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Antimicrobial Stewardship (AMS)

In this section, you will find resources for health professionals about empiric antimicrobial treatment, antimicrobial resistance and Te Whatu Ora | Te Toka Tumai Auckland's Antimicrobial Stewardship (AMS) programme.

Resources

Community Antibiotics Guidance (BPAC)() (for adults and children)

NZ STI Guidelines()

NextDose()

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

 

Adults Paediatrics

Empirical Treatment Guidelines

Starship Clinical Guidelines()

Surgical Prophylaxis [PDF, 224 KB]

Surgical Prophylaxis [PDF, 213 KB]

Aminoglycoside flowchart [PDF, 126 KB]

Aminoglycosides()

Vancomycin()(Te Whatu Ora | Te Toka Tumai Auckland intranet only)
The calculator is now located within Concerto

Vancomycin()

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

Penicillin allergy assessment tool (Monochrome [PDF, 248 KB])

 

 Adult restricted list [PDF, 266 KB] *

 Paediatric restricted list [PDF, 222 KB] *

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

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

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

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

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

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


Adult Empiric Antibiotic Treatment Guidelines

Sepsis

e.g. neutropenic sepsis

Respiratory tract

e.g. CAP

Ear, nose and throat

e.g. pharyngitis

Ophthalmology

e.g. conjunctivitis

Central nervous system

e.g. meningitis

Cardiothoracic

e.g. endocarditis

Skin and soft tissue

e.g. cellulitis

Bone and joint

e.g. septic arthritis

Gastrointestinal

e.g. cholangitis

Genitourinary tract

e.g. pyelonephritis

 

Sepsis
If patients are colonised with ESBL-E or other MRO call Infectious Disease service

Neutropenic sepsis

 

FIRST

ALTERNATIVE

Haematology  

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

cefepime 2g IV q8h
AND gentamicin 5mg/kg IV q24h

Oncology  

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

ceftriaxone 2g IV q24h

Non-neutropenic sepsis

 

FIRST

ALTERNATIVE

Community onset sepsis – unknown source. Assess MRO risk, travel history, recent inpatient stay

5 days total if no source found
cefuroxime
750mg IV q6h
AND gentamicin 5mg/kg IV q24h

5 days total if no source found
clindamycin
600mg IV q8h
AND gentamicin 5mg/kg IV q24h

 

Respiratory tract

Community acquired pneumonia

 

FIRST

ALTERNATIVE

CURB65 0 – 1 

5 days total
amoxicillin 
500mg po TDS

5 days total
doxycycline 
200mg po BD on day 1 then 100mg po BD

CURB65 2 

5 days total
amoxicillin 
500mg po TDS
AND doxycycline 100mg po BD

5 days total
doxycycline 
200mg po BD on day 1 then 100mg po BD

CURB65 3 – 5 

5 days total
amoxicillin + clavulanic acid
1.2g IV q8h for 1 or 2 days
AND azithromycin 500mg po daily
------
THEN
complete 5 days total with  amoxicillin + clavulanic acid 625mg po TDS
AND azithromycin 500mg po daily

5 days total
clarithromycin
500mg IV q12h for 1 or 2 days
THEN complete 5 days total with
azithromycin 500mg po daily

Pathogen specific regimens

 

FIRST

 

S.pneumoniae or S.aureus (PSSA)

benzylpenicillin 1.2g IV q6h 
THEN penicillin V 500mg po QDS

 

S. aureus (MSSA)

flucloxacillin 2g IV q6h 
THEN flucloxacillin 1g po TDS

 

H. influenzae (amoxicillin S) 

amoxicillin 1g IV q6h
THEN amoxicillin 1g po TDS

 

H. influenzae (amoxicillin R)

amoxicillin + clavulanic acid 1.2g IV q8h
THEN amoxicillin + clavulanic acid 625mg po TDS
AND amoxicillin 500mg po TDS

 

M.pneumoniae or Chlamydophila spp.

clarithromycin 500mg IV q12h
THEN azithromycin 500mg po daily

 

Legionella spp.

ciprofloxacin 400mg IV q8h
THEN ciprofloxacin 750mg oral BD

 

Aspiration pneumonia

               

FIRST

ALTERNATIVE

Many are not infective and represent chemical pneumonitis

5 days total
amoxicillin + clavulanic acid
1.2g IV q8h for 1 or 2 days
THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS

5 days total
cefuroxime
750mg IV q8h
THEN complete 5 days total with doxycycline 200mg po BD on day 1 then 100mg po BD

Hospital acquired pneumonia

Infection caused by more resistant Gram-negatives is increased by ICU ventilation, thoracic surgery or course of broad-spectrum antibiotic during this admission

               

FIRST

ALTERNATIVE

Low risk of resistant Gram-negative infection

5 days total
amoxicillin + clavulanic acid
1.2g IV q8h for 1 or 2 days
THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS

5 days total
cefuroxime
750mg IV q8h
THEN complete 5 days total with doxycycline 200mg po BD on day 1 then 100mg po BD

High risk of resistant Gram-negative infection

5 days total
piperacillin-tazobactam
4.5g IV q6h for 1 or 2 days
AND gentamicin 5mg/kg IV q24h
------
THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS

5 days total
ceftazidime
2g IV q8h for 1 or 2 days

THEN complete 5 days total with
co-trimoxazole
960mg po BD 

Acute exacerbation of COPD or chronic bronchitis

               

FIRST

ALTERNATIVE

Acute bronchitis does not require antibiotics

5 days total
amoxicillin 500mg po TDS

5 days total
doxycycline 200mg po BD on day 1 then 100mg po BD

Influenza

               

FIRST

 

Immunocompromised or critically unwell

5 days total
oseltamivir 75mg po BD

 

 

Ear, nose & throat

Sinusitis

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

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

 

FIRST

ALTERNATIVE

Uncomplicated

7 days total
amoxicillin
 500mg po TDS

7 days total
doxycycline
 200mg on day 1 then 100mg daily

Complicated

7 days total
amoxicillin + clavulanic acid
 1.2g IV q8h for 1 or 2 days
THEN complete 7 days total with
amoxicillin + clavulanic acid
625mg po TDS

7 days total
cefuroxime
750mg IV q6h for 1 or 2 days
THEN complete 7 days total with cefalexin 1g po TDS

Otitis media

 

FIRST

ALTERNATIVE

Severe or bilateral disease

5 days total
amoxicillin 500mg po TDS


5 days total
co-trimoxazole 
960mg po BD

Pharyngitis

 

FIRST

ALTERNATIVE

If at risk of rheumatic fever i.e.

- Past history of Rh fever
- Māori/Pacific ethnicity
- Aged under 30
with fever, cervical nodes
or tonsillar swelling

10 days total
penicillin V 500mg po BD

Note: amoxicillin is avoided due to rash in EBV co-infected patients

 

10 days total
erythromycin 400mg po BD

Epiglottitis

 

FIRST

ALTERNATIVE

 

5 days total
amoxicillin + clavulanic acid
 1.2g IV q8h for 1 or 2 days

THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS

5 days total
cefuroxime
750mg IV q6h for 1 or 2 days

THEN complete 5 days total with cefalexin 1g po TDS

Tonsillitis (including quinsy and deep neck space infections)

 

FIRST

ALTERNATIVE

 

10 days total
benzylpenicillin 
1.2g IV q6h for 1 or 2 days
AND metronidazole 400mg po BD
-----
THEN complete 10 days total with penicillin V 500mg po QDS
AND metronidazole 400mg po BD

10 days total
cefazolin 
1g IV q8h for 1 or 2 days
AND metronidazole 400mg po BD
-----
THEN complete 10 days total with cefalexin 1g po TDS
AND metronidazole 400mg po BD

 

Ophthalmology

Blepharitis

 

FIRST

 

 

5 days total
chloramphenicol 
1% eye ointment topically BD

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

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

 

FIRST

 

 

7 days total
chloramphenicol 
0.5% eye drops 1 drop every 4 hours
AND chloramphenicol 1% eye ointment at night

 

 

Central nervous system

Meningitis
Call Infectious Disease if concern for bacterial meningitis or post-neurosurgical meningitis
Treatment should be initiated after blood cultures are taken, and after consultation with infectious diseases

 

FIRST

ALTERNATIVE

If patient over 50 years old, pregnant or immunosuppressed

 

Administer in this order:
dexamethasone* 10mg IV q6h for 4 days
AND ceftriaxone 2g IV q12h
AND benzylpenicillin 2.4g IV q4h
AND vancomycin as per vanculator

Administer in this order:
dexamethasone* 10mg IV q6h for 4 days
AND ceftriaxone 2g IV q12h
AND co-trimoxazole 960mg IV q6h
AND vancomycin as per vanculator

All other patients

Administer in this order:
dexamethasone* 10mg IV q6h for 4 days
AND ceftriaxone 2g IV q12h
AND vancomycin as per vanculator

*starting before or with the first dose of antimicrobial 

Administer in this order:
dexamethasone* 10mg IV q6h for 4 days
AND ceftriaxone 2g IV q12h
AND vancomycin as per vanculator

*starting before or with the first dose of antimicrobial 

Meningitis pathogen specific regimens

 

THEN

ALTERNATIVE THEN

N.meningitidis

3 days total
benzylpenicillin 
1.2g IV q4h

3 days total
ceftriaxone
2g IV q12h

H.influenzae

7 days total
amoxicillin 
2g IV q4h

7 days total
ceftriaxone
2g IV q12h

S.pneumoniae 

10 days total
benzylpenicillin 
2.4g IV q4h

10 days total
ceftriaxone
2g IV q12h

Listeria spp.

14 days total
benzylpenicillin 
2.4g IV q4h

14 days total
co-trimoxazole
960mg IV q6h

Encephalitis

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

 

FIRST

ALTERNATIVE

Antibiotics for listeria encephalitis and bacterial meningitis are recommended until diagnosis excluded

Complete 14 to 21 days of aciclovir if HSV confirmed and bacterial meningitis/encephalitis excluded

dexamethasone* 10mg IV q6h for 4 days
AND ceftriaxone 2g IV q12h
AND benzylpenicillin 2.4g IV q4h
AND aciclovir 10mg/kg IV q8h
AND vancomycin as per vanculator

*starting before or with the first dose of antimicrobial 

dexamethasone* 10mg IV q6h for 4 days
AND ceftriaxone 2g IV q12h
AND aciclovir 10mg/kg IV q8h
AND co-trimoxazole 960mg IV q6h
AND vancomycin as per vanculator

*starting before or with the first dose of antimicrobial 

Brain abscess

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

 

FIRST

ALTERNATIVE

Community onset

amoxicillin 2g IV q4h
AND metronidazole 400mg po BD

ceftriaxone 2g IV q12h
AND metronidazole 400mg po BD

Trauma/neurosurgical source

ceftriaxone 2g IV q12h
AND vancomycin as per vanculator

 

 

Cardiothoracic

Endocarditis (native valve)

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

 

FIRST

ALTERNATIVE

 

 

 

benzylpenicillin 1.2g IV q4h 
AND gentamicin 3mg/kg IV q24h

Note: flucloxacillin 2g IV q4h should be used instead of penicillin if staphylococcal sepsis suspected e.g. injecting drug user

THEN therapy rationalised following cultures with Infectious Disease consult

cefazolin 2g IV q8h
AND gentamicin 3mg/kg IV q24h

THEN therapy rationalised following cultures with Infectious Disease consult

 

 

Skin and soft tissue

Cellulitis

 

FIRST

ALTERNATIVE

EWS 0 -1

5 days total
flucloxacillin
1g po TDS

5 days total
cefalexin
1g po TDS

EWS 2 – 5 or marked systemic symptoms with PVD, inc BSA, BMI or venous insufficiency

5 days total
flucloxacillin 1g po TDS
AND probenecid 500mg po TDS

5 days total
cefalexin
1g po TDS
AND probenecid 500mg po TDS

EWS 6 – 7 or RED/BLUE zone vital sign

5 days total
flucloxacillin
1g IV q6h for 1 or 2 days

THEN complete 5 days total with flucloxacillin 1g po TDS

5 days total
cefazolin
1g IV q8h for 1 or 2 days

THEN complete 5 days total with cefalexin 1g po TDS

EWS ≥ 8

5 days total
flucloxacillin 2g IV q6h for 1 or 2 days
AND clindamycin 600mg IV q6h
AND gentamicin 5mg/kg IV q24h
-----
THEN complete 5 days total with flucloxacillin 1g po TDS

5 days total
cefazolin
2g IV q8h for 1 or 2 days
AND clindamycin 600mg IV q6h
AND gentamicin 5mg/kg IV q24h
-----
THEN complete 5 days total with cefalexin 1g po TDS

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

 

FIRST

ALTERNATIVE

No signs of sepsis

5 days total
amoxicillin + clavulanic acid 625mg po TDS

5 days total
cefalexin
1g po TDS
AND metronidazole 400mg po BD

Signs of sepsis

14 days total
amoxicillin + clavulanic acid 
1.2g IV q8h for 1 or 2 days

THEN complete 14 days total with
amoxicillin + clavulanic acid
 625mg po TDS

14 days total
cefuroxime 
750mg IV q6h for 1 or 2 days
AND metronidazole 400mg po BD
-----
THEN complete 14 days total with
cefalexin
1g po TDS
AND metronidazole 400mg po BD

Mastitis/breast abscess

 

FIRST

ALTERNATIVE

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

5 days total
flucloxacillin
1g IV q6h for 1 or 2 days
THEN complete 5 days total with flucloxacillin 1g po TDS

5 days total
cefazolin
1g IV q8h for 1 or 2 days
THEN complete 5 days total with cefalexin 1g po TDS

Impetigo

 

FIRST

ALTERNATIVE

Less than 4 lesions

5 days total
hydrogen peroxide 1% cream applied BD

 

4 or more lesions

5 days total
penicillin V
500mg po QDS 

5 days total
erythromycin
400mg po QDS 

Boils

Most lesions may be treated with incision and drainage alone.  Antibiotics may be considered if there is, surrounding cellulitis.

Bites – human and animal

 

FIRST

ALTERNATIVE

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

7 days total
amoxicillin + clavulanic acid 625mg po TDS

7 days total
doxycycline 200mg on day 1 then 100mg po BD
AND metronidazole 400mg po BD

 

Bone and joint infections

Osteomyelitis

 

FIRST

ALTERNATIVE

 

42 days
flucloxacillin 2g IV q6h
THEN therapy rationalised following cultures with Infectious Disease consult

42 days
cefazolin 2g IV q8h
THEN therapy rationalised following cultures with Infectious Disease consult

Septic arthritis

 

FIRST

ALTERNATIVE

 

21 days
flucloxacillin 2g IV q6h
THEN therapy rationalised following cultures with Infectious Disease consult

21 days
cefazolin 2g IV q8h
THEN therapy rationalised following cultures with Infectious Disease consult

 

Gastrointestinal tract

Peritonitis, severe diverticulitis, intra-abdominal abscesses

 

FIRST

ALTERNATIVE

 

5 days following drainage
amoxicillin 1g IV q6h for 1 or 2 days
AND gentamicin 5mg/kg IV q24h
AND metronidazole 400mg po BD
-----
THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS

5 days following drainage
cefuroxime 
750mg IV q6h for 1 or 2 days
AND metronidazole 400mg po BD
-----
THEN complete 5 days total with cefalexin 1g po TDS
AND metronidazole 400mg po BD

Biliary tree infections (cholangitis or cholecystitis)

 

FIRST

ALTERNATIVE

 

5 days total
amoxicillin
 1g IV q6h for 1 or 2 days
AND gentamicin 5mg/kg IV q24h
------
THEN complete 5 days total with amoxicillin + clavulanic acid 625mg po TDS

5 days total
cefuroxime 
750mg IV q6h for 1 to 2 days

THEN complete 5 days total with cefalexin 1g po TDS

Gastroenteritis

 

FIRST

 

C.difficile infection
Mild-moderate

10 days total
metronidazole
400mg po TDS

 

C.difficile infection
Severe

14 days total
vancomycin
125mg po QDS

 

Giardia

3 days total
metronidazole
2g po daily

 

Campylobacter

5 days total
erythromycin
400mg po QDS 

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

Oral/mucocutaneous candidiasis

 

FIRST

ALTERNATIVE

Immunocompetent

7 days total
nystatin
1mL topical q2-3h

7 days total
amphotericin B
lozenge 10mg topical QDS

Immunocompromised

7 days total
nystatin
1mL topical q2-3h

If no response discuss fluconazole 800mg as a single dose with ID

H.pylori eradication

 

FIRST

ALTERNATIVE

 

14 days total
amoxicillin 
1g po BD
(or metronidazole 400mg po BD)
AND clarithromycin 500mg BD
AND omeprazole 40mg BD

If treatment failure on standard regimens:

14 days total
amoxicillin 1g po BD
AND tetracycline 250mg po QDS
AND omeprazole 40mg po BD
AND bismuth 120mg po QDS

 

Genitourinary tract

Cystitis (lower UTI)

 

FIRST

ALTERNATIVE

 

5 days total
nitrofurantoin MR 100mg po BD
Note: See SCRIPT for local recommendations about renal dysfunction

ESBL-E
fosfomycin
3g po single dose
OR pivmecillinam 400mg load then 200mg po TDS for 3 days

Pyelonephritis (severe upper UTI)

 

FIRST

ALTERNATIVE

Uncomplicated

7 days total
gentamicin
5mg/kg IV q24h for 1 or 2 days
-----
THEN
rationalise based on cultures and complete 7 days total with for example:
co-trimoxazole 960mg po BD

7 days total
cefuroxime 750mg IV q8h for 1 or 2 days if gentamicin contra-indicated
-----
THEN
rationalise based on cultures and complete 7 days total with for example:
co-trimoxazole 960mg po BD

Complicated

7 days total
gentamicin 
5mg/kg IV q24h for 1 or 2 days
AND amoxicillin 1g IV q6h
-----
THEN rationalise based on cultures and complete 7 days total with for example:
co-trimoxazole 960mg po BD

7 days total
ceftazidime
1g IV q8h for 1 or 2 days if gentamicin contra-indicated
-----
THEN
rationalise based on cultures and complete 7 days total with for example:
co-trimoxazole 960mg po BD

If ESBL-E colonised discuss these options with Infectious Disease

amikacin 15mg/kg IV q24h for 1 or 2 days
-----
THEN rationalise based on cultures and complete 7 days total with for example: fosfomycin 3g po daily

meropenem 500mg IV q6h for 1 or 2 days
-----
THEN rationalise based on cultures and complete 7 days total with for example: fosfomycin 3g po daily

PID/endometritis/cervicitis

 

FIRST

 

 

14 days total
ceftriaxone 1g IV q24h
AND doxycycline 100mg po BD
AND metronidazole 400mg po BD