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) IV, 8 hourly until surgery

---

Then, after surgery is performed, if perforation or abscess was uncovered then consider step down to oral after initial improvement:

Amoxycillin+clavulanate 875+125 mg (child: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12 hourly to make up 7 days total treatment post appendicectomy

---

Code for piperacillin is: 2int

---

• Following successful surgery IV therapy can be rapidly switched to oral therapy if patient is improving
• If the appendix was not perforated then antibiotic therapy can be discontinued immediately post appendicectomy
• If the appendix was perforated or an appendiceal abscess was uncovered then total treatment duration (IV and oral) should usually only continue for 7 days
• When available the results of susceptibility testing should always guide treatment

If the patient tolerates penicillin and gentamicin give:

Gentamicin IV, dosed as per nomograms below

AND,

Ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, every 6 hours

AND,

Metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV, every 12 hours until clinical condition improves

---

Then, after clinical condition improves switch to oral:

Amoxycillin+clavulanate 875+125 mg (child: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12 hourly to make up 7 days total treatment post appendicectomy

---

Initial Gentamicin/Tobramycin Dosing (age > 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate

---

• Following successful surgery IV therapy can be rapidly switched to oral therapy if patient is improving. Please see the switch to oral guideline on the PGC for information on how to identify when to switch to oral
• If the appendix was perforated or an appendiceal abscess was uncovered then total treatment duration (IV and oral) should usually only continue for 7 days
• When available the results of susceptibility testing should always guide treatment

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

---

• Penicillin anaphylaxis is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Has a cholecystectomy been performed?

• Yes
• No

If the patient has a mild penicillin allergy or does not tolerate gentamicin treat empirically with:

Ceftriaxone 1 g (child 1 month or older: 50 mg/kg up to 1 g) IV, daily until surgery or until clinical improvement then switch to oral

OR

Cefotaxime 1 g (child 1 month or older: 50 mg/kg up to 1 g) IV, 8 hourly, until surgery or until clinical improvement then switch to oral

Once the patient's condition has improved, change to:

Trimethoprim+sulfamethoxazole 160+800 mg (child 1 month or older: 4+20 mg/kg up to 160+800 mg) orally, 12 hourly until surgery or for a maximum of 7 days total treatment (IV and oral)

---

Code for cefotaxime is: 2int

---

• Antibiotic therapy should be stopped within 24 hours of cholecystectomy as the source of the infection has been removed
• If surgery is not performed the total treatment duration should not exceed 7 days (IV + oral).
• When available the results of susceptibility testing should always guide treatment
• Acute cholecystitis is usually caused by enteric Gram-negative bacilli (eg Escherichia coli and Klebsiella species) and, less commonly, Enterococcus faecalis. Infrequently, infection is caused by anaerobic bacteria.
• Please see the switch to oral guideline on the PGC for information on how to identify when to switch to oral

Treatment post cholecystectomy should normally be ceased within 24 hours. If a further dose of surgical prophylaxis is deemed necessary give:

Ceftriaxone 1 g (child 1 month or older: 50 mg/kg up to 1 g) IV, as a single dose

---

• If surgery is not performed the total treatment duration should not exceed 7 days (IV + oral).
• When available the results of susceptibility testing should always guide treatment
• Acute cholecystitis is usually caused by enteric Gram-negative bacilli (eg Escherichia coli and Klebsiella species) and, less commonly, Enterococcus faecalis. Infrequently, infection is caused by anaerobic bacteria.

Has a cholecystectomy been performed?

• Yes
• No

Is gentamicin contraindicated in this patient? (See below for contraindications)

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

Is gentamicin contraindicated in this patient? (See below for contraindications)

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

If the patient has a severe penicillin allergy cover with:

Gentamicin IV, dosed as per nomograms below:

Then, after clinical improvement or after 72 hours consider step down to oral:

Trimethoprim+Sulfamethoxazole 160+800 mg (child 1 month or older: 4+20 mg/kg up to 160+800 mg) orally, 12 hourly to make up a maximum of 7 days total treatment or until cholecystectomy

---

Initial Gentamicin/Tobramycin Dosing (age > 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate

---

• Antibiotic therapy should be stopped within 24 hours of cholecystectomy as the source of the infection has been removed
• If surgery is not performed the total treatment duration should not exceed 7 days (IV + oral).
• When available the results of susceptibility testing should always guide treatment
• Acute cholecystitis is usually caused by enteric Gram-negative bacilli (eg Escherichia coli and Klebsiella species) and, less commonly, Enterococcus faecalis. Infrequently, infection is caused by anaerobic bacteria.

Following cholecystectomy antibiotic treatment should cease within 24 hours as the source of the infection has been removed. If a further dose of surgical prophylaxis is deemed necessary give:

Gentamicin IV, as a single dose as the per nomogram below

---

Initial Gentamicin/Tobramycin Dosing (age > 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate

---

• When available the results of susceptibility testing should always guide treatment
• Acute cholecystitis is usually caused by enteric Gram-negative bacilli (eg Escherichia coli and Klebsiella species) and, less commonly, Enterococcus faecalis. Infrequently, infection is caused by anaerobic bacteria.

If the patient has a contraindication to gentamicin and a severe penicillin allergy:

Please contact IFD for advice

---

• Please note, following cholecystectomy antibiotic treatment should cease within 24 hours as the source of the infection has been removed.

Has a cholecystectomy been performed?

• Yes
• No

Is gentamicin contraindicated in this patient? (See below for contraindications)

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

If the patient tolerates penicillin but not gentamicin and a cholecystectomy has been performed:

Ongoing antibiotic treatment should be continued for a maximum of 24 hours only:

Piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) IV, 8 hourly for 24 hours

OR

Ceftriaxone 1g IV (child: 50 mg/kg up to 1g) IV, as a single dose

OR if patient is tolerating orals:

Amoxycillin+clavulanate 875+125 mg (child: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12 hourly for 24 hours

---

Code for piperacillin is: 1int

---

• Following successful surgery antibiotic therapy can normally be ceased within 24 hours
• When available the results of susceptibility testing should always guide treatment
• Acute cholecystitis is usually caused by enteric Gram-negative bacilli (eg Escherichia coli and Klebsiella species) and, less commonly, Enterococcus faecalis. Infrequently, infection is caused by anaerobic bacteria.

If the patient tolerates penicillin cover with:

Gentamicin IV, dosed as per nomograms below

AND,

Ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, every 6 hours until surgery

---

Then, after clinical improvement switch to:

Amoxycillin+clavulanate 875+125 mg (child: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12 hourly

Initial Gentamicin/Tobramycin Dosing (age > 12 years)

---

• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Patients with severe sepsis have higher volumes of distribution and therefore require a higher mg/kg dose

---

• Following successful cholecystectomy all antibiotic therapy should be ceased within 24 hours as the source of infection has been removed
• Total treatment duration (IV + oral) should not exceed 7 days if surgery is not performed
• When available, the results of susceptibility testing should always guide treatment
• If IV therapy is required beyond 72 hours, cease the gentamicin-containing regimen and use ceftriaxone, cefotaxime or piperacillin+tazobactam (see the therapeutic guidelines for details)

If the patient tolerates penicillin but not gentamicin cover with:

Piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) IV, 8 hourly until surgery or clinically improved then switch to oral

OR

Ceftriaxone 1g IV (child: 50 mg/kg up to 1g) IV, daily until surgery or clinically improved then switch to oral

OR

Cefotaxime 1g IV (child: 50 mg/kg up to 1g) IV, 8 hourly until surgery or clinically improved then switch to oral

---

Then, after clinical improvement:

Amoxycillin+clavulanate 875+125 mg (child: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12 hourly to make up a maximum of 7 days total treatment (IV and oral)

---

Code for piperacillin or cefotaxime is: 2int

---

• Antibiotic therapy should be stopped within 24 hours of cholecystectomy as the source of the infection has been removed
• If surgery is not performed the total treatment duration should not exceed 7 days (IV + oral).
• When available the results of susceptibility testing should always guide treatment
• Acute cholecystitis is usually caused by enteric Gram-negative bacilli (eg Escherichia coli and Klebsiella species) and, less commonly, Enterococcus faecalis. Infrequently, infection is caused by anaerobic bacteria.

How would you grade the diverticulitis? (see below)

• Mild
• Severe

---

• Patients with mild abdominal pain and tenderness who do not have significant systemic signs or symptoms should be considered to have mild diverticulitis.
• Patients with peritonism, or those who have signs of diverticulitis and significant systemic signs or symptoms (eg fever, elevated white cell count), should be treated as severe or complicated diverticulitis.

Is the patient showing any systemic symptoms?

• Yes
• No

---

• Antibiotics should only be considered for patients showing systemic symptoms such as fever or elevated white cell count, or patients who have failed to respond to conservative management (IV fluids and bowel rest)

For mild diverticulitis with no systemic involvement:

Antibiotic treatment may not be required.

Recent trials have suggested that antibiotic therapy may not be required for patients with mild abdominal pain and tenderness who do not have significant systemic signs or symptoms. If antibiotic therapy is deemed necessary then use the link below to continue to treatment:

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

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• Anaphylactic penicillin allergy is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

For diverticulitis in a patient with mild penicillin allergy use:

Trimethoprim+sulfamethoxazole 160+800 mg (child 1 month or older: 4+20 mg/kg up to 160+800 mg) orally, 12-hourly

AND

Metronidazole 400 mg (child: 10 mg/kg up to 400 mg) orally, 12-hourly

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• Total antibiotic therapy should not normally exceed 5 days treatment.

For diverticulitis in a patient tolerant of penicillin use as a single agent:

Amoxycillin+clavulanate 875+125 mg (child: 22.5+3.2 mg/kg up to 875+125 mg) orally, 12-hourly

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• Total antibiotic therapy should not normally exceed 5 days treatment.

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

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• Anaphylactic penicillin allergy is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Is gentamicin contraindicated in this patient? (See below for contraindications)

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

Is gentamicin contraindicated in this patient? (See below for contraindications)

• Gentamicin contraindicated
• Gentamicin not contraindicated

Aminoglycoside Contraindications and Precautions

For diverticulitis in a patient with non-life threatening penicillin hypersensitivity use:

Ceftriaxone 1g IV, (child 1 month or older: 50 mg/kg up to 1 g) Daily

AND

Metronidazole 500mg IV, (child 1 month or older: 7.5 mg/kg up to 500 mg) 12 hourly

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• Consider a switch to oral once patient has been afebrile for 24 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not exceed 7 days treatment.

For diverticulitis in a patient with life threatening penicillin hypersensitivity intolerant of gentamicin:

Please contact IFD for advice

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• Consider a switch to oral once patient has been afebrile for 24 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not exceed 7 days treatment.

For diverticulitis in a patient with life threatening penicillin hypersensitivity use:

Gentamicin IV, dosed as per table below

AND

Lincomycin 600 mg (child: 15 mg/kg up to 600 mg) IV, 8-hourly

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Code for lincomycin is: 3int

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Initial Paediatric Gentamicin Dosing (Age < 12 years)

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Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

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• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR.
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)

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• Consider a switch to oral once patient has been afebrile for 24 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not exceed 7 days treatment.

For diverticulitis in a patient who can tolerate penicillin and gentamicin:

Ampicillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly

AND

Metronidazole 500mg IV, (child 1 month or older: 12.5 mg/kg up to 500 mg) 12 hourly

AND

Gentamicin IV, dosed as per table below

If IV treatment is required after 72 hours change to Piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) IV, 8-hourly.

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Initial Paediatric Gentamicin Dosing (Age < 12 years)

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Initial Gentamicin/Tobramycin Dosing (Age > 12 years)

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• Gentamicin should be dosed based on ideal body weight or actual body weight (whichever is lower)
• Critically ill patients with severe sepsis have higher volumes of distribution. In these patients a dose of 7mg/kg may be appropriate
• For dosing in children with cystic fibrosis or those receiving chemotherapy, seek expert advice
• For children with impaired renal function (estimated glomerular filtration rate [eGFR] less than 50 mL/min/1.73 m²), give a single dose, then seek expert advice for subsequent dosing or selection of alternative drug. Use the modified Schwartz formula to estimate GFR.
• Postmenstrual age is the time elapsed between the first day of the last menstrual period and birth (gestational age) plus the time elapsed after birth (postnatal age)

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• Consider a switch to oral once patient has been afebrile for 24 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not exceed 7 days treatment.

For diverticulitis in a patient tolerant of penicillin but intolerant of gentamicin use:

Piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) IV, every 8 hours

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Code for piperacillin is: 3int

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• Consider a switch to oral once patient has been afebrile for 24 hours as with all abdominal infections
• Total antibiotic therapy (IV and PO) should not exceed 7 days treatment.

How severe is the pancreatitis?

• Mild or Moderate
• Severe (for ICU/HDU)

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• Severe pancreatitis occurs in approximately 10-20% of patients with pancreatitis and is characterised by development of a systemic inflammatory response in the first 7-10 days, and/or pancreatic necrosis and infection in the late phase
• All patients with severe pancreatitis should be referred to ICU for assessment
• Most episodes of acute pancreatitis are due to prolonged excessive alcohol consumption, are associated with gallstones (particularly bile duct stones), or are idiopathic. The recognition of persisting obstruction and acute cholangitis in patients with severe acute pancreatitis is important

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

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• Anaphylactic penicillin allergy is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

For severe infected/necrotising pancreatitis in a patient with mild penicillin allergy:

Metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) IV, 12 hourly

AND either

Ceftriaxone 1 g (child 1 month or older: 50 mg/kg up to 1 g) IV, daily

OR

Cefotaxime 1 g (child: 50 mg/kg up to 1 g) IV, 8 hourly

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Code for cefotaxime is: 2int

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• Patients with severe pancreatitis can intermittently appear septic during a prolonged hospitalisation. Before giving antibiotics, every effort should be made to perform image-guided percutaneous aspiration of any pancreatic collection, with Gram stain and cultures of the aspirate
• Data to support the use of carbapenems in empirical treatment are lacking
• This is a guide for empirical therapy only. Modify therapy according to the results of cultures and susceptibility testing. Reserve carbapenems for infections caused by resistant pathogens.
• Antibiotics are not indicated in the management of mild to moderate acute pancreatitis
• The optimal duration for treatment with antibiotics for infective pancreatitits is uncertain. An initial treatment course of 7 days is commonly used
• All patients with signs of infective necrotic pancreatitis should have an ICU assessment
• Acute pancreatitis may also be induced by drugs such as azathioprine and antiretroviral and chemotherapeutic drugs. However, when drug-induced pancreatitis is suspected, every drug that the patient is taking should be considered a possible cause

For infected/necrotising pancreatitis in a patient with major penicillin allergy:

Please contact IFD for advice

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• Patients with severe pancreatitis can intermittently appear septic during a prolonged hospitalisation. Before giving antibiotics, every effort should be made to perform image-guided percutaneous aspiration of any pancreatic collection, with Gram stain and cultures of the aspirate
• Data to support the use of carbapenems in empirical treatment are lacking
• This is a guide for empirical therapy only. Modify therapy according to the results of cultures and susceptibility testing. Reserve carbapenems for infections caused by resistant pathogens.
• Antibiotics are not indicated in the management of mild to moderate acute pancreatitis
• The optimal duration for treatment with antibiotics for infective pancreatitits is uncertain. An initial treatment course of 7 days is commonly used
• All patients with signs of infective necrotic pancreatitis should have an ICU assessment
• Acute pancreatitis may also be induced by drugs such as azathioprine and antiretroviral and chemotherapeutic drugs. However, when drug-induced pancreatitis is suspected, every drug that the patient is taking should be considered a possible cause

For infected necrotising pancreatitis in a patient with no penicillin allergy:

Piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) IV, 8 hourly

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Code for piperacillin is: 3int

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• Patients with severe pancreatitis can intermittently appear septic during a prolonged hospitalisation. Before giving antibiotics, every effort should be made to perform image-guided percutaneous aspiration of any pancreatic collection, with Gram stain and cultures of the aspirate
• Data to support the use of carbapenems in empirical treatment are lacking
• This is a guide for empirical therapy only. Modify therapy according to the results of cultures and susceptibility testing. Reserve carbapenems for infections caused by resistant pathogens.
• Antibiotics are not indicated in the management of mild to moderate acute pancreatitis
• The optimal duration for treatment with antibiotics for infective pancreatitits is uncertain. An initial treatment course of 7 days is commonly used
• All patients with signs of infective necrotic pancreatitis should have an ICU assessment
• Acute pancreatitis may also be induced by drugs such as azathioprine and antiretroviral and chemotherapeutic drugs. However, when drug-induced pancreatitis is suspected, every drug that the patient is taking should be considered a possible cause

For mild to moderate pancreatitis:

Antibiotics are not indicated for the management of mild or moderate pancreatitis

Antibiotics are only indicated if necrosis or systemic signs of infection are observed in severe cases of pancreatitis. These cases should be managed in the ICU/HDU. Gut rest, fluid administration and pain management are the mainstay of treatment for most cases of mild or moderate pancreatitis

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• Severe pancreatitis occurs in approximately 10-20% of patients with pancreatitis and is characterised by development of a systemic inflammatory response in the first 7-10 days, or pancreatic necrosis on imaging
• All patients with signs of infective necrotic pancreatitis should have an ICU assessment
• Acute pancreatitis may also be induced by drugs such as azathioprine and antiretroviral and chemotherapeutic drugs. However, when drug-induced pancreatitis is suspected, every drug that the patient is taking should be considered a possible cause

What is the cause of the peritonitis?

• Perforated viscus
• Spontaneous (SBP)

Does the patient have a penicillin allergy?? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

---

• Anaphylactic penicillin allergy is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin

Does the patient have a penicillin allergy? (See below for details on penicillin allergy severity)

• No penicillin allergy
• Minor penicillin allergy
• Penicillin anaphylaxis

---

• Anaphylactic penicillin allergy is defined as a clear history of: Bronchospasm, rash, anaphylaxis, SJS or DRESS immediately after administration of a penicillin
• There is only a 2.5% chance of cephalosporin allergy in a patient previously allergic to penicillin. In most cases it is safe to administer a cephalosporin to a patient who has had a non-life threatening reaction to penicillin