Antibiotic man

Question 1

What NEWS score coupled with infection would make you think Sepsis and what do you need to complete thereafter ?

Answer 1

A NEWS score of equal to or greater than 5

You must complete sepsis 6 bundle within 1 hr (BUFALO)

Question 2

What SIRS score and likely source of infection would make you think Sepsis and thereafter what must you do ?

Answer 2

SIRS of equal to or greater than 2:

• Temperature >38°C < 36°C
• HR > 90 beats per minute
• Altered mental state
• RR >20 breaths/min
• WCC <4 or >12
• Known or suspected neutropenia

Complete Sepsis 6 bundle within 1 hr (BUFALO)

Question 3

How often should IV antibiotic therapy be reviewed ?`

Answer 3

Every 12-24hrs

Question 4

What are the indications to continue with IV antibiotics and not change to oral ?

Answer 4

Continuing serious sepsis (2 or more of the following):

1. temp > 38°C or < 36°C
2. tachycardia ≥ 90/min
3. tachypnoea > 20 breaths/min
4. WCC > 12 or < 4
5. Febrile with neutropenia (WCC <1.0) or immunosuppression

Specific infections which require high dose IV therapy eg endocarditis, septic arthritis, osteomyelitis, meningitis, abscess, cystic fibrosis patients, prosthetic infection

Oral route compromised:

1. vomiting
2. nil by mouth
3. reduced absorption e.g. severe diarrhoea or steatorrhoea
4. mechanical swallowing disorder
5. unconscious

Patient post surgery not tolerated 1 litre of oral fluids

IV antibiotic not included in IVOST protocol

Question 5

What should you always check prior to prescribing gentamicin ?

Answer 5

Exclusion criteria

Question 6

What is the exclusion criteria for giving a patient Gentamicin?

Answer 6

• Children < 16 years old
• Ascites > 20% body weight
• Major burns > 20% body surface
• Decompensated Liver Disease
• Myasthenia Gravis
• Renal Transplant
• Acute Kidney Injury (AKI 3) on dialysis or eGFR <20ml/min
• End stage renal failure on dialysis with residual kidney function

Question 7

What 3 things should be done if IV gentamicin is still indicated after 72hrs of treatment (or if poor/deteriorating renal function)?

Answer 7

1. Check microbiology results & sensitivities
2. Consider switch to aztreonam
3. If required ask Infectious diseases (ID) or microbiology for advice

Question 8

What is the standard treatment for bacterial meningitis ?

Answer 8

IV ceftriaxone + IV dexamethasone (started with or just before first dose of antibiotics)

Question 9

What is the treatment of bacterial meningitis in those equal to or >60 or immunocompromised ?

Answer 9

IV ceftriaxone + IV dexamethasone + IV amoxicillin

Question 10

What is the treatment of suspected encephalitis ?

Answer 10

IV aciclovir

Question 11

What is the treatment of epiglottis/supraglottis ?

Answer 11

1. IV ceftriaxone
2. Step down to Co-amoxiclav PO (or in penicillin allergy: PO Doxycycline + Metronidazole)

Question 12

What should be done to assess the severity of a pneumonia and ==> decide the treatment ?

Answer 12

CURB65 score

• Confusion
• Urea > or equal to 7 mmol/l
• RR > or equal to 30
• BP: SBP < 90 or DBP < 60
• Age > or equal to 65

Question 13

What is the treatment of a mild/moderate community acquired pneumonia (CAP) and what CURB65 score classifys it as one ?

Answer 13

Score of 0-2

Amoxicillin IV/PO (If penicillin allergic: Doxycycline PO on day 1 then or IV Clarithromycin if NBM - nil by mouth)

Question 14

What is the standard treatment of a severe CAP and what CURB65 score classifys it as one ?

Answer 14

• Score of 3-5
• Co-amoxiclav IV + Doxycycline PO (If penicillin allergic: IV Levofloxacin)

Question 15

What is the standard treatment of a severe CAP in ICU/HDU or one who is NBM ?

Answer 15

Co-amoxiclav IV + Clarithromycin IV (If penicillin allergic: IV Levofloxacin)

Question 16

What is the stepdown treatment for ALL patients with severe CAP?

Answer 16

Doxycycline IV/PO

Question 17

What is the treatment of a non-severe hospital acquired pneumonia (HAP)?

Answer 17

PO Amoxicillin (If penicillin allergic: Doxycycline)

Question 18

What is the treatment of a severe HAP ?

Answer 18

IV Amoxicillin + Gentamicin (If penicillin allergic:IV Co-trimoxazole + Gentamicin)

Question 19

What is the step down treatment of a severe HAP ?

Answer 19

PO Co-trimoxazole

Question 20

What should be done if a patient has a severe HAP with a previous ICU admission or history of MRSA?

Answer 20

seek advice

Question 21

What is the treatment of a non-severe aspiration pneumonia ?

Answer 21

PO Amoxicillin + Metronidazole (If penicillin allergic: PO Doxycycline + Metronidazole)

Question 22

What is the treatment of a severe aspiration pneumonia ?

Answer 22

IV Amoxicillin + Metronidazole + Gentamicin (If penicillin allergic: replace amoxicillin with PO Doxycycline or IV Clarithromycin)

Question 23

What is the stepdown treatment of a severe aspiration pneumonia ?

Answer 23

PO Amoxicillin + Metronidazole (If pencillin allergic replace amoxicillin with doxycyline)

Question 24

When should antibiotics be given and when should they not be in an acute exacerbation of COPD?

Answer 24

1. Give antibiotics if ↑ sputum purulence.
2. If no ↑ sputum purulence then no antibiotics unless consolidation on CXR or signs of pneumonia

Question 25

What is the 1st and 2nd line treatment of acute exacerbations of COPD ?

Answer 25

* 1st line = Amoxicillin * 2nd line = Doxycyline

Question 26

When are antibiotics given for acute cough/bronchitis ?

Answer 26

They are not usually given as they provide no significant benefit in clinical improvement but may be considered in the frail elderly

Question 27

If antibiotics where to be given for acute cough/bronchitis what is 1st and 2nd line ?

Answer 27

* 1st line = Amoxicillin * 2nd line = Doxycyline

Question 28

What 3 things should always be done for endocarditis?

Answer 28

1. Take blood cultures 2. Start empirical antibiotic therapy and refer to ID/microbiology 3. **Always** check full endocarditis guidance for gentamicin/vancomycin dosing especially if reduced renal function

Question 29

What is the treatment of Native valve indolent (Subacute) endocarditis ?

Answer 29

IV Amoxicillin + Gentamicin (If true penicillin allergy use Vancomycin + Gentamicin)

Question 30

What is the treatment of Native valve severe sepsis (Acute) endocarditis ?

Answer 30

IV Flucloxacillin (If true penicillin allergy use Vancomycin + Gentamicin)

Question 31

What is the treatment of Prosthetic valve or Suspected MRSA endocarditis ?

Answer 31

IV Vancomycin + Gentamicin + when therapeutic vancomycin levels reached add Rifampicin PO

Question 32

How is the severity of C.diff assessed ?

Answer 32

Severe if one or more of the following severity markers: * Temperature \> 38.5°C * Ileus, colonic dilatation \>6cm on AXR/CT, toxic megacolon and/or pseudomembranous colitis * WBC \>15 cells x 109 L * Acute rising serum creatinine \>1.5 x baseline * Has persisting CDI where the patient has remained symptomatic and toxin positive despite 2 courses of appropriate therapy

Question 33

What is the treatment of non-severe C.diff ?

Answer 33

* 1st line = Metronidazole PO * 2nd line = Vancomycin

Question 34

What is the 1st and 2nd line treatment of severe C.diff?

Answer 34

* 1st line = PO Vancomycin if oral not available give via NG tube * 2nd line = If ileus is detected or NG route not available treat with IV metronidazole + vancomycin (via NG or intracolonic) until ileus is resolved.

Question 35

What is classified as recurrent C.diff infection and what is the treatment of it ?

Answer 35

Recurrent if positive CDI in previous 8 weeks Fidaxomicin +/- Vancomycin tapering regime

Question 36

What is the antibiotic treatment of acute gastroenteritis or acute pancreatitis ?

Answer 36

Antibiotics unlikely to affect outcome. Seek advice

Question 37

What is the treatment of Peritonitis/biliary tract/ intra-abdominal infection ?

Answer 37

* IV Amoxicillin + Metronidazole + Gentamicin (Think GAM) * (If penicillin allergic: IV Vancomycin + Metronidazole + Gentamicin

Question 38

What is the step-down treatment of Peritonitis/biliary tract/ intra-abdominal infection ?

Answer 38

PO Co-trimoxazole + Metronidazole

Question 39

What is the treatment of mild proven spontaneous bacterial peritonitis ?

Answer 39

PO Co-trimoxazole

Question 40

What is the initial and stepdown treatment of severe proven spontaneous bacterial peritonitis ?

Answer 40

* IV Piperacillin/Tazobactam * then step down to Co-trimoxazole PO

Question 41

What are the 3 key things to remember when investigating and treating UTI's in catheterised patients ?

Answer 41

1. Do not use urinanalysis 2. Do not treat unless clinical signs/symptoms of infection 3. If definite infection treat as per complicated UTI guidance

Question 42

What are the 3 key things to remember when investigating and treating UTI's in older adults ?

Answer 42

1. Do not use urinanalysis 2. Do not treat unless clinical signs/symptoms of infection 3. If definite infection treat as per normal guidelines

Question 43

What is the initial and step-down treatment of complicated UTI/pyelonephritis/ urosepsis ?

Answer 43

1. IV Amoxicillin + Gentamicin (If penicillin allergic: IV Co-trimoxazole + Gentamicin) 2. Step down: PO Co-trimoxazole or as per sensitivities

Question 44

What is the treatment of uncomplicated female lower UTI's and for how long?

Answer 44

* 1st line = Nitrofurantoin * 2nd line = Trimethoprim 3 days

Question 45

What is the treatment of uncatheterised male UTI's and for how long?

Answer 45

1. 1st line = Nitrofurantoin 2. 2nd line = Trimethoprim 7 days

Question 46

What is the treatment of acute bacterial prostatits ?

Answer 46

1st line = PO Ofloxacin or Ciprofloxacin or PO Trimethoprim if high CDI risk If IV required: Amoxicillin IV + Gentamicin IV then step down as per oral options above

Question 47

What is the treatment of Epididymo-orchitis ?

Answer 47

1. If urethral discharge, new sexual partner in last 3/12 or \<35yrs old then treat as likely STI and give Doxycyline (unless history of anal then give Ofloxacin or ciprofloxacin) 2. If no urethral discharge, No recent change sexual partner And \>35 years old then ask about Any fever or back pain or signs of sepsis? ==\> If YES then treat as Upper UTI, if NO then treat with Ofloxacin or ciprofloxacin

Question 48

How is the severity of cellulitis assessed ?

Answer 48

(essentially assessing if they have sepsis or not) 1. **Mild** = No signs of systemic toxicity 2. **Sepsis** = Systemically unwell and/or NEWS ≥5 3. **Septic Shock and/or Necrotising Fasciitis (NF)** = Evidence of end organ dysfunction despite fluid resuscitation and/or local signs of necrotising fasciitis (e.g. pain / systemic upset disproportionate to appearance, bullae, haemorrhage / bruising, rapid progression, crepitus)

Question 49

What is the treatment of mild cellulitis ?

Answer 49

* 1st line = Flucloxacillin PO for 7 days * 2nd line = If not resolving or penicillin allergy: Doxycycline for 7 days

Question 50

What is the treatment for septic cellulitis ?

Answer 50

1st line = IV flucloxacillin with stepdown to PO flucloxacillin (if penicillin allergy IV vancomycin with stepdown to PO doxycycline)

Question 51

What is the treatment of Septic Shock and/or Necrotising Fasciitis cellulitis ?

Answer 51

1st line = IV Flucloxacillin + Clindamycin + Gentamicin (if penicillin allergy then IV Clindamycin + Gentamicin +/- Vancomycin if risk of MRSA)

Question 52

How is the severity of diabetic foot infections classified ?

Answer 52

Mild: * **Either: 2 or more features of inflammation**: pus,erythema, pain, tender, warmth, induration **Or (b) Cellulitis \<2cm.** Confined to skin or subcutaneous tissue and **No evidence of systemic illness** Moderate: * As per mild with either: (a) Lymphatic streaking, deep tissue infection (subcutaneous, fascia, tendon, bone), abscess Or (b) Cellulitis \>2cm and No evidence of systemic illness Severe: * Any infection with evidence of severe sepsis. Osteomyelitis

Question 53

What is the treatment of a mild infected diabetic foot ?

Answer 53

* 1st line = PO flucloxacillin * 2nd line = PO doxycycline

Question 54

What is the treatment of a moderate infected diabetic foot ?

Answer 54

* 1st line = PO Flucloxacillin + Metronidazole * 2nd line = If deep tissue infection: IV Flucloxacillin + PO Metronidazole

Question 55

What is the treatment of a severe diabetic infected foot ?

Answer 55

* IV Flucloxacillin + Gentamicin (or Aztreonam) + IV/PO Metronidazole

Question 56

What is the treatment of acute septic arthritis/ostemyelitis ?

Answer 56

* IV flucloxacillin and seek ID advice

Question 57

What is the open fracture prophylaxis treatment and when should it be started ?

Answer 57

* IV Co-amoxiclav (or IV Co-trimoxazole + Metronidazole) * Start within 3 hours for max 72 hours

Question 58

What is the antibiotic treatment for severe systemic infections of unknown origin ?

Answer 58

1st line = IV Amoxicillin + Metronidazole + Gentamicin (GAM) (If PWID add S. aureus cover IV Flucloxacillin) (If penicillin allergy IV Vancomycin + Metronidazole + Gentamicin)