Quality Use of Medicines
For complex drug information and aminoglycoside monitoring contact Hunter Drug Information Service 02 4014 3695
Hunter New England Health
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
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
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
Meningococcal Infection
Empirical Antibiotic Regimen
Benzylpenicillin 2.4 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
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)
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
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)
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)
Antibiotic Administration - Intravenous
ampicillin
| Presentation(Adult) | Vial 1 g |
| Reconstitution Fluid/Volume | 10 mL WFI |
| Final Volume* | 10-20 mL |
| Minimum Administration Time |
3-5 min |
| Notes | Penicillin class antibiotic |
azithromycin
| Presentation(adult) | Vial 500 mg |
| Reconstitution Fluid/Volume | 4.8mL 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/Volume | 2 mL WFI | 4 mL WFI |
| Final Volume* | 10-20 mL |
| Minimum Administration Time |
3-5 min |
| Notes | Penicillin class antibiotic
Consider administering doses ≥ 2.4 g over 30 mins |
ceftriaxone
| Presentation(Adult) | Vial
1 g | Vial
2 g |
| Reconstitution Fluid/Volume | 10 mL WFI | 20 mL WFI |
| Final Volume* | 10-20 mL | 20 mL |
| Minimum Administration Time |
2-4 min |
4 min |
| Notes | Cephalosporin 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/Volume | N/A |
| Minimum Administration Time |
60 minutes |
| Notes | May induce seizures in epileptics. Local site reactions are more frequent when shorter infusion times are used |
flucloxacillin
| Presentation(Adult) | Vial 1 g |
| Reconstitution Fluid/Volume | 5 mL WFI |
| Final Volume* | 10 mL | 50 mL |
| Minimum Administration Time | 3-5 min(1 g) | 30 min(2 g) |
| Notes | Penicillin class antibiotic. Irritant, subsequent doses as an infusion or PICC line |
gentamicin
| Presentation(Adult) | Ampoule 80 mg/2 mL |
| Reconstitution Fluid/Volume | N/A |
| Final Volume* | 10-20 mL |
| Minimum Administration Time |
3-5 min |
| Notes | May give up to 640mg IV push over 3-5 min |
metronidazole
| Presentation(Adult) | Infusion bag 500 mg/100 mL |
| Reconstitution Fluid/Volume | N/A |
| Minimum Administration Time |
20 min |
vancomycin
| Presentation(Adult) | Vial 500 mg | Vial 1 g |
| Reconstitution Fluid/Volume | 10 mL WFI | 20 mL WFI |
| Final Volume* | 250 to 500mL (depending on dose) |
| Minimum Administration Time | The rate of administration not > 10 mg/min |
| Notes | Infusion related effects are common, decrease infusion rate and monitor closely if these occur |
HNE Adult Community Acquired Pneumonia Guideline
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
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
Adult Hospital Acquired Pneumonia
Aspiration pneumonia: see therapeutic Guidelines: Antibiotic
Test all early onset intensive care cases for Legionella
Test for influenza May-November
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 orally 12-hourly, 5-7 days
OR
amoxycillin/clavulanate 1200mg IV, 8-hourly for 5-7 days
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
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
HNE Surgical Antibiotic Prophylaxis Guideline
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
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.
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
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
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
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
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
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
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 |
Vascular (Angiography and InfrarenalPprocedures)
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
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
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-hourly | Amoxycillin 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)
|
JHH Pharmacy Department Discharging on Medications
When the JHH Pharmacy is Open
- At discharge patients should be provided with:
- A medication list (JHH Discharge Medicines List from MedChart)
- 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
HNE Warfarin Initiation Guideline
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) |
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) |
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) |
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) |
Warfarin Maintenance Therapy
- Consider cause of INR change
- Drug interactions including antibiotics, herbal and over the counter medications
- Changes in dietary vitamin K intake
- Excess alcohol
- Illness and weight gain or loss
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 |
- Notes:
- Round doses to nearest 0.5 mg
- Use alternate day (or less frequent) doses for smaller adjustments e.g. to increase a 2 mg dose by approximately 10% give 2 mg / 2.5 mg on alternate days - an increase of 12.5%
- Use similar percentage changes for patients with higher target INR
- Remember there is a 2 to 3 day lag from dose change to INR change
- For INR > 4.9 or bleeding patient see HNELHD Clinical Guideline Warfarin Reversal in Adults
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
Infusion rate adjustment instructions
Heparin - Sites serviced by Pathology North
Infusion Instructions:
- Loading dose: heparin sodium 5,000 units bolus
- 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)
- 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
|
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.
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.
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.