NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update Acute

Therapeutics Handbook: Infection Section Changes

Information below is specific to the use of medicines in the adult setting.

IV-Oral Antibiotic Switch Therapy (IVOST)
The combination of “aztreonam + amoxicillin” has been added to the list in the IVOST table.  The recommended oral switch for this intravenous (IV) combination is co-amoxiclav.

Alert antibiotics
Fosfomycin IV has been added to the Alert Antibiotic list.  The permitted indication for this is “only on the advice of a microbiologist or ID physician”.

Community Acquired Pneumonia (CAP)
-Non-severe CAP:  antibiotic course length is now 5 days.
-Severe CAP with penicillin allergy:  layout/format improved but guidance unchanged.  Patients should be treated with levofloxacin monotherapy i.e. levofloxacin should NOT be co-prescribed with clarithromycin.

Intra-abdominal sepsis (IAS)
The specific indication of “post-op intra-abdominal infection (laparotomy)” has been removed and IAS guidance should be followed for such patients.

Cellulitis
Gentamicin has been removed from the treatment regimen for severe or rapidly spreading cellulitis in non-drug user patients.  This is due to the low risk of gram negative organism involvement in this patient group.

Urinary Tract Infections (UTIs)
For urinary sepsis, in patients without penicillin allergy, aztreonam is now recommended as an alternative to gentamicin in frail elderly patients or patients with an eGFR < 50 ml/min.

Immunocompromised patients with fever
-All immunocompromised patients with fever, regardless of neutrophil count, should now be initially treated according to Initial Management of Neutropenic Sepsis in Adults guideline (direct link to the PDF of the guideline is now provided).  Changes to the initial management are: 
1) Definition of a high risk patient has changed to ‘septic shock or NEWS ≥5’.
2) High risk patients with penicillin allergy (NOT anaphylaxis) should now be prescribed the following: vancomycin, gentamicin and aztreonam 2 grams SIX hourly.
-Once an anatomical source is identified in immunocompromised patients without neutropenia, these patients can be managed as per GGC Empirical Infection Management Guideline.

Endocarditis
Sodium fusidate is no longer routinely recommended as an alternative to rifampicin in Prosthetic Heart Valve patients.  Contact Microbiology for advice if rifampicin is not suitable.

Meningitis
If Listeria is suspected, or if aged > 50 years, in a patient with life-threatening penicillin allergy, vancomycin has been replaced with IV co-trimoxazole; such patients should also be treated with chloramphenicol and dexamethasone.

Splenectomy
Meningitis B vaccine has been added to the splenectomy schedule.

Clostridium Difficle Infection (CDI)
-Immunosuppression has been removed as a severity marker.  This is in line with the new Health Protection Scotland (HPS) guidelines for the management of CDI.
-First relapse treatment of CDI is not dependent on severity markers and should be treated with oral vancomycin for 10 days.
-For second or subsequent CDI relapses, guidance is to contact microbiology or Infectious Diseases (ID) for advice on treatment protocol.

Genito-Urinary (GU) infections
Acute care guidelines now include severe Pelvic Inflammatory Disease (within intra-abdominal sepsis section) and vaginal candidiasis only.  For all other conditions please refer to Sandyford Guidance or Primary Care Guidelines.