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Azithromycin dose calculator abbreviations

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NCHD.ie©2017 Dr. ÍOS

Thank you

We would like to thank a number of people who made this app. possible.

Fiona Ahern (pharmacist Cork University Hospital), Frank O'Riordan (antibiotic pharmacist, Mercy University Hospital, SIVUH), Mala Shah and Paula Murphy (pharmacists, CUH), who work tirelessly to ensure the medication / antimicrobial guidelines are correct and up to date. Many thanks to Dr. Sile O'Connor for her work in preparing the BSH Tralee antibiotic guidelines.

Ms. Terri Goulding, for her fantastic organisation and dedication to NCHD training/education in CUH.

The Cork & Kerry Infection Control Committee kindly provided funding for a laptop to enable development of the mobile application.

For more comprehensive clinical guidelines please visit EMed.ie.

We would like to give a special Thank You to Dr. Tim Keady (Intern in CUH 2014), Dr. Nick Barrett, Anaesthetic Reg., Dr. Dominic Hegarty, Pain Specialist, and Marih O'Leary, Pharmacist, for the Analgesia Ladder (Adults) information.

Dr. Íomhar O' Sullivan.
Consultant in Emergency Medicine, Cork.

Disclaimer

The antimicrobial information contained in this App was collated by the Cork Kerry antimicrobial stewardship sub-committee and reflect the antimicrobial guidelines of the (CUH, MUH, SIVUH and Bon Secours hospitals in Tralee & Cork). Therefore use of this app by any persons including health professionals working within other hospitals, is at your own risk, and we make no representations or guarantees as to the adequacy or completeness of any of the information contained in this app, or the app’s compatibility with any policies or procedures of other hospitals, where the app is used by persons other than healthcare professionals working within the CK hospitals.

This app is intended as a support tool for health professionals working within CK hospitals and is provided for reference only. It does not take into account the individual circumstance of a patient and may not contain all the information you require. It should therefore not be used as the sole basis for prescribing any drugs or for the care of any patient. While every attempt has been made to ensure the accuracy of the content, doctors and other healthcare professionals should ensure that the correct drug and dose is prescribed, as is appropriate for each individual patient.

References that should be used in conjunction with these guidelines include the British National Formulary (BNF) and the drug data sheets (available on www.medicines.ie). The interpretation and application of the guidelines remains the responsibility of the individual clinician. Please seek advice if in doubt.

Updates may be released periodically and it is the responsibility of the user that they have the most up to date version available. Thas is available on the hospital Intranet.

NCHD.ie©2017 Dr. ÍOS
NCHD.ie©2017 Dr. ÍOS

Phone List

NCHD.ie©2017 Dr. ÍOS

Phone List

NCHD.ie©2017 Dr. ÍOS

Checking the directory:

Log on to ‘HSE staff directory’ icon which is on most computers. The following screen will appear and it is self explanatory. When on call, make sure you have the right date. Also, note the ‘liaison psych consultation’ icon in the top left of the screen.

logon screen

Using PIMS:

Most interns will have to print off lists of in-patients each day as well as having patient stickers available. Log into you Citrix 4.5 account and click on the PIMS icon. The following screen will then appear. The four main buttons are identified in the diagram.

drill down

  1. To look up a patient’s details and past history click button 1 and follow the links.
  2. To PRINT a list of in-patients, click button 3 and click OK. When the list appears, press F2 to print.

ward or patient view

  1. You need to ring IT to get your list changed to a different consultant every time you change jobs. They’ve cracked down on this for data protection purposes, there are no longer any generic passwords and you can only print your own consultants list.
  2. To print stickers, click button 2 and enter the ward that the patient is on. Right click on the patient’s name and select ‘labels and front-sheets’ from the options. Untick front-sheet. The following screen will follow. Click OK to print. Make sure that the small labels are in the printer.

results

NCHD.ie©2017 Dr. ÍOS

Microbiology section

These guidelines are for adults only. For pregnancy/breastfeeding guidelines please change your hospital to CUMH. Click for Paediatric Guidelines.

These.

©CKICC 2017 Dr. ÍOS

Microbiology section

These guidelines are for CUMH patients only. For general hospital or paediatric patients please change your hospital to CUH.

These.

Before prescribing any antibiotics, please read this advice.

©CKICC 2017 Dr. ÍOS
©CKICC 2017 Dr. ÍOS

Aspiration pneumonia

©CKICC 2017 Dr. ÍOS

Cardiac section

©CKICC 2017 Dr. ÍOS

CURB-65 score

For estimating severity / prognosis in community acquired pneumonia.

CURB-65 score Symptom Score
Confusion 1
Urea > 7 mmol/l 1
Resp rate >30 1
SBP<90 or DBP<60 mmHg 1
Age ≥ 65 1

Risk of death at 30 days

Predicted mortality Score Risk RIP
0 <1%
1 3%
2 13%
3 17%
4 42%
5 57%

CURB-65 also good predictor of mortality with ANY infection (not just pneumonia).

General management advice CURB-65 Advice 0 - 1 2 3-5
Treat as out-patient
Consider a short stay in hospital or watch closely as an outpatient
Requires admission +/- ITU
©CKICC 2017 Dr. ÍOS

ENT section

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Gastrointestinal section

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Genitourinary section

©CKICC 2017 Dr. ÍOS

Neurological section

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Ophthalmology section

©CKICC 2017 Dr. ÍOS

Respiratory section

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Soft tissue and bone section

©CKICC 2017 Dr. ÍOS

Anatomical systems

©CKICC 2017 Dr. ÍOS
©CKICC 2017 Dr. ÍOS
©CKICC 2017 Dr. ÍOS

Gynaecology antimicrobials

©CKICC 2017 Dr. ÍOS

Infections in pregnancy

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Pregnancy wound infections

©CKICC 2017 Dr. ÍOS

Pregnancy antibiotic prophylaxis

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Pregnancy viral infections

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Pregnancy fungal infections

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Pregnancy - bacterial infections

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Pregnancy parasitic infections

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Antimicrobials in pregnancy & lactation

    

        

Aminoglycosides

     Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding Gentamicin
Low risk Compatible Developmental toxicity has not been associated with gentamicin. Due to the limited available data and the theoretical toxicity risks, gentamicin use in pregnancy is generally reserved for serious/ life threatening infections where standard antibiotic therapy has not been effective.

        

Antifungals/antivirals

     Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding Fluconazole Aciclovir
Valaciclovir Oseltamivir
Risk (≥400mg/day). Discuss with Pharmacy if considering treatment Compatible Reports of teratogenicity with Fluconazole at continuous daily doses of 400mg/day or more in the 1st trimester. Risk of adverse outcomes appears low with lower doses. A low, single oral dose of Fluconazole during pregnancy is unlikely to pose a substantial teratogenic risk, but the data are insufficient to state that there is no risk.
Compatible Compatible
Compatible Compatible Maternal benefit far outweighs the unknown risk, if any, to the foetus.

        

Cephalosporins

   Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding Cefalexin Ceftriaxone Cefuroxime
Compatible Compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when cephalosporins given to a nursing mother. Monitor infant for diarrhoea or thrush.
Compatible Compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when cephalosporins given to a nursing mother. Monitor infant for diarrhoea or thrush.
Compatible Compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when cephalosporins given to a nursing mother. Monitor infant for diarrhoea or thrush.

        

Penicillins

   Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding Benzylpenicillin Flucloxacillin Amoxicillin Co-amoxiclav Piptazobactam Meropenem
Compatible Compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when penicillins given to a nursing mother.
Monitor infant for diarrhoea or thrush.
BNF consider Co-amoxiclav and piptazobactam appropriate to use in breastfeeding.
Compatible Compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when penicillins given to a nursing mother.
Monitor infant for diarrhoea or thrush.
BNF consider Co-amoxiclav and piptazobactam appropriate to use in breastfeeding.
Compatible Compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when penicillins given to a nursing mother.
Monitor infant for diarrhoea or thrush.
BNF consider Co-amoxiclav and piptazobactam appropriate to use in breastfeeding.
Compatible No human data (for clavulanic) probably compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when penicillins given to a nursing mother.
Monitor infant for diarrhoea or thrush.
BNF consider Co-amoxiclav and piptazobactam appropriate to use in breastfeeding.
Animal data suggests low risk Probably compatible Disruption of the infant's gastrointestinal flora has been reported occasionally when penicillins given to a nursing mother.
Monitor infant for diarrhoea or thrush.
BNF consider Co-amoxiclav and piptazobactam appropriate to use in breastfeeding.
Animal data suggest low risk Probably compatible

        

Macrolides

Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding Azithromycin Clarithromycin Erythromycin
Animal data suggest low risk Probably compatible Limited human data do not suggest risk of developmental toxicity with Azithromycin. Unconfirmed epidemiologic evidence indicates that the risk of hypertrophic pyloric stenosis in infants might be increased by maternal use of macrolide antibiotics during breastfeeding.
Monitor infant for possible effects on the gastrointestinal flora, such as diarrhoea, candidiasis.
Animal data suggest high risk Probably compatible Animal data with clarithromycin suggest risk but human pregnancy experience suggests the risk, if it exists, is low. Unconfirmed epidemiologic evidence indicates that the risk of hypertrophic pyloric stenosis in infants might be increased by maternal use of macrolide antibiotics during breastfeeding.
Monitor infant for possible effects on the gastrointestinal flora, such as diarrhoea, candidiasis.
Compatible Compatible Unconfirmed epidemiologic evidence indicates that the risk of hypertrophic pyloric stenosis in infants might be increased by maternal use of macrolide antibiotics during breastfeeding.
Monitor infant for possible effects on the gastrointestinal flora, such as diarrhoea, candidiasis.

        

Quinolones

Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding Ciprofloxacin Ofloxacin
Human data suggest low risk. Discuss with Pharmacy if considering treatment Potential toxicity The use of ciprofloxacin during human gestation does not appear to be associated with an increased risk of major congential malformations.
Briggs: "Although a number of birth defects have occurred in the offspring of women who had taken ciprofloxacin, the lack of a pattern to these anomalies is considered reassuring. Other authors consider fluoroquinolones to be contraindicated in pregnancy due to animal studies."
Fluoroquinolones have traditionally not been used in nursing mothers due to concerns about adverse effects on the infants' developing joints. However, recent studies indicate little risk.
Human data suggest low risk. Discuss with Pharmacy if considering treatment Probable compatible Use with caution in 1st trimester.
Although a number of birth defects have occurred in the offspring of women who had taken ofloxacin, the lack of a pattern to these anomalies is considered reassuring.
Fluoroquinolones have traditionally not been used in nursing mothers due to concerns about adverse effects on the infants' developing joints. However, recent studies indicate little risk.
    

        

Tetracyclines

Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding Doxycycline
Contraindicated in 2nd and 3rd trimester Compatible BNF: "Doxycycline may be used for malaria prophylaxis if other regimens are unsuitable, and if the entire course of doxycycline is completed before 15 weeks' gestation".
Contact Infectious Diseases/ Pharmacy if 1st trimester treatment being considered.
Unlike to cause harmful effects in breastfeeding infants if short-term use. Avoid prolonged or repeat courses during nursing.
Theoretical risk of dental staining and decreased bone growth in infant. However, risk appears remote (drug levels in breast milk undetectable).
Monitor the infant for rash and for possible effects on the gastrointestinal flora, such as diarrhoea or thrush.

        

Miscellaneous

Drug Use in pregnancy Use in breastfeeding Info pregnancy Info breastfeeding Clindamycin Mebendazole Metronidazole Mupirocin
(nasal) Nitrofurantoin Permethrin
(topical) Vancomycin
Compatible Compatible Monitor infant for possible effects on the gastrointestinal flora, such as diarrhoea or candidiasis.
Low risk Probably compatibel; Avoid in 1st trimester Mebendazole is poorly absorbed from the GI tract.
Low risk Potential toxicity
Discuss with pharmacy if considering.
Avoid in 1st trimester With maternal intravenous and oral therapy, breastfed infants receive metronidazole in doses that are less than those used to treat infections in infants, although the active metabolite adds to the total infant exposure.
Case reports of candida infections and diarrhoea have been reported.
Probably compatible Probably compatible 1% of mupirocin is absorbed after topical application. Considered to be low risk to the nursing infant.
Risk in 3rd triemster Probably compatible but
Avoid first 8 days of life.
Theoretical risk of neonatal haemolytic anaemia if used in last few weeks of pregnancy. If nitrofurantoin treatment indicated in nursing mother, start after the first week of life (risk of haemolytic anaemia greater).
Compatible Compatible
Compatible Probably compatible Only low levels secreted into breast milk. Poor oral absorption.
Monitor infant for possible effects on gastrointestinal flora, such as diarrhoea.
Guide©2017 Dr. ÍOS

Categorisation of Drug Risk in Pregnancy and Lactation

Previous versions of the CUMH Antimicrobial Guideline used the FDA (Food and Drug Administration) pregnancy labelling categories A, B, C, D and X to categorise risk in pregnancy. The FDA have discontinued using this nomenclature, due to limitations of the system including:

  • over-simplistic categorisation of drug risk
  • the assumption that there is a graduated level of risk from one category to the next and also
  • the lack of detail provided.

For the purposes of this guideline, the Briggs Classification has been adapted for assessing risk in pregnancy and lactation.

In pregnancy

  • The decision to administer a drug to a mother should only be made after assessing the risks and the benefits to both the mother and the foetus.
  • The guidance provided in this guideline only applies to the usual therapeutic dose and in a typical patient. The recommendations presented in Appendix 9.4 may not necessarily be applied to the entire population.

In lactation

The decision to administer a drug to a nursing mother should only be made after assessing the risks and the benefits to both the mother and nursing infant.

Several factors should be considered prior to prescribing:

  1. The need for maternal treatment and the drug choice.
  2. The age and maturity of the baby - liver and kidney systems do not work fully for some time after birth. Premature babies are particularly susceptible to drugs and may exhibit higher than expected drug levels.
  3. The volume of breastmilk being taken daily - a fully fed two-week-old baby consumes more milk than a nine-month-old feeding just once or twice a day.

Briggs classification of risk in pregnancy

Compatible

The human pregnancy experience, either for the drug itself or drugs of the same class or with similar mechanisms of action, is adequate to demonstrate that the embryo-foetal risk is very low or nonexistent. Animal reproductive data are not relevant.

Limited human data - probably compatible

There may or may not be human pregnancy experience, but the characteristics of the drug suggest that it does not represent a significant risk to embryo-foetus. For example other drugs in the same class or with similar mechanisms are compatible or the drug does not obtain significant systemic concentrations. Any animal reproductive data are not relevant.

Human data suggests low risk

There is limited human pregnancy experience, either for the drug itself or drugs of the same class or with similar mechanisms of action, including the 1st trimester, suggesting that the drug does not represent a significant risk of developmental toxicity (growth restriction, structural anomalies, functional/ behavioural deficits, or death) at any time in the pregnancy. The human pregnancy data outweigh any animal reproductive data.

Risk in 3rd trimester

Evidence (for the drug or similar drugs) suggests that there may be a foetal risk of developmental toxicity (growth restriction, structural anomalies, functional/ behavioural deficits, or death) in the 3rd trimester, or close to delivery, but not in the 1st or 2nd trimesters. The human pregnancy data outweigh any animal reproductive data.

Contraindicated in 2nd and 3rd trimester

Human exposures in the 2nd and 3rd trimesters, either to the drug itself or to the drugs in the same class or with similar mechanisms of action, have been associated with developmental toxicity (growth restriction, structural anomalies, functional/ behavioural deficits, or death). The drug should not be used in the 2nd and 3rd trimesters.

Limited human data - animal data suggest low risk

Either there is no human pregnancy experience or few pregnancy exposures have not been associated with developmental toxicity (growth restriction, structural anomalies, functional/ behavioural deficits, or death). The drug does not cause developmental toxicity (at doses that did not cause maternal toxicity) in all animal species studied at doses ≤ 10 times the human dose based on body surface are (BSA) or AUC.

Human data suggest risk

The human data for the drug or drugs in the same class or with the same mechanism of action, and animal reproduction data if available, suggest there may be a risk of developmental toxicity (growth restriction, structural anomalies, functional/ behavioural deficits, or death) throughout the pregnancy. Usually, pregnancy exposure should be avoided, but the risk may be acceptable if the maternal condition requires the drug.

Limited human data - suggest high risk

Either there is no human pregnancy experience or few pregnancy exposures have not been associated with developmental toxicity (growth restriction, structural anomalies, functional/ behavioural deficits, or death). The drug causes developmental toxicity (at doses that did not cause maternal toxicity) in three or more animal species at doses ≤10 times the human dose based on body surface are (BSA) or AUC.

Briggs classification of risk in breastfeeding

Compatible

Either the drug is not excreted in clinically significant amounts into human breast milk or its use during lactation does not, or is not expected to, cause toxicity in a nursing infant.

Limited human data - probably compatible

Either there is no human data or the human data are limited. The available data suggest that the drug does not represent a significant risk to a nursing infant.

Limited human data suggests toxicity

Either there is no human data or the human data are limited. The characteristics of the drug suggest that it could represent a clinically significant risk to a nursing infant. Breastfeeding is not recommended.

Guide©2017 Dr. ÍOS

Microbiology section

These guidelines are for children only. For adult patients, please see adult guidelines.For pregnancy/breastfeeding guidelines please change your hospital to CUMH.

©CKICC 2017 Dr. ÍOS
2017 Dr. ÍOS

Ophthalmology-Paeds

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ENT(Paed)

2017 Dr. ÍOS

Paed-Respiratory

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Urinary Paeds

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Neurological (Paed)

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Soft tissue(Paed)

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Bone / joint (Paed)

2017 Dr. ÍOS

Prophylaxis

NCHD.ie©2017 Dr. ÍOS

Endocarditis prophylaxis is only recommended in the situations detailed below, as antibiotic prophylaxis may only be effective at preventing a very small number of endocarditis cases. Infective endocarditis is much more likely to be caused by frequent exposure to random bacteraemias than bacteraemias caused by dental, GI tract or GU tract procedures. The risk of antibiotic-related adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy.

Maintenance of optimal oral health and hygiene is important in reducing the risk of endocarditis from dental procedures

Cardiac conditions that require endocarditis prophylaxis:

  • Prosthetic cardiac valve or prosthetic material used for cardiac valve repair.
  • Previous infective endocarditis
  • The following forms of Congenital Heart Disease (CHD):
    • Any type of cyanotic heart disease
    • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or catheter intervention, during the first 6 months after the procedure.
    • Repaired CHD with residual defects at or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialisation).

Dental procedures:

Endocarditis prophylaxis recommended only in patients with the above cardiac conditions, for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of oral mucosa.

Endocarditis prophylaxis NOT recommended for the following:

  • routine anaesthetic injections through non-infected tissue
  • taking dental radiographs
  • placement of removable prosthodontic or orthodontic appliances
  • adjustment of orthodontic appliances
  • placement of orthodontic brackets
  • shedding of deciduous teeth
  • bleeding from trauma to the lips or oral mucosa which also includes: treatment of superficial caries, removal of sutures etc.

For Dental procedures:

Given single dose 30-60 min. prior to procedure: 1st line option In penicillin allergy
Adults: Amoxicillin 2 grams po/iv Adults: Clindamycin 600mg po/iv

GI tract or GU tract procedures:

Endocarditis prophylaxis not recommended.

Respiratory procedures:

Endocarditis prophylaxis is only recommended in patients with the above cardiac conditions for patients undergoing the following:

  • Invasive procedure to treat infections: e.g. drainage of abscess or empyema.

NB: if the infection is known to be caused by S. aureus, use Flucloxacillin 1g po / iv single dose for prophylaxis. If caused by MRSA or penicillin allergic, use vancomycin 15mg/kg single dose iv infusion one hour prior to procedure.

Infected skin, skin structure and musculoskeletal tissue:

Endocarditis prophylaxis is only recommended in patients undergoing surgical procedures with the above cardiac conditions.

Flucloxacillin 1g iv / po should be given 30-60 mins prior to procedure.

If MRSA or penicillin allergic: give vancomycin 15mg/kg single dose iv infusion one hour prior to procedure.

NCHD.ie©2017 Dr. ÍOS

Prophylaxis-Meningitis

Bacterial meningitis is a notifiable disease. Inform Public Health: Tel.: 021 4927601 or out of hours through ambulance service 021 4921114. Public Health will advise on chemoprophylaxis of contacts.

Meningococcal Infection

  • Chemoprophylaxis is indicated only for close contacts, defined as those who, in the preceding seven days:
    • shared living/sleeping accommodation with case.
    • mouth kissing contacts.
    • boarding school dormitory contacts.
  • Chemoprophylaxis may be indicated for contacts in childcare facilities. Seek Public Health advice.
  • Casual contacts, e.g. school classmates, playmates and neighbours are generally not considered to need chemoprophylaxis.
  • Seek advice from Public Health or microbiology if unsure.
  • Unless the index case has received Ceftriaxone in hospital, chemoprophylaxis should also be given to the patient prior to discharge. When the disease has been treated with cefotaxime it may be prudent to give chemoprophylaxis until studies are available on its effectiveness in eradicating carriage.
  • Only healthcare workers who do not wear a mask and whose mouth or nose is directly exposed to respiratory secretions and / or droplets, from a case of meningococcal disease are at risk.
Adults and children >12 years Female adults on the oral contraceptive pill Pregnant women Children: 1-12 years Infant <1 year
1st line: Rifampicin 600mg every 12 hours for 4 doses.
Alternative: Ciprofloxacin 500mg po stat.
Ciprofloxacin 500mg po stat
Ceftriaxone 250mg im stat
1st line: Rifampicin 10mg/kg (max. 600mg) every 12 hours for 4 doses.
Alternativen: only for children >2 years.
2-5 years: Ciprofloxacin 125mg po stat.
5-12 years: Ciprofloxacin 250mg po stat.
Rifampicin syrup 5mg/kg every 12 hours for 4 doses

Haemophilus influenzae type b (Hib) infection

Chemoprophylaxis is rarely indicated in Hib infection; only when there are unvaccinated or incompletely vaccinated children or persons at increased risk (e.g. asplenia or complement deficiency) in the household. Unless the index case has received Ceftriaxone or cefotaxime in hospital, chemoprophylaxis should also be given to the patient prior to discharge. Seek advice from Public Health or microbiology if unsure.

Adults Child:1-12yrs Infant:<1 yr Pregnant women
Rifampicin 600mg once daily for 4 days
Rifampicin 20mg/kg (max 600mg) once daily for 4 days
Rifampicin syrup 10mg/kg once daily for 4 days
Not indicated

Notes on Rifampicin: Rifampicin may colour urine / tears red and stain contact lenses – do not wear contact lenses for a few days after Rifampicin treatment. If on other drugs, check BNF, product data sheets on www.medicines.ie / consult pharmacy regarding drug interactions with Rifampicin

Vaccination
If Neisseria meningitidis Groups B, C, A, Y, W, 135 vaccination of contacts and index may be indicated. Please refer to Public Health for advice.
If Haemophilus influenzae type b or pneumococcal meningitis: vaccination of contacts and index may be indicated. Please refer to Public Health for advice.

NCHD.ie©2017 Dr. ÍOS

Principles of surgical prophylaxis

  1. Prophylaxis should be given within 60 minutes prior to surgical incision. Please note that certain antibiotics (e.g. vancomycin, gentamicin 5mg/kg, clindamycin and metronidazole) cannot be given as bolus injections. It is important that the infusions are completed before incision. Reduce gentamicin dose to 3mg/kg iv if CrCl <30ml/min.
  2. Always check previous microbiology cultures and sensitivities (MC&S) to guide choice of antibiotic for surgical prophylaxis. Consult micro. If recent Hx of MRSA, vancomycin should be given as part of surgical prophylaxis.
  3. Prophylaxis should be confined to the peri-operative period (i.e. immediately before and during procedure). The administration of additional doses of antibiotic after the end of procedure provides little or no additional prophylactic benefit.
  4. An additional peri-operative prophylactic dose should be considered by the surgeon for procedures lasting >4 hours for cefuroxime and co-amoxiclav, or if there is blood loss >1500ml or haemodilution >15ml/kg
  5. Post operative doses of antibiotics will further disturb normal microbiological flora and increase the risk of Clostridium difficile. Only use post-operative antibiotics if specifically advised in the guideline or the patient requires treatment of infection (e.g. peritonitis post- perforated appendicitis).
  6. Clean surgery is associated with a low risk of infection and there is usually no indication for surgical antibiotic prophylaxis.
NCHD.ie©2017 Dr. ÍOS

Prophylaxis-Post Splenectomy

Please refer to local Intranet staff directory or NCHD.ie/asplenic.html (internet access required)..

NCHD.ie©2017 Dr. ÍOS

List of procedures requiring antibiotic prophylaxis is not exhaustive.

NCHD.ie©2017 Dr. ÍOS

CUMH Surg. prophylaxis

Indications

Surgical antibiotic prophylaxis is recommended for the following procedures:

  • Caesarean sections
  • Hysterectomies
  • Laparotomies
  • Major laparoscopic / open surgery involving vaginal incision

Surgical prophylaxis is not routinely necessary for other laparoscopic procedures, minor operations or diagnostic hysteroscopies.

Timing

Antibiotic prophylaxis should be started ideally within 60 minutes prior to incision for all surgery, including Caesarean section.

Ensure that the antibiotic prophylaxis administered is documented.

Additional doses

Prophylaxis should be confined to the peri-operative period (i.e. immediately before and during procedure). The administration of additional doses of antibiotic after the end of procedure provides little or no additional prophylactic benefit.

An additional peri-operative prophylactic dose should only be considered by the surgeon for:

  • procedures lasting >4 hours
  • if there is blood loss >1500ml

If clinical findings are suggestive of infection, a course of appropriate antimicrobial treatment should be prescribed.

Surgical prophylaxis for C-section

Single dose Cefuroxime 1.5g IV within 60 minutes prior to incision.

In penicillin allergy: single dose of Clindamycin 900mg iv plus Gentamicin 5mg/kg iv (Max dose 480mg), within 60 minutes prior to incision.

Surgical prophylaxis excluding C-section

Single dose Co-amoxiclav 1.2g IV within 60 minutes prior to incision.

In penicillin allergy: single dose of Clindamycin 900mg iv plus Gentamicin 5mg/kg IV (Max dose 480mg), within 60 minutes prior to incision.

Endocarditis prophylaxis

No longer indicated for vaginal deliveries. Refer to appropriate surgical prophylaxis protocol if undergoing surgery.

MRSA

If recent history of MRSA colonisation, vancomycin 15mg/kg should be given as part of surgical prophylaxis. See Vancomycin dosing, administration and monitoring.

Guide©2017 Dr. ÍOS

Prescribing tips

Antimicrobials

  • Piperacillin-tazobactam: should not be used for the empiric treatment of community acquired pneumonia.
  • Ciprofloxacin: should not be used to treat community acquired lower respiratory tract infections (LRTIs), and should not be used as a sole agent for empiric treatment of hospital acquired LRTIs as it has poor activity against S. pneumoniae.
  • UTIs: Co-amoxiclav, Trimethoprim and Ciprofloxacin should not be used for empiric treatment of urinary tract infections due to concerns regarding resistance.
  • Warfarin drug interactions. INR must be closely monitored and warfarin doses adjusted for patients on warfarin and antimicrobials, particularly macrolides (clarithromycin, erythromycin).
  • Monitoring levels: Gentamicin, vancomycin, tobramycin, streptomycin and amikacin levels must be monitored appropriately and where possible, doses should not be held unnecessarily, as this will lead to a reduced treatment response and promote antibiotic resistance.
  • Vancomycin IV: To ensure adequate serum concentrations are achieved, 25mg/kg (max 2g) loading dose is recommended followed by 15mg/kg q12h iv. Ensure dose is altered according to serum levels, not only dose decrease for high pre-dose levels, but also dose increase for low pre-dose levels. (Pre-dose reference range: 10-20mg/L (15-20mg/L for invasive infections)).
  • IV to PO switch: Use oral treatment where possible for the following antimicrobials: Ciprofloxacin, Metronidazole, clarithromycin, Moxifloxacin, Linezolid, Fluconazole, Rifampicin, Clindamycin.
  • Reviewing treatment: Always document indication for antimicrobial and proposed duration of treatment.
    • Always review cultures daily, and use the results try to streamline to a narrow spectrum agent where appropriate.
    • Seek advice if unsure.
    • Review need for antimicrobial therapy daily. Prolonged therapy can lead to resistance and serious adverse effects, e.g. C. difficile.
    • If in doubt, always seek advice.
NCHD.ie©2017 Dr. ÍOS

Amikacin dosing

Once daily dosing

Once daily dose

Not for endocarditis, febrile neutropenia or meningitis.

15mg/kg q24h iv.

Max 1.5g daily for up to 10 days (max cumulative dose per course 15g) unless specifically advised.

Correct dose in obesity below.

Adjustment in renal impairment below.

Administration

iv infusion: Dilute in 100ml sodium chloride 0.9% and adsminister over 30-60 minutes.

When to monitor levels

Pre-dose (‘trough’) levels taken between 18-24 hours after last dose administered. Initially monitor pre-dose level before second dose and then every 48 hours or daily if renal function poor.

Reference range

Pre-dose (trough) level ≤5mg/L.

Taking the sample

Send blood to microbiology, with the following information:

  • Name of antibiotic and prescribed dose.
  • Time and date the level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose or post dose level.

Interpreting result

You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.

Other monitoring parameters

Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. ringing / feeling of fullness in the ears, hearing loss, dizziness, vertigo, jittery / bouncing vision). Monitor for concomitant use of potent diuretics, ototoxic or nephrotoxic medicines e.g. NSAIDS, ACE inhibitors. Check vestibular and auditory function weekly if prescribed for more than 7 days.

Twice daily dosing

Twice daily dosing

7.5 mg/kg q12h iv
(can be increased in severe infections to 7.5 mg/kg q8h).

Max 1.5g daily for up to 10 days (max cumulative dose per course 15g) unless specifically advised.

Correct dose in obesity as below.

Adjustment in renal impairment - see below.

Administration

iv bolus over 32-3 minutes or (preferred): dulute to 2.5mg/ml with 0.9% NaCl and admin. over 30 mins.

When to monitor levels

Take “Trough” level immediately pre-dose
Take “Peak” level one hour post dose

Initially monitor peak and trough levels with 3rd or 4th dose, then trough levels every 48 hours, or more often if renal function unstable or poor.
Peak levels do not need to be monitored more than once a week.

Reference range

Pre-dose level (trough) ≤10mg/L
Post dose level (peak) ≤ 30mg/L (aim for 20-30mg/L)

Taking the sample

Send blood to microbiology, with the following information:

  • Name of antibiotic and prescribed dose.
  • Time and date the level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose or post dose level.

Interpreting result

You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.

Other monitoring parameters

Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. ringing / feeling of fullness in the ears, hearing loss, dizziness, vertigo, jittery / bouncing vision). Monitor for concomitant use of potent diuretics, ototoxic or nephrotoxic medicines e.g. NSAIDS, ACE inhibitors. Check vestibular and auditory function weekly if prescribed for more than 7 days.

Correcting in obesity

Correcting for obesity

Patients whose Actual Body Weight (ABW) is more than 120% of their ideal body weight (IBW) should receive an aminoglycoside dose calculated using these equations to provide a Dose Determining Weight (DDW):

Step 1: Calculate IBW.

Step 2: If ABW > (IBW + (20% of IBW)) then use Dose Determining Weight (DDW).

DDW = IBW + 0.4(ABW - IBW)

Renal impairment

Dosing in renal impairment

Amikacin dosing GFR 20-50ml/min:
GFR 10-30ml/min: GFR <10ml/min:

CAPD: Dose as per <10ml/min.
HD: 5mg/kg after dialysis
Give dose after dialysis.
CVVH: 7.5mg/kg q24h, as per levels

10mg/kg q24h

3-4mg/kg q24h

2mg/kg q24h-q48h

NCHD.ie©2017 Dr. ÍOS

Clostridium Difficile assoc. Diarrhoea

Antibiotic Associated Diarrhoea (AAD) occurs in association with the administration of antibiotics. The spectrum of findings ranges from colitis to so-called 'nuisance' diarrhoea. Infection with Clostridium difficile (CDI) accounts for only 10 to 20% of the cases of AAD, but it accounts for the majority of cases of colitis. Major risk factors for C. difficile infection include: advanced age, hospitalisation, exposure to antibiotics.

Some antibiotics are frequently implicated in C. difficile associated diarrhoea (CDAD) – e.g. Cephalosporins, Clindamycin, Quinolones and broad spectrum antibiotics, but virtually any antibiotic may be implicated, including brief courses e.g. surgical prophylaxis. Occasional cases follow treatment with Methotrexate or Paclitaxel (chemotherapy treatments of cancer).

Definition of Clostridium Difficile Associated Diarrhoea (CDAD):

Patient with ≥1 of:

  • Diarrhoeal stools or toxic megacolon, with a positive laboratory assay for C. difficile toxin A or B in stools, or a C. difficile organism detected in stool via culture. (NB: patients with a positive assay for C difficile toxin who do not have diarrhoea are not considered to have CDAD).
  • Pseudomembranous colitis revealed by lower gastrointestinal endoscopy.
  • Colonic histopathology characteristic of C difficile infection (with or without diarrhoea).
  • Diarrhoea is defined as three or more loose / watery bowel movements (which are unusual or different for the patient) in a 24 hour period.

Classification of CDAD

Mild to moderate CDI

Has no features of severe CDI.

Severe CDI (any of):

  • Clinical: fever, rigors, abdominal pain.
  • Labs: WCC ≥ 15x 109/L, ↑ creatinine of >50% above baseline or serum Cr > 133µmol/L
  • Endoscopic Dx pseudomembranous colitis
  • CT evidence of colitis or ascites

Severe, complicated CDI:

Severe disease with ↓BP, shock, ↑lactate, ileus or mega colon.

Diagnosis

Refer to local microbiology laboratory for testing procedures. Testing of asymptomatic individuals is not recommended.

General Mx

  • Adequate replacement of fluid & electrolytes.
  • Immediately discontinue unnecessary antimicrobial therapy.
  • Avoid antimotility medications.
  • Review other risk factors for CDI.
  • Review proton pump inhibitor use.
  • Appropriate infection prevention and control to include patient isolation with Contact precautions and appropriate hand washing: refer to local infection control guidelines.
  • Asymptomatic carriers of C. difficile should not be treated.
  • Patients with CDI should be reviewed on a daily basis by the medical and nursing team for deterioration, monitoring bowel function using the Bristol Stool Chart.
  • There is no need to check for microbiological clearance of C. difficile toxins as a patient can remain toxin positive for an indefinite period. Resolution of symptoms is the main clinical consideration.
  • Alcohol hand rub must not be used as an alternative to soap as C. difficile spores are known to be highly resistant to killing by alcohol. It can be applied after washing to rid the hands of remaining non-clostridial organisms
NCHD.ie©2017 Dr. ÍOS

Gentamicin dosing

Once daily dosing

Once daily dose

5mg/kg q24h iv (30-60 minutes), maximum 480mg in 24 hours.

Correct dose in obesity below.

In pregnancy please use booking weight.

Administration

In 100ml sodium chloride 0.9% over 30-60 minutes.

When to monitor levels

Pre-dose (‘trough’) levels taken between 18-24 hours after last dose administered. Initially monitor pre-dose level before second dose and then every 48 hours or daily if renal function poor.

Reference range

Pre-dose level ≤1mg/L.

Taking the sample

Send blood to microbiology, with the following information:

  • Name of antibiotic and prescribed dose.
  • Time and date the level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose or post dose level.

Interpreting result

You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.

Other monitoring parameters

Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. tinnitus/fullness in the ears/↓hearing, vertigo, jittery / bouncing vision).

More on Tobramycin and Amikacin monitoring.

Multiple daily dosing

Multiple daily dosing

tds for meningitis, extensive burns (1 – 1.7mg/kg q8h iv)
bd for endocarditis (1mg/kg q12h)
max 480mg in 24 hrs

Pregnancy: refer to CUMH antibiotic guidelines.

Correct dose in obesity.

Administration

iv bolus over 3-5 minutes or infuse in 100ml sodium chloride 0.9% over 30 minutes.

When to monitor levels

Take “Trough” level immediately pre-dose
Take “Peak” level one hour post dose
Initially monitor peak and trough levels with 3rd or 4th dose, then trough levels every 48 hours, or more often if renal function unstable or poor.
Peak levels do not need to be monitored more than once a week.

Reference range

Pre-dose level (trough) ≤2mg/L
Post dose level (peak) 5-10mg/L
Endocarditis pre-dose level ≤1mg/L
Endocarditis post dose level 3-5mg/L

Taking the sample

Send blood to microbiology, with the following information:

  • Name of antibiotic and prescribed dose.
  • Time and date the level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose or post dose level.

Interpreting result

You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.

Other monitoring parameters

Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. tinnitus/fullness in the ears/↓hearing, vertigo, jittery / bouncing vision).

More on Tobramycin and Amikacin monitoring.

Correcting in obesity

Correcting for obesity

Patients whose Actual Body Weight (ABW) is more than 120% of their ideal body weight (IBW) should receive an aminoglycoside dose calculated using these equations to provide a Dose Determining Weight (DDW):

Step 1: Calculate IBW.

Step 2: If ABW > (IBW + (20% of IBW)) then use Dose Determining Weight (DDW).

DDW = IBW + 0.4(ABW - IBW)

Renal impairment

Dosing in renal impairment

Gentamicin Once daily dosing GFR 30-50ml/min: GFR 10-30ml/min: GFR 5-10ml/min:
3-5mg/kg q24h 3mg/kg q24h 3mg/kg and re-dose when level ≤1mg/L
Use with caution in renal impairment. Discuss with micro./pharmacy. Monitor serum gentamicin levels daily and dose accordingly.
  • Gentamicin calculator
  • Gentamicin Multiple daily dosing GFR 30-70ml/min: GFR 10-30ml/min: GFR 5-10ml/min:
    80mg q12h (60mg if <60kg) 80mg q24h (60mg if <60kg) 80mh q48h (60mg if <60kg)
    Use with caution in renal impairment. Discuss with micro./pharmacy. Monitor serum gentamicin levels daily and dose accordingly.
NCHD.ie©2017 Dr. ÍOS

MRSA

MRSA is resistant to all β-lactam antibiotics including flucloxacillin. MRSA varies in its sensitivity to other antibiotics but is almost always sensitive to glycopeptides (i.e. Vancomycin and Teicoplanin).

MRSA colonisation/carriage

MRSA may be present at superficial sites without causing clinical signs of infection. This is termed colonisation or carriage. Topical antiseptics may be used to eradicate / reduce MRSA carriage. Please refer to the Infection Control Guidelines for full details on screening and eradication of MRSA. Prescribe Naseptin® on the patient’s MRS.

MRSA colonisation eradication(↓) regimen - 7 days

More detals on Infection Control Guidelines.

  1. Apply a small amount of 2% Mupirocin (Bactroban®) nasal ointment using a cotton bud to each nostril q8h. (Use Naseptin® cream, if Bactroban® unavailable)
  2. Use chlorhexidine gluconate 4% as a body wash in place of soap daily.
  3. Wash hair twice a week with chlorhexidine gluconate 4%.
  4. Apply chlorhexidine CX® powder to groin and axilla daily.
  5. Wash teeth / dentures with "Colgate Total" toothpaste (individual patient use) twice daily.
  6. Use chlorhexidine mouth wash twice daily if throat carriage is suspected.

Systemic treatment of MRSA with antibiotics should only be initiated if there are clinical signs of infection. If a patient who is colonised with MRSA develops an infection usually caused by staphylococci, it is likely that MRSA is the causative pathogen and this should be considered when treating the patient empirically.

Empirical/targeted regimens

Seek advice from Micro./I.D. regarding choice of agent and duration of treatment.

Surgical antibiotic prophylaxis

Patients who require surgery and have a history of MRSA colonisation or infection without documented eradication, or those who are at a high risk of MRSA colonisation should receive glycopeptide prophylaxis alone or in combination with other antibiotics active against other potential pathogens.

The use of glycopeptides may also be considered if there is an appreciable risk that patients’ MRSA carriage may have recurred or they come from facilities with a high prevalence of MRSA.

Glycopeptide antibiotics are recommended for surgical prophylaxis, administration to be completed within 60 minutes prior to incision: Vancomycin 15mg/kg iv. Refer to surgical prophylaxis guidelines for further detail.

MRSA practice points

  • Patients require isolation - follow Infection Control Guidelines
  • Handwashing is critical in the prevention of cross-infection
  • Rifampicin and Sodium fusidate must never be used as single agents, to prevent development of resistance to these agents
  • The minimum duration of treatment for MRSA bacteraemia is 14 days. Some indications may need longer durations of treatments. Consult microbiologist for specific recommendations regarding duration of treatment.
  • MRSA packs are available from Pharmacy.
©CKICC 2017 Dr. ÍOS

Penicillin allergy

All drug allergies must be specified on medication charts (with patient’s reaction).

In TRUE penicillin allergy: ALL penicillins, cephalosporins and other beta lactam antibiotics should be avoided.

TRUE penicillin allergy includes anaphylaxis, urticaria or rash immediately after penicillin administration.

In cases of intolerance to penicillin (e.g. GI upset) or rash occurring >72 hrs after administration, penicillins / related antibiotics should not be withheld unnecessarily in severe infection, but the patient must be monitored closely after administration.

If in doubt, seek advice from Microbiology or Pharmacy.

AVOID in Penicillin allergy:

Amoxicillin, Ampicillin, Flucloxacillin, Benzylpenicillin, Co-amoxiclav (e.g. Augmentin®/ Pinaclav®), Phenoxymethylpenicillin (Calvapen®), Piperacillin-tazobactam (Tazocin®), Extencilline®, Temocillin (Negaban®), Ticarcillin (Timentin®).

CAUTION in in Penicillin allergy:

Cephalosporins: Cefaclor, Cefadroxil, Cefalexin (Keflex®), Cefamandole, Cefazolin, Cefixime (Suprax®), Cefotaxime (Claforan®), Cefpodoxime, Ceftazidime (Fortum®), Ceftriaxone (Rocephin®), Cefuroxime (Zinacef®), Other beta lactam antibiotics: Aztreonam, Imipenem (Primaxin®), Meropenem, Ertapenem, Doripenem.

SAFE in Penicillin allergy:

Amikacin, Metronidazole, Ciprofloxacin, Moxifloxacin, Clarithromycin, Nitrofurantoin, Clindamycin, Rifampicin, Colistin, Sodium fusidate, Doxycycline, Teicoplanin, Erythromycin, Tobramycin, Gentamicin, Trimethoprim, Linezolid, Vancomycin.

©CKICC 2017 Dr. ÍOS

Antimicrobial dosing in renal compromise

A (antimicrobial agent)

B - C

D - F

G - L

M - R

T - V

©CKICC 2017 Dr. ÍOS

Tobramycin dosing

Once daily dosing

Once daily dose

Not for endocarditis, meningitis or extensive burns.

5mg/kg q24h iv, maximum 480mg in 24 hours.

Correct dose in obesity below.

Administration

In 100ml sodium chloride 0.9% over 60 minutes.

When to monitor levels

Pre-dose (‘trough’) levels taken between 18-24 hours after last dose administered. Initially monitor pre-dose level before second dose and then every 48 hours or daily if renal function poor.

Taking the sample

Send blood to microbiology, with the following information:

  • Name of antibiotic and prescribed dose.
  • Time and date the level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose or post dose level.

Interpreting result

You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.

Other monitoring parameters

Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. ringing / feeling of fullness in the ears, hearing loss, dizziness, vertigo, jittery / bouncing vision). Monitor for concomitant use of potent diuretics, ototoxic or nephrotoxic medicines e.g. NSAIDS, ACE inhibitors. Check vestibular and auditory function weekly if prescribed for more than 7 days.

Multiple daily dosing

Multiple daily dosing

1 - 1.7 mg/kg q8h iv, max 480mg in 24 hours

Correct dose in obesity as below.

IOS - CHECK LINK TO RENAL DOSING

Administration

iv bolus over 3-5 minutes or infuse in 50-100ml sodium chloride 0.9% over 20-60 minutes.

When to monitor levels

Take “Trough” level immediately pre-dose
Take “Peak” level one hour post dose

Initially monitor peak and trough levels with 3rd or 4th dose, then trough levels every 48 hours, or more often if renal function unstable or poor.
Peak levels do not need to be monitored more than once a week.

Reference range

Pre-dose level (trough) ≤2mg/L
Post dose level (peak) 5-12mg/L

Taking the sample

Send blood to microbiology, with the following information:

  • Name of antibiotic and prescribed dose.
  • Time and date the level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose or post dose level.

Interpreting result

You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.

Other monitoring parameters

Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. ringing / feeling of fullness in the ears, hearing loss, dizziness, vertigo, jittery / bouncing vision). Monitor for concomitant use of potent diuretics, ototoxic or nephrotoxic medicines e.g. NSAIDS, ACE inhibitors. Check vestibular and auditory function weekly if prescribed for more than 7 days.

Correcting in obesity

Correcting for obesity

Patients whose Actual Body Weight (ABW) is more than 120% of their ideal body weight (IBW) should receive an aminoglycoside dose calculated using these equations to provide a Dose Determining Weight (DDW):

Step 1: Calculate IBW.

Step 2: If ABW > (IBW + (20% of IBW)) then use Dose Determining Weight (DDW).

DDW = IBW + 0.4(ABW - IBW)

Renal impairment

Dosing in renal impairment

Tobramycin Once daily dosing GFR 20-50ml/min:
GFR 10-30ml/min: GFR <10ml/min:

CAPD/HD: Dose as per <10ml/min.
HD: Give dose after dialysis.
Monitor levels daily and adjust dose accordingly.
CVVH: 2mg/kg q24h, according to levels

Give 1-2mg/kg then dose according to serum levels

Give 1mg/kg then dose according to serum levels

Give 1mg/kg then dose according to serum levels

NCHD.ie©2017 Dr. ÍOS

Vancomycin levels are monitored to ensure efficacy and to minimise toxicity (mainly nephrotoxicity and ototoxicity)

Step 1 - Give ONE Loading Dose to all patients

Give one loading dose 25mg/kg (max 2g) to all patients.

Infusion rate: max 10mg/kg to avoid infusion-related reactions (incl. "red man" syndrome).

Infusion vol.: Dilute each 500mg in al least 100 ml 0.9% saline.

Step 2 - Maintenance Dose

In normal renal function : 15mg/kg IV every 12 hours at 10am and 10pm

  • Use actual body weight to calculate dose.
  • Round up to nearest 250mg.
  • Do not exceed 2g per dose.
  • To commence approximately 12 hours after loading dose.

In renal impairment (after loading dose given)

Creatinine ClearanceVanc. dose
>50ml/min 15mg/kg q12h (to start 12 hours after loading dose)
20-50ml/min 15mg/kg q24h (to start 24 hours after loading dose)
<20ml/min or haemodialysis 15mg/kg & re-dose once level <20mg/L

Step 3- Monitoring levels

Send blood to microbiology, with the following information

  • Name of antibiotic and prescribed dose
  • Time and date level was taken (The sample will be meaningless without this information).
  • The time and date of previous dose and whether it is a pre-dose level.
  • For twice daily dosing, check first level immediately prior to the first dose of day 3 of treatment.
  • Check levels more frequently in renal impairment and if concerned about toxicity or sub-therapeutic levels.
  • Do not withhold doses whilst waiting for a vancomycin assay result unless specifically advised in cases of renal impairment or suspected toxicity. The assay results should be used to guide subsequent doses.

Target pre-dose (trough) level: 10-20mg/L

  • 15-20mg/L in endocarditis, meningitis, pneumonia, osteomyelitis, MRSA  bacteraemia
  • NB: post dose levels only recommended in certain cases of endocarditis - check with microbiologist

Step 4 - Suggested vancomycin dose adjustments

Ensure level taken at the correct time, i.e. within two hours of next dose (preferably just prior to next dose)

Pre-dose (trough) level Suggested dose alteration <10mg/L 10-15mg/L 15-20mg/L >20mg/L

↑ each dose by 250mg-500mg.

If dose exceeds 2g bd, seek advice from micro./pharmacy regarding dosing strategies.

Desired range 10-20mg/L: no change
Desired range 15-20mg/L: ↑ each dose by 250mg

Max single dose is 2g. If total dose to exceed 2g q12h, contact pharmacy/micro for advice.

No change
Omit next dose(s) until level <20mg/L and then reduce each dose by 500mg
NCHD.ie©2017 Dr. ÍOS
Antibiotic Class Interacting Drug Comment Macrolides e.g. Erythromycin, Clarithromycin Statins Warfarin NOACs - Dabigatran,
Rivaroxaban, Apixaban, Edoxaban Drugs that prolong QT interval   Colchicine Metronidazole Warfarin Quinolones e.g. Ciprofloxacin, Levofloxacin, Moxifloxacin Warfarin Drugs that prolong QT interval Amiodarone Antacids / Iron / Calcium / Dairy products / phosphate binders Tetracyclines e.g. Doxycycline, Lymecyclin, Minocycline Antacids Iron Calcium Warfarin Carbapenems  e.g. Meropenem Sodium Valproate Linezolid Serotonergic Drugs Trimethoprim
and Co-Trimoxazole Warfarin Methotrexate Amiodarone Systemic Fusidic Acid Statins Rifampicin Consult product SPC for extensive list. Azole Anti-fungals e.g. Ketaconazole, Fluconazole, Miconazole (incl. Daktarin oral gel) Statins NOACs – Dabigatran,
Rivaroxaban, Apixaban, Edoxaban Warfarin Drugs that prolong QT interval
Risk of myopathy. Simvastatin contraindicated with clarithromycin and erythromycin. Where possible, hold pravastatin or atorvastatin whilst on macrolides, or consult product literature for statin dosing advice.
Risk of bleeding. Monitor INR closely.
Monitor, increased risk of bleeding.
Consider risk vs. benefit for each individual patient.
Contraindicated with clarithromycin
Increases half-life of warfarin by 60% - Monitor INR closely.
Risk of bleeding. Monitor INR closely.
Consider risk vs. benefit for each individual patient. (Moxifloxacin – contraindicated)
Avoid due to increased risk of arrhythmias
Risk of reduced bioavailability and efficacy.
Separate the doses by 2 to 3 hours or more to avoid interaction.
Risk of reduced bioavailability and efficacy.
Separate the doses by 2 to 3 hours or more to avoid interaction.
Risk of bleeding - monitor INR closely.
Contraindicated - Potential for inadequate seizure control.
Caution, risk of serotonin syndrome.
Risk of bleeding - monitor INR closely
Risk of severe bone marrow depression avoid is possible
Avoid due to increased risk of arrhythmias.
Risk of myopathy. Avoid if possible or hold for duration of antibiotic treatment and for a further 7 days.
Causes many drug interactions due to potent enzyme induction. May require dose adjustment or additional monitoring.
Risk of myopathy. Recommended to hold the statin for duration of antibiotic treatment.
Not recommended, increased risk of bleeding.
Risk of bleeding. Monitor INR closely.
Consider risk vs. benefit for each individual patient.

Warfarin and NOACs: Penicillins and cephalosporins are preferred alternatives when patients are on anticoagulants. Documented reports of bleeding incidents are rare even though a theoretical risk exists. Monitor INR during warfarin treatment.

Drugs that prolong QT interval: Imidazoles, tricyclic antidepressants, atypical antipsychotics, amiodarone & other anti-arrhythmics, some antidepressants (citalopram, escitalopram, fluoxetine, mirtazapine, paroxetine, sertraline, trazodone, venlafaxine) alfuzosin, chlorpromazine & domperidone, galantamine, haloperidol, indapamide, lithium, methadone, quinine sulphate, tamoxifen, tizanidine, co-trimoxazole. For or a composite list of drugs that can prolong QT Interval visit www.crediblemeds.org.

Non-drug risk factors for ↑ QTc: Family history, electrolyte abnormalities (hypokalaemia, hypocalcaemia, hypomagnesaemia), cardiac ischaemia, cardiomyopathies, hypothyroidism and hypoglycaemia.

Serotonergic Drugs: Triptans (e.g. sumatriptan); antidepressants; antipsychotics; anticonvulsants; antiparkinsonian agents; analgesics (e.g., fentanyl, pethidine, tramadol); cough and cold medication containing dextromethorphan; herbal products (St. John's wort). This is not a complete list; please consult with product SPCs for further information.

OF NOTE: Combined Hormonal Contraception: Guidance from the UK Faculty of Sexual & Reproductive Healthcare no longer advises that extra precautions are required when using combined hormonal contraception (CHC) with antibiotics. (Unless those antibiotics are enzyme inducers e.g. rifampicin, rifabutin, isoniazid).

Alcohol & Metronidazole: A disulfiram-like reaction dose can occur between metronidazole and alcohol. The reaction is generally more unpleasant than serious. Warn all patients of the potential effects (flushing and tachycardia). A reaction can occur up to 72 hours after stopping metronidazole.

Guide©2017 Dr. ÍOS

Sepsis section

©CKICC 2017 Dr. ÍOS
©CKICC 2017 Dr. ÍOS

Respiratory section

©CKICC 2017 Dr. ÍOS

Neurological sepsis

©CKICC 2017 Dr. ÍOS
Emergency Medicine Programme

Please approach in the chronological order as below and tick each positive item.

1. Infection suspected

Abdominal Neutropenic No focus Skin/soft tissue Urinary

2. SIRS criteria

3. Sepsis 6 (within 1 hour)

Take

  • Bld cultures (2 sites before antibiotics if possible)
  • Check venous lactate and Hb
  • Monitor Urine Output(±catheter)

Give

  • O2 (94-98% SpO2 or 88-92% in Chronic Lung Disease)
  • Fluid (500ml bolus - up to 30ml/kg) & reassess. Target SBP>100/MAP>65. Monitor response to IV fluids and titrate to effect
  • Give IV antibiotics

Lab tests available and acted upon within an hour.

4. Look for organ dysfunction

SBP <90mmHg or MAP <65mmHg or SBP >40 mmHg below patients usual New need for O2 to keep sats >90% Lactate > 2 mmol/L (post fluid bolus) Urine output ≤0.5ml/kg for 2 hrs - despite fluid resusc. Acutely altered mental status Glucose > 7.7 mmol/L (no Hx DM) Creatinine > 177 µmol/L Bilirubin > 34 micromol/L INR > 1.5 or aPTT > 60s Platelets < 100 x 109/L

5. Look for septic shock (post fluid bolus)

Lactate > 4 mmol/L Hypotensive (SBP < 90 or MAP < 65)
NCHD.ie©2017 Dr. ÍOS

SIRS - Systemic inflam. response syndrome

Two or more of :

  • Body temp. >38.50C or <350C
  • Heart rate >90bpm
  • RR >20 or PaCO2 <32mmHg or need mech. vent
  • WCC >12 or <4 x 109/L or immature forms >10%
  • Altered mental state
  • Glucose ≥7.7mmol/l

Sepsis

SIRS and documented infection (culture or gram stain of blood, sputum, urine or normally sterile body fluid positive for pathogenic micro-organism; or focus of infection identified by visual inspection). More and management on EMed.ie.

Severe sepsis

Sepsis and at least one sign of organ hypoperfusion or organ dysfunction:

  • Areas of mottled skin or CRT ≥3 sec
  • Urine <0.5ml/kg for at least 1 hr or renal replacement therapy
  • Lactates >2mmol/L
  • Abrupt change in mental status or abnormal EEG
  • Platelets <100x 109/L or DIC
  • Acute lung injury – ARDS
  • Cardiac dysfunction (ECHO)

More and management on EMed.ie.

Septic shock

Severe sepsis and one of:

  • MBP <60mmHg (<80mmHg if Hx ↑BP) after 40-60ml/kg saline, or pulmonary capillary wedge pressure between 12 and 20 mmHg.
  • Need for dopamine >5mcg/kg per min or norepinephrine or epinephrine >0.25mcg/kg per min to maintain mean blood pressure above 60 mmHg (80 mmHg if previous hypertension).

More and management on EMed.ie.

©CKICC 2017 Dr. ÍOS

NCHDs

NCHD.ie©2017 Dr. ÍOS

Interns

  • On-line only
  • NITP
NCHD.ie©2017 Dr. ÍOS

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Floating

Bricking it aren't you?

It is so very easy to sit here a few weeks from the end of intern year and tell you that it wasn't that bad, that you have nothing to worry about and that you will be grand. That old 30th June feeling has been replaced with that second Sunday in July feeling, and nothing will make it go away. Except of course the feeling you'll have when it hits 5pm on 11th July. You'll have done it then, one day down and only 364 minus holidays, weekends, bank holidays and sick days to go. That's like 250 or 270 tops!

You are able for this, you have read, studied, learned and practiced for five years and you know a lot more than you think you do. You know a lot less than you think you do too, but that you will pick up in a matter of weeks. Intern year may feel like an endpoint, but it is not. This is just an addendum to your studying, you will learn more this year than in the last two years of college - practical, useful stuff that just can't be read in a book. And that's what you're here for.

This guide is written by interns who have been around the block of CUH, and made it out the other side. It's written for interns about to start that journey for themselves. If you need to know a phone number, it's in here; if you're not quite sure where the radiology regs are hiding (and they are hiding), we'll tell you in here; if you do not know which blood test goes in which bottle, look in here and if you're starving and the canteen is closed and the microwave in the res is broken again, look up local numbers.

So take a deep breath and remind yourself that you are a capable, confident young doctor who will graciously take the advice of your senior colleagues be they nurses, doctors, healthcare assistants or porters. Whether it's patient management or which box you're supposed to leave your blood samples in, they do know better. But you must trust yourself above all other people.

So take a deep breath, close the EMed.ie and try to get some sleep on Sunday night. Because honestly, it's not that bad, you have nothing to worry about and you will in fact be grand. You did bring your pen right??

All the best!

Brendan, Catriona & Mwenya

Dr. Íomhar O' Sullivan

NCHD.ie©2017 Dr. ÍOS

Intern commandments

  1. Thou shalt not leave day jobs and admissions for on-call colleagues.
  2. Thou shalt not forget thy busy colleagues on-call.
  3. Thou shalt hand over seriously ill patients.
  4. Thou shalt remember to eat, drink and take a break when on-call.
  5. Thou shalt keep thy cool.
  6. Thou shalt call for help.
  7. Thou shalt answer thy bleep.
  8. Thou shalt attend intern teaching.
  9. Thou shalt take thy holidays.
  10. Thou shalt have fun!
NCHD.ie©2017 Dr. ÍOS

Preps for procedures

If required, please place any IV line on the back of the hand (keep it out of the way should the cardiologist be using radial access).

Diazepam is usually only given to patients who are highly anxious and NOT charted routinely.

Angiography/Interventional

  1. Normal creatinine for procedures requiring IV contrast.
  2. If abnormal consider US/MR Angiography instead.
  3. Cessation / reversal of medications affecting bleeding /coagulation.
  4. Consent.
  5. IV Access.
  6. FBC, U&E.
  7. INR & APTT.
  8. Fasting 6hrs.

Bronchoscopy

  1. IV line.
  2. Coag.
  3. Consent.
  4. Risks: Bleeding, Infection, MI, Pneumothorax.

Cardioversion

  1. ECG directly prior to procedure to confirm still fibrillating.
  2. Coag: Confirm INR therapeutic.
  3. Consent.
  4. IV line.
  5. Consider accompanying patient to theatre as you may be allowed to do it.
  6. Risks: ECG changes, Arrhythmias, Myocardial necrosis, Transient ↓BP.

CT

  1. Ensure creatinine is normal prior to any scan requiring IV contrast.
  2. Thorax /Abdomen/ Pelvis / fasting 6 hrs.
  3. CT Colonography 1 & 2 above and full bowel preparation. Ask for CT Colon bowel prep protocol at reception.
  4. CT guided biopsies & drainages /- As for angio. / interventional prep.

Endoscopy

Your reg. will invariably ask for an INR (in case of need for biopsy) so try to have this result available before sending the patient down. Make sure you have also consented the patient (incl. biopsy).

Fluoroscopy / IVP

  1. Barium Swallow / Meal / Follow Through need Fasting 6 hrs.
  2. Barium Enema need Bowel preparation: ask at reception for barium enema bowel prep protocol.
  3. Venography need Normal creatinine.
  4. IVP need normal creatinine.

MRI

  1. For Patients requiring contrast, please include the patient’s most recent Creatinine level on the request form.
  2. IV access (Pink/Blue) will also be required for in-patients that are having contrast exams.
  3. Please ensure that the patient safety questionnaire is completed accurately and in full.
  4. Do not refer patients that have pacemakers, or are known to have metal in their eye. These are total contraindications. Please organise orbit x-rays or chest x-rays if you are unable to ascertain these key safety questions.
  5. Patients with artificial heart valves, aneurysm clips, stents, shunts, implanted devices or prosthetics need careful vetting before MRI can be performed. So ensure you provide the correct information to the MRI department. Get family members to assist if the patient has difficulty in communicating.

PET CT

  1. Fasting for an absolute minimum of 6 hours prior to scan.
  2. During 6 hour fasting period, PLAIN WATER ONLY is allowed. No sweets, chewing gum, or other little treats that could result in the scan being cancelled are allowed. Target blood sugar levels for scan are 4.1-8.3 mmol/L.
  3. For diabetic patients, please contact PET CT Department for additional instructions.
  4. In-patients require IV access prior to arriving in PET/CT (blue or pink).
  5. Avoid booking patients for other procedures on same day as PET/CT to allow radiation to decay.

Prep. for theatre

  1. ECG in male > 40 or female > 50 or if Hx of IHD.
  2. Bloods only if clinically indicated.
  3. Patients going for major surgery will need full work-up i.e. FBC, U&E, Coag, G&S/ G&C in major procedure.
  4. Some patients require CXR pre-op. If in doubt, ask your SHO.
  5. Consent.

Beware. Often difficulties surrounding patients on anticoagulants - it should be mentioned at time of booking whether they are on aspirin, Clopidogrel, Warfarin or on a NOAC. Usually Aspirin should not be a problem.

Ultrasound

  1. US Abdomen need fasting 6hrs.
  2. US Pelvis need full bladder.
  3. US guided biopsies & drainages need as for angio. or interventional prep.
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data-referral-
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Coroner

Role

The Coroners’ core function is to investigate sudden and unexplained deaths so that a death certificate can be issued. The Coroner Service not only provides closure for those bereaved suddenly but also performs a wider public service by identifying matters of public interest that can have life/death consequences.

Reporting of a Sudden Death

Those deaths which should be reported to a Coroner are listed in the Deaths Reportable section of the coroners.ie site.

In summary, these are deaths that are sudden, unexpected, violent or unnatural.

What happens when a death is reported?

When a death has been reported to the Coroner, they or their staff will contact the doctor of the deceased and establish if:

  • The doctor has seen the deceased within the last month.
  • The cause of death is known.
  • The death was due to natural causes?

If these conditions are met, and there are no other matters needing investigation, the Coroner will allow the doctor to complete a Medical Certificate of the Cause of Death and the death will be registered with the Registrar of Deaths. No unnatural causes of death can be certified by a doctor. Based on the information available, the Coroner will decide:

  • A death can be certified without any further action.
  • A post mortem is needed to gather further information.
  • A post mortem and inquest are needed.

What deaths are reported to the Coroner?

  • Where a death may have resulted from an accident, suicide or homicide.
  • Where any question of misadventure arises in relation to the clinical or pharmaceutical treatment of the deceased.
  • Where a patient dies before a diagnosis is made.
  • Where any patient dies within 24 hours of admission to hospital.
  • When death occurred while a patient was undergoing an operation or was under the effect of an anaesthetic or following an operation.
  • Where the death occurred during or as a result of any procedure.
  • Where the death resulted from any occupational disease.
  • Where a death was due to neglect or lack of care (including self neglect).
  • Where death is directly due to a hospital acquired infection in the absence of other significant co-morbidities.
  • Where although a patient is known to have a significant co-morbidity hospital acquired infection has brought about death at a time much earlier than would otherwise have been expected.
  • Where a death occurs to a person in the care of the State.
  • All deaths occurring in the Emergency Department (or ITU).
  • All deaths in association with intra-cerebral haemorrhage.
  • All deaths occurring in patients who have been referred from a Nursing Home or long term residential care facility.

If in doubt as to whether or not a death is properly reportable, please consult with the Coroner who will advise accordingly. Please have a clear clinical (incl. PMHx) available before contacting the coroner. The fact that a death is reported to the Coroner does not mean that an autopsy will always be required.

Contact: (office) or Coroners mobile number via switch (The Coroner is available for consultation outside office hours, however except when the matter is urgent cases will normally be reported before 11pm or after 7am).

NCHD.ie©2017 Dr. ÍOS

Daffodil centre

The Daffodil Centre is an extension of the Irish Cancer Society’s ‘Cancer Information Service’. This free service offers confidential advice, information, and support to anyone worried about any aspect of cancer through a number of mediums. The Irish Cancer Society has been establishing Daffodil Centres where cancer care is delivered, as there is a body of international evidence showing that having access to the type of support that a Daffodil Centre provides can contribute positively to patients and their families throughout their cancer journey.

There are currently four Daffodil Centres based in the Munster region, these are located in Cork University Hospital, Bon Secours Hospital Cork, Waterford University Hospital, and University Hospital Limerick. Daffodil Centres provides free cancer information, support and advice. Last year the Cork Daffodil Centres received 5,978 contacts.

The CUH Daffodil Centre service runs from 9am-5pm Monday-Friday and is run by a specially trained cancer nurse and volunteers. No referral or appointment is necessary. Staff can be assured they are directing their patients to a trusted source of support and information, delivered by a professional and expert organisation.

Who can use the Daffodil Centres

Daffodil Centres are open to all, no referral or appointment is necessary: cancer patients (in-patients and out-patients), family members and the general public can come in and get information, including:

  • Cancer prevention and early detection diagnosis
  • Cancer treatments and related side-effects
  • Talking about cancer to children, family and friends
  • The emotional effects of cancer
  • Coping with life after a cancer diagnosis
  • Practical assistance (e.g. travel insurance information, transport to services)
  • Financial advice
  • Palliative care services
  • Support and psychological care
  • Practical entitlements and services available

Contact details:

Tel: (021)4234536.

Email:.

Visit: cancer.ie/how-we-can-help/daffodil-centres/university-hospital-cork

Cancer Nurseline Freephone: 1800 200 700.

NCHD.ie©2017 Dr. ÍOS
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Common calls

Documentation:

Whenever you treat a patient ("routine" contact or "on-call") “always write your impression of the patient and a plan”.

When you are on call always begin your note with the date, time, your rank (MIOC) and your name. All your notes during the day should contain the same information. It is also important to include the patient’s name and MRN at the top of your notes. Each page of medical notes should contain the MRN and name.

Every note should end with a signature and your MCRN.

NCHD.ie©2017 Dr. ÍOS
Approach to fluids - adults
NCHD.ie©2017 Dr. ÍOS

Useful medications

The medication information was kindly updated by Fiona Ahern on 02/02/2015.

NCHD.ie©2017 Dr. ÍOS

Pain Mx Adults

  • Assess Pain Location, Radiation pattern & likely cause of the pain.
  • Assess Pain Intensity ( 0 is “no pain” and 10 the “worst pain”).
  • Was the patient previously on Oral Analgesics including Opioids, if so are they prescribed?

Doses below are for adults >50kg. Consider mg/kg dose for adults < 50kg.

Refer problems with epidurals/local anaesthetic infusions/morphine via PCA to an anaesthetist.

The pain management advice was kindly prepared by Dr. Tim Keady (Intern in CUH 2014), Dr. Nick Barrett, Anaesthetic Reg., Dr. Dominic Hegarty, Pain Specialist, and Marih O'Leary, Pharmacist.

NCHD.ie©2017 Dr. ÍOS

Useful IV Admin. guide

Antibiotic preparations.

data-iv-ab-prep-
NCHD.ie©2017 Dr. ÍOS

Nicotine replacement therapy

Revised Fagerstrom Tolerance Scale

1. Assess Nicotine Dependence

0 1 2 How soon after you wake do you smoke? Do you find it difficult to refrain from smoking where it is forbidden Which cigarette would you most be willing to give up? Do you smoke more in the morning than the rest of the day? How many cigarettes do you smoke each day? Do you smoke if you are so ill that you are in bed all day? What is the nicotine level of your usual brand of cigarettes Do you inhale the smoke from your cigarette? Total
After 30 min Within 30 min  
No Yes  
Any other First one in the morning  
No Yes  
Up to 15 16-25 >25
No Yes  
Up to 0.9mg 1-1.2mg >1.3mg
No Sometimes Always
     

2. Prescribe NRT

Score Cigarettes per day Recommended dose NRT 0-3
Low nicotine dependence 4-6
Moderate dependence

7+
High dependence

0-10 10mg if required
11-20 15mg
20+ 25mg

Points to note:

  • NRT patches are applied for 16 hours. Apply in the morning and remove at night.
  • For best results patients need to remain on NRT for 12 weeks.
  • For pregnant clients advise smoking cessation and /or NRT

For High Dependency Smokers a 3 step down programme of NRT is recommended:

  • 8 weeks on 25mgs: 9-10 weeks at 15mgs and 11-12 weeks – 10mgs

For Moderate to Low Dependency smokers a 2 step down programme is recommended:

  • 8 weeks at 15mgs: 9-10 weeks at 10mgs and 11-12 weeks at 10 mgs

3. Offer Support

From your local Smoking Cessation Services.

NCHD.ie©2017 Dr. ÍOS

Useful NOACs

New Oral Anticoagulants.

NCHD.ie©2017 Dr. ÍOS

Stroke prevention in NVAF

Prevention VTE post elective ortho surgery

Treatment of DVT or PE

Prevention of recurrent DVT & PE

Switching Warfarin to

Switching LMWH/UFH to

Switching to Warfarin

Switching from to LMWH/UFH

NCHD.ie©2017 Dr. ÍOS

Pain Mild

Drug Dose Freq Route Note Paracetamol Ibuprofen
1g qds po/pr/iv In adults <50kg, IV dose is 15mg/kg max QDS. PO/PR route should be used unless contra-indicated.
400mg tds po Prescribe with PPI. See NSAID side-effects and contraindications. Less analgesia/anti-inflammatory action than diclofenac but side effects are less severe.
NCHD.ie©2017 Dr. ÍOS

Pain Moderate

Paracetamol + NSAID or Weak Opioid or both.

Drug Dose Freq Route Note Diclofenac Diclofenac Mefenamic
acid Tramadol
75mg bd po

Max 150mg/24hrs. Prescribe with PPI.

See NSAID side-effects and contraindications.

PR route has no ⇓ in side effects and no ⇑ in analgesia.

Assess risk/benefit (e.g. cardiovascular risk factors) and use lowest dose for shortest duration.

Diclofenac now contraindicated in IHD, CVD, CCF, PVD.

100mg 16hrly pr
500mg tds po

Prescribe with PPI.

See NSAID side-effects and contraindications.

Useful in both menstrual and inflammatory pain.

50–100mg qds po/im

See opioid side effects.

Avoid in epileptics and patients on medications which inhibit the re-uptake of serotonin (e.g. SSRIs, Linezolid).

In elderly can cause confusion, hallucination, N&V.

Good in neuropathic pain. Monitor INR (Tramadol can ⇑ INR).

NCHD.ie©2017 Dr. ÍOS

Pain Severe

Drug Dose Freq Route Note Oramorph Morphine Morphine OxyContin OxyNorm Pecfent Actiq Targin
10mg 4hrly. po

Morphine solution

5-10mg 4hrly im/sc

See opioid prescribing guide for side-effects and contraindications.

5-10mg 4hrly iv Slow injection
5-20mg bd po

Prolonged release oxycodone.

5-20mg 4hrly po

Oxycodone – good for breakthrough pain for patients on OxyContin or Targin - give 1/6 of total daily dose of opioid.

100mcg ii sprays
4hrly
IN

Fentanyl nasal spray – good for breakthrough pain.

Pecfent is cheaper than Instanyl and includes dose counter.

200mcg i-ii
4hrly
po

Fentanyl lozenge – good for breakthrough pain and cancer pain.

One lozenge initially, repeated if necessary after 15 minutes.

No more than 2 lozenges for each pain episode.

If adequate pain relief not achieved with one dose unit for consecutive breakthrough pain episodes, increase the strength of the dose unit until adequate pain relief achieved with 4 lozenges or less daily.

5/2.5mg – 20/10mg po Prolonged release oxycodone with naloxone for prevention of opioid induced constipation. Restricted to initiation by a pain specialist only, where oxycodone + laxative was ineffective.
NCHD.ie©2017 Dr. ÍOS

Pain compounds adults

Useful Compound Medications

Drug Active
Ingredients Dose/Route/Freq Note Solpadol Solpadeine Cyclimorph-10
Paracetamol
Codeine
500mg/30mg ii po qds See opioid side-effects and contraindications. Caution against dual prescription of paracetamol.
Paracetamol
Codeine
Caffeine
500mg/8mg/30mg ii po qds See opioid side-effects and contraindications. Caution against dual prescription of paracetamol.
Morphine
Cyclizine
10mg/50mg i im tds Max 3 doses/24hrs. Not to be used in case of MI; Cyclizine may aggravate heart failure.

Antispasmodics

Drug Active Ingredients Dose/Route/Freq Buscopan Colofac
Hyoscine Butylbromide 20mg po qds
Mebeverine 135mg po tds
NCHD.ie©2017 Dr. ÍOS

Prescribe controlled drugs

Legal requirements for Controlled Drug prescription (CD schedule 2 & 3)

  • Must be written in indelible ink.
  • Must be dated & signed by practitioner in their usual signature.
  • Must specify the address of the prescriber.
  • Patient´s name & address must be handwritten (no addressograph stickers).
  • Must handwrite the following drug details:
    • Dose to be taken.
    • Form.
    • Strength.
    • Total quantity to be supplied in words & figures.
  • Clearly indicate the prescribers name & state whether the person is a registered medical practitioner. (The Medical Council recommends including doctors registration number ­ not a legal requirement).
  • Specify a telephone number at which the prescriber may be contacted.
NCHD.ie©2017 Dr. ÍOS

Prescription writing policy for CUH

  1. Drug charts must include patient’s full name and hospital number and date of birth. Preferably attach an addressograph sticker.
  2. Drugs must be prescribed legibly and in capital print.
  3. Prescriptions must be signed by a registered medical practitioner & include the prescriber’s bleep number.
  4. Names of drugs must be in generic format except:
    1. Combination drugs e.g. FRUMIL.
    2. Preparations using slow or modified release formulations e.g. MST
    3. The following drugs because of reasons of bioequivalence: all lithium, theophylline & diltiazem products.
  5. Abbreviations e.g. NSA, GTN, ASA are not permitted.
  6. Corrections can only be made by re-writing the prescription; crossing out, tipp-ex etc. are not permitted.
  7. Discontinued drugs must be signed & dated by the prescriber.
  8. All drugs prescribed on separate charts, e.g. Insulin must be included on the prescription chart.
  9. Doses should follow the normal convention as follows; g for grams, mg for milligrams, micrograms & nanograms written in full. Avoid decimal points where possible, e.g. 250micrograms not 0.25mg.
  10. Drug sensitivities (allergies) should be entered in the allocated box.
  11. The same guidelines apply for drug prescriptions on HIPE forms & yellow prescriptions.
NCHD.ie©2017 Dr. ÍOS

Legal requirements for prescriptions

  • Must be in ink.
  • Must be dated & signed by practitioner in their usual signature.
  • Clearly indicate the prescriber’s name.
  • Specify the prescriber’s address.
  • State whether the prescriber is a doctor, dentist or nurse. (The Medical Council recommends including doctors registration number – not a legal requirement).
  • Specify the name & address of the patient.
  • State the age of the patient if under twelve years.
NCHD.ie©2017 Dr. ÍOS

NSAID Prescribing

Caution in:

  • Asthma
  • Elderly patients
  • Renal impairment
  • Hx of peptic ulcer
  • GI bleed
  • Anticoagulants
  • Nephrotoxic medications

Prescribe with PPI.

NCHD.ie©2017 Dr. ÍOS

Opioid prescribing for patients on chronic opioids

Clarify total daily regular dose + PRN given over last 24 hours and prescribe equivalent. (SC/IM/IV Morphine dose x2 = Equivalent oral dose of morphine.) If increased dose is needed, 25% increase is good starting point. Titrate dose to response/side effects.

Side effects.

Nausea, drowsiness are common, but tolerance develops in 5-7 days; respiratory depression; constipation; confusion; hallucinations; especially in elderly. Myoclonus is a sign of toxicity due to build up of metabolites.

Prescribe anti-emetic PRN and regular laxative. Lactulose 15mls BD with PRN Senna recommended (Lactulose can take 48 hours to take effect).

Reversal

For suspected respiratory depression, evaluate for RR<8 bpm, hypoxia, difficulty rousing. Naloxone: goal of therapy is to control the resp rate, not completely reverse opioid effect. Give 0.4mg IV q 2-3 min until resp. rate above 12/min. Effect lasts 15-90 mins. After initial reversal, give continuous infusion at hourly rate of 1/3rd of dose needed to reverse. See EMed.ie for further info.

NCHD.ie©2017 Dr. ÍOS

Heparin

Dose adjustments based on APTT ratio / APTT (sec) # APTT
Ratio # APTT
(secs) Heparin Infusion Rate (change) Recheck
APTT
(hours)
> 6.6 > 178 Stop infusion for 1 hour, then
↓ by 500 units/hr (↓ by 1ml/hr)
(and maintain this rate until next APTT)
4
5.1 – 6.6 137 – 178 ↓ by 500 units/hr (↓ by 1ml/hour)
(and maintain this rate until next APTT)
4
4.1 – 5.0 110 – 136 ↓ by 300 units/hr (↓ by 0.6ml/hour)
(and maintain this rate until next APTT)
4
3.1 – 4.0 84 – 109 ↓ by 100 units/hr (↓ by 0.2ml/hour)
(and maintain this rate until next APTT)
4
2.6 – 3.0 70 – 83 ↓ by 50 units/hr (↓ by 0.1ml/hour)
(and maintain this rate until next APTT)
4
1.5 – 2.5 40 – 69 No change if patient clinically stable 4
1.2 – 1.4 33 – 39 ↑ infusion by 200 units/hr (↑ by 0.4ml/hr)
(and maintain this rate until next APTT)
4
< 1.2 < 33 ↑ infusion by 400 units/hour (↑ by 0.8ml/hour)
(and maintain this rate until next APTT)
4

# Use APTT Ratio if available. If not, use APTT (secs) and adjust dose accordingly.

Please check EMed.ie for more details / print prescription chart.

NCHD.ie©2017 Dr. ÍOS

Insulin Sliding scale

Insulin sliding scale CUH Capillary Blood Glucose (mmol/L) Insulin (units/hr)
<4.5 Hold infusion
4.5-6.5 1
6.5-9 2
9-17 4
17-28 8
28 10

50ml syringe.

Dilute 50 units Actrapid to total of 50 mls normal saline (giving 1 unit/ml).

Dilute in saline (for hyperglycaemia) or 5% dextrose (for hyperkalaemia).

Start infusion depending on hourly GM readings as follows: Check level at 22:00 hours. If BM stable at 6-7 mmol, halve infusion rate overnight and check BM hourly.

BMs may be checked 2 hourly if stable.

IV fluids should be administered through a separate cannula.

Dextrose saline should be used if capillary blood glucose is less than 12mmol/l and normal saline should be used at higher glucose levels. The rate of fluid administration will be governed by the patient’s fluid requirements, state of hydration, etc.

Subcutaneous insulin can be recommenced when the patient is eating and drinking as normal.

N.B. This sliding scale is arbitrary. Insulin requirements vary from person to person and you may need to alter this accordingly.

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Procedures

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Take Aways

Maps

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Rate us please

Hospital: Please select BGH CUH MGH MUH SIVUH BSH

Ease of use:

Information Useful?:

Best feature:

Suggestions to improve please:

Close Thank you for submitting your feedback.

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Calculators

CKICC©2017 Dr. ÍOS

ABCD2 score

Stroke risk after TIA

  • Diabetes: Diabetic? No Yes
  • Hypertension: Hypertension? No Yes
  • Age >60 yrs: Age? No Yes
  • Clinical: Clinical? Unilateral weakness (face/arm/leg) with or without speech disturbance Speech disturbance (without motor weakness)
  • Symptom duration: Duration? 0 - 59 min >60 min

ABCD2 =

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Anion Gap

  • Na+:

    Cl-:

  • HCO3:

Anion gap =

Metab Acidosis ↑ AG Metab. Acidosis Normal AG Metab. Acidosis

MUDPILERS

  • Methanol
  • Uraemia
  • DKA/Alcoholic KA
  • Paraldehyde
  • Isoniazid
  • Lactic Acidosis
  • Etoh/Ethylene Glycol
  • Rhabdomyolysis
  • Salicylates

HARDUPS

  • Hyperalimentation
  • Acetazolamide
  • Renal Tubular Acidosis
  • Diarrhoea
  • Uretero-Pelvic Shunt
  • Post-Hypocapnia
  • Spironolactone
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Barthel Index

Activities of Daily Living

  • Bowels: Please select Incontinent(or needs to be given enemata) Occasional accident (once/week) Continent
  • Bladder: Please select Incontinent, or catheterised & unable to manage Occasional accident (max 1 per 24hrs) Continent (for over 7 days)
  • Grooming: Please select Needs help with personal care Independent face/hair/teeth/shaving(implements provided).
  • Toilet Use: Please select Dependent Needs some help but can do something alone Independent (on&off,dressing, wiping)
  • Feeding: Please select Unable Needs help cutting, spreading butter etc. Independent (food provided within reach)
  • Transfer: Please select Unable - no sitting balance Major help (1 or 2 people), can sit Minor help Independent
  • Mobility: Please select Immobile Wheelchair independent, incl. corners etc. Walks with help of 1 person (verbal or physical) Independent (but may use an aid e.g. stick)
  • Dressing: Please select Dependent Needs help (but can do about ½ unaided) Independent (incl. buttons/zips/laces)
  • Stairs: Please select Unable Needs help (verbal, physical, carrying aid) Independent up and down
  • Bathing: Please select Dependent Independent (or in shower)

Barthel index =

NCHD.ie©2017 Dr. ÍOS

ChadsVASC

  • CCF:
  • Hypertension:
  • Age ≥ 75 years 65-74 years <65 years
  • Diabetes:
  • Stroke/TIA/VTE:
  • Vascular disease:
  • Sex: Female:

CHA2DS2-VASc score =.

Chads2VaSc Stroke rate (%/yr) 0 1 2 3 4 5 ≥6
0%
1%
2%
3%
4%
7%
10-15%
Related : HasBled (risk of bleeding in AF).
NCHD.ie©2017 Dr. ÍOS

eGFR

eGFR is estimated GFR calculate using the abbreviated MDRD equation:

eGFR (ml/min/1.73m2) = 186 x (Creat / 88.4)-1.154 x (Age)-0.203 x (0.742 if female) x (1.210 if black)

  • Creat(µmol/L):

    Age:

  • Gender: Please select Male Female

    Race: Please select Other Black

eGFR = 00 (ml/min/1.73m2) =

Normal GFR is approx. 100mls/min/1.73m2.

This formula is inaccurate in those with extremes in muscle mass (creatinine).

This formula is accurate in those with chronic renal disease but underestimated GFR in healthy patients.

The MDRD equation is not valid for children.

NCHD.ie©2017 Dr. ÍOS

Gentamicin once-daily dosing

This calculator computes the correct dose of gentamicin for a once-daily dosing regimen, in accordance with Cork University Hospital (CUH) antimicrobial prescribing guidelines (updated May 2016).

Renal impairment and obesity are taken into account when calculating the dose.

The once-daily gentamicin regimen should not be used for patients with endocarditis, meningitis, extensive burns, severe renal impairment, or patients on dialysis or haemofiltration.

  • Gender: Male Female
  • Age:

    Weight (kg):

  • Height Units:(height required if
    patient is overweight)

    Imperial Metric

  • Feet:Inches:Height(cm):
  • Creatinine (µmol/l):
NCHD.ie ©2017 Dr. R. McEvoy

HEART score

For risk stratifying ED patients with chest pain

  • History: Please select Highly suspicious Moderately suspicious Slightly/non-suspicious
  • ECG: Please select Significant ST-depression Non-specific re-polarisation Normal
  • Age: Please select ≥ 65 years > 45-65 years < 45 years
  • Risk factors: Please select x3 risk factors or Hx CAD 1 -2 risk factors No risk factors
  • Troponin: Please select >x3 normal limit >1 - <3 normal limit < Normal limit

HEART score = :

Risk factors: DM, smoker, ↑BP, FHx of CAD, ↑Lipids

Score 1-3: 2.5% MACE over next 6/52 » CUH - Admit to CDU for 2nd TnI ± home.

Score 4-6: 20.3% MACE over next 6/52 » Discuss with senior/cardiology

Score 7-10: 72.7% MACE over next 6 weeks » Admit cardiology

NCHD.ie©2017 Dr. ÍOS

Na+ deficit in hyponatraemia

Na+ requirement (mmol) =
total body water x (target Na+ - serum Na+ )

Rate of infusion (ml/hr) =
(Na+ requirement (mmol) x 1000) / (infused Na+ (mmol/L) x time (hours))

  • Age/Gender Age/Gender Child Female Male Elderly Female Elderly Male

    Weight (Kg):

  • Serum Na+:

    Target Na+:

0.9% NaCl (154mmol/L) rate: ml/hr for hours.

The above formula does not include insensible water losses.

Total body water

Children

0.6 x weight

Women

0.5 x weight

Men

0.6 x weight

Elderly women

0.45 x weight

Elderly men

0.5 x weight

Ref: Adrogue, HJ, Madias, NE. Hyponatremia. NEJM 2000; 342(21):1581-1589.

NCHD.ie©2017 Dr. ÍOS

For the older ones

1 olde stone = 6.35026 kg

1 olde pound = 0.45359 kg

1 olde foot = 30.48 cm

1 olde inch = 2.54 cm

  • Stones:

    Pounds:

Weight: 000 kg

  • Feet:

    Inches:

Height: 000 cm

NCHD.ie©2017 Dr. ÍOS

NIHSS

  • 1a. LOC: Please select Alert; keenly responsive Easily rousable to answer questions Needs repeated stimulation or pain to make movements Responds only with reflex, flaccid or unresponsive
  • 1b. Questions: Please select Answers both questions correctly Answers one question correctly Answers neither question correctly
  • 1c. Commands: Please select Performs both tasks correctly Performs one task correctly Performs neither task correctly
  • 2. Best gaze: Please select Normal Partial gaze palsy; gaze abnormal in 1 or both eyes but total paresis not present Forced deviation or total gaze paresis not overcome by oculocephalic manoeuvre
  • 3. Visual: Please select No visual loss Partial hemianopia Complete hemianopia Blind (incl. cortical blindness)
  • 4. Facial palsy: Please select Normal symmetrical movements Minor paralysis (asymmetry on smiling) Partial paralysis (total/near total paralysis of lower face) Complete (no facial movement in upper or lower face) paralysis
  • 5. Motor arm: Please select No drift; holds arms 90° or 45° x 10 sec Drift; holds arm but drifts (not hit bed) in 10 sec Drifts down to bed but has some effort against gravity No effort against gravity: limb falls No movement UN (=amputation or joint fusion)
  • 6. Motor leg: Please select No drift: holds 30° for 5 sec Drift: Leg drops but not hit bed at 5 sec Effort against gravity: but hits bed before 5 sec No effort against gravity No movement UN (=amputation or joint fusion)
  • 7. Limb ataxia: Please select Absent Present in one limb Present in 2 limbs UN (=amputation or joint fusion)
  • 8. Sensory: Please select Normal: no sensory loss Mild-moderate sensory loss Severe-total sensory loss
  • 9. Language: Please select No aphasia; normal Mild-moderate aphasia Severe aphasia Mute, global aphasia
  • 10. Dysarthria: Please select Normal Mild-moderate dysarthria Severe dysarthria UN (intubated or other physical barrier)
  • 11. Inattention: Please select No abnormality Visual, tactile, auditory, spatial or personal inattention to bilateral stimulus Profound hemi-inattention to more that one modality; does not recognise own hand or orientates to only one side
  • NIHSS=

NCHD.ie©2017 Dr. ÍOS

Osmolarity

Calculated Osmolarity = 2 Na + 2 K + Glucose + Urea ( all in mmol/L)

  • Na+:

    K+:

  • Glucose:

    Urea:

Osm: 0

Osmolar Gap = Serum Osm (lab) - Calculated Osm

Normal Gap 10 to 15 mOsm/kg water

Causes: ↑ Osmolar Gap

A) ↓serum water

  • Hyperproteinaemia
  • Hypertriglyceridaemia

B) Unmeasured Osm

  • Ethanol/Methanol
  • Ethylene Glycol
  • Diuretics (Mannitol)
  • Glycerol
  • Sorbitol
  • Acetone
  • Paraldehyde

For more please see EMed.ie

NCHD.ie©2017 Dr. ÍOS

PERC rule

PERC rules out PE if no criteria are present and pre-test probability is low. No need for further tests as <2% changce of PE.

  • Age ≥50:
  • Heart rate ≥100 bpm:
  • O2 Sats <95%:
  • Prior Hx DVT or PE:
  • Recent Trauma or Surgery:
  • Haemoptysis:
  • Exogenous Oestrogen:
  • Unilateral leg swelling:

Probability of PE <2%

NCHD.ie©2017 Dr. ÍOS

Vancomycin intravenous dosing

This calculator computes the correct doses of vancomycin for an intravenous dosing regimen, in accordance with Cork University Hospital (CUH) antimicrobial prescribing guidelines (updated May 2016).

  • Gender: Male Female
  • Age:

    Weight (kg):

  • Height Units: (height required if
    patient is overweight)

    Imperial Metric

  • Feet:Inches:

    Height(cm)

  • Creatinine (µmol/L):
nchd.ie ©2017 Dr. R. McEvoy

Wells score DVT

Validated Out-patient model for estimating pre-test probability of DVT.

Low probability : d-dimers will help exclude DVT.

High probability: do not do d-dimers but requires imaging

  • Active cancer:
  • Bed ridden (>3/7) or maj. surgery in last 4/52:
  • Calf swelling>3cm than other:
  • Collateral (non-varicose) veins:
  • Entire leg swollen:
  • Local tender along deep venous system:
  • Pitting oedema greater in symptomatic:
  • Paralysis, paresis or PoP of lower limb:
  • Previous confirmed DVT:
  • Alternative Dx to DVT more likely:

Score =

DVT "Likely" if Well's ≥2
DVT "Unlikely" if Wells ≤1

NCHD.ie©2017 Dr. ÍOS

Wells score PE

Pre-test probability of PE

  • Clinical signs DVT:
  • PE is most likely Dx:
  • Heart rate >100:
  • Immobilisation (3/7) or surgery last 4/52:
  • Past Hx confirmed DVT/PE:
  • Haemoptysis:
  • Malignancy treatment in past 6/12 or palliative:
  • Score =

    Wells Score >4 = PE likely. Consider imaging.

    Wells Score 0-4 = PE unlikely. Consider D-dimer to rule out PE.

NCHD.ie©2017 Dr. ÍOS

interacts with:

Ideal Body Weight

IBW ♂ = [(height (cm) x 0.9] - 88

IBW ♀ = [(height (cm) x 0.9] - 92

  • Gender: Gender Male Female

    Height(cm):

IBW: 000Kg

Adult PEFR

♂:(([Ht5.48]+1.58)-(Age0.041))60

♀:(([Ht3.72]+2.24)-(Age0.03))60

  • Gender: Gender Male Female

    Height(cm):

  • Age:

    Measured PEFR:


Source: http://www.nchd.ie/


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