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Slán, Íomhar
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.
Ms. Terri Goulding, for her fantastic organisation and dedication to DiT 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.
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).
Updates may be released periodically. If you think you have an outdated version, please close and reopen your browser.
These guidelines are for adults only. For pregnancy/breastfeeding guidelines please change your hospital to CUMH. Click for Paediatric Guidelines.
These .
These guidelines are for CUMH patients only. For general hospital or paediatric patients please change your hospital to MUH.
Before prescribing any antibiotics, please read this advice.
These .
For estimating severity / prognosis in community acquired pneumonia.
A CXR should be performed to confirm new consolidation.
| Symptom | Score |
|---|---|
| Confusion | 1 |
| Urea > 7 mmol/l | 1 |
| Resp rate >30 | 1 |
| SBP<90 or DBP<60 mmHg | 1 |
| Age ≥ 65 | 1 |
| 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).
| CURB-65 | Class. | Advice |
|---|---|---|
| 0 - 1 | Mild | Treat as out-patient |
| 2 | Moderate | Consider a short stay in hospital or watch closely as an outpatient |
| 3-5 | Severe | Requires admission ± ITU |
| 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. |
| Drug | Use in pregnancy | Use in breastfeeding | Info pregnancy | Info breastfeeding |
|---|---|---|---|---|
| Fluconazole | 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. | |
| Aciclovir Valaciclovir |
Compatible | Compatible | ||
| Oseltamivir | Compatible | Compatible | Maternal benefit far outweighs the unknown risk, if any, to the foetus. |
| Drug | Use in pregnancy | Use in breastfeeding | Info pregnancy | Info breastfeeding |
|---|---|---|---|---|
| Cefalexin | 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. | |
| Ceftriaxone | 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. | |
| 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. |
| Drug | Use in pregnancy | Use in breastfeeding | Info pregnancy | Info breastfeeding |
|---|---|---|---|---|
| Benzylpenicillin | 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. |
|
| Flucloxacillin | 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. |
|
| Amoxicillin | 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. |
|
| Co-amoxiclav | 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. |
|
| Piptazobactam | 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. |
|
| Meropenem | Animal data suggest low risk | Probably compatible |
| Drug | Use in pregnancy | Use in breastfeeding | Info pregnancy | Info breastfeeding |
|---|---|---|---|---|
| Azithromycin | Animal data suggest low risk | Probably compatible | Limited human data do not suggest risk of developmental toxicity with Azithromycin. | Unconfirmed epidemiological 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. |
| Clarithromycin | 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 epidemiological 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. |
| Erythromycin | Compatible | Compatible | Unconfirmed epidemiological 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. |
| Drug | Use in pregnancy | Use in breastfeeding | Info pregnancy | Info breastfeeding |
|---|---|---|---|---|
| Ciprofloxacin | 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 congenital 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. |
| Ofloxacin | 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. |
| 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. |
| Drug | Use in pregnancy | Use in breastfeeding | Info pregnancy | Info breastfeeding |
|---|---|---|---|---|
| Clindamycin | Compatible | Compatible | Monitor infant for possible effects on the gastrointestinal flora, such as diarrhoea or candidiasis. | |
| Mebendazole | Low risk | Probably compatible; | Avoid in 1st trimester | Mebendazole is poorly absorbed from the GI tract. |
| Metronidazole | 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. |
| Mupirocin (nasal) |
Probably compatible | Probably compatible | 1% of mupirocin is absorbed after topical application. | Considered to be low risk to the nursing infant. |
| Nitrofurantoin | Risk in 3rd trimester | 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). |
| Permethrin (topical) |
Compatible | Compatible | ||
| Vancomycin | Compatible | Probably compatible | Only low levels secreted into breast milk. Poor oral absorption. Monitor infant for possible effects on gastrointestinal flora, such as diarrhoea. |
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:
For the purposes of this guideline, the Briggs Classification has been adapted for assessing risk in pregnancy and 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:
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 non-existent. Animal reproductive data are not relevant.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
These guidelines are for children only. For adult patients, please see adult guidelines. For pregnancy/breastfeeding guidelines please change your hospital to CUMH.
These paediatric antibiotic guidelines were written by Dr Íomhar O’ Sullivan and Prof. Ronan O’Sullivan. Updates, by Dr ÍOS in 2024 were based on the 2021 and 2024 ICH 2021 guidelines. They have not yet been endorsed by the CKICC. Please click for CKICC adult guidelines or change your hospital to CUMH for breastfeeding/pregnant patients.
If penetrating injury to foot use Pip-Taz iv ± Gentamicin iv.
Antibiotic preparations.
Amikacin is an aminoglycoside, and is a restricted antimicrobial in CUH, reserved for use on advice of microbiology or ID only. Please see Restricted antimicrobial policy.
If clinical response does not occur within three to five days, consideration should be given to alternative therapy. Seek advice from Microbiology/ID. Maximum cumulative dose per course is 15g.
Amikacin can cause nephrotoxicity:
Amikacin can cause ototoxicity:
Amikacin may cause muscle weakness:
To reduce the risk of side effects:
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 administer over 30 minutes.
When to monitor levels
Interpreting result
| Amikacin level | Action |
|---|---|
| Next dose due and no trough available | If normal renal function, and no previous dose change, administer dose at scheduled time. DO NOT administer any further doses without a trough level result. If renally impaired, await level before administering. |
| <5mg/L (target) | Continue with same dose. Monitor renal function. Review ongoing need on a daily basis- discuss with microbiology/ID |
| ≥5mg/L | Check level taken at the correct time pre-dose. If yes, HOLD next dose. Do not redose until level <5mg/l. Monitor renal function. Review ongoing need- discuss with microbiology/ID. When redosing, the dosing interval can be increased or the dose reduced. Seek advice from microbiology/ID/Antimicrobial Pharmacist. |
Twice daily dosing
Please check details with Micro./I.D./Pharmacy.
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)
Dosing in renal impairment
| CrCl ≥50ml/min: | CrCl 21-49ml/min: | CrCl 10-20ml/min: | CrCl <10ml/min: |
|---|---|---|---|
| 15mg/kg q24h (max 1.5g) | 10mg/kg q24h(max 1.5g)** | 3-4mg/kg once daily ** | 2mg/kg stat * CAPD: 2mg/kg stat * HD: Give 5mg/kg stat. Give after dialysis. Always d/w renal/pharmacy. CVVH: 7.5mg/kg q24h. Always d/w as renal/pharmacy. |
*See above for dosing in obesity
** For critically ill patients with sepsis or septic shock, the first dose can be given as a stat dose of 5mg/kg, even in renal dysfunction, unless the patient is frail, elderly or has very low body weight.
Background: Clostridioides difficile is the leading cause of infectious nosocomial diarrhoea in industrialised countries. It is a Gram-positive spore-forming anaerobic bacillus. The spectrum of C. difficile infection (CDI) ranges from mild diarrhoea to potentially fatal colitis. C.DIFFICILE infection (CDI) occurs when the bacterium produces toxins that causes diarrhoea and inflammation in the colon.
A patient in whom ≥1 of the following applies:
* Clinical Findings: Diarrhoea is defined as ≥3 loose stools, i.e. Bristol stool scale 6–7, in 24 hours.
Patients who are C. difficile PCR positive but are toxin negative and asymptomatic may be colonised with C. difficile.
Increase in WBCs but <15 x 109/l and typically associated with 3-5 loose stools per day. No symptoms of severe CDI.
Severe CDI with hypotension, septic shock, rising serum lactic acid levels, partial or complete ileus, toxic megacolon or bowel perforation, any rapid deterioration of the patient.
Those at high risk of recurrence: older age of the patient (>65 yrs) plus the presence of one or more additional risk factor(s):
Dosing below assumes normal renal function - please click on individual drug for dosing in renal impairment, cautions in use and administration information.
First line: Vancomycin* 125mg QDS PO for 10 days.
Second line: Fidaxomicin** 200mg BD PO for 10 days. Consider for patients at high risk of recurrence (above). Fidaxomicin should only be used in consultation with clinical microbiology or ID teams.
Monitor closely for deterioration/progression to severe CDI.
Seek early Surgical Opinion.
Vancomycin* 125mg QDS PO for 10 days
OR
Fidaxomicin** 200mg BD PO for 10 days. Consider for patients at high risk of recurrence. Fidaxomicin should only be used in consultation with clinical microbiology or ID teams.
Monitor closely for progression to severe-complicated CDI
Recommend urgent MDT approach with surgical consultation.
Vancomycin* 500mg QDS PO/NG plus Metronidazole 500mg TDS IV for 10 days.
Consider intracolonic # route for Vancomycin 500mg every 4-6 hours if ileus present or suspected.
* Vancomycin IV 500mg vials can be used for oral or nasogastric (NG) or PEG administration.
Vancomycin 125mg PO: reconstitute vancomycin 500mg vial with 10ml WFI. Withdraw 2.5ml (125mg) from the reconstituted vial and mix with 30ml water and administer to patient orally or NG/PEG. Reconstituted vials can be stored at 2-8°C for 24 hrs.
Vancomycin 500mg PO: reconstitute vancomycin 500mg vial with 10ml WFI. Withdraw 10ml (500mg) from the reconstituted vial and mix with 30ml water and administer to patient orally/NG or via PEG.
# If oral route is not possible give vancomycin via intracolonic route see below
** Fidaxomicin is only available on the high tech scheme, and must be on the recommendation of Microbiology/ID. Can be given NG.
Rectal Vancomycin can be given as a retention enema containing 500mg in 100ml of normal saline every 4 to 6 hours.
Using Vancomycin 500mg IV vial to prepare a retention enema:
Method for administration:
Caution: Dose adjustments may be required depending on individual circumstances including extent of colonic disease and patient weight. Vancomycin can be absorbed through inflamed colonic mucosa and cause toxicity if it accumulates in patients with renal failure. Consider checking vancomycin levels if absorption is suspected.
For first episode / first recurrence please see CDAD 1st episode.
Dosing below assumes normal renal function - please click on individual drug for dosing in renal impairment, cautions in use and administration information.
Monitor closely for progression to severe-complicated CDI - Recommend all recurrences discussed with clinical microbiology or ID teams.
Fidaxomicin** 200mg BD PO for 10 days in consultation with clinical microbiology or ID teams
or
Fidaxomicin** Prolonged course: Fidaxomicin 200mg BD on days 1-5, followed by 200mg OD on alternate days on days 7 to 25 (Note: day six is tablet free)1 Fidaxomicin should only be used in consultation with clinical microbiology or ID teams
OR
Vancomycin Tapering/Pulse Therapy:
OR
Vancomycin followed by Rifaximin Therapy: Vancomycin 125mg PO QDS for 10 days followed by Rifaximin 400mg TDS for 20 days.
Recommend MDT approach with surgical consultation, treat as for initial episode of severe-complicated CDI.
Vancomycin 500mg QDS PO/NG PLUS Metronidazole 500mg TDS IV for 10 days.
Consider intracolonic # route for Vancomycin 500mg q4-6h if ileus present or suspected.
* Vancomycin IV 500mg vials can be used for oral or nasogastric (NG) or PEG administration.
Vancomycin 125mg PO: reconstitute vancomycin 500mg vial with 10ml WFI. Withdraw 2.5ml (125mg) from the reconstituted vial and mix with 30ml water and administer to patient orally or NG/PEG. Reconstituted vials can be stored at 2-8°C for 24 hrs.
Vancomycin 500mg PO: reconstitute vancomycin 500mg vial with 10ml WFI. Withdraw 10ml (500mg) from the reconstituted vial and mix with 30ml water and administer to patient orally/NG or via PEG.
# If oral route is not possible give vancomycin via intracolonic route see below
** Fidaxomicin is only available on the high tech scheme, and must be on the recommendation of Microbiology/ID. Can be given NG.
Rectal Vancomycin can be given as a retention enema containing 500mg in 100ml of normal saline every 4 to 6 hours.
Using Vancomycin 500mg IV vial to prepare a retention enema:
Method for administration:
Caution: Dose adjustments may be required depending on individual circumstances including extent of colonic disease and patient weight. Vancomycin can be absorbed through inflamed colonic mucosa and cause toxicity if it accumulates in patients with renal failure. Consider checking vancomycin levels if absorption is suspected.
For microbiologist supervision only.
Dose adjustments may be required depending on individual circumstance including extent of colonic disease and patient weight. Vancomycin can be absorbed through inflamed colonic mucosa and cause toxicity if it accumulates in patients with renal failure.
Treat as CDAD 1st episode
Gentamicin and Tobramycin are aminoglycoside. Tobramycin is restricted antimicrobial in CUH.
Aminoglycosides can cause nephrotoxicity:
Aminoglycosides can cause ototoxicity:
Aminoglycosides may cause muscle weakness:
To reduce the risk of side effects:
Once daily dose
5mg/kg q24h iv (20 minutes), maximum 480mg in 24 hours.
Once daily gentamicin regimen should not be used for patients with meningitis or extensive burns (>20% BSA).
Correct dose in obesity below.
In pregnancy please use booking weight.
Blood Sampling
Interpretation of level result
| Gent/Tobra level | Action |
|---|---|
| Next dose due and no trough available | If normal and stable renal function, and no previous dose change, administer dose at scheduled time. DO NOT administer any further doses without a trough level result. If renally impaired, await level before administerin |
| <1mg/L ( Target) | Continue with same dose. Monitor renal function. Review ongoing need on a daily basis- discuss with Microbiology/ID |
| ≥1mg/L | Check level taken at the correct time pre-dose. If yes, HOLD next dose. Do not redose until level <1mg/L. Monitor renal function. Review ongoing need- discuss with microbiology/ID. When redosing, the dosing interval can be increased or the dose reduced. Seek advice from Microbiology/ID/Antimicrobial Pharmacist. |
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)
Dosing in renal impairment
| CrCl >50ml/min: | CrCl 30-50ml/min: | CrCl 10-30ml/min: | CrCl 5-10ml/min | RRT |
|---|---|---|---|---|
| 5mg/kg q24h (max 480mg) | 4mg/kg q24h ** | 3mg/kg q24h ** | 2mg/kg STAT ** | CAPD: 2mg/kg STAT * HD: 2mg/kg STAT. Give after dialysis. Always d/w renal/pharmacy * CVVH: 3mg/kg q24h. Always d/w renal/pharmacy * |
* see above for dosing in obesity
** For critically ill patients with sepsis or septic shock, the first dose can be given as a stat dose of 5mg/kg, even in renal dysfunction, unless the patient is frail, elderly or has very low body weight.
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 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 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 infection. This is termed colonisation or carriage. Topical antiseptics may be used to eradicate / reduce MRSA carriage.
MRSA colonisation eradication (or ↓) regimen - for 7 days. Please refer to infection control guidelines for full details.
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, MRSA could be the causative pathogen and this should be considered when treating the patient empirically.
Seek advice from Micro./I.D. regarding choice of agent and duration of treatment.
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.
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.
Amoxicillin, Ampicillin, Flucloxacillin, Benzylpenicillin, Co-amoxiclav (e.g. Augmentin®/ Pinaclav®), Phenoxymethylpenicillin (Calvapen®), Piperacillin-tazobactam (Tazocin®), Extencilline®, Temocillin (Negaban®), Ticarcillin (Timentin®).
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.
Amikacin, Metronidazole, Ciprofloxacin, Moxifloxacin, Clarithromycin, Nitrofurantoin, Clindamycin, Rifampicin, Colistin, Sodium fusidate, Doxycycline, Teicoplanin, Erythromycin, Tobramycin, Gentamicin, Trimethoprim, Linezolid, Vancomycin.
Vancomycin levels are monitored to ensure efficacy and to minimise toxicity (mainly nephrotoxicity and ototoxicity)
For MUH advice please contact antibiotic pharmacist or ward pharmacist, or microbiology. Pharmacy: x 5632, Micro lab: xt 5719, Consultant microbiologist: xt 5716 or via switch on 021 2935201.
For CUH advice please contact Antimicrobial Pharmacist: 0861727887 or your ward pharmacist, Microbiology: xt 22504/22694, Pharmacy xt 22542/22146 or ID SpR: bleep 203.
Request MRSA screen if not done.
Give one loading dose 25mg/kg (max 2g) to all patients.
Infusion rate: max 10mg/minute to avoid infusion-related reactions (incl. "red man" syndrome).
Infusion vol.: Dilute each 500mg in al least 100 ml 0.9% saline.
In renal impairment (after loading dose given)
| Creatinine Clearance | Vanc. dose |
|---|---|
| >50ml/min | 15mg/kg(max 2g) twice daily (10am and 10pm) to commence 6-18hrs after loading dose given. |
| 20-50ml/min | 15mg/kg(max 2g) once daily to commence 24hrs after loading dose given. |
| <20ml/min or haemodialysis | Contact Micro/ID/Renal team/Pharmacy for advice. |
| General points: Use actual body weight to calculate dose. Do not exceed 2grams per dose. Round up dose to the nearest 250mg. Request MRSA screen if not done and prescribed for presumed MRSA carriage. | |
Send blood to microbiology, with the following information
When result will be available:
Ensure level taken at the correct time, i.e. within two hours of next dose (preferably just prior to next dose)
| Vancomycin level |
Guidance on dose adjustments based on Target pre-dose (trough) level 15-20mg/L |
Comment |
|---|---|---|
| <6mg/L | Contact Micro/ID/ Antimicrobial pharmacist. If it is the first level, check it was taken on Day 3 (or day 2 if renal impairment). |
|
| 6 - 10 | ↑ each dose by 100% e.g. 1g BD to 2g BD |
|
| 10 - 12.9 | ↑ each dose by 50% e.g. 1g DB to 1.5g BD |
|
| 13 - 14.9 | ↑ each dose by 25% e.g. 1g BD to 1.25g BD |
|
| 15 - 20 | Maintain current dose | This is the target range |
| 20.1 - 25.0 | ↓ each dose by 25% and give dose. Check level pre-subsequent dose |
|
| 25.1 - 39 | Hold doses until level <20mg/L. Reduce each dose by 50% | |
| >39 | Hold doses until level <20mg/L. Seek advice. | |
In general, adjustment of the total daily dose will result in a proportional change in the trough concentrations i.e. a 50% increase in daily dose is expected to increase the trough concentration by 50% - providing the dosage interval remains the same. If high doses are required, it may be appropriate to split the daily dose into 3 equal doses to yield higher trough concentrations.
If this dose is exceeded, seek advice from pharmacy/microbiology.
| Antibiotic Class | Interacting Drug | Comment |
|---|---|---|
| Macrolides e.g. Erythromycin, Clarithromycin | Statins | 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. |
| Warfarin* | Risk of bleeding. Monitor INR closely. | |
| NOACs* - Dabigatran, Rivaroxaban, Apixaban, Edoxaban |
Monitor, increased risk of bleeding. | |
| Drugs that prolong QT interval** | Consider risk vs. benefit for each individual patient. | |
| Colchicine | Contraindicated with clarithromycin | |
| Metronidazole | Warfarin* | Increases half-life of warfarin by 60% - Monitor INR closely. |
| Quinolones e.g. Ciprofloxacin, Levofloxacin, Moxifloxacin | Warfarin* | Risk of bleeding. Monitor INR closely. |
| Drugs that prolong QT interval** | Consider risk vs. benefit for each individual patient. (Moxifloxacin – contraindicated) | |
| Amiodarone | Avoid due to increased risk of arrhythmias | |
| Antacids / Iron / Calcium / Dairy products / phosphate binders | Risk of reduced bioavailability and efficacy. Separate the doses by 2 to 3 hours or more to avoid interaction. |
|
| Tetracyclines e.g. Doxycycline, Lymecyclin, Minocycline | Antacids | Risk of reduced bioavailability and efficacy. Separate the doses by 2 to 3 hours or more to avoid interaction. |
| Iron | ||
| Calcium | ||
| Warfarin* | Risk of bleeding - monitor INR closely. | |
| Carbapenems e.g. Meropenem | Sodium Valproate | Contraindicated - Potential for inadequate seizure control. |
| Linezolid | Serotonergic Drugs*** | Caution, risk of serotonin syndrome. |
| Trimethoprim and Co-Trimoxazole |
Warfarin* | Risk of bleeding - monitor INR closely |
| Methotrexate | Risk of severe bone marrow depression avoid is possible | |
| Amiodarone | Avoid due to increased risk of arrhythmias. | |
| Systemic Fusidic Acid | Statins | Risk of myopathy. Avoid if possible or hold for duration of antibiotic treatment and for a further 7 days. |
| Rifampicin | Consult product SPC for extensive list. | Causes many drug interactions due to potent enzyme induction. May require dose adjustment or additional monitoring. |
| Azole Anti-fungals e.g. Ketaconazole, Fluconazole, Miconazole (incl. Daktarin oral gel) | Statins | Risk of myopathy. Recommended to hold the statin for duration of antibiotic treatment. |
| NOACs – Dabigatran, Rivaroxaban, Apixaban, Edoxaban |
Not recommended, increased risk of bleeding. | |
| Warfarin | Risk of bleeding. Monitor INR closely. | |
| Drugs that prolong QT interval** | 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 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 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. |
||
Please approach in the chronological order as below and tick each positive item.
Lab tests available and acted upon within an hour.
Two or more of :
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.
Sepsis and at least one sign of organ hypoperfusion or organ dysfunction:
More and management on EMed.ie.
Severe sepsis and one of:
More and management on EMed.ie.
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
Dear Interns,
Welcome to the South Intern Network! This training year will be busy and challenging at times but hopefully it will be an enjoyable part of your journey in your Medical career.
I will be in constant contact with you throughout your Intern training year but I felt it might be helpful to summarise the main requirements that need to be met in order for you to be signed off by the South Intern Network to the Irish Medical Council for a Certificate of Experience in July 2022.
As well as your day to day training in your assigned Hospital you will also be required to meet the following criterion:
My office (email:medsouthinterns@ucc.ie) is happy to help answer any queries or issues that arise during your Training year, we are here to support you.
You will also have the opportunity to raise issues/seek information through your Intern REPS which form part of the South Intern Network Committee which meets 4 times during your Intern year.
Nearly all communication is via email or mobile telephone contacts so if your email address or telephone number changes during the year it is imperative that you let me know.
Wishing you all a very successful Internship.
Geraldine McNamee
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.
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).
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.
The Coroner's 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.
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.
When a death has been reported to the Coroner, they or their staff will contact the doctor of the deceased and establish if:
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:
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).
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.
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:
Tel: (021)4234536.
Email: daffodilcentrecuh@irishcancer.ie.
Visit: cancer.ie/how-we-can-help/daffodil-centres/university-hospital-cork
Cancer Nurseline Freephone: 1800 200 700.
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.
The medication information was kindly updated by Fiona Ahern on 02/02/2015.
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.
Antibiotic preparations.
IV drug dilutions (Paediatric).
Revised Fagerstrom Tolerance Scale
| 0 | 1 | 2 | |
|---|---|---|---|
| How soon after you wake do you smoke? | After 30 min | Within 30 min | |
| Do you find it difficult to refrain from smoking where it is forbidden | No | Yes | |
| Which cigarette would you most be willing to give up? | Any other | First one in the morning | |
| Do you smoke more in the morning than the rest of the day? | No | Yes | |
| How many cigarettes do you smoke each day? | Up to 15 | 16-25 | >25 |
| Do you smoke if you are so ill that you are in bed all day? | No | Yes | |
| What is the nicotine level of your usual brand of cigarettes | Up to 0.9mg | 1-1.2mg | >1.3mg |
| Do you inhale the smoke from your cigarette? | No | Sometimes | Always |
| Total | |||
| Score | Cigarettes per day | Recommended dose NRT |
|---|---|---|
| 0-3 Low dependence | 0-10 | 10mg if required |
| 4-6 Moderate dependence | 11-20 | 15mg |
| 7+ High dependence | 20+ | 25mg |
For High Dependency Smokers a 3 step down programme of NRT is recommended:
For Moderate to Low Dependency smokers a 2 step down programme is recommended:
From your local Smoking Cessation Services .
| Drug | Dose | Freq | Route | Note |
|---|---|---|---|---|
| Paracetamol | 1g | q6h | po/pr/iv | In adults <50kg, IV dose is 15mg/kg max QDS. PO/PR route should be used unless contra-indicated. |
| Ibuprofen | 400mg | q8h | po | Prescribe with PPI. See NSAID side-effects and contraindications. Less analgesia/anti-inflammatory action than diclofenac but side effects are less severe. |
Paracetamol + NSAID or Weak Opioid or both.
| Drug | Dose | Freq | Route | Note |
|---|---|---|---|---|
| Diclofenac | 75mg | q12h | 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 contraindicated in IHD, CVD, CCF, PVD. |
| Diclofenac | 100mg | q16h | pr | |
| Mefenamic acid |
500mg | q8h | po | Prescribe with PPI. See NSAID side-effects and contraindications. Useful in both menstrual and inflammatory pain. |
| Tramadol | 50–100mg | q6h | 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). |
| Drug | Dose | Freq | Route | Note |
|---|---|---|---|---|
| Oramorph | 10mg | q4h | po | Morphine solution |
| Morphine | 5-10mg | q4h | im/sc | See opioid prescribing guide for side-effects and contraindications. |
| Morphine | 5-10mg | q4h | iv | Slow injection |
| OxyContin | 5-20mg | q12h | po | Prolonged release oxycodone |
| OxyNorm | 5-20mg | q4h | po | Oxycodone – good for breakthrough pain for patients on OxyContin or Targin - give 1/6 of total daily dose of opioid |
| Pecfent | 100mcg | ii sprays q4h | IN | Fentanyl nasal spray – good for breakthrough pain. Pecfent is cheaper than Instanyl and includes dose counter |
| Actiq | 200mcg | i-ii q4h | 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 |
| Targin | 5/2.5mg – 20/10mg | q12h | 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. |
| Drug | Active Ingredients |
Dose/Route/Freq | Note |
|---|---|---|---|
| Solpadol | Paracetamol Codeine |
500mg/30mg ii po qds | See opioid side-effects and contraindications. Caution against dual prescription of paracetamol. |
| Solpadeine | Paracetamol Codeine Caffeine |
500mg/8mg/30mg ii po qds | See opioid side-effects and contraindications. Caution against dual prescription of paracetamol. |
| Cyclimorph-10 | Morphine Cyclizine |
10mg/50mg i im tds | Max 3 doses/24hrs. Not to be used in case of MI; Cyclizine may aggravate heart failure. |
| Drug | Active Ingredients | Dose/Route/Freq |
|---|---|---|
| Buscopan | Hyoscine Butylbromide | 20mg po qds |
| Colofac | Mebeverine | 135mg po tds |
Legal requirements for Controlled Drug prescription (CD schedule 2 & 3)
| Schedule | Example |
|---|---|
| Schedule 1 | Substances not ordinarily used as medicines e.g. Raw Opium, Coca Leaf |
| Schedule 2 | Opiate substances for example, Morphine, Fentanyl and Oxycodone. Some Stimulants e.g. Lisdexamphetamine |
| Schedule 3 | Certain Benzodiazepines and painkillers e.g. Temazepam, Flunitrazepam, Pentazocine, Ketamine |
| Schedule 4 (1) | Most Benzodiazepines and 'Z-drugs' e.g. Diazepam, Alprazolam, Clonazepam, Midazolam and Zolpidem |
| Schedule 4 (2) | Certain Anti-Epileptics for example, Phenobarbitone <100mg. Certain MAOIs e.g. Selegiline |
| Schedule 5 | Lower strengths of painkillers for example, Codeine (below specified concentration) |
Caution in:
Prescribe with PPI.
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.
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).
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.
| # 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.
| 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.
| ↑ AG Metab. Acidosis | Normal AG Metab. Acidosis |
|---|---|
|
MUDPILERS
|
HARDUPS
|
| Chads2VaSc | Stroke rate (%/yr) |
|---|---|
| 0 | 0% |
| 1 | 1% |
| 2 | 2% |
| 3 | 3% |
| 4 | 4% |
| 5 | 7% |
| ≥6 | 10-15% |
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)
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.
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 Jan 2023).
Renal impairment and obesity are taken into account when calculating the dose.
For critically ill septic patients, the first dose can be given as a stat dose of 5mg/kg, even in renal dysfunction, unless the patient is frail or has very low body weight.
For risk stratifying ED patients with chest pain
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
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))
The above formula does not include insensible water losses.
Ref: Adrogue, HJ, Madias, NE. Hyponatremia. NEJM 2000; 342(21):1581-1589.
1 olde stone = 6.35026 kg
1 olde pound = 0.45359 kg
1 olde foot = 30.48 cm
1 olde inch = 2.54 cm
Calculated Osmolarity = 2 Na + 2 K + Glucose + Urea ( all in mmol/L)
Osmolar Gap = Serum Osm (lab) - Calculated Osm
Normal Gap 10 to 15 mOsm/kg water
For more please see EMed.ie
PERC rules out PE if no criteria are present and pre-test probability is low. No need for further tests as <2% chance of PE.
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).
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
DVT "Likely" if Well’s ≥2
DVT "Unlikely" if Wells ≤1
While every attempt has been made to ensure the accuracy of the content, prescribers should ensure that the correct drug and dose is prescribed, as is appropriate, for each individual patient. The interpretation and application of the guidelines remains the responsibility of the individual clinician. Please seek advice if in doubt.
When albumin <40g/L: Corrected Ca level (mmol/L) = 0.02 x (40 - albumin g/L) + Measured Ca level (mmol/L).
The Cockcroft-Gault equation:
Creatinine clearance ml/min = N x (140-age) x wt*(kg)/Serum creatinine (micromol/L).
Where N= 1.23 for ♂‚ 1.04 for ♀.
6 - Obeys
5 - Localises
4 - Withdraws
3 - AbN Flex
2 - AbN Ext.
1 - None
5 - Converse
4 - Sentences
3 - Words
2 - Sounds
1 - None
4 - Spont.
3 - To voice
2 - To pain
1 - None
IBW ♂ = [(height (cm) x 0.9] - 88
IBW ♀ = [(height (cm) x 0.9] - 92
AdjBW = IBW + 0.4 (ActualBW-IBW)
Risk factors for MDRO (Multi-drug resistant organisms):
Prognosis in hepatic failure.
| Points | Class | 1yr survival | 2yr survival |
|---|---|---|---|
| 5-6 | A | 100% | 85% |
| 7-9 | B | 81% | 57% |
| 10-15 | C | 45% | 35% |
Simplified PE Severity Index - predicts 30 day outcome. 1.1% risk RIP in those with 0 points
Apologies but the medications data has not yet been validated in pregnant patients. If you wish to check medications for non-pregnant adult patients please change your hospital to CUH.
