SESIAHS

ADULT Empiric Antibiotic Guidelines1

CNS

Bacterial
meningitis

Ceftriaxone 2g IV every 12 hours

If the patient is immunocompromised or Listeria is suspected ADD
benzylpenicillin 2.4g IV every 4 hours

HSV
encephalitis

Aciclovir 10mg per kg IV every 8 hours for at least 14 days

(adjust dose if reduced renal function)

URINARY

Acute cystitis

Non-pregnant women: Trimethoprim 300mg orally daily for 3 days

Pregnant women: Cephalexin 500mg orally every 12 hours for 5 days
Men: Trimethoprim 300mg orally daily for 14 days

Acute
pyelonephritis

Mild: Cephalexin 500mg orally every 6 hours for 10 days

Severe: Ampicillin 2g IV every 6 hours PLUS
gentamicin2 4 to 6mg per kg IV daily for max of 3 doses
If gentamicin contraindicated: Ceftriaxone 1g IV daily as a single agent

GASTROINTESTINAL

Cholecystitis

Ampicillin 1g IV every 6 hours PLUS

gentamicin2 4 to 6mg per kg IV daily for max of 3 doses
(PLUS metronidazole 500mg IV every 12 hours if biliary obstruction)

Cholangitis

Ampicillin 1g IV every 6hours PLUS

gentamicin2 4 to 6mg per kg IV daily for max of 3 doses (PLUS
metronidazole 500mg IV every 12 hours if biliary surgery or obstruction)
If gentamicin contraindicated: Ceftriaxone 1g IV daily (PLUS
metronidazole 500mg IV every 12 hours if biliary surgery or obstruction)

Peritonitis due
to perforation

Ampicillin 1g IV every 6 hours PLUS gentamicin2 4 to 6mg per kg IV

daily for max of 3 doses PLUS metronidazole 500mg IV every 12 hours
If gentamicin contraindicated, as single agent: Ticarcillin with clavulanate
3.1g IV every 6 hours OR piperacillin with tazobactam 4.5g IV every 8 hours

SKIN and SOFT TISSUE

Cellulitis
Assess exposure
risk for gram
negative organisms
(and seek expert
advice)

Mild outpatient therapy

Flucloxacillin 500mg orally every 6 hours for 7 to 10 days, OR
Cephazolin 2g IV daily PLUS probenecid 1g orally daily
Requiring admission
Flucloxacillin 2g IV every 6 hours OR cephazolin 2g IV every 8 hours
If MRSA risk (prior colonisation, MRSA infection or hospital association):
ADD vancomycin 1.5g IV every 12 hours (adjust in renal impairment and
check level at 48 hours)

This guideline must not replace clinical judgement. May not apply to immunocompromised
patients
Detailed guidelines available via CIAP on intranet: Therapeutic Guidelines Antibiotic v 14, 2010.
Check local antibiotic restriction policies
1

doses are for normal renal function

Check eTG for gentamicin dosing

Expires Jan 2013

RESPIRATORY

Communityacquired
pneumonia
(CAP)

Mild CAP
Amoxycillin 1g orally every 8 hours for 5 to 7 days OR
Doxycycline orally, 200mg for 1st dose, then 100mg daily for 5 days
Moderate CAP (requiring admission)

Benzylpenicillin 1.2g IV every 6 hours initially then amoxycillin as above

(with CXR changes)
totalling 7 days PLUS
doxycycline 100mg orally every 12 hours for 7 days
Severe CAP (requiring HDU/ICU management)

Ceftriaxone 1g IV daily PLUS

azithromycin 500mg IV daily for 7 to 14 days

Hospitalacquired
pneumonia
(HAP)

Low MRO risk and Mild HAP

Amoxycillin with clavulanate 875/125 mg orally every 12 hours
for 5 to 7 days
If penicillin hypersensitive (but not anaphylaxis):
Cefuroxime 500 mg orally every 12 hours for 5 to 7 days

assess risk for

multi-resistant
organisms (MROs)

If patient is unable to take oral therapy: Benzylpenicillin 1.2 g IV every 6

hours PLUS gentamicin2 4 to 6 mg per kg IV daily for max of 3 doses
Low MRO risk and Moderate to Severe HAP
(switch to oral as above as improves)
Ceftriaxone 1 g IV daily OR
Benzylpenicillin 1.2 g IV every 6hours PLUS
gentamicin2 4 to 6 mg per kg IV daily for max of 3 doses

HAP in high-risk
wards for 5 days or
longer (e.g. ICU,
high-dependency
units, known specific
resistance problem)
Infective
exacerbation of

COPD

High MRO Risk and Moderate to Severe HAP

Piperacillin with tazobactam 4.5g IV every 6 hours OR

Ticarcillin with clavulanate 3.1g IV every 6 hours OR

Cefepime 2 g IV every 8 hours
If MRSA likely ADD vancomycin 1.5g IV every 12 hours and monitor levels
Consider treatment with bronchodilators and oral corticosteroids
If antibiotics required: Amoxycillin 500mg orally every 8 hours OR
doxycycline 100mg orally every 12 hours for 5 days

TIMELY CONVERSION FROM IV TO ORAL AGENTS

Reassess the need for IV antibiotic administration in your patient when they are
tolerating oral intake, have no absorption problems and show clinical improvement.
For oral formulations or suitable alternatives check with ward pharmacist.
Oral therapy is NOT suitable for initial treatment of endocarditis, meningitis, osteomyelitis,
septic arthritis or Staph. aureus bacteraemia where a high tissue antibiotic concentration is
required.
DAILY REVIEW OF ANTIBIOTIC MANAGEMENT FOR CONSIDERATION OF RATIONALISATION
AND DE-ESCALATION IS REQURIED.

This card has been produced by the Area Antimicrobial Stewardship Committee, Clinical Governance
Unit, SESIAHS. http://sesiweb.lan.sesahs.nsw.gov.au/clinical%20Governance%20unit/default.asp
Expires Jan 2013