Due to a global shortage, many Hunter New England Local Health District sites have low supplies of piperacillin+tazobactam with shortages likely until after September. It is essential that further use of this agent is conserved as below. Amoxycillin+clavulanate is now available in a parenteral form and is a suitable option in many circumstances, contingent on local hospital pharmacy access/availability.
RECOMMENDATIONS (approved June 2017 by HNELHD Executive)
All patients should be reviewed once microbiology results are available (48-72hrs) and treatment refined, favouring narrow spectrum and oral agents.
Existing piperacillin+tazobactam stock is to be removed from imprest at all sites.
|Clinical situation||Alternative agents||References|
|Acceptable indications for piperacillin+tazobactam – adults 4+0.5g IV, 8 hrly; children 100+12.5 mg/kg up to 4+0.5g, 6-hourly|
|Febrile neutropenia – adults where clinical guideline criteria met||Ceftazidime 2g IV, 8 hrly (non-acute penicillin allergy)
Meropenem 1g IV, 8 hrly (immediate hypersensitivity to betalactams)
|HNELHD CG 16_07: Management of Suspected Neutropenic Sepsis in Adult Haematology and/or Medical Oncology Patients Receiving Chemotherapy who present with Fever|
|Febrile neutropenia – children where clinical guideline criteria met||NSW GL2015_013 Infants and Children: Initial Management of Fever/Suspected Sepsis in Oncology /Transplant Patients|
|Hospital acquired pneumonia (ICU cases admitted >5 days or severe pneumonia)||Cefepime 2g IV 8 hrly OR Ceftazidime 2g IV 8 hrly||Consult the Quality Use of Medicines Smart phone page– the HAP guideline section provides detailed advice.`|
|Indications where an alternative agent should be used (unless approved by Inf. Diseases)|
|Suspected or proven pseudomonal infection||Ceftazidime 2g IV, 8 hrly OR
Ciprofloxacin (oral preferred)
|Dependent on demonstrated susceptibility of the isolate(s)|
|Community acquired pneumonia (CAP)
Pip+tazo is seldom indicated for community acquired pneumonia. Pseudomonas, if present , usually represents colonization. If coverage required see above.
|Consult CAP Guideline (adult) or Therapeutic Guidelines-Antibiotic for children.
Benzylpenicillin is the mainstay of treatment.
|HNELHD CD 15_34: Adult Community Acquired Pneumonia: Initial Investigation and Empiric Antibiotic Therapy
Tazocin misconceptions: misuse in community-acquired pneumonia discussion.
|Hospital acquired pneumonia (ICU or non-ICU HAP cases admitted < 5 days)||Amoxycillin+clavulanate 1.2g IV 8 hrly IV or 875/125mg oral, 12 hrly OR benzylpenicillin with gentamicin||Consult the Quality Use of Medicines Smart phone page– the HAP guideline section provides detailed advice.|
If pseudomonal or multi-resistant Gram negative coverage required, check susceptibilities & consult ID or Clinical Microbiology.
|Amoxycillin+clavulanate 1.2g IV 8 hrly IV ADD gentamicin (as per eTG) if perforated viscus or peritonitis (see JHH_0263).
OR (non-acute penicillin allergy / therapy > 48 hrs required) ceftriaxone 1g IV, daily AND metronidazole 400mg oral, 12 hrly
|Local Guideline JHH_0263: Short Course Antibiotics for Intra-abdominal Sepsis – Adult
|Serious skin/soft tissue infection:
Limb threatening diabetic foot infection or infected ischaemic ulcer
Open contaminated fracture PLUS wound soiling, severe tissue damage or delayed washout
Bites/clenched fist injury (moderate – severe)
Bites/clenched fist injury (mild severity)
Amoxycillin+clavulanate 1.2g IV 8-hrly IV
OR (non-acute penicillin allergy) ceftriaxone 1g IV, daily AND metronidazole 400mg oral, 12 hrly
Ceftriaxone 1g IV, daily AND metronidazole 400mg oral, 12 hrly
Amoxycillin+clavulanate 875/125mg oral, 12-hrly
Pip+tazo is seldom indicated for urinary tract infection. For proven pseudomonal infection, see above.
|Ampicillin 2g IV, 6 hrly AND gentamicin IV (as per eTG)
Ceftriaxone 1g IV daily (non acute allergy)
Urinary isolate antibiograms for your facility also include a commentary guide.