Guideline Revision History

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University Hospital Waterford & South East Hospitals Antimicrobial Guideline

HSE South East Hospital Guidelines for the Empiric Use of Antimicrobials in Adults

University Hospital Waterford

Kilcreene Regional Orthopaedic Hospital

Tipperary University Hospital

St Luke’s Hospital, Kilkenny

Wexford General Hospital

First issue: June 2006

Revision: No 15

Approval Date: November 2025

Review Date: November 2028

South East Antimicrobial Stewardship Group

Disclaimer:

Whilst every effort has been made to ensure the accuracy of the information and material contained in this document, errors or omissions may occur in the content. We acknowledge that new evidence may emerge that may over take some of these recommendations. The guideline will be reviewed regularly and revised at a minimum of every 3 years. Prescribers 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), the drug data sheets and SPCs. Clinical guidelines are guidelines only and the interpretation and application of the guidelines remains the responsibility of the individual clinician.

Changes for this Edition – Revision No. 13 (August 2023)
General Guidance on Antimicrobial Prescribing	Updated fluoroquinolone warnings throughout guideline with link to 2023 HPRA drug safety newsletter attached. Inclusion of neuropsychiatric disorders as potential fluoroquinolone ADR.
Antimicrobial Susceptibility	Section updated in line with EUCAST changes to the interpretation of antimicrobial susceptibility testing. Common examples included of increased dose regimens when susceptibility reported as ‘I’ Susceptible, increased exposure.
Central Nervous System & ENT	Review of acyclovir dosing for meningitis and viral encephalitis. Terminology changed from Obese Dosing Weight to Adjusted Body Weight throughout.
Obstetrics	Review of cefuroxime dosing for Sepsis in Pregnancy to 1.5g QDS. Inclusion of link to National Clinical Practice Guideline Prevention of Early-Onset GBS in Term Infants 2023.
Urinary Tract Infection	Update to nitrofurantoin dosing in acute simple cystitis - Immediate release VS prolonged release dosing options included.
Gastrointestinal	Addition of Helicobacter pylori section with link to HSE Antimicrobial Prescribing Guideline. Clostridium difficile section revised in line with updated HSE AMRIC C. diff Infection Treatment Guidance 2023.
Genital Tract Infection	Addition of Epididymo-orchitis section including link to HSE antibiotic prescribing guidelines.
Bone and Joint Infection	Removal of sodium fusidate as adjunct treatment option.
Malaria	Addition of malaria section adapted from UHW guideline with Riamet pregnancy disclaimer included. Please refer to local hospital policy for out of hours medication supply.
Teicoplanin Dosing Schedule	Reformatting of dosing section to include table for moderate and deep-seated infections. Information on teicoplanin trough levels including when TDM should be carried out.
IV to PO switch	Section updated with inclusion of high dose oral options for complex/severe infections.
Formulae for Ideal Body Weight, Adjusted Body Weight, Body Mass Index and Body Surface Area	Standardisation of terminology from Obese Dosing Weight to Adjusted Body Weight throughout guidelines. Hyperlinks to “Ideal Body Weight and Adjusted Body Weight” and “Body Mass Index and Body Surface Area” calculators were also added throughout to facilitate ease of formulae calculation.
Creatinine Clearance Calculator	Addition of link to MdCalc Creatinine Clearance (Cockrauft&Gault) calculator.
Revision No. 13.1 (March 2024)
Surgical Prophylaxis Guidelines	Revision of South East Acute Hospitals Surgical Prophylaxis Guidelines Incorporation of National Surgical Antibiotic Prophylaxis Duration Position Statement - October 2021 Review of Dosage and Administration by Type of Surgical Procedures

Revision No. 13.2 (May 2024)
Aciclovir	Update to wording with heightened emphasis on requirement for dose adjustments in both renal impairment and obesity.

Sepsis	Formatting update for “Sepsis of Undetermined Origin/Source Unclear” to emphasise importance of amikacin addition if history of infection or colonisation with gentamicin resistant Gram-negative bacteria, severe illness or septic shock.
Spontaneous Bacterial Peritonitis	Update to Ceftriaxone dosing for SBP in line with Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases.

Revision No. 14 (July & August 2024)
Penicillin Allergy Antibiotic Prescribing Aid	Update to “Penicillin Allergy” section with addition of a Penicillin Allergy Antibiotic Prescribing Aid.

Teicoplanin	Update to Teicoplanin Dosing Schedule to include target “reference ranges” and further detail in relation to indications for moderate/deep-seated infections.
Amikacin	Update to Amikacin Dosing Schedule to include maximum treatment course of 15g.
Tobramycin	Addition of Tobramycin Dosing Schedule to “Algorithms and Appendices.”
Cefiderocol	Addition of Cefiderocol to reserve list
Surgical Prophylaxis Guidelines	Correction to section 5.6.3: GI PEG insertion single dose surgical prophylaxis.

Revision No. 14.1 (December 2024)
Influenza Guidelines	Update to “Influenza” section to include link to 2024 HSE HPSC Guidance on the use of antiviral agents for the treatment and prophylaxis of Influenza (03.12.2024).

Revision No. 14.2 (April 2025)
C. difficile Infection Guidelines	Note added to " Initial Episode & First Recurrence of C. difficile Infection " section advising instances where fidaxomicin is the agent of choice PO Fosfomycin removed from Reserve antimicrobial list Meropenem added to Reserve antimicrobial list

Revision No. 15 (November 2025)
Respiratory Tract Infection	Increase oral Amoxicillin dosage to 1g TDS and oral Co-amoxiclav to 875/125mg TDS New section on Pneumonia Acquired in Residential Care Facilities Levofloxacin dosage increased for legionellosis Fluoroquinolone use warning Update of the general points for Hospital Acquired Pneumonia Addition of comments: Antibiotics are not indicated for aspiration or aspiration pneumonitis without evidence of bacterial infection Updated references

Febrile Neutropenia/Neutropenic Sepsis	Updated definitions of neutropenia and fever Update to "NOT IgE-mediated/anaphylaxis/severe penicillin allergy" scetion: (routine addition of Gram-positive cover no longer recommended for all patients) Update to"IgE-mediated/anaphylaxis/severe penicillin allergy" section: Ciprofloxacin dosing increased to 400mg TDS IV dose; Aztreonam 2g TDS IV added as an option if risk of ciprofloxacin toxicity* Caveat included stating that gentamicin should be added if high risk of infection; and replaced with amikacin in severe illness, haemodynamic instability, septic shock or if history of infection/colonisation with gentamicin resistant Gram-negative bacteria Neutropenic Sepsis added to title Vancomycin added if history of MRSA colonization/infection OR suspected line-related sepsis OR critically ill OR active mucositis Advice to consider the addition of anti-fungal agent if fever persists after 3 days. Updated references
Sepsis	Update of new link to "2025 National Clinical Guideline No 26 (version 2) Sepsis Management for Adults (including maternity)" Update of new sepsis forms for adults Update of new sepsis forms for maternity
Infective Endocarditis	Empiric therapy for native valve, prosthetic valve and culture negative endocarditis
Voriconazole Levels	Addition of general information regarding obtainment and processing of voriconazole samples
Covid-19 update	Inclusion of link to revised "HSE Clinical Guidance on Paxlovid™ (nirmatrelvir/ritonavir) for use in the Treatment of COVID-19"
Influenza	Addition of tables outlining oseltamivir dosing for both treatment and prophylaxis of influenza

High Tech Antimicrobials

Addition of a new section pertaining to High Tech antimicrobials