Piperacillin+tazobactam shortage – recommended alternatives – HNELHD

SITUATION

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.
Intra-abdominal sepsis

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

Therapeutic Guidelines-Antibiotic

 

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

Therapeutic Guidelines-Antibiotic

 

 

 

 

 

 

 

Urosepsis

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)

Therapeutic Guidelines-Antibiotic

Urinary isolate antibiograms for your facility also include a commentary guide.

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