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Slán, Íomhar

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Acknowledgements

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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.

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.


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).

Updates may be released periodically. If you think you have an outdated version, please close and reopen your browser.

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Hospital

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Microbiology

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Microbiology section

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


These .

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Microbiology

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Microbiology section

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 .

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Empiric treatment

testing empiric

In penicillin allergy

testing pen allergy

Duration

testing duration

Comments

testing comments
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Aspiration pneumonia

Aspiration pneumonia

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Cardiac

Cardiac section

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CURB-65

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CURB-65 score

For estimating severity / prognosis in community acquired pneumonia.

A CXR should be performed to confirm new consolidation.

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 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
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ENT

ENT section

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Gastrointestinal

Gastrointestinal section

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Genitourinary

Genitourinary section

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Neurological

Neurological section

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Ophthalmology

Ophthalmology section

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Respiratory

Respiratory section

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Soft Tissue/ Bone

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Soft tissue and bone section

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Anatomical systems

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Viral Infections

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Gynaecology

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Gynaecology antimicrobials

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Pregnancy

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Infections in pregnancy

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Wound infection (pregnancy)

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Pregnancy wound infections

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Prophylaxis (in pregnancy)

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Pregnancy antibiotic prophylaxis

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Viral infection (pregnancy)

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Pregnancy viral infections

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Fungal infection (pregnancy)

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Pregnancy fungal infections

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Bacterial infection (pregnancy)

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Pregnancy - bacterial infections

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Parasitic infection (pregnancy)

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Pregnancy parasitic infections

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Malaria (pregnancy)

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Malaria (suspected) in pregnancy

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Antimicrobials in pregnancy & lactation

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 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.

Cephalosporins

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.
        

Penicillins

  
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
        

Macrolides

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.
        

Quinolones

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.
    
        

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 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.
Guide©2024 Dr ÍOS

Antimicrobials in pregnancy and lactation

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:

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

In pregnancy

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 breast milk 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 non-existent. 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©2024 Dr ÍOS

Microbiology- Paeds

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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.


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.

2024©Dr ÍOS

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Empiric treatment

testing empiric

In penicillin allergy

testing pen allergy

Duration

testing duration

Comments

testing comments
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Eye (Paed)

Ophthalmology-Paeds

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ENT

ENT(Paed)

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Respiratory (Paed)

Paed-Respiratory

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Urinary (Paed)

Urinary Paeds

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Neurological (Paed)

Neurological (Paed)

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Soft tissue (Paed)

Soft tissue(Paed)

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Bone/Joint (Paed)

Bone / joint (Paed)

If penetrating injury to foot use Pip-Taz iv ± Gentamicin iv.

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IV-AB Admin. Paed

Useful IV Admin. guide (Paeds)

Antibiotic preparations.

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Prescribe Tips

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Prescribing tips

Antimicrobials

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Amikacin dosing

Amikacin dosing

Information

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:

  • Risk ↑ in renal impairment, where therapy is prolonged, or in those receiving higher doses
  • Extended interval (once daily) dosing may reduce the risk

Amikacin can cause ototoxicity:

  • Risk ↑ in renal impairment
  • Impaired hepatic function or auditory function, bacteraemia and fever have been reported to increase the risk
  • Risk also increased with higher cumulative doses and longer treatment courses
  • Usually irreversible- If treatment expected to last ≥7 days, a pre-treatment audiogram should be obtained and repeated during therapy. Treatment should be stopped if tinnitus or subjective hearing loss develops, or audiograms demonstrate significant loss of high frequency response

Amikacin may cause muscle weakness:

  • Contra-indicated in myasthenia gravis
  • Caution in other conditions characterised by muscular weakness, such as Parkinsons, as amikacin may impair neuromuscular transmission

To reduce the risk of side effects:

  • Avoid or minimise the use of other nephrotoxic or ototoxic agents
  • Ensure patient is well hydrated during therapy
  • Monitor renal function
  • Monitor vestibular and auditory function if treatment expected to last ≥7 days
  • Use extended interval (once daily) dosing ( BUT see exceptions in Table below)
  • Monitor serum levels. Target pre-dose level <5mg/L
  • Review ongoing need on a daily basis

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 administer over 30 minutes.

When to monitor levels

  • Take first sample immediately prior to scheduled second dose. Thereafter, levels should be monitored at least twice weekly, or daily if renal function poor or unstable. It should also be monitored if any dose change
  • Label as Amikacin, and the time and date the level was taken
  • Send blood to Biochemistry lab as soon as possible
  • In normal and stable renal function, DO NOT wait for the result before administering the next dose, unless specifically advised

Interpreting result

  1. Ensure sample collected at the right time. Level should be taken within 30 minutes of next due dose. If not, please contact pharmacy for advice
  2. Target pre-dose (trough) level <5mg/L. Use Table below to determine course of action based on level 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

Twice daily dosing

Please check details with Micro./I.D./Pharmacy.

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
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.

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CDAD

Clostridioides difficile Infection (CDI)

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.

Definition of CDI

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.

For all patients with suspected or confirmed C.difficile assess:

  1. The severity of C.difficile (see below)
  2. If it is a first or further episode of C.difficile
  3. Individual risk factors that may affect the risk of complications or recurrence (below)

Classification of CDAD

Non-severe CDI

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 (any of):

Severe complicated 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.

Risk factors for CDI, CDI recurrence & implicated meds.

Individual risk factors for CDI

Risk of recurrent CDI

Those at high risk of recurrence: older age of the patient (>65 yrs) plus the presence of one or more additional risk factor(s):

Meds. often implicated in CDI

Diagnosis

General recommendations


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CDAD 1st or 1st recurrence

CDAD - Initial or 1st recurrence

General Advice

Dosing below assumes normal renal function - please click on individual drug for dosing in renal impairment, cautions in use and administration information.

Non-severe CDI:

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.

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

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.

Notes

* 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.

# Intracolonic Vancomycin regimen

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:

  1. Add 10ml Sterile Water for injection to the 500mg IV vial
  2. Dilute further with 100ml normal saline 0.9%

Method for administration:

  1. An 18G Foley catheter is inserted per rectum and the balloon is inflated
  2. The vancomycin solution is instilled into the rectum and retained for 60 minutes by clamping the catheter
  3. Once retention time is complete, the catheter is unclamped, the balloon deflated and the catheter removed
  4. This process can be repeated every 4-6 hours depending on clinical response

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.

nchd.ie©2024 Dr ÍOS

CDAD recurrent episode

CDAD - 2nd and subsequent recurrences

For first episode / first recurrence please see CDAD 1st episode.

General Advice

Dosing below assumes normal renal function - please click on individual drug for dosing in renal impairment, cautions in use and administration information.

Non-severe and severe CDI recurrences:

Monitor closely for progression to severe-complicated CDI - Recommend all recurrences discussed with clinical microbiology or ID teams.

Options include:

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.


Other therapies to consider: (seek specialist advice, limited evidence of benefit and not always readily available)

Severe-complicated CDI recurrence:

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.

Notes

* 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.

# Intracolonic Vancomycin regimen

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:

  1. Add 10ml Sterile Water for injection to the 500mg IV vial
  2. Dilute further with 100ml normal saline 0.9%

Method for administration:

  1. An 18G Foley catheter is inserted per rectum and the balloon is inflated
  2. The vancomycin solution is instilled into the rectum and retained for 60 minutes by clamping the catheter
  3. Once retention time is complete, the catheter is unclamped, the balloon deflated and the catheter removed
  4. This process can be repeated every 4-6 hours depending on clinical response

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.

nchd.ie©2024 Dr ÍOS

CDAD Intra-colic Vancomycin

Intra-colic Vancomycin

For microbiologist supervision only.

Method

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

nchd.ie©2024 Dr ÍOS

Gentamicin

Gentamicin dosing

Information

Gentamicin and Tobramycin are aminoglycoside. Tobramycin is restricted antimicrobial in CUH.

Aminoglycosides can cause nephrotoxicity:

  • Risk ↑ in renal impairment, where therapy is prolonged, or in those receiving higher doses
  • Extended interval (once daily) dosing may reduce the risk

Aminoglycosides can cause ototoxicity:

  • Risk ↑ in renal impairment
  • Impaired hepatic function or auditory function, bacteraemia and fever have been reported to ↑ the risk
  • Risk also increased with higher cumulative doses and longer treatment courses
  • Usually irreversible- If treatment expected to last ≥7 days, a pre-treatment audiogram should be obtained and repeated during therapy. Treatment should be stopped if tinnitus or subjective hearing loss develops, or audiograms demonstrate significant loss of high frequency response

Aminoglycosides may cause muscle weakness:

  • Contra-indicated in myasthenia gravis
  • Caution in other conditions characterised by muscular weakness, such as Parkinsons, as aminoglycosides may impair neuromuscular transmission

To reduce the risk of side effects:

  • Avoid or minimise the use of other nephrotoxic or ototoxic agents
  • Ensure patient is well hydrated during therapy
  • Use extended interval (once daily) dosing ( BUT see exceptions in Table below)
  • Monitor serum levels. Target pre-dose level <1mg/L
  • Review ongoing need for aminoglycosides daily

Once daily dosing

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

  • Take first sample 18-24 hours after last dose. Thereafter, levels should be monitored at least twice weekly, or daily if renal function poor or unstable. Levels should also be monitored if any dose change
  • Levels should not be taken from the site of the venous catheter where Gentamicin/Tobramycin has been administered
  • Label as Gentamicin or Tobramycin, and the time and date the level was taken
  • Send blood to Biochemistry lab as soon as possible
  • In normal and stable renal function, DO NOT wait for the result before administering the next dose, unless specifically advised

Interpretation of level result

  1. Ensure sample collected at the right time. Level should be taken 18-24 hours after administered dose. If not, please contact pharmacy for advice
  2. Target pre-dose (trough) level <1mg/L. Use Table below to determine course of action based on level result
Action based on Gentamicin/Tobramicin level
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 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
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.

nchd.ie©2024 Dr ÍOS

MRSA

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.

Treatment of 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 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.

  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 octenidine hydrochloride 0.1% (Octenisan®) as a body wash in place of soap daily
  3. Wash hair twice a week with octenidine hydrochloride 0.1% (Octenisan®)
  4. Wash teeth / dentures with toothpaste (individual patient use) twice daily
  5. 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, MRSA could be 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

©CKICC 2023 Dr ÍOS

Penicillin Allergy

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 2023 Dr ÍOS

Renal dosing

Antimicrobial dosing in renal compromise

A (antimicrobial agent)

B - C

D - F

G - L

M - R

T - V

©CKICC 2023 Dr ÍOS

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.

Step 1 - Give ONE Loading Dose to all patients

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.

Step 2 - Maintenance Dose

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 haemodialysisContact 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.

Step 3- Monitoring levels

Send blood to microbiology, with the following information

When result will be available:

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)

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
  • If dose exceeds 2g BD seek advice from pharmacy/micro/ID (max. single dose 2g).
  • Check previous doses were given at the correct time
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
  • Check renal function
  • Check previous doses were given at the correct time
  • Check level was taken 0-2hrs pre-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.

nchd.ie©2024 Dr ÍOS

Antibiotic interactions

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.

DiT©2024 Dr ÍOS

Sepsis

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Sepsis section




Risk factors for MDRO.

©CKICC 2023 Dr ÍOS

Header

 


Empiric treatment

testing empiric

In penicillin allergy

testing pen allergy

Duration

testing duration

Comments

testing comments
©CKICC 2023 Dr ÍOS

Header

 


Empiric treatment

testing empiric

In penicillin allergy

testing pen allergy

Duration

testing duration

Comments

testing comments
©CKICC 2023 Dr ÍOS

Sepsis-Six

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


1. Infection suspected

2. SIRS criteria

Or at least two or more SIRS

3. Sepsis 6 (within 1 hour)

Take

  • Blood 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

5. Look for septic shock (post fluid bolus)

nchd.ie©2024 Dr ÍOS

SIRS

SIRS - Systemic inflam. response syndrome

Two or more of :

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:

More and management on EMed.ie.

Septic shock

Severe sepsis and one of:

More and management on EMed.ie.

CKICC©2023 Dr ÍOS

DiTs

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DiTs


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Intern Guide

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Interns

nchd.ie©2024 Dr ÍOS

Welcome - Interns

Welcome to

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©2024 Dr ÍOS

SINC

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Message from South Intern Network Administrator

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:

  1. Attendance at Hospital Teaching sessions: You will be required to attend a minimum of 70% of teaching sessions. Attendance will be logged and noted in your quarterly Intern Assessment Reports.
  2. Successful completion of ACLS training: This will be organised at the start of your Intern year by the South Intern Network and your employing Hospital will request proof of successful completion of same to be uploaded onto the National Employment Record N.E.R system.
  3. BMJ online learning modules: You will be required to submit proof of completion of 12 BMJ modules for Interns by 31st March 2022 (6 to be completed by January and remaining 6 by March) to the office of the South Intern Network Administrator.
  4. Attendance at SIMulated training session for Interns: You will be assigned a date to attend your SIMulated training session (scenario based) by the UCC ASSERT Centre. Attendance on your assigned day is mandatory.
  5. Submission of 4 x satisfactory Intern Assessment Reports at the end of each rotation: Interns are required to submit 4 x fully signed (Intern, Supervising Consultant and Hospital Intern Tutor) satisfactory digital Intern Assessment Reports in a timely fashion by the end of each rotation. Failure to do so may jeopardise sign off.

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

nchd.ie©2024 Dr ÍOS

Intern commandments

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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©2024 Dr ÍOS

Preps

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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.
nchd.ie©2024 Dr ÍOS

Coroner

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Coroner

Role

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.

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:

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:

What deaths are reported to the Coroner?

  1. Where a patient dies before a diagnosis is made sufficient to complete a death notification form.
  2. Where death is due to a contributing factor of alcohol, toxin related cirrhosis/ cirrhosis of the liver, cirrhosis of the liver due to IV drug use.
  3. Where the death may have resulted from an accident, suicide or homicide.
  4. The question of misadventure may arise in relation to the clinical or pharmaceutical treatment of the Deceased.
  5. Where any patient dies within 24 hours of admission to hospital.
  6. When death occurs when the patient is undergoing an operation or under the effect of an anaesthetic or following an operation.
  7. Where a death occurs during or as a result of any procedure.
  8. Where death occurs from any occupational disease.
  9. Where a death was due to neglect or lack of care including self neglect.
  10. Where death is directly due to a hospital acquired infection in the absence of other significant co- morbidities.
  11. Where a patient is known to have a significant co-morbidity but a hospital acquired infection has brought about death at a time much earlier than would otherwise have been expected.
  12. Where a death occurs to a person in the care of the state. This includes mental care patients, prisoners, prisoners on day release, prisoners released on licence.
  13. All deaths occurring in the accident and emergency department.
  14. All deaths occurring in the Intensive Care Unit.
  15. All deaths in association of cerebral haemorrhage.
  16. Any death that may be murder, manslaughter or infanticide.
  17. Any death that appears to be connected with a crime or suspected crime.
  18. Any death, whether or not accidental, caused wholly or partially by stabbing, drowning ,poisoning, hanging, electrocution ,asphyxia ,or a gunshot wound.
  19. Any death where the deceased person is dead on arrival at a hospital.
  20. Any death where the body of the deceased person is unidentified.
  21. Any death where no family member of the deceased person can be traced within a reasonable time of the death.
  22. Any death where the body of the deceased is found or recovered in circumstances that indicate that the death may have occurred a considerable time previously.
  23. Any death (other than in circumstances to which paragraph 22 applies) in respect of which the date of death may not be ascertainable.
  24. Any death caused wholly or partly by any of the following;
    1. An incident, whether or not accidental, resulting in any physical injury, including a cut, fracture or contusion.
    2. A fall.
    3. Self – neglect.
    4. An eating disorder.
    5. Exposure or hypothermia.
    6. Burns.
  25. Any death which may be by assisted suicide.
  26. Any death caused wholly or partly by any of the following:
    1. An accident arising out of the use of a vehicle in a public place.
    2. An incident arising on a train ,aircraft, ship or other vessel.
  27. Any death caused wholly or partly by any of the following;
    1. A notifiable disease or condition that is ,under provisions in that behalf in any other enactment, required to be notified to a Minister of the Government, a Department of State or a Statutory Body or to an Inspector or other Officer of a Minister of the Government, a Department of State or a Statutory Body including a public health official.
    2. An adverse reaction to any drug.
    3. A drugs overdose or the presence of toxic substances.
    4. An over prescription or application or infusion of a prescribed drug whether accidental or otherwise.
    5. In the case of an infant death, maternal drug addiction.
    6. An infection contracted as a result of previously contaminated blood product administration.
    7. A lack of care or neglect.
    8. Starvation or malnutrition.
  28. Any death due to a prion disease.
  29. Any death caused wholly or partly by an accident at work or due to industrial or occupational disease e.g. "Farmers' Lung", asbestos related deaths etc.
  30. Any maternal or late maternal death.
  31. Any death of a stillborn child, death intrapartum or infant death.
  32. Any death occurring in a hospital or other health institution that is directly or indirectly related to a surgical operation or anaesthesia (including recovery from the effects of anaesthesia ) or to any other medical, surgical or dental, procedure, regardless of the length of time between the procedure and death.
  33. Any death where an allegation is made or a concern has been expressed regarding the medical treatment provided to the deceased person or the management of his or her health care.
  34. Any death which may be as a result of an unconventional medical procedure or treatment.
  35. Any death of a child in care.
  36. Any death occurring in:
    1. An institution for the care and treatment of persons with a physical or mental disability or
    2. any public or private institution for the care of elderly or infirm persons, including a nursing home.
  37. All deaths occurring in patients having been referred from a Nursing Home or long- term residential care centre.

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).

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Daffodil

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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:

Contact details:

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.

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Administration

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Intern posts

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Common calls

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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.

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Fluids

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Approach to fluids - adults
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Medications

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Useful medications

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



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Pain

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Pain Mx Adults

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.

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IV-AB Admin.

Useful IV Admin. guide

Antibiotic preparations.

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IV Drug Preps (Paed)

Useful IV Admin. guide

IV drug dilutions (Paediatric).

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Nicotine replacement

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Nicotine replacement therapy

Revised Fagerstrom Tolerance Scale


1. Assess Nicotine Dependence

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

2. Prescribe NRT

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

Points to note:

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:

3. Offer Support

From your local Smoking Cessation Services .

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NOACs

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Useful NOACs

New Oral Anticoagulants.

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Header

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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

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Pain Mild

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Pain Mild

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.
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Pain Moderate

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Pain Moderate

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).
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Pain Severe

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Pain Severe

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.
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Pain Compounds

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Pain compounds adults

Useful Compound Medications

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.

Antispasmodics

Drug Active Ingredients Dose/Route/Freq
Buscopan Hyoscine Butylbromide 20mg po qds
Colofac Mebeverine 135mg po tds
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Analgesia liver patients

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Analgesia in liver failure

Analgesia in hepatic/liver patients
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Prescribe controlled meds

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Prescribe controlled drugs

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

Approach to fluids - adults
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)
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How to prescribe

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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.
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Prescribe NSAIDs

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NSAID Prescribing

Caution in:

Prescribe with PPI.

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Prescribe Opioids

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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.

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Heparin

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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.

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Insulin
sliding scale

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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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Procedures

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Calc

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Calculators



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ABCD2

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ABCD2 score


Stroke risk after TIA


  • ABCD2 =


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AG

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Anion Gap


  • 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

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Barthel Index

Activities of Daily Living


  • Barthel index =


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ChadsVASC

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ChadsVASC


  • CHA2DS2-VASc score =



Chads2VaSc Stroke rate (%/yr)
0 0%
1 1%
2 2%
3 3%
4 4%
5 7%
≥6 10-15%

Related : HasBled (risk of bleeding in AF).
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eGFR

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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)


  • 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.

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Gentamicin once-daily dosing

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 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.


  • (height required if
    patient is overweight)
  • Feet:Inches:

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HEART score

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HEART score


For risk stratifying ED patients with chest pain


  • 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

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⇓Na+

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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))


  • 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.

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Olde

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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


  • Weight: 000 kg



  • Height: 000 cm


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NIHSS

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NIHSS


  • NIHSS=


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OSM

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Osmolarity


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

  • Osm: 0



Osmolar Gap = Serum Osm (lab) - Calculated Osm

Normal Gap 10 to 15 mOsm/kg water

Causes: ↑ Osmolar Gap

A) ↓serum water

B) Unmeasured Osm

For more please see EMed.ie

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PERC

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PERC rule


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.


  • Probability of PE <2%



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Vancomycin intravenous dosing

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).


  • (height required if
    patient is overweight)
  • Feet:Inches:



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Wells DVT

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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

Score =

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


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Wells PE

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Wells score PE


Pre-test probability of PE


  • Score =

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

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