Blood cultures before starting antibiotics.
Surgical intra-abdominal infections
Including: biliary tract infections, appendicitis, diverticulitis, peritonitis, suspected perforation.
Recommended total duration:
- 5 days after adequate source control (either surgery or radiological drainage).
- 7 days for uncomplicated infections not requiring surgical intervention.
- After uncomplicated appendicectomy/cholecystectomy postoperative antibiotics may not be required.
- The role of antibiotics in uncomplicated acute diverticulitis is unclear.
Recommended total duration:
- 5 days after adequate source control (either surgery or radiological drainage).
- 7 days for uncomplicated infections not requiring surgical intervention.
- After uncomplicated appendicectomy/cholecystectomy postoperative antibiotics may not be required.
- The role of antibiotics in uncomplicated acute diverticulitis is unclear.
Recommended antibiotics |
Amoxicillin 1g every 8 hours IV AND Gentamicin (use NHS Lothian Calculator located AMT intranet page) AND Metronidazole 400mg every 8 hours orally (500mg every 8 hours IV if oral route unavailable) |
Penicillin allergy or known MRSA carriage |
Vancomycin (use NHS Lothian Calculator located AMT intranet page) - target trough level 10-15mg/L AND Gentamicin (use NHS Lothian Calculator located AMT intranet page) AND Metronidazole 400mg every 8 hours orally (500mg every 8 hours IV if oral route unavailable) |
@48-72 HRS REVIEW WITH SENIOR TEAM MEMBER
- Is the patient improving? If not, phone microbiology.
OTHERWISE
- Has an AKI developed whilst in hospital? AKI stage 1 is defined as x1.5 rise in creatinine from baseline.
- Has the patient developed new hearing or balance symptoms (think about gentamicin toxicity)?
- Has the patient grown gentamicin-resistant organisms?
If the answer is “No” to all these questions and IV antibiotics are still required, continue the above IV regimens to Day 5.
IV Antibiotic Recommendations (after 5 days) if IV to oral switch not possible:
- Phone microbiology to discuss patient.
- Gentamicin is associated with hearing and balance problems; only continue regimens containing gentamicin past 5 days on recommendation from Microbiology/Infectious Disease.
Recommended total duration:
- 5 days after adequate source control (either surgery or radiological drainage).
- 7 days for uncomplicated infections not requiring surgical intervention.
- After uncomplicated appendicectomy/cholecystectomy postoperative antibiotics may not be required.
- The role of antibiotics in uncomplicated acute diverticulitis is unclear.
Preferred |
Co-trimoxazole 960mg every 12 hours orally PLUS Metronidazole 400mg every 8 hours orally |
Alternative |
Co-amoxiclav 625mg every 8 hours orally Suitable for those ≤ 65 years old with a low risk of C.diff infection. |
Likely organisms: Coliforms, anaerobes (for example Bacteroides), Enterococci, Anginosus group streptococci.
- Metronidazole has excellent oral bioavailability – only give IV in severe illness, suspected malabsorption or oral route compromised.
- Dual-anaerobe cover: adding Metronidazole to Co-amoxiclav: is not usually required.
- General advice on management of sepsis can be found here Sepsis 6
- Sending samples from abscess drainage or at the time of surgery is helpful.