DO     use antibiotic only when necessary. Antibiotics are drugs, with side-effects. 
DO     seek advice early rather than late in a seriously ill patient.
DO     give the antibiotic parenterally if the patient is seriously septic, unable to take it orally, or vomiting. 
DO     move from iv to oral antibiotic as soon as it is safe to do so (“switch” therapy) because iv lines can become infected e.g. they are a risk of MRSA bacteraemia.  
DO     stop the antibiotic as soon as possible, otherwise you waste money and risk toxicity and superinfection e.g. Clostridium difficile diarrhoea. Generally, antibiotic can safely be stopped when the patient has fully recovered for 48 hours. 
DO     DE-ESCALATE i.e. move to a narrower spectrum antibiotic as soon as the pathogen’s sensitivity is known e.g. pneumococcal pneumonia, patient improving on co-amoxiclav: move to iv benzylpenicilin or oral amoxicillin. 
DO     seek advice on an alternative if the patient is allergic to the suggested antibiotic. 
DO     alert the Microbiology Serology laboratory if you are going to send a clotted blood for antibiotic assay, other than gentamicin, at weekends. We can assay gentamicin, amikacin, teicoplanin, vancomycin. Usual gentamicin regimen is 5mg/kg body weight once a day, or 7mg/kg for neutropenic patients with sepsis. There are different nomograms to check/reset the dose interval for these 2 regimens.
DO     be aware of possible interactions e.g. metronidazole and warfarin, gentamicin and furosemide. Macrolides (erythromycin, clarithromycin, azithromycin) especially can interact with many other drugs. 
DO     consult your clinical senior or Microbiologist before using: ·          clindamycin: risk of C. difficile, especially in hospital ·          aminoglycosides other than gentamicin: all are toxic, usually best avoided in renal impairment and require measurement of serum levels –
BUT they do NOT cause C. difficile diarrhoea: a major advantage ·          glycopeptides: vancomycin is more toxic and requires serum levels (predose 3-10 mg/L; 1 or 2 hours post dose, 18-30 mg/L), teicoplanin is less toxic and does not require levels  unless the patient isn’t getting better on it: a serum predose level should be at least 10 mg/L, and at least 20 mg/L in severe sepsis, endocarditis or MRSA septicaemia. These levels are usually best achieved with 400mg or more once a day, after loading. Teicoplanin rarely needs reducing to 200mg od, even in renal failure and renal failure patients do not need a teicoplanin level measuring before the 4th day of treatment.These agents are only active against Gram positive bacteria. They are less active against Methicillin sensitive Staphylococcus aureus (MSSA) than flucloxacillin is.  ·              note that reserve antibiotics = daptomycin, tigecycline, iv polymixin (colistin), meropenem, ceftazidime, linezolid, Synercid. These antibiotics are only to be used when authorised by a Consultant Microbiologist.  Please … 
DO NOT      chop and change antibiotics unless patient is deteriorating. Give them a chance to work. Expect improvement within 48 hours. 
DO NOT      use toxic or expensive antibiotics or antibiotics that are not in these guidelines without consultation. There are often better alternatives. 
DO NOT      give aminoglycosides (e.g. gentamicin) or parenteral vancomycin without monitoring serum levels. 
DO NOT      use topical antibiotics except in special circumstances or on eyes. Topical use may lead to skin allergy or resistance. If you believe a topical antibiotic is necessary, consult Microbiologist. Especially, do not use topical fusidic acid on skin in a hospitalised patient (J. Antimicrobial Chemotherapy 2003; 51: 1033-6). 
DO NOT      use fusidic acid alone ® resistance in Staphylococci. Decrease this risk by using combined anti-Staph. therapy. 
DO NOT      use tetracycline in pregnancy, in children < 12 years or in renal impairment. If tetracycline is unavoidable in renal impairment use doxycycline. 
DO NOT      use clindamycin after erythromycin ® resistance in Staphylococci.  
DO NOT      expect antibiotics alone to resolve large deep abscesses or infected/colonised catheters. Surgical drainage or removal of foreign body (catheter) may be necessary. 
DO NOT      prolong antibiotics unnecessarily; a 5-7 day course is usually sufficient. There are exceptions e.g. infective endocarditis, septic arthritis. If in doubt consult Microbiologist.                      NB: the ward pharmacist is empowered to stop antibiotic after the desired duration according to these guidelines. Extensions will only be allowed if justified on the prescription sheet by the prescriber. 
DO NOT      use 3rd generation cefalosporins e.g. ceftriaxone, cefixime or cefotaxime except for bacterial meningitis, epiglottitis, empirical treatment of gonorrhoea or severe pelvic inflammatory disease – they cause C. difficile diarrhoea and predispose to multi-resistant (Extended Spectrum Beta Lactamase producing) coliforms and MRSA. 

DO NOT      use ciprofloxacin or moxifloxacin unless there is no alternative. They have recently been linked internationally and in the UK with C. difficile 027 diarrhoea – a highly pathogenic strain with outbreak potential. Multi-resistant coliforms are often resistant to ciprofloxacin and may be selected by it. In 2006, 23% of E. colis causing bacteraemias in England, Wales and N. Ireland were resistant to ciprofloxacin. (Health Protection Report Vol. 1, no. 20, 18th May 07) Ciprofloxacin resistance easily arises in pseudomonas and campylobacter, if it is used.