Antimicrobial Stewardship (AMS)

In this section you will find resources for health professionals about empiric antimicrobial treatment, antimicrobial resistance and Auckland DHB's Antimicrobial Stewardship (AMS) programme.

Resources

Antimicrobial Stewardship Committee
Community Antibiotics Guidance (BPAC) (external link)  (for adults and children)

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

(external link) (external link)

Adults Paediatrics

Empirical Treatment Guidelines

Starship Clinical Guidelines (external link)

Surgical Prophylaxis [PDF, 236 KB]

Surgical Prophylaxis [PDF, 226 KB]

Aminoglycoside flowchart [PDF, 126 KB]

Aminoglycosides (external link)

Vancomycin (external link) (Auckland DHB intranet only)

Vancomycin (external link)

Cefuroxime [PDF, 683 KB], and meropenem [PDF, 211 KB] dosing guides

 Adult restricted list [PDF, 103 KB] *

 Paediatric restricted list [PDF, 92 KB] *

  The antimicrobials highlighted in yellow in the above restricted lists may be exempted pre-approval if one of the relevant listed criteria is met:

  • When indicated on the list, a special authority number exists for community prescription
  • Prescription is for an approved indication
  • Prescription is by an approved prescriber

There are no exemptions for antimicrobials highlighted in red in the above adult and paediatrics restricted lists.

When pre-approval is required, this will be issued after telephone consultation with a member of the infectious diseases or microbiology teams. These services provide a 24-hour on call service for approvals and clinical advice. Restricted antimicrobials may only be dispensed or administered if the medication chart is completed correctly. All prescriptions should be clearly annotated with: 

  • the indication (e.g. “CAP”) and
  • the planned duration (e.g. “x3/7”) and
  • name of approver (e.g. App’d Dr Handy) or
  • relevant exemption (e.g. “CHEM/123456789/July 2016 or “TB SMO, Dr Nisbet”).

Should the approved agent be required after hours, supplies can be obtained through the usual routes.


 Adult Empirical Antimicrobial Treatment Guidelines

 

Sepsis
CNS 
OPHTHALMOLOGY 
EAR, NOSE AND THROAT 
RESPIRATORY TRACT 
CARDIOTHORACIC 
SKIN AND SOFT TISSUE 
BONE AND JOINT
 
GASTROINTESTINAL TRACT 
GENITO-URINARY TRACT 
 

Note the following colour-coded key for the table below:

  • Red      Penicillin-based
  • Yellow   Suitable for penicillin rash allergy
  • Green   Not penicillin based
  • Purple   Requires pre-approval

Sepsis

Neutropenic sepsis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Haematology

piperacillin-tazobactam 4.5g IV q6h
± gentamicin 5mg/kg IV q24h

Oral therapy not appropriate As above

A minimum of 72 hours to a maximum of 14 days

See full guidelines for advice

Oncology 

cefuroxime 1.5g IV q8h
± gentamicin 5mg/kg IV q24h

As above

As above

 As above

Patients colonised with MROs Consult ID

     

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

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Normal host

 

flucloxacillin 2g IV q6h 
benzylpenicillin 1.2g IV q6h
gentamicin 5mg/kg IV q24h

Oral therapy not appropriate

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

 

Compromised host

 

amoxicillin-clavulanate 1.2g IV q8h 
+ gentamicin 5mg/kg IV q24h

As above

As above  

Respiratory tract
Community acquired pneumonia

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment (for all CURB scores)

CURB-65
0-1

 

 

Oral treatment only

amoxicillin 500mg po TDS
OR
doxycycline 200mg po BD on day 1 then 100mg po BD

 

 

 

5-7  days in total

 

S.pneumoniae  or S.aureus (penicillin S)
benzylpenicillin 600mg IV q6h 
→ penicillin V 500mg oral QDS

S. aureus (penicillin R)
flucloxacillin 2g IV q6h →  500mg oral QDS

CURB65
2:

 

 Oral treatment only

amoxicillin 500mg po TDS
+ roxithromycin 
300mg po daily

 

 

 5-7  days in total

S. aureus (methicillin R)
vancomycin (as per Vanculator) 
→ oral as per sensitivities

H. influenzae (amoxicillin S)
amoxicillin 1g IV q6h → 500mg oral TDS

H. influenzae (amoxicillin R)
amoxicillin + clavulanic acid 1.2g IV q8h 
→ 625mg oral TDS

CURB65
3-5:

 

amoxicillin + clavulanic acid 1.2g IV q8h
erythromycin 1g IV q6h

OR, if anaphylaxis with penicillins/cephalosporins:
discuss with ID

 

 

 

 5-7  days in total

M. pneumoniae  or Chlamydophila spp. 
erythromycin 1g IV q6h 
→ roxithromycin 300mg oral daily

 Legionella spp.
ciprofloxacin ID 400mg IV q8h 
→ 750mg oral BD

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

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

amoxicillin + clavulanic acid 1.2g IV q8h

amoxicillin + clavulanic acid 625mg po TDS

5 days

 

Hospital acquired pneumonia

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Low Risk

amoxicillin + clavulanic acid 1.2g IV q8h

amoxicillin + clavulanic acid 625mg po TDS

7 days  

High Risk

piperacillin-tazobactamID  4.5g IV q8h 
gentamicin 5mg/kg IV q24h

amoxicillin + clavulanic acid 625mg po TDS

7 days

 

Acute exacerbation of COPD or chronic bronchitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV treatment unnecessary

amoxicillin 500mg po TDS
or doxycycline 200mg BD on day 1 then 100mg BD

5 days

S.pneumoniae 
penicillin VK 500mg po QDS

M.catarrhalis
trimethoprim 300mg po daily

H.influenzae
amoxicillin 500mg po TDS

Acute bronchitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

No antibiotics required

Influenza

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

No IV treatment available

See end

5 days

Treatment is an option in critically ill or immunocompromised patients.
oseltamivirID 75mg po BD

 Ear, nose & throat

Sinusitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Uncomplicated:

Most patients with sinusitis will not have a bacterial infection. Even for those that do, antibiotics only offer a marginal benefit and symptoms will resolve in most patients in 14 days, without antibiotics.

 Consider antibiotics for patients with severe sinusitis symptoms (e.g. purulent nasal discharge, nasal congestion and/or facial pain or pressure) for more than 14 days plus any of the following features: fever, unilateral maxillary sinus tenderness, severe headache, symptoms worsening after initial improvement. 

amoxicillin 500mg po TDS
or  doxycycline 200mg on day 1 then 100mg daily

 7 days  

Complicated:
amoxicillin + clavulanic acid 1.2g IV q8h

No improvement on amoxicillin then  amoxicillin + clavulanic acid 625mg po TDS

7 days

Pathogens often not identified.

Otitis media

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV treatment is unnecessary

Oral treatment is also usually unnecessary

amoxicillin 500mg po TDS or cotrimoxazole 960mg po BD if severe or bilateral disease

5 days

Pathogens often not identified

Pharyngitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV treatment is unnecessary

No antibiotics necessary unless at risk of rheumatic fever

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

 Throat swab to guide treatment. 

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

10 days

Group A Strep
 
penicillin VK 500mg po BD

Amoxicillin is avoided due to rash in EBV co-infected patients

Other pathogens do not require treatment

 

Epiglottitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

amoxicillin-clavulanate 1.2g IV q8h
or cefuroxime 750mg IV q6h

amoxicillin + clavulanic acid 625mg po TDS

5 days

H.influenzae   
amoxicillin 500mg po TDS

Tonsillitis (including quinsy and deep neck space infections)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

benzylpenicillin 1.2g IV q6h± metronidazole 400mg po TDS (equivalent to IV)

penicillin VK 500mg po QDS
 ± metronidazole 400mg po TDS

10 days

Group A Strep/S.milleri group: 
penicillin VK 500mg po QDS

 Ophthalmology

Blepharitis

Empiric IV treatment

Empiric treatment

Duration of therapy

Pathogen directed treatment

IV Treatment is unnecessary

Use of non-pharmaceutical intervention is most helpful including warm compress and cleansing of the eyelid margins

chloramphenicol 1% eye ointment topically BD

5 days

Pathogens often not identified.

Conjunctivitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV Treatment is unnecessary

Can be viral, bacterial or allergic. Bacterial infection is usually associated with mucopurulent discharge.  Most bacterial conjunctivitis is self-limiting and the majority of people improve without treatment, in two to five days.

chloramphenicol 0.5% eye drops 1 drop every 4 hours
+ chloramphenicol 1% eye ointment at night

7 days

Chlamydia:      azithromycin 1g po single dose

 Viral/allergic: No antibiotic

 

 CNS

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

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Treatment should be initiated after blood cultures are taken, and after consultation with infectious diseases

dexamethasone* 10mg IV q6h for 4 days
+ benzylpenicillin 1.2g IV q4h
± vancomycin as per Vanculator®
(stop if S. pneumoniae meningitis disproven)

*starting before or with the first dose of antimicrobial 

Oral therapy not appropriate

Pathogen specific

N.meningitidis
benpenicillin 2.4g IV q4h for 3 days

H.influenzae
amoxicillin 2g IV q4h for 7 days

S.pneumoniae 
benzylpenicillin 2.4g IV q4h for 10 days

Listeria 
benpen/amox/cotrim for 14 days

Encephalitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

aciclovirID 10mg/kg IV q8h
+ benzylpenicillin 1.2g IV q4h

Oral therapy not appropriate

14 – 21 days

HSV: aciclovirID10mg/kg IV q8h

Brain abscess

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Treatment should be initiated after blood cultures are taken, and after consultation with infectious diseases

Unknown source/mastoiditis:
amoxicillin 2g IV q4h
+metronidazole 400mg po TDS

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

Oral therapy not appropriate (except metronidazole)

28 days

P.acnes  benzylpenicillin

S.aureus  flucloxacillin

S.milleri group  benzylpenicillin

Anaerobes  metronidazole

Cardiothoracic

Endocarditis (native valve)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Treatment should be initiated after blood cultures are taken, and after consultation with cardiology and infectious diseases 

*benzylpenicillin 1.2g IV q4h 
+ gentamicin 3mg/kg IV q24h
(*flucloxacillin 2g IV q4h should be used instead of penicillin if staphylococcal sepsis suspected e.g. IV drug user)

Oral treatment is inappropriate

As per organism below

Advice will be provided from infectious diseases about ongoing therapy

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

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

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

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

 Skin & soft tissue

Cellulitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

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

flucloxacillin 500mg po QDS
or  cefalexin 500mg po QDS

5 days

MSSA  
flucloxacillin 500mg po QDS

Beta-haemolytic strep  
penicillin VK 500mg po QDS

MRSA  
cotrimoxazole 960mg po BD

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

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Mild or early

 

flucloxacillin 2g IV q6h
or cefazolin 2g IV q8h

flucloxacillin 500mg po QDS 

14 days

MSSA

flucloxacillin 500mg po QDS

Beta-haemolytic Strep

penicillin VK 500mg po QDS

Severe or refractory

amoxicillin + clavulanic acid 1.2g IV q8h  

or cefuroxime 750mg IV q6h 
metronidazole 400mg po TDS

amoxicillin + clavulanic acid 625mg po TDS

or 
cefalexin 500mg po QDS
metronidazole 400mg po TDS

14 days

MRSA

cotrimoxazole 960mg po BD

Gram negatives

As per culture results

Mastitis/breast abscess

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Conservative management of mastitis to alleviate symptoms and ensure on going breast emptying may be all that is required for treatment.

flucloxacillin 1g IV q6h 
or 
cefazolin 1g IV q8h if intolerant

flucloxacillin 500mg po QDS

 

5 days

MSSA  
flucloxacillin 500mg po QDS

Beta-haemolytic Strep
penicillin VK 500mg po QDS

Gram negatives
amoxicillin + clavulanic acid 625mg po TDS

Impetigo

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV therapy unnecessary

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

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

5 days

MRSA – cotrimoxazole 960mg po BD

Boils

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV therapy unnecessary

Most lesions may be treated with incision and drainage alone.  Antibiotics may be considered if there is fever, surrounding cellulitis or co-morbidity, e.g. diabetes, or if the lesion is in a site associated with complications, e.g. face.

flucloxacillin 500mg po QDS

5 days

MRSA – cotrimoxazole 960mg po BD

Bites – human & animal

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV therapy unnecessary

Clean and debride wound thoroughly and assess the need for tetanus immunisation.

amoxicillin + clavulanic acid 625mg po TDS
or
d
oxycycline  200mg on day 1 then 100mg po BD
metronidazole 400mg po TDS

7 days

Usually polymicrobial

Bone & joint

Osteomyelitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

flucloxacillin 2g IV q6h

Oral therapy not appropriate

6 weeks – Consult ID 
Consider oral switch

MRSA:  vancomycin IV as per vanculator®

Septic arthritis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

flucloxacillin 2g IV q6h

flucloxacillin 500mg po QDS

3 weeks with an early oral switch (e.g. 7-10 days)

Extend to 4 weeks if S.aureus or slow to settle.

MRSA  vancomycin  IV as per vanculator®

MSSA  flucloxacillin

Group A strep benzylpenicillin

Compound fractures (prophylaxis)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

amoxicillin + clavulanic acid 1.2g IV q8h

Oral therapy not appropriate

Until surgery or 72 hours, whichever is sooner

Prophylactic polymicrobial cover

Gastrointestinal tract

Peritonitis, severe diverticulitis, intra-abdominal abscesses

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

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

or cefuroxime 750mg IV q6h 
metronidazole 400mg po TDS

amoxicillin + clavulanic acid 625mg po TDS

5 days unless undrained

S.milleri  penicillin VK

Enterococci amoxicillin (+ clavulanic acid)

Gram negatives as per culture

Biliary tree infections (cholangitis or cholecystitis)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

amoxicillin 1g IV q6h 
+gentamicin 5mg/kg IV q24h

or cefuroxime 750mg IV q6h

amoxicillin + clavulanic acid 625mg po TDS

5 days

S.milleri  penicillin VK

Enterococci  amoxicillin (+ clavulanic acid)

Gram negatives as per culture

Gastroenteritis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV Treatment is unnecessary

See for pathogens

 

Campylobacter

Most people will recover with symptomatic treatment only. Antibiotics have little impact on the duration and severity of symptoms but eradicate stool carriage.

Treatment is indicated for severe or prolonged infection, for pregnant women nearing term and for people who are immunocompromised. Treatment may also be appropriate for food handlers, childcare workers and those caring for immunocompromised patients.

erythromycin 400mg po QDS for 5 days

   

Clostridum difficile

metronidazole 400mg po TDS for 10 days
or vancomycinID 125mg po QDS for 14 days if no response to 2 courses of metronidazole

   

Giardia

Metronidazole 2g po daily for 3 days
or 400mg po TDS for 7 days

Oral/mucocutaneous candidiasis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV treatment is unnecessary

Immunocompetent

Nystatin topical q2-3h

7 days

 

Immunocompromised

 

As above.  If no response consider fluconazoleID 800mg as a single dose.

H.pylori eradication

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV treatment is unnecessary

amoxicillin 1g po BD (or metronidazole 400mg po BD)
clarithromycin 500mg BD
+ omeprazole 40mg BD

7 days

If treatment failure on standard regimens:
amoxicillin 1g po BD
tetracycline 250-500mg po QDS
omeprazole 40mg po BD
bismuth 120mg po QDS

Genito-urinary tract

Cystitis (lower UTI)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

IV treatment is unnecessary

nitrofurantoin 100mg po QDS

5 days

MSSA  flucloxacillin 500mg po QDS

Group B Strep penicillin VK 500mg po QDS

Gram negative as per culture but refer trimethoprim 300mg po aily and nitrofurantoin over beta-lactams.

ESBL fosfomycinID 3g po single dose
or pivemecillinamID 400mg load then 200mg po TDS

Pyelonephritis (severe upper UTI)

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

Uncomplicated

 

gentamicin 5mg/kg IV q24h
or cefuroxime 750mg IV q8h

trimethoprim 300mg po daily

 

 

10 days

MSSA  flucloxacillin 500mg po QDS

Group B strep  penicillin VK 500mg po QDS

Complicated

 

gentamicin 5mg/kg IV q24h
amoxicillin 1g IV q6h

  10 days

Gram negatives as per culture but prefer trimethoprim over beta-lactams.

ESBL fosfomycinID 3g po q72h (2 doses) 
or pivemecillinamID 400mg po TDS

PID/endometritis/cervicitis

Empiric IV treatment

Empiric po treatment

Duration of therapy

Pathogen directed treatment

ceftriaxone 1g IV single dose
doxycycline 100mg po BD
metronidazole 400mg po TDS

14 days

-

Antimicrobial Stewardship Committee

Auckland DHB has a multi-disciplinary committee that ensures a rational, appropriate and cost effective approach to the use of antimicrobials. The committee meets every two months and the minutes will be posted here following ratification at the subsequent meeting. Any questions regarding the committee or antimicrobial use at Auckland DHB please contact either the chair or secretary.

Current committee members:

Rupert Handy (chair) Service Clinical Director Adult Infectious Diseases
Eamon Duffy (sec) Lead Antimicrobial Stewardship pharmacist
Catherine Jackson Public Health physician
Emma Best  Infectious Diseases paediatrican
Joshua Freeman Clinical Microbiologist
Lesley Voss  Clinical Lead Paediatric Infectious Disease
Margaret Johnston Nurse Specialist Liver Transplant
Nigel Patton Haematologist
Sally Roberts Clinical Lead Clinical Microbiology
Stephen Ritchie Infectious disease physician
Stephen Streat Intensivist and Clinical Director Organ Donation New Zealand
 - Antimicrobial Stewardship pharmacist
 - Surgical representative
  Advanced trainees in infectious diseases or microbiology also attend

 Minutes and Terms of Reference  (Please note that due to sensitive information and particular cases discussed, these are internal access only.)

2012

March

May

July

November

 

 

2013

March

May

August

November

 

 

2014

February

April

July

August

October

December

2015

 March

 April

 July

 August

 October

 

2016

April

July

October 

December