Quality Use of Medicines
For complex drug information and aminoglycoside monitoring contact Hunter Drug Information Service 02 4014 3695
Hunter New England Health

10-00-00-sepsis: HNE Adult Sepsis First Dose Guideline

The HNE Adult Sepsis Empirical Intravenous Antibiotic Guideline aims to guide the prescription and timely administration of the FIRST DOSE of intravenous (IV) antibiotics for adult patients who have a diagnosis of sepsis

10-10-00-inotes: Important Notes

  • PROMPT ADMINISTRATION OF ANTIBIOTICS (within one hour of provisional diagnosis) and resuscitation fluids is vital
  • TIMELY ADMINISTRATION of both gentamicin and the penicillin agent is more important than any reduction in gentamicin activity. DO NOT delay administration of both agents
  • An antimicrobial treatment indication and plan should be documented in the patient record. A differential diagnosis should always be considered and also documented
  • Obtain at least two sets of blood cultures from separate venepunctures before antibiotic administration
  • Obtain other clinical specimens as appropriate but do not delay administration of antibiotics or wait for results of investigations
  • Patients with febrile neutropenia should always be discussed with the relevant Oncology or Haematology consultant (via 49213000)
  • ALL penicillin AND cephalosporin class antibiotics are contraindicated in patients with history of drug rash with eosinophilia and systemic symptoms, Stevens-Johnson Syndrome or documented past immediate allergy to penicillin or cephalosporin

10-20-00-aprescribe: Antibiotic Prescribing

10-20-10-ssepsis: Severe sepsis, No Obvious Source Of Infection

Severe sepsis, no obvious source of infection (vancomycin added due to significant number of severe MRSA infection presentations from community settings)

Empirical Antibiotic Regimen

flucloxacillin 2 g IV, 4-hourly
plus
gentamicin 7 mg/kg IV, for 1 dose (max 640 mg)
plus
vancomycin
First dose: 25-30mg/kg (this also acts as a loading dose)
-Subsequent doses and interval are determined by actual body weight and estimated GFR

Penicillin allergic – Not Immediate Hypersensitivity

cephazolin 2 g IV, 6-hourly
plus
gentamicin 7 mg/kg IV, for 1 dose (max 640 mg)
plus
vancomycin
First dose: 25-30mg/kg (this also acts as a loading dose)
-Subsequent doses and interval are determined by actual body weight and estimated GFR

Penicillin allergic – Immediate Hypersensitivity (Anaphylaxis)

gentamicin 7 mg/kg IV, for 1 dose (max 640 mg)
plus
vancomycin
First dose: 25-30mg/kg (this also acts as a loading dose)
-Subsequent doses and interval are determined by actual body weight and estimated GFR

10-20-20-minfect: Meningococcal Infection

Empirical Antibiotic Regimen

benzyl penicillin 1.8 g IV, 4-hourly

Penicillin Allergic – Not Immediate Hypersensitivity

ceftriaxone 2 g IV, 12-hourly

Penicillin Allergic – Immediate Hypersensitivity (Anaphylaxis)

ciprofloxacin 400 mg IV, 8-hourly

10-20-30-pcomm: Pneumonia Community Acquired

Pneumonia – community acquired (CORB severity score ≥ 2) see HNE Clinical Guideline Adult Community acquired pneumonia
Note: If Legionella unlikely cease azithromycin at day 3

Empirical Antibiotic Regimen

benzyl penicillin 1.2 g IV, 4-hourly
plus
gentamicin 7 mg/kg IV, (ideal body weight) for 1 dose (max 640 mg)
plus
azithromycin 500 mg IV, daily

Penicillin Allergic – Not Immediate Hypersensitivity

ceftriaxone 1 g IV, 12-hourly
plus
azithromycin 500 mg IV, daily

Penicillin Allergic – Immediate Hypersensitivity (Anaphylaxis)

moxifloxacin 400mg, PO, daily
plus
Seek ID/MICRO advice (The on-call ID Physician / Microbiologist is available via 49213000)

10-20-40-iasource: Intra-abdominal source

Note: Metronidazole can be omitted in biliary sepsis e.g.,ascending cholangitis unless chronic biliary obstruction suspected.

Empirical Antibiotic Regimen

ampicillin 2 g IV, 6-hourly
plus
gentamicin 7 mg/kg IV, (ideal body weight) for 1 dose (max 640 mg)
plus
metronidazole 500 mg IV, 12-hourly

Penicillin Allergic – Not Immediate Hypersensitivity

ceftriaxone 1 g IV, 12-hourly
plus
metronidazole 500 mg IV, 12-hourly

Penicillin Allergic – Immediate Hypersensitivity (Anaphylaxis)

gentamicin 7 mg/kg IV, (ideal body weight) for 1 dose (max 640 mg)
plus
clindamycin 600 mg, 8-hourly

10-20-50-ursource: Urinary source likely e.g., pyelonephritis

Empirical Antibiotic Regimen

ampicillin 2g IV, 6-hourly
plus
gentamicin 7 mg/kg IV, (ideal body weight) for 1 dose (max 640 mg)

Penicillin Allergic – Not Immediate Hypersensitivity

gentamicin 7 mg/kg IV, (ideal body weight) for 1 dose (max 640 mg)

Penicillin Allergic – Immediate Hypersensitivity (Anaphylaxis)

gentamicin 7 mg/kg IV, (ideal body weight) for 1 dose (max 640 mg)
plus
Seek ID/Micro advice (The on-call ID Physician / Microbiologist is available via 49213000)

10-20-60-idsource: Intravascular Device Source (Suspected)

Removal of infected device is usually required

Empirical Antibiotic Regimen

flucloxacilin 2g IV, 6-hourly
plus
vancomycin
First dose: 25-30mg/kg (this also acts as a loading dose) -Subsequent doses and interval are determined by actual body weight and estimated GFR
plus
gentamicin 7 mg/kg IV,(ideal body weight) for 1 dose (max 640 mg)

Penicillin Allergic – Not Immediate Hypersensitivity

cephazolin 2g IV, 8-hourly
plus
vancomycin
First dose: 25-30mg/kg (this also acts as a loading dose)
-Subsequent doses and interval are determined by actual body weight and estimated GFR
plus
gentamicin 7 mg/kg IV, (ideal body weight) for 1 dose (max 640 mg)

Penicillin Allergic – Immediate Hypersensitivity (Anaphylaxis)

vancomycin
First dose: 25-30mg/kg (this also acts as a loading dose)
-Subsequent doses and interval are determined by actual body weight and estimated GFR
plus
gentamicin 7 mg/kg IV,(ideal body weight) for 1 dose (max 640 mg)

10-30-00-aadmin: Antibiotic Administration - Intravenous

ampicillin

Presentation(Adult)Vial 1 g
Reconstitution Fluid/Volume10 mL WFI
Final Volume*10-20 mL
Minimum Administration Time 3-5 min
NotesPenicillin class antibiotic

azithromycin

Presentation(adult)Vial 500 mg
Reconstitution Fluid/Volume4.8mL WFI, then add to infusion fluid bag
Final Volume*500 mL (250 mL for fluid restricted patients)
Minimum Administration Time 60 min
Notes Final concentration must be 1 or 2 mg/mL (fluid restricted) to avoid local infusion site reaction. Rare cause of prolonged QT Interval

benzylpenicillin

Presentation(Adult)Vial
600 mg
Vial
1.2 g
Reconstitution Fluid/Volume2 mL WFI4 mL WFI
Final Volume*10-20 mL
Minimum Administration Time 3-5 min
NotesPenicillin class antibiotic
Consider administering doses ≥ 2.4 g over 30 mins

ceftriaxone

Presentation(Adult)Vial
1 g
Vial
2 g
Reconstitution Fluid/Volume10 mL WFI20 mL WFI
Final Volume*10-20 mL20 mL
Minimum Administration Time 2-4 min 4 min
NotesCephalosporin class. Incompatible with calcium containing solutions, flush thoroughly before and after with normal saline

cephazolin

Presentation(Adult) Vial 1 g
Reconstitution Fluid/Volume 10 mL WFI
Final Volume* 10-20 mL
Minimum Administration Time 3-5 min
Notes Cephalosporin class

ciprofloxacin

Presentation(Adult)Infusion bag or infusion vial 200 mg/100 mL or 400 mg/200 mL
Reconstitution Fluid/VolumeN/A
Minimum Administration Time 60 minutes
NotesMay induce seizures in epileptics. Local site reactions are more frequent when shorter infusion times are used

flucloxacillin

Presentation(Adult)Vial 1 g
Reconstitution Fluid/Volume5 mL WFI
Final Volume*10 mL50 mL
Minimum Administration Time3-5 min(1 g)30 min(2 g)
NotesPenicillin class antibiotic. Irritant, subsequent doses as an infusion or PICC line

gentamicin

Presentation(Adult)Ampoule 80 mg/2 mL
Reconstitution Fluid/VolumeN/A
Final Volume*10-20 mL
Minimum Administration Time 3-5 min
NotesMay give up to 640mg IV push over 3-5 min

metronidazole

Presentation(Adult)Infusion bag 500 mg/100 mL
Reconstitution Fluid/VolumeN/A
Minimum Administration Time 20 min

vancomycin

Presentation(Adult)Vial 500 mgVial 1 g
Reconstitution Fluid/Volume10 mL WFI20 mL WFI
Final Volume*250 to 500mL (depending on dose)
Minimum Administration TimeThe rate of administration not > 10 mg/min
NotesInfusion related effects are common, decrease infusion rate and monitor closely if these occur

10-40-00-aspath: Adult Sepsis pathways

20-00-00-cap: HNE Adult Community Acquired Pneumonia Guideline

20-10-00-commnotk: No Known Allergy to Penicillin

Step 1: Calculate Patient's CORB Factor

  Confusion - new onset
pO2 < 60mm or O2 saturation ≤ 90%
  RR ≥ 30/min
  BP systolic < 90 mmHg or diastolic ≤ 60 mmHg

Mild:
Zero CORB Factors; Social Supports OK; Stable Co-morbidities

amoxycillin 1 g oral 8-hourly, 5-7 days

Moderate:
One CORB Factor OR Requires Admission (May Still Require ICU Assessment)

benzylpenicillin 1.2 g IV 6-hourly, 5-7 days
PLUS
doxycycline 100mg orally, 12 hourly for 7days

Severe:**
ICU / HDU; ≥ Two CORB Factors

benzylpenicillin 1.2 g IV 4-hourly
PLUS
gentamicin daily IV
PLUS
azithromycin 500 mg IV/oral daily

Investigation (severe): acute serology, two blood culture sets, urinary Legionella and pneumococcal antigens, nose and throat swab OR endotracheal aspirate (if intubated) for respiratory multiplex PCR (R10 PCR) and legionella PCR

**Note: If MSSA or MRSA pneumonia probable, consult Infectious Diseases and add
vancomycin
First dose: 25-30 mg/kg (this also acts as a loading dose)
-Subsequent doses and interval are determined by actual body weight and estimated GFR

20-20-00-commapen:Allergic to Penicillin

Step 1: Calculate Patient's CORB Factor

  Confusion - new onset
pO2 < 60mm or O2 saturation ≤ 90%
  RR ≥ 30/min
  BP systolic < 90 mmHg or diastolic ≤ 60 mmHg

Mild:
Zero CORB Factors; Social Supports OK; Stable Co-morbidities

doxycycline 100 mg orally, 12 hourly for 5 to 7 days

Moderate:
One CORB Factor OR Requires Admission (May Still Require ICU Assessment)

ceftriaxone* 1 g IV daily, 5-7 days
PLUS
doxycycline 100 mg orally, 12 hourly for 7 days
* Immediate β-lactam hypersensitivity: Consult Infectious Diseases.

Severe:**
ICU / HDU; ≥ Two CORB factors

ceftriaxone* 1 g IV daily
PLUS
azithromycin 500 mg IV / oral daily
(usually stop azithromycin at 3 days if Legionella unlikely)

Investigation (severe): acute serology, two blood culture sets, urinary Legionella and pneumococcal antigens, nose and throat swab OR endotracheal aspirate (if intubated) for respiratory multiplex PCR (R10 PCR) and legionella PCR

* Immediate β-lactam hypersensitivity: Consult Infectious Diseases.

**Note: If MSSA or MRSA pneumonia probable, consult Infectious Diseases and add
vancomycin
First dose: 25-30 mg/kg (this also acts as a loading dose)
-Subsequent doses and interval are determined by actual body weight and estimated GFR

30-00-00-hap:Adult Hospital Acquired Pneumonia

Aspiration pneumonia: see therapeutic Guidelines: Antibiotic
Test all early onset intensive care cases for Legionella
Test for influenza May-November

30-10-00-hospnotkn:No Known Allergy to Penicillin

Low Risk - (Multi-Resistant Gram Negative Micro Organism)
- Non-ICU or
- ICU/HDU Cases Admitted to Hospital < 5 Days

amoxycillin/clavulanate 875/125 mg 12-hourly, 5-7 Ddays
OR
benzylpenicillin 1.2 g IV 6-hourly, 5-7 days
PLUS
gentamicin

High Risk - (Multi-Resistant Gram Negative Micro Organism)
- ICU/HDU Admission ≥ 5 Days
- Known MRO

piperacillin/tazobactam 4 /0.5 g IV 6-hourly

ADD vancomycin for patients with severe sepsis or if at increased risk of MRSA

ADD gentamicin for patients with severe sepsis if there is an increased risk of pseudomonas or other MDR Gram-negative pathogens

Review status and microbiology results at 3 days to decide if further antimicrobials required. Duration for confirmed ventilator-associated pneumonia is usually 7-8 days

MRSA

ADD vancomycin
First dose: 25-30 mg/kg (this also acts as a loading dose)
-Subsequent doses and interval are determined by actual body weight and estimated GFR and Consult Infectious Diseases

30-20-00-hospapen:Allergic to Penicillin

Aspiration pneumonia: see therapeutic Guidelines: Antibiotic
Test all early onset intensive care cases for Legionella
Test for influenza May-November

Low Risk - (Multi-Resistant Gram Negative Micro Organism)
- Non-ICU or
- ICU/HDU Cases Admitted to Hospital < 5 Days

ceftriaxone 1 g IV daily, 5 days

High Risk - (Multi-Resistant Gram Negative Micro Organism)
- ICU/HDU Admission ≥ 5 Days
- Known MRO

cefepime 2 g IV 8-hourly

ADD vancomycin for patients with severe sepsis or if at increased risk of MRSA

ADD gentamicin for patients with severe sepsis if there is an increased risk of pseudomonas or other MDR Gram-negative pathogens

Review status and microbiology results at 3 days to decide if further antimicrobials required. Duration for confirmed ventilator-associated pneumonia is usually 7-8 days

MRSA

ADD vancomycin
First dose: 25-30mg/kg (this also acts as a loading dose)
-Subsequent doses and interval are determined by actual body weight and estimated GFR and Consult Infectious Diseases

40-00-00-sprophy:HNE Surgical Antibiotic Prophylaxis Guideline

40-10-00-spabdo: Abdominal Surgery

Initial doses must be given close to induction (within 1 hour)

First Line Treatment

cephazolin 2 g IV (child 25 mg/kg up to 2 g)

For small intestine surgery with obstruction and in colorectal surgery,
PLUS
metronidazole 500 mg IV Infusion over 15-30 mins (child; 12.5 mg.kg upto 500 mg

Second Line (MRSA colonised or β-lactam allergy)

clindamycin or lincomycin 600 mg IV
PLUS
gentamicin 2 mg/kg up to 500 mg

40-20-00-spamp:Amputation (Ischaemic Limb)

Initial doses must be given close to induction (within 1 hour)

First Line Treatment

benzylpenicillin 1.2 g IV at induction and 6-hourly for 24 hours

Second Line (MRSA colonised or β-lactam allergy)

metronidazole 500 mg IV infusion over 15-30 minutes. Repeat at 12 hours.

40-30-00-spcaesar: Caesarean Section

Initial doses must be given close to induction (within 1 hour)

First Line Treatment

cephazolin 2 g IV (child 25 mg/kg up to 2 g)

Second Line (MRSA colonised or β-lactam allergy)

clindamycin or lincomycin 600 mg IV

40-40-00-spcard:Cardiac Catheter Laboratory (Defibrillator device/permanent pacemaker insertion)

Initial doses must be given close to induction (within 1 hour)

First Line Treatment

cephazolin 2g IV
AND if re-do: teicoplanin 800 mg IV

Second Line (MRSA colonised or β-lactam allergy)

teicoplanin 800 mg IV

40-50-00-sphead: Head, Neck & Ear/Nose/Throat (ENT) Surgery

Initial doses must be given close to induction (within 1 hour)

First Line Treatment

cephazolin 2 g IV (child 25 mg/kg up to 2 g)
and in some cases ADD metronidazole 500mg IV infusion over 15-30 minutes.

Repeat dose intra-operatively if procedure lasts more than 3 hours

Second Line (MRSA colonised or β-lactam allergy)

clindamycin or lincomycin 600 mg IV

40-60-00-sphyst:Hysterectomy or Termination of Pregnancy

Initial doses must be given close to induction (within 1 hour)

First Line Treatment

cephazolin 2g IV (child 25 mg/kg up to 2g)
PLUS
metronidazole 500 mg IV infusion over 15-30 minutes

Second Line or (MRSA colonised or β-lactam allergy)

metronidazole 500 mg IV infusion over 15-30 minutes
PLUS
gentamicin 2 mg/kg IV

40-70-00-spneuro: Neurosurgery - Prolonged procedure, Re-explorations

Initial doses must be given close to induction (within 1 hour)

The value of prophylaxis for the insertion of shunts, ventricular drains or pressure monitors remains unproven and is not recommended

First Line Treatment

cephazolin 2 g IV (child 25 mg/kg up to 2 g)

Repeat dose intra-operatively if procedure lasts more than 3 hours

Second Line (MRSA colonised or β-lactam allergy)

teicoplanin 800 mg (child 20 mg/kg up to 800 mg) IV prior to induction

40-80-00-sportho: Orthopaedics: Elective Surgery

Initial doses must be given close to induction (within 1 hour)

Repeat dose intra-operatively if procedure lasts more than 3 hours
  • Arthroscopy does not require antibiotic prophylaxis
  • In knee operations, administer prophylaxis at the time of tourniquet removal
  • Preoperative MRSA nasal screening is indicated for prosthetic hip and knee joint surgery

First Line Treatment

cephazolin 2 g IV(child 25 mg/kg up to 2 g)
PLUS
if MRSA positive: teicoplanin 800 mg child 20 mg/kg up to 800 mg) IV prior to induction

Second Line (MRSA colonised or β-lactam allergy)

teicoplanin 800 mg (child 20 mg/kg up to 800 mg) IV prior to induction

40-90-00-sptraum:Trauma Orthopaedics and Multi-Trauma

If a fracture is debrided, fixed and closed within 6 hours of injury then no post-operative doses are required. Otherwise, presumptive therapy for early infection (not yet clinically overt) is indicated (see below).
Note that presence of an external fixtator is not considered to represent an 'open wound' for this guideline.
  • Initial doses must be given close to induction (within 1 hour)
  • Repeat dose intra-operatively if procedure lasts more than 3 hours

First Line Treatment

cephazolin 2 g IV child 25 mg/kg up to 2 g)
PLUS
if MRSA positive: teicoplanin 800 mg child 20 mg/kg up to 800 mg) IV prior to induction

Second Line (MRSA colonised or β-lactam allergy)

teicoplanin 800 mg (child 20 mg/kg up to 800 mg) IV prior to induction

In other circumstances use modified Gustillo Classification scheme for presumptive treatment (below)
Type Size of Facture Wound Duration of antibiotic course
I < 1 cm 24 hours after wound closure or 2 days if wound still open
II 1 - 3 cm 24 hours after wound closure or 3 days if wound still open
III > 3 cm
24 hours after wound closure or 5 days if wound still open
IIIA Bone coverable
IIIB Bone not coverable
IIIC + arterial injury
Other multi-trauma cases including brain injury, base of skull fracture and CSF pressure monitored case. 24 hours after procedure

40-95-00-spvasct: Vascular (Angiography and InfrarenalPprocedures)

40-95-10-spangio:Vascular Angiography

Initial doses must be given close to induction (within 1 hour)

First Line Treatment

cephazolin 2 g IV (child 25 mg/kg up to 2 g)

Second Line (MRSA colonised or β-lactam allergy)

teicoplanin 800 mg IV (child 20 mg/kg up to 800 mg) IV prior to induction

40-95-20-spinfrarenal:Vascular All Infrarenal procedures

First Line Treatment

tephazolin 2g IV THENCE 8-hourly fro 24 hours
AND (if inguinal or more distal incision with insertion of graft)
   ADD teicoplanin 800mg IV prior to induction

Second line (MRSA colonised or β-lactam allergy)

teicoplanin 800mg (child 20mg/kg upto 800mg) IV
AND
gentamicin 5mg/kg Single dose IV prior

45-00-00-ivswit: HNE Antibiotics: IV to Oral Switch Guideline

Switching to Oral Criteria
  • Patient is clinically improving and no indication to continue IV
  • Temperature < 38°C for 24 hours
  • Normotensive for at least 48 hours
  • Able to swallow & oral fluids tolerated
  • No ongoing or potential absorption problems
  • A suitable oral formulation or alternative is available
If switch not recommended, continue IV therapy and review in 24 hours

ampicillin (IV)

Intravenous*Oral Suggestion*
Ampicillin 1-2g 6-hourlyAmoxycillin 500mg - 1g 8 hourly

azithromycin (IV)

Intravenous*Oral Suggestion*
Azithromycin 500 mg, once daily
(Doxycycline not for pertussis
or severe Legionella e.g. ICU)
Azithromycin 500 mg, daily
OR
doxycycline 100 mg 12-hourly

benzylpenicillin (IV)

Intravenous*Oral Suggestion*
Benzylpenicillin 1.2-1.8g, 6-hourly Amoxycillin 500mg - 1g, 8-hourly
OR
phenoxymethylpenicillin 500mg - 1g 6-hourly for Streptococcal throat

cephazolin (IV)

Intravenous*Oral Suggestion*
Cephazolin 1-2g, 8-hourly Cephalexin 500mg - 1g, 6-hourly
OR
dicloxacillin 500mg - 1g, 6-hourly if only Staph cover required

ceftriaxone/cefotaxime (IV)

Intravenous*Oral Suggestion*
Ceftriaxone 1 g, once daily (higher doses in brain and bone infections) and cefotaxime 1 g, 8-hourly Choice of oral antibiotic depends on infection site & microbiological results(consult therapeutic guidelines or ID advice)

ciprofloxacin (IV)

Intravenous*Oral Suggestion*
Ciprofloxacin 400 mg, 12-hourly Ciprofloxacin 500-750 mg, 12-hourly (higher doses for Pseudomonas)

clindamycin (IV)

Intravenous*Oral Suggestion*
Clindamycin 600 mg, 8-hourly Clindamycin 300-450 mg, 6-8 hourly (up to 600 mg, 8-hourly)

flucloxacillin (IV)

Intravenous*Oral Suggestion*
Flucloxacillin 1-2g, 6-hourly Dicloxacillin 500mg - 1g, 6-hourly

fluconazole (IV)

Intravenous*Oral Suggestion*
Fluconazole 200-400 mg, daily Fluconazole 200-400 mg, daily

gentamicin (IV)

Intravenous*Oral Suggestion*
Gentamicin (dose as per guidelines) Choice of oral antibiotic depends on infection site & microbiological results(consult therapeutic guidelines or ID advice)

metronidazole (IV)

Intravenous*Oral Suggestion*
Metronidazole 500 mg, 8-12 hrly Metronidazole 400 mg, 8-12 hourly

piperacillin + tazobactam (IV)

Intravenous*Oral Suggestion*
Piperacillin + tazobactam 4.5 g, 6-8 hourly Choice of oral antibiotic depends on infection site & microbiological results (consult therapeutic guidelines or ID advice) In most situations: Amoxycillin + clavulanic acid 875/125 mg 12-hourly ADD ciprofloxacin 500-750 mg 12-hourly if Pseudomonas or resistant Gram negatives

vancomycin (IV)

Intravenous*Oral Suggestion*
Vancomycin (dose as per guidelines) DO NOT USE ORAL VANCOMYCIN (poor oral bioavalability) Choice of oral antibiotic depends on infection site & microbiological results (consult therapeutic guidelines or ID advice)

50-00-00-dinfo:JHH Pharmacy Department Discharging on Medications

When the JHH Pharmacy is Open

  • At discharge patients should be provided with:
    • A letter/list of changes to medications (JHH Discharge Medicines List from HNE Health Intranet)
    • Drug information about new medications (CMI from eMIMS / CIAP)
    • Up to 7 day's supply for any NEW or ALTERED medications
  • On the discharge prescription, DO NOT include medications that the patient has a supply of, at home
  • Patients may receive a whole course of e.g. antibiotics or steroids
  • For medications ONLY available from John Hunter Hospital an outpatient prescription may be written
  • Note: Compliance aids (Websterpak®) take time to organise - need prior planning

When the JHH Pharmacy is Closed - PBS Emergency Prescription

This allows the patient to obtain medicines from a community pharmacy
  • Check the medicine is on the Pharmaceutical Benefits Scheme (PBS online via HNE Health intranet search)
  • Annotate the prescription with 'PBS Emergency' and include the JHH Prescriber code
Please Note: There will be a charge to the patient

When the JHH Pharmacy is Closed - Dispense Ward Stock

The Medical Officer may dispense a limited supply to the patient from ward stock.
Boxes and blank labels available on wards.
All medications MUST be labelled with:
  • Patient Name
  • Drug Name
  • Directions

60-00-00-warfarin: HNE Warfarin Guidelines

60-10-00-warfinit: HNE Warfarin Initiation Guideline

60-10-10-wflt50:Age <50 years

Day 1 INR reflects pre-warfarin baseline. Subsequent warfarin dose based on INR 16-18 hours post previous dose.

Day 1

      INR          Warfarin Dose  
   <1.4          10mg

Day 2

      INR            Warfarin Dose  
   <1.6          10mg
   ≥1.6          0.5mg

Day 3

      INR            Warfarin Dose  
   <1.8          10mg
   1.8 - 2.3          5mg
   2.4 - 2.7          4mg
   2.8 - 3.1          3mg
   3.2 - 3.3          2mg
   3.4          1.5mg
   3.5          1mg
   3.6 - 4.0          0.5mg
   >4.0       Omit dose

Day 4

      INR            Warfarin Dose  
<1.6     10mg - 15mg
1.6          8mg
1.7 - 1.8          7mg
1.9          6mg
2.0 - 2.6          5mg
2.7 - 3.0          4mg
3.1 - 3.5          3.5mg
3.6 -4.0          3mg
4.1 - 4.5  Omit next day's dose then 1mg - 2mg
4.6 - 5.0  Omit dose & review management with caring physician or surgeon
>5.0  Omit dose & consider need for 0.5mg - 1mg of vitamin K (PO or IV)

60-10-20-wf51-65:Age 51-65 years

Day 1 INR reflects pre-warfarin baseline. Subsequent warfarin dose based on INR 16-18 hours post previous dose.

Day 1

      INR          Warfarin Dose  
   <1.4          9mg

Day 2

      INR            Warfarin Dose  
   <1.6          9mg
   ≥1.6          0.5mg

Day 3

      INR            Warfarin Dose  
   <1.8          9mg
   1.8 - 2.3          4.5mg
   2.4 - 2.7          3.5mg
   2.8 - 3.1          2.5mg
   3.2 - 3.3          2mg
   3.4          1.5mg
   3.5          1mg
   3.6 - 4.0          0.5mg
   >4.0       Omit dose

Day 4

      INR            Warfarin Dose  
<1.6     9mg - 14mg
1.6          7mg
1.7 - 1.8          6mg
1.9          5mg
2.0 - 2.6          4.5mg
2.7 - 3.0          3.5mg
3.1 - 3.5          3mg
3.6 -4.0          2.5mg
4.1 - 4.5  Omit next day's dose then 0.5mg - 1.5mg
4.6 - 5.0  Omit dose & review management with caring physician or surgeon
>5.0  Omit dose & consider need for 0.5mg - 1mg of vitamin K (PO or IV)

60-10-30-wf66-80:Age 66-80 years

Day 1 INR reflects pre-warfarin baseline. Subsequent warfarin dose based on INR 16-18 hours post previous dose.

Day 1

      INR          Warfarin Dose  
   <1.4          7.5mg

Day 2

      INR            Warfarin Dose  
   <1.6          7.5mg
   ≥1.6          0.5mg

Day 3

      INR            Warfarin Dose  
   <1.8          7.5mg
   1.8 - 2.3          4mg
   2.4 - 2.7          3mg
   2.8 - 3.1          2mg
   3.2 - 3.3          1.5mg
   3.4          1mg
   3.5          1mg
   3.6 - 4.0          0.5mg
   >4.0       Omit dose

Day 4

      INR            Warfarin Dose  
<1.6     7.5mg - 11mg
1.6          6mg
1.7 - 1.8          5mg
1.9          4.5mg
2.0 - 2.6          4mg
2.7 - 3.0          3mg
3.1 - 3.5          2.5mg
3.6 -4.0          2mg
4.1 - 4.5  Omit next day's dose then 0.5mg - 1.5mg
4.6 - 5.0  Omit dose & review management with caring physician or surgeon
>5.0  Omit dose & consider need for 0.5mg - 1mg of vitamin K (PO or IV)

60-10-40-wfgt80:Age >80 years

Day 1 INR reflects pre-warfarin baseline. Subsequent warfarin dose based on INR 16-18 hours post previous dose.

Day 1

      INR          Warfarin Dose  
   <1.4          6mg

Day 2

      INR            Warfarin Dose  
   <1.6          6mg
   ≥1.6          0.5mg

Day 3

      INR            Warfarin Dose  
   <1.8          6mg
   1.8 - 2.3          3mg
   2.4 - 2.7          2mg
   2.8 - 3.1          1mg
   3.2 - 3.3          1mg
   3.4          1mg
   3.5          0.5mg
   3.6 - 4.0          0.5mg
   >4.0       Omit dose

Day 4

      INR            Warfarin Dose  
<1.6     6mg - 9mg
1.6          5mg
1.7 - 1.8          4mg
1.9          3.5mg
2.0 - 2.6          3mg
2.7 - 3.0          2.5mg
3.1 - 3.5          2mg
3.6 -4.0          1.5mg
4.1 - 4.5  Omit next day's dose then 0.5mg - 1mg
4.6 - 5.0  Omit dose & review management with caring physician or surgeon
>5.0  Omit dose & consider need for 0.5mg - 1mg of vitamin K (PO or IV)

60-20-00-warfmain: Warfarin Maintenance Therapy

Think in terms of percentage changes

Suggested dose changes for maintaining INR within a target range of 2-3
INR Dose Change
<1.5  Increase by 20%
1.6 - 1.9  Increase by 10%
2 - 3  Do not adjust for minor changes within the therapeutic range
3.1 - 3.4  Decrease by 10%, adjustment may not be necessary
3.5 - 3.9  Decrease by 20%, consider withholding one dose
4 - 4.9  Withhold until INR returns to range then decrease by 20-30%
Adapted from Philip A Tideman et a. Aust Prescr 2015;38:44-8

70-00-00-heparin: HNE Heparin Infusion Guideline (Pathology North Sites Only)

CAUTION

This Heparin Infusion Titration Table is to be used ONLY:
  • In Conjunction with HNE Health Clinical Guideline for
    Heparin Sodium Intravenous Loading Dose and Infusion (Adult)
  • By those sites serviced by Pathology North - JHH, CMNH, Maitland, Belmont, Tomaree and Hunter Valley sites ONLY
  • As a reference range for aPTT when adjusting Heparin Sodium Infusion (Adult) 500 units/mL

70-10-00-hpinfuse: Infusion rate adjustment instructions

Heparin - Sites serviced by Pathology North

Infusion Instructions:
  1. Loading dose: heparin sodium 5,000 units bolus
  2. Initial infusion rate (for the first six hours) via syringe driver is according to actual patient weight - see HNE Clinical Guideline for Heparin Sodium Intravenous Loading Dose and Infusion (Adult)
  3. Infusion rate adjustment instructions:
    • Check aPTT six hours AFTER commencement of Heparin Sodium Infusion 500 units/mL
    • Adjust rate of Heparin Sodium Infusion 500 units/mL according to the following aPTT result/range and titration (table below)
    • Recheck aPTT as instructed and make further infusion rate adjustment only if necessary

aPTT ≤ 49 seconds

Infusion rate change mL/hour(of 25000 units in 50 mL = 500 units/mL)
Give another single bolus of 5000 units IV & increase infusion rate ONCE by 0.5 mL then recheck aPTT after 6 hours

aPTT 50 - 55 seconds

Infusion rate change mL/hour(of 25000 units in 50 mL = 500 units/mL)
increase infusion rate ONCE by 0.5 mL then recheck aPTT after 6 hours

aPTT 56 - 59 seconds

Infusion rate change mL/hour(of 25000 units in 50 mL = 500 units/mL)
increase infusion rate ONCE by 0.2 mL then recheck aPTT after 6 hours

aPTT 60 - 80 seconds

Infusion rate change mL/hour(of 25000 units in 50 mL = 500 units/mL)
No change and recheck aPTT after 24 hours

aPTT 81 - 100 seconds

Infusion rate change mL/hour(of 25000 units in 50 mL = 500 units/mL)
decrease infusion rate ONCE by 0.1 mL then recheck aPTT after 6 hours

aPTT 101 - 120 seconds

Infusion rate change mL/hour (of 25000 units in 50 mL = 500 units/mL)
Stop infusion for 30 min, then decrease infusion rate ONCE by 0.2 mL then recheck aPTT after 6 hours
if aPTT persistently greater than 100 seconds seek Haematology advice

aPTT ≥ 121 seconds

Infusion rate change mL/hour (of 25000 units in 50 mL = 500 units/mL)
Stop infusion for 2 hours, then recheck aPTT
Do not restart until the aPTT result is back.

If aPTT is less than 100 seconds - restart at a decreased rate.
  • Reduce rate ONCE by 0.4 mL/h - i.e. 0.4 mL/h lower than the rate prior to stopping infusion.
  • Do not give bolus
  • Recheck aPTT after 6 hours

If aPTT does not fall to less than 100 seconds in 2 hours seek Haematology advice

70-20-00-hpadd: Heparin Additional information

Additional Notes:

BEFORE COMMENCING or ADJUSTING intravenous heparin sodium refer to the HNE Health Clinical Guideline for Heparin Sodium Intravenous Loading Dose and Infusion (Adult)

The reagent used by Pathology North may change, which will affect the aPTT reference range. This titration table will be updated as the reagent changes and is CURRENT AS AT JULY 2015 (Revisions dependent on aPTT methodology).

Patient assessment, precautions, loading dose, initial infusion rate and other information regarding the commencement of Heparin treatment is found within the relevant HNE Health Clinical Guideline or reference texts.

For sites that are NOT serviced byPathology North, refer to local guidelines or the pharmacy servicing your site.

80-00-00-potass: HNE Adult Potassium Replacement Guidelines

Critical Deficit

Critical Potassium < 2 mmol/L  OR
Potassium 2 – 2.5 mmol/L  and
severe acidosis pH < 7.2 (e.g. diabetic ketoacidosis) or
severe cardiac disease or
ECG changes of hypokalaemia
Critical emergency
  • Urgent specialist consultation with ICU, ED or the patient’s physician is necessary for management advice
  • IV replacement required
  • Initial treatment may be administered in ED or a ward setting. Patients should then be transferred for ECG monitoring if required (e.g. in ICU or CCU)
  • Carefully monitor fluid balance
Potassium products available at John Hunter Hospital

Severe Deficit

Severe Potassium 2 – 2.5 mmol/L
(without critical conditions or ECG changes described above)
Intravenous
40 mmol potassium/L at maximum rate of 10 mmol per hour (250 mL per hour)
For fluid restricted patients use pre mixed "mini-bags" of potassium chloride 10 mmol in sodium chloride 0.29% 100 mL at maximum rate of 10 mmol per hour
OR
Oral
40 – 120 mmol potassium per day
  • Check potassium level every 6 hours
  • Repeat until serum potassium > 3.2 mmol / L
  • If this fails to raise potassium levels over 24 hours, or potassium falls into critical range, contact treating consultant or ICU for advice
Potassium products available at John Hunter Hospital

Moderate Deficit

Moderate Serum potassium 2.5 – 3 mmol / L
Oral (preferred)
40 – 120 mmol potassium per day
OR
Intravenous
30 mmol potassium / L up to maximum rate of 10 mmol per hour (325 mL per hour)
For fluid restricted patients use pre mixed "mini-bags" of 10 mmol potassium chloride in sodium chloride 0.29% 100mL at maximum rate of 10 mmol per hour
  • Check potassium level – every 24 hours
  • Repeat until serum potassium > 3.2 mmol / L
  • If unsuccessful, use severe deficit guidelines (above)
Potassium products available at John Hunter Hospital

Mild Deficit

Mild Serum potassium 3 – 3.5 mmol / L
Oral
40 – 120 mmol potassium per day
Normal potassium requirement is approximately 1 mmol / kg / day
  • Check potassium level – every 24 to 48 hours
  • Continue replacement until potassium 3.5 to 4 mmol / L, then as clinically indicated
Potassium products available at John Hunter Hospital

Potassium additional information

  • Serum potassium reference range is 3.5 – 5 mmol / L
  • Maximum IV infusion rate of potassium on a general ward is 20 mmol / h
  • For rates over 10 mmol / h ECG monitoring is mandatory and a senior medical officer MUST be involved. Administering too rapidly risks cardiac arrest
  • Maximum concentration via a peripheral line is 40 mmol / L,
    • except when using potassium chloride 10 mmol in sodium chloride 0.29% 100mL (isotonic) pre-mixed "mini-bags"
      Hypertonic potassium solutions where concentration is greater than 40 mmol / L may cause phlebitis.
  • Prescribe standard IV premix solution whenever possible.
  • Do NOT use chemical symbols when charting
  • For clinical information to assist in the prevention and management of hypokalaemia see Safe Handling of Adult Intravenous Potassium Chloride Preparations PD2005_342:PCP2 on the HNELHD intranet and discuss with senior colleagues.

90-00-00-inotes: HNE Disclaimer

Disclaimer on this Application

By downloading/installing this application and proceeding to use it you acknowledge that you have read the following disclaimer and agree to same.

The information and guidelines contained in this application is presented by the HNE Quality Use of Medicines Committee (QUMC), for the purposes of disseminating - educational material to Clinicians within HNE LHD. These guidelines have been prepared and are meant to be read in conjunction with the HNE LHD Clinical Guidelines.

The guidelines are based on the best available evidence, however, as in any clinical situation there may be factors which cannot be covered by a single set of guidelines. Therefore the guidelines do not replace the need for the application of clinical judgment to each individual presentation. Clinicians must use their own judgement and consider the patient´s individual presentation and needs when making use of the information contained in these guidelines.

Although the QUMC has prepared the information and guidelines with all due care and diligence and the guidelines are updated regularly, the QUMC do not warrant or represent that the guidelines are free from errors or omission or represent the most current information available. QUMC recommends that you validate the currency of the information contained in these guidelines prior to their application.

The information is made available on the understanding that HNE LHD and its employees shall have no liability (including liability by reason of negligence) to the users or any third party for any loss, damage, cost or expense incurred or arising by reason of any person using or relying on the information contained in these guidelines whether caused by reason of any error, negligent act, omission or misrepresentation in the information and/or otherwise.