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This NCHD guide is a small web app that will work off line once you have chosen your current hospital.
Please "add to home screen" and an icon link will be downloaded for future easy access.
You may be asked to permit future guideline or medication updates to reflect local protocols.
No personal data has or will be collected.
You are free (as in speech or beer) to use the app. in any local clinical environment.
Please take a moment to provide feedback (under settings on the home screen) when you get a chance.
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. Many thanks to Dr. Sile O'Connor for her work in preparing the BSH Tralee antibiotic guidelines.
Ms. Terri Goulding, for her fantastic organisation and dedication to NCHD training/education in CUH.
The Cork & Kerry Infection Control Committee kindly provided funding for a laptop to enable development of the mobile application.
For more comprehensive clinical guidelines please visit EMed.ie.
We would like to give a special Thank You to Dr. Tim Keady (Intern in CUH 2014), Dr. Nick Barrett, Anaesthetic Reg., Dr. Dominic Hegarty, Pain Specialist, and Marih O'Leary, Pharmacist, for the Analgesia Ladder (Adults) information.
Dr. Íomhar O' Sullivan.
Consultant in Emergency Medicine, Cork.
The antimicrobial information contained in this App was collated by the Cork Kerry antimicrobial stewardship sub-committee and reflect the antimicrobial guidelines of the (CUH, MUH, SIVUH and Bon Secours hospitals in Tralee & Cork). Therefore use of this app by any persons including health professionals working within other hospitals, is at your own risk, and we make no representations or guarantees as to the adequacy or completeness of any of the information contained in this app, or the app’s compatibility with any policies or procedures of other hospitals, where the app is used by persons other than healthcare professionals working within the CK hospitals.
This app is intended as a support tool for health professionals working within CK hospitals and is provided for reference only. It does not take into account the individual circumstance of a patient and may not contain all the information you require. It should therefore not be used as the sole basis for prescribing any drugs or for the care of any patient. While every attempt has been made to ensure the accuracy of the content, doctors and other healthcare professionals should ensure that the correct drug and dose is prescribed, as is appropriate for each individual patient.
References that should be used in conjunction with these guidelines include the British National Formulary (BNF) and the drug data sheets (available on www.medicines.ie). The interpretation and application of the guidelines remains the responsibility of the individual clinician. Please seek advice if in doubt.
Updates may be released periodically and it is the responsibility of the user that they have the most up to date version available. This is available on the hospital Intranet.
Log on to ‘HSE staff directory’ icon which is on most computers. The following screen will appear and it is self explanatory. When on call, make sure you have the right date. Also, note the ‘liaison psych consultation’ icon in the top left of the screen.
Most interns will have to print off lists of in-patients each day as well as having patient stickers available. Log into you Citrix 4.5 account and click on the PIMS icon. The following screen will then appear. The four main buttons are identified in the diagram.
These guidelines are for adults only.
Please check your local guidelines for children, pregnant or breastfeeding patients.
These .
For estimating severity / prognosis in community acquired pneumonia.
| 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 | Advice |
|---|---|
| 0 - 1 | Treat as out-patient |
| 2 | Consider a short stay in hospital or watch closely as an outpatient |
| 3-5 | Requires admission +/- ITU |
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.
Endocarditis prophylaxis is only recommended in the situations detailed below, as antibiotic prophylaxis may only be effective at preventing a very small number of endocarditis cases. Infective endocarditis is much more likely to be caused by frequent exposure to random bacteraemias than bacteraemias caused by dental, GI tract or GU tract procedures. The risk of antibiotic-related adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy.
Maintenance of optimal oral health and hygiene is important in reducing the risk of endocarditis from dental procedures
Endocarditis prophylaxis recommended only in patients with the above cardiac conditions, for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of oral mucosa.
Endocarditis prophylaxis NOT recommended for the following:
| Given as a single dose 30- 60 minutes prior to the procedure: | |
|---|---|
| 1st line option | In penicillin allergy |
| Adults: Amoxicillin 2 grams po/iv | Adults: Clindamycin 600mg po/iv |
Endocarditis prophylaxis not recommended.
Endocarditis prophylaxis is only recommended in patients with the above cardiac conditions for patients undergoing the following:
NB: if the infection is known to be caused by S. aureus, use Flucloxacillin 1g po / iv single dose for prophylaxis. If caused by MRSA or penicillin allergic, use vancomycin 15mg/kg single dose iv infusion one hour prior to procedure.
Endocarditis prophylaxis is only recommended in patients undergoing surgical procedures with the above cardiac conditions.
Flucloxacillin 1g iv / po should be given 30-60 mins prior to procedure.
If MRSA or penicillin allergic: give vancomycin 15mg/kg single dose iv infusion one hour prior to procedure.
Bacterial meningitis is a notifiable disease. Inform Public Health: Tel.: 021 4927601 or out of hours through ambulance service 021 4921114. Public Health will advise on chemoprophylaxis of contacts.
| Adults and children >12 years | 1st line: Rifampicin 600mg every 12 hours for 4 doses. Alternative: Ciprofloxacin 500mg po stat. |
|---|---|
| Female adults on the oral contraceptive pill | Ciprofloxacin 500mg po stat |
| Pregnant women | Ceftriaxone 250mg im stat |
| Children: 1-12 years | 1st line: Rifampicin 10mg/kg (max. 600mg) every 12 hours for 4 doses. Alternativen: only for children >2 years. 2-5 years: Ciprofloxacin 125mg po stat. 5-12 years: Ciprofloxacin 250mg po stat. |
| Infant <1 year | Rifampicin syrup 5mg/kg every 12 hours for 4 doses |
Chemoprophylaxis is rarely indicated in Hib infection; only when there are unvaccinated or incompletely vaccinated children or persons at increased risk (e.g. asplenia or complement deficiency) in the household. Unless the index case has received Ceftriaxone or cefotaxime in hospital, chemoprophylaxis should also be given to the patient prior to discharge. Seek advice from Public Health or microbiology if unsure.
| Adults | Rifampicin 600mg once daily for 4 days |
|---|---|
| Child:1-12yrs | Rifampicin 20mg/kg (max 600mg) once daily for 4 days |
| Infant:<1 yr | Rifampicin syrup 10mg/kg once daily for 4 days |
| Pregnant women | Not indicated |
Notes on Rifampicin: Rifampicin may colour urine / tears red and stain contact lenses – do not wear contact lenses for a few days after Rifampicin treatment. If on other drugs, check BNF, product data sheets on www.medicines.ie / consult pharmacy regarding drug interactions with Rifampicin
Vaccination
If Neisseria meningitidis Groups B, C, A, Y, W, 135 vaccination of contacts and index may be indicated. Please refer to Public Health for advice.
If Haemophilus influenzae type b or pneumococcal meningitis: vaccination of contacts and index may be indicated. Please refer to Public Health for advice.
Please refer to local Intranet staff directory or NCHD.ie/asplenic.html (internet access required)..
List of procedures requiring antibiotic prophylaxis is not exhaustive.
Once daily dose
Not for endocarditis, febrile neutropenia or meningitis.
15mg/kg q24h iv.
Max 1.5g daily for up to 10 days (max cumulative dose per course 15g) unless specifically advised.
Correct dose in obesity below.
Adjustment in renal impairment below.
Administration
iv infusion: Dilute in 100ml sodium chloride 0.9% and adsminister over 30-60 minutes.
When to monitor levels
Pre-dose (‘trough’) levels taken between 18-24 hours after last dose administered. Initially monitor pre-dose level before second dose and then every 48 hours or daily if renal function poor.
Reference range
Pre-dose (trough) level ≤5mg/L.
-->Taking the sample
Send blood to microbiology, with the following information:
Interpreting result
You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.
Other monitoring parameters
Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. ringing / feeling of fullness in the ears, hearing loss, dizziness, vertigo, jittery / bouncing vision). Monitor for concomitant use of potent diuretics, ototoxic or nephrotoxic medicines e.g. NSAIDS, ACE inhibitors. Check vestibular and auditory function weekly if prescribed for more than 7 days.
Twice daily dosing
7.5 mg/kg q12h iv
(can be increased in severe infections to 7.5 mg/kg q8h).
Max 1.5g daily for up to 10 days (max cumulative dose per course 15g) unless specifically advised.
Correct dose in obesity as below.
Adjustment in renal impairment - see below.
Administration
iv bolus over 32-3 minutes or (preferred): dulute to 2.5mg/ml with 0.9% NaCl and admin. over 30 mins.
When to monitor levels
Take “Trough” level immediately pre-dose
Take “Peak” level one hour post dose
Initially monitor peak and trough levels with 3rd or 4th dose, then trough levels every 48 hours, or more often if renal function unstable or poor.
Peak levels do not need to be monitored more than once a week.
Reference range
Pre-dose level (trough) ≤10mg/L
Post dose level (peak) ≤ 30mg/L (aim for 20-30mg/L)
Taking the sample
Send blood to microbiology, with the following information:
Interpreting result
You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.
Other monitoring parameters
Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. ringing / feeling of fullness in the ears, hearing loss, dizziness, vertigo, jittery / bouncing vision). Monitor for concomitant use of potent diuretics, ototoxic or nephrotoxic medicines e.g. NSAIDS, ACE inhibitors. Check vestibular and auditory function weekly if prescribed for more than 7 days.
Correcting 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
| GFR 20-50ml/min: | GFR 10-30ml/min: | GFR <10ml/min: | CAPD: Dose as per <10ml/min. |
|---|---|---|---|
10mg/kg q24h |
3-4mg/kg q24h |
2mg/kg q24h-q48h |
Antibiotic Associated Diarrhoea (AAD) occurs in association with the administration of antibiotics. The spectrum of findings ranges from colitis to so-called 'nuisance' diarrhoea. Infection with Clostridium difficile (CDI) accounts for only 10 to 20% of the cases of AAD, but it accounts for the majority of cases of colitis. Major risk factors for C. difficile infection include: advanced age, hospitalisation, exposure to antibiotics.
Some antibiotics are frequently implicated in C. difficile associated diarrhoea (CDAD) – e.g. Cephalosporins, Clindamycin, Quinolones and broad spectrum antibiotics, but virtually any antibiotic may be implicated, including brief courses e.g. surgical prophylaxis. Occasional cases follow treatment with Methotrexate or Paclitaxel (chemotherapy treatments of cancer).
Patient with ≥:
Has no features of severe CDI.
Severe disease with ↓BP, shock, ↑lactate, ileus or mega colon.
Refer to local microbiology laboratory for testing procedures. Testing of asymptomatic individuals is not recommended.
* Fidaxomicin has not been tested in pregnant or breastfeeding women or in patients with a history of inflammatory bowel disease.
The solution will be best prepared immediately before use, as there is no preservative. Sterile Water for injection may be used to prepare the solution, as Vancomycin hydrochloride is freely soluble in water and also to try and maintain an aseptic as possible environment.
Using the 500mg vial to prepare the oral solution: Add 10ml water to the vial and withdraw 2.5ml in order to achieve 125mg.
After this initial reconstitution of the vial, the selected dose may be diluted in 30ml of water and given to the patient to drink or it may be administered in a naso-gastric tube if necessary.
Storage: Store the reconstituted injection in the fridge for no more than 24 hours and the date and time the vial was reconstituted should be clearly marked.
Patients discharged on oral vancomcyin: Oral capsules (125mg strength) are available in the community, on the Hi-Tech scheme.
For first episode / first recurrence please see CDAD 1st episode.
Mx of 2nd & subsequent episodes of CDI.
Treat as CDAD 1st episode
The solution will be best prepared immediately before use, as there is no preservative. Sterile Water for injection may be used to prepare the solution, as Vancomycin hydrochloride is freely soluble in water and also to try and maintain an aseptic as possible environment.
Using the 500mg vial to prepare the oral solution; Add 10ml water to the vial and withdraw 2.5ml in order to achieve 125mg. After this initial reconstitution of the vial, the selected dose may be diluted in 30ml of water and given to the patient to drink or it may be administered in a naso-gastric tube if necessary.
Storage: Store the reconstituted injection in the fridge for no more than 24 hours and the date and time the vial was reconstituted should be clearly marked.
Patients discharged on oral vancomcyin: Oral capsules (125mg strength) are available in the community, on the Hi-Tech scheme.
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
Once daily dose
5mg/kg q24h iv (30-60 minutes), maximum 480mg in 24 hours.
Correct dose in obesity below.
Administration
In 100ml sodium chloride 0.9% over 30-60 minutes.
When to monitor levels
Pre-dose (‘trough’) levels taken between 18-24 hours after last dose administered. Initially monitor pre-dose level before second dose and then every 48 hours or daily if renal function poor.
Reference range
Pre-dose level ≤1mg/L.
Taking the sample
Send blood to microbiology, with the following information:
Interpreting result
You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.
Other monitoring parameters
Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. tinnitus/fullness in the ears/↓hearing, vertigo, jittery / bouncing vision).
Multiple daily dosing
tds for meningitis, extensive burns (1 – 1.7mg/kg q8h iv)
bd for endocarditis (1mg/kg q12h)
max 480mg in 24 hrs
Pregnancy: refer to CUMH antibiotic guidelines.
Correct dose in obesity.
Administration
iv bolus over 3-5 minutes or infuse in 100ml sodium chloride 0.9% over 30 minutes.
When to monitor levels
Take “Trough” level immediately pre-dose
Take “Peak” level one hour post dose
Initially monitor peak and trough levels with 3rd or 4th dose, then trough levels every 48 hours, or more often if renal function unstable or poor.
Peak levels do not need to be monitored more than once a week.
Reference range
Pre-dose level (trough) ≤2mg/L
Post dose level (peak) 5-10mg/L
Endocarditis pre-dose level ≤1mg/L
Endocarditis post dose level 3-5mg/L
Taking the sample
Send blood to microbiology, with the following information:
Interpreting result
You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.
Other monitoring parameters
Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. tinnitus/fullness in the ears/↓hearing, vertigo, jittery / bouncing vision).
For tobramycin and Amikacin monitoring details, please see your Own Intranet guidelines.
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
| GFR 30-50ml/min: | GFR 10-30ml/min: | GFR <10ml/min: | Monitor levels daily in renal impairment. CAPD/HD: Dose as per <10ml/min. Give dose post HD CVVH: 1mg/kg q24h, according to levels |
|---|---|---|---|
3mg/kg q24h |
2mg/kg q24h |
Seek advice and consider risks / benefits of using gentamicin. Consider 1.5mg/kg and re-dose when level <1mg/L. |
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.
| Day 1 | Hibiscrub Shower / Wash & Shampoo Hair Naseptin Nasal cream to both nostrils q8h |
|---|---|
| Day 2 | Hibiscrub Shower / Wash & Shampoo Hair Naseptin Nasal cream to both nostrils q8h |
| Day 3 | Hibiscrub Shower / Wash Naseptin Nasal cream to both nostrils q8h |
| Day 4 | Hibiscrub Shower / Wash Naseptin Nasal cream to both nostrils q8h |
| Day 5 | Hibiscrub Shower / Wash & Shampoo Hair Naseptin Nasal cream to both nostrils q8h |
| Day 6 | No Treatment for 2 days (Day 1) |
| Day 7 | No Treatment for 2 days (Day 2) |
| Day 8 | Re – swab all areas and wait for results. Continue Standard Isolation and maintain All Precautions to prevent cross - infection |
| Day 9 | Standard and Contact Isolation |
| Day10 | Standard and Contact Isolation |
Systemic treatment of MRSA with antibiotics should only be initiated if there are clinical signs of infection. If a patient who is colonised with MRSA develops an infection usually caused by staphylococci, it is likely that MRSA is the causative pathogen and this should be considered when treating the patient empirically.
Apply a small amount of Naseptin® (with cotton swab or gloved tip of little finger) to the inner surface of each nostril (anterior nares) three times daily for five days. Apply enough to cover the inner surface. Pinch the distal end of nose gently after application, the patient should be able to taste the Naseptin at the back of the throat a minute or so later.
The skin should be moistened and the antiseptic applied thoroughly to all areas before rinsing in the bath or shower. Special attention should be paid to known possible carriage sites including axilla, groin, perineum and buttock area. The antiseptic detergent should also be used for all other washing procedures and for bed bathing.
Hibiscrub may cause side effects: skin reactions (e.g. rash, redness, swelling, itching) and generalised allergic reactions (e.g. difficulty in breathing). If these reactions occur, stop using Hibiscrub (chlorhexidine) and contact Infection Control for specialist advice.
Systemic antibiotics are indicated where there are clinical signs of infection & MRSA is known or strongly suspected to be the cause of infection.
Empirical/targeted regimensSeek advice from Microbiology / Infectious Diseases regarding choice of agent and duration of treatment. |
Surgical antibiotic prophylaxisPatients 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 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 (↓) regimen for 7 days: Please refer to the Infection Control Guidelines for full details on screening and eradication of MRSA.
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.
Systemic antibiotics are indicated where there are clinical signs of infection & MRSA is known or strongly suspected to be the cause of infection.
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.
Many patients are given intravenous antibiotics at the time of admission to hospital. As they improve and investigations reveal the site and extent of any infective process, it may be appropriate to discontinue antibiotics or to change from the intravenous to the oral route.
Patients on intravenous antibiotics should be reviewed daily to decide if they can be switched to an oral antibiotic.
If a switch is not appropriate at this stage, continue to review need for IV therapy every 24 hours. Reasons why a switch is not appropriate should be documented in the patient notes.
| C | Clinical improvement |
|---|---|
| O | Oral/NG route is available i.e. the patient is not:
|
| M | Markers and observations normal or improving:
|
| E | Exclude high risk or deep seated infection requiring prolonged IV therapy. Such infections include: Deep seated infections
High risk infections
Note: This list is not conclusive. |
| T | Tachycardia and tachypnoea resolved
|
Unless contraindicated - consider oral route from commencement of therapy.
* if patient on enteral nutrition, iv ciprofloxacin preferable to oral as bioavailability may be decreased.
** when used parenterally, clarithromycin can cause damage at the injection site and/or thrombophlebitis.
Once daily dose
Not for endocarditis, meningitis or extensive burns.
5mg/kg q24h iv, maximum 480mg in 24 hours.
Correct dose in obesity below.
Administration
In 100ml sodium chloride 0.9% over 60 minutes.
When to monitor levels
Pre-dose (‘trough’) levels taken between 18-24 hours after last dose administered. Initially monitor pre-dose level before second dose and then every 48 hours or daily if renal function poor.
Taking the sample
Send blood to microbiology, with the following information:
Interpreting result
You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.
Other monitoring parameters
Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. ringing / feeling of fullness in the ears, hearing loss, dizziness, vertigo, jittery / bouncing vision). Monitor for concomitant use of potent diuretics, ototoxic or nephrotoxic medicines e.g. NSAIDS, ACE inhibitors. Check vestibular and auditory function weekly if prescribed for more than 7 days.
Multiple daily dosing
1 - 1.7 mg/kg q8h iv, max 480mg in 24 hours
Correct dose in obesity as below.
IOS - CHECK LINK TO RENAL DOSING
Administration
iv bolus over 3-5 minutes or infuse in 50-100ml sodium chloride 0.9% over 20-60 minutes.
When to monitor levels
Take “Trough” level immediately pre-dose
Take “Peak” level one hour post dose
Initially monitor peak and trough levels with 3rd or 4th dose, then trough levels every 48 hours, or more often if renal function unstable or poor.
Peak levels do not need to be monitored more than once a week.
Reference range
Pre-dose level (trough) ≤2mg/L
Post dose level (peak) 5-12mg/L
Taking the sample
Send blood to microbiology, with the following information:
Interpreting result
You do not need to wait for the result before administering the next dose unless specifically advised or patient has impaired renal function. If result is high, first check that the level was taken at the correct time. In general, if the result is high, reduce the dose or increase the dosing interval. If in doubt, seek advice from Microbiology or Pharmacy.
Other monitoring parameters
Monitor renal function at least twice weekly. Monitor for signs of ototoxicity (e.g. ringing / feeling of fullness in the ears, hearing loss, dizziness, vertigo, jittery / bouncing vision). Monitor for concomitant use of potent diuretics, ototoxic or nephrotoxic medicines e.g. NSAIDS, ACE inhibitors. Check vestibular and auditory function weekly if prescribed for more than 7 days.
Correcting 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
| GFR 20-50ml/min: | GFR 10-30ml/min: | GFR <10ml/min: | CAPD/HD: Dose as per <10ml/min. |
|---|---|---|---|
Give 1-2mg/kg then dose according to serum levels |
Give 1mg/kg then dose according to serum levels |
Give 1mg/kg then dose according to serum levels |
Vancomycin levels are monitored to ensure efficacy and to minimise toxicity (mainly nephrotoxicity and ototoxicity)
Give one loading dose 25mg/kg (max 2g) to all patients.
Infusion rate: max 10mg/kg to avoid infusion-related reactions (incl. "red man" syndrome).
Infusion vol.: Dilute each 500mg in al least 100 ml 0.9% saline.
In normal renal function : 15mg/kg IV every 12 hours at 10am and 10pm
In renal impairment (after loading dose given)
| Creatinine Clearance | Vanc. dose |
|---|---|
| >50ml/min | 15mg/kg q12h (to start 12 hours after loading dose) |
| 20-50ml/min | 15mg/kg q24h (to start 24 hours after loading dose) |
| <20ml/min or haemodialysis | 15mg/kg & re-dose once level <20mg/L |
Send blood to microbiology, with the following information
Ensure level taken at the correct time, i.e. within two hours of next dose (preferably just prior to next dose)
| Pre-dose (trough) level | Suggested dose alteration |
|---|---|
| <10mg/L | ↑ each dose by 250mg-500mg. If dose exceeds 2g bd, seek advice from micro./pharmacy regarding dosing strategies. |
| 10-15mg/L | Desired range 10-20mg/L: no change Max single dose is 2g. If total dose to exceed 2g q12h, contact pharmacy/micro for advice. |
| 15-20mg/L | No change |
| >20mg/L | Omit next dose(s) until level <20mg/L and then reduce each dose by 500mg |
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
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 Coroners’ core function is to investigate sudden and unexplained deaths so that a death certificate can be issued. The Coroner Service not only provides closure for those bereaved suddenly but also performs a wider public service by identifying matters of public interest that can have life/death consequences.
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 service offers 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. They are staffed by a Cancer Information Nurse and trained volunteers, and are open Monday to Friday 9-5. Last year the Cork Daffodil Centres received 5,978 contacts.
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:
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.
| 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 nicotine dependence |
0-10 | 10mg if required |
| 4-6 Moderate dependence |
11-20 | 15mg |
7+ |
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:
From your local Smoking Cessation Services .
| Drug | Dose | Freq | Route | Note |
|---|---|---|---|---|
| Paracetamol | 1g | qds | po/pr/iv | In adults <50kg, IV dose is 15mg/kg max QDS. PO/PR route should be used unless contra-indicated. |
| Ibuprofen | 400mg | tds | po | Prescribe with PPI. See NSAID side-effects and contraindications. Less analgesia/anti-inflammatory action than diclofenac but side effects are less severe. |
Paracetamol + NSAID or Weak Opioid or both.
| Drug | Dose | Freq | Route | Note |
|---|---|---|---|---|
| Diclofenac | 75mg | bd | po | Max 150mg/24hrs. Prescribe with PPI. See NSAID side-effects and contraindications. PR route has no ⇓ in side effects and no ⇑ in analgesia. Assess risk/benefit (e.g. cardiovascular risk factors) and use lowest dose for shortest duration. Diclofenac now contraindicated in IHD, CVD, CCF, PVD. |
| Diclofenac | 100mg | 16hrly | pr | |
| Mefenamic acid |
500mg | tds | po | Prescribe with PPI. See NSAID side-effects and contraindications. Useful in both menstrual and inflammatory pain. |
| Tramadol | 50–100mg | qds | po/im | See opioid side effects. Avoid in epileptics and patients on medications which inhibit the re-uptake of serotonin (e.g. SSRIs, Linezolid). In elderly can cause confusion, hallucination, N&V. Good in neuropathic pain. Monitor INR (Tramadol can ⇑ INR). |
| Drug | Dose | Freq | Route | Note |
|---|---|---|---|---|
| Oramorph | 10mg | 4hrly. | po | Morphine solution |
| Morphine | 5-10mg | 4hrly | im/sc | See opioid prescribing guide for side-effects and contraindications. |
| Morphine | 5-10mg 4hrly | iv | Slow injection | |
| OxyContin | 5-20mg | bd | po | Prolonged release oxycodone. |
| OxyNorm | 5-20mg | 4hrly | 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 4hrly |
IN | Fentanyl nasal spray – good for breakthrough pain. Pecfent is cheaper than Instanyl and includes dose counter. |
| Actiq | 200mcg | i-ii 4hrly |
po | Fentanyl lozenge – good for breakthrough pain and cancer pain. One lozenge initially, repeated if necessary after 15 minutes. No more than 2 lozenges for each pain episode. If adequate pain relief not achieved with one dose unit for consecutive breakthrough pain episodes, increase the strength of the dose unit until adequate pain relief achieved with 4 lozenges or less daily. |
| Targin | 5/2.5mg – 20/10mg | po | Prolonged release oxycodone with naloxone for prevention of opioid induced constipation. Restricted to initiation by a pain specialist only, where oxycodone + laxative was ineffective. | |
| 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)
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 | Action |
|---|---|
| <20 | Bolus 5000 iu and ↑ by 100 iu/hr. |
| 20-40 | ↑ by 200 iu/hr. |
| 40-60 | ↑ by 100 iu/hr. |
| 60-90 | Continue same rate. |
| 90-100 | ↓ by 100 iu/hr. |
| APTT > 100 seconds: | Stop infusion for 1 hour or ↓ rate by 100iu/hr. Repeat APTT 4 hours post infusion change. |
Add 10,000 iu to 100ml 0.9% NaCl = 1000 iu in 10ml.
For continuous iv infusion initiate at 1000 iu/hr aiming to maintain APTT between 60-90 seconds. (Will need 4-6 hourly APTT).
Usually give a Bolus of 5,000iu IV before starting infusion.
| 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
|
| CHADS2 Score |
Annual Stroke Risk % |
Advice |
|---|---|---|
| 0 | 2 | No anticoagulation |
| 1 | 3 | ± anticoagulation |
| 2 | 4 | Oral anticoagulation recommended |
| 3 | 3 | |
| 4 | 9 | |
| 5 | 13 | |
| 6 | 18 |
More on EMed.ie
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.
This calculator computes the correct dose of gentamicin for a once-daily dosing regimen, in accordance with Mercy University Hospital (MUH) antimicrobial prescribing guidelines.
Renal impairment and obesity are taken into account when calculating the dose.
The once-daily gentamicin regimen should not be used for patients with endocarditis, meningitis, extensive burns, severe renal impairment, or patients on dialysis or haemofiltration.
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 » Discharge home
Score 4-6: 20.3% MACE over next 6/52 » Refer 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))
0.9% NaCl (154mmol/L) rate: ml/hr for 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
Weight: 000 kg
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% changce of PE.
This calculator computes the correct doses of vancomycin for an intravenous dosing regimen, in accordance with Mercy University Hospital (MUH) antimicrobial prescribing guidelines.
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
When albumin <40g/L: Corrected Ca level (mmol/L) = 0.02 x (40 - albumin g/L) + Measured Ca level (mmol/L).
Corrected Ca++:
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 ♀.
1-year risk for major bleeding in patients with AF.
Anticoagulation should be considered for patients with a relatively low risk for major bleeding (~1/100 patient-years).
IBW ♂ = 50kg+[(height (cm) -154) x0.9]
IBW ♀ = 45.5kg+[(height (cm) -154) x0.9]
We could have added feet & inches but ... for imperial to metric conversion please see "Ye olde units".
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
Low risk patients (score ≤0) are suitable for home treatment with Rivaroxaban.
