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GLOBAL RPH ANTIBIOTICS GUIDELINE

Acinetobacter spp
Drugs of Choice: [Selection guided by in vitro sensitivity tests]
Gentamicin, Tobramycin, Imipenem-Cilastatin.
Alternatives: Ticarcillin-Clavulonate, Piperacillin-Tazobactam,
Ceftazidime, Meropenem, Ciprofloxacin, Levofloxacin
Third-Line agents: Cefotaxime, Ceftizoxime, Ceftriaxone, Cefepime,
Amikacin, Moxifloxacin
Comments: (Gram Negative Bacilli - Aerobe). Combination therapy
recommended (Examples: Ciprofloxacin + ceftazidime, or Imipenem +
Gentamicin)

Bacteroides fragilis
Drugs of Choice: Metronidazole, Ampicillin-Sulbactam, Piperacillin-
Tazobactam, Ertapenem, Imipenem-Cilastatin, Meropenem, Tigecycline
Alternatives: Amoxicillin-Clavulonate, Ticarcillin-Clavulonate,
Cefotetan, Cefoxitin, Clindamycin
Third-Line agents: Moxifloxacin, Chloramphenicol, Doxycycline
Comments: (Gram Negative Anaerobe).

Bordetella pertussis
Drugs of Choice: Azithromycin, Clarithromycin
Alternatives: Erythromycin, TMP-SMX
Third-Line agents: Ciprofloxacin, Chloramphenicol, Levofloxacin,
Moxifloxacin, Vancomycin
Comments: (Gram Negative(Coccobacilli) - Aerobe).

Borrelia burgdorferi
Drugs of Choice: Amoxicillin, Cefuroxime, Doxycycline
Alternatives: Cefotaxime, Ceftriaxone, Azithromycin, Clarithromycin
Third-Line agents: Erythyromcyin
Comments: (Spiral organism). Drug of choice depends on stage of
disease
Brucella spp
Drugs of Choice: TMP-SMX
Alternatives: Cefotetan, Cefoxitin, Cefuroxime, Cefotaxime,
Ceftazidime, Ceftriaxone, Gentamicin, Chloramphenicol, Doxycyline,
Vancomycin
Third-Line agents: Cefazolin, Cefprozil, Azithromycin, Clarithromycin,
Erythromycin, Ciprofloxacin
Comments: (Gram-Negative Aerobe (Coccobacilli)). Usually requires
two agents (combination therapy). Examples: (TMP-SMX + Gentamicin)
or (Doxycycline + Gentamicin)

Camphylobacter jejuni
Drugs of Choice: Ciprofloxacin, Moxifloxacin, Levofloxacin
Alternatives: Imipenem-Cilastatin, Meropenem, Azithromycin,
Clarithromycin, Erythromycin
Third-Line agents: Amoxicillin-Clavulonate, Ticarcillin-Clavulonate,
Clindamycin, Doxycycline
Comments: (Gram-Negative Aerobe (Coccobacilli)).

Chlamydia pneumonia
Drugs of Choice: Doxycycline
Alternatives: Azithromycin, Clarithromycin, Erythromycin,
Ciprofloxacin, Moxifloxacin, Levofloxacin
Third-Line agents:
Comments: (Gram-Negative Aerobe (Coccobacilli)).

Chlamydia psittaci
Drugs of Choice: Azithromycin, Clarithromycin, Erythromycin
Alternatives: Levofloxacin, Doxycycline, Dirithromycin
Third-Line agents: Rifampin
Comments: (Gram-Negative Aerobe (Coccobacilli)).

Chlamydia trachomatis
Drugs of Choice: Azithromycin, Doxycycline
Alternatives: Erythromycin, Moxifloxacin, Levofloxacin, Dirithromycin,
Rifampin
Third-Line agents: Ciprofloxacin, Clindamycin, Nitrofurantoin, TMP-
SMX
Comments: (Gram-Negative Aerobe (Coccobacilli)).
Citrobacter spp
Drugs of Choice: Imipenem, Meropenem, Ertapenem, Tobramycin,
Gentamicin, Cefepime
Alternatives: Moxifloxacin, Levofloxacin, Ciprofloxacin, Aztreonam,
Ceftazidime, Amikacin
Third-Line agents:
Comments: (Enterobacteriaceae (Enteric gram-negative bacilli)).

Clostridium difficile
Drugs of Choice: Metronidazole
Alternatives: Vancomycin (oral)
Third-Line agents:
Comments: (Gram positive anaerobe).

Clostridium perfringens
Drugs of Choice: Penicillin G +/- Clindamycin
Alternatives: Azithromycin, Ampicillin, Piperacillin-tazobactam,
Unasyn, Ceftriaxone, Cefepime, Cefotaxime, Doxycycline, Linezolid,
Syncercid
Third-Line agents: Cefazolin, Cefuroxime, Erythromycin
Comments: (Gram positive anaerobe).

Clostridium tetani
Drugs of Choice: Metronidazole, Penicillin G, Azithromycin
Alternatives: Doxycyline, Clindamycin
Third-Line agents: Others
Comments: (Gram positive anaerobe).

Corynebacterium diphtheriae
Drugs of Choice: Erythromycin, Penicillin G
Alternatives: Clindamycin
Third-Line agents: Vancomycin
Comments: (Aerobic Gram Positive Bacilli).
Enterobacter spp
Drugs of Choice: Imipenem, Meropenem, Ertapenem, (Piperacillin-
tazobactam + Gentamicin), Cefepime
Alternatives:
Third-Line agents:
Comments: (Enterobacteriaceae (Enteric gram-negative bacilli)).

Enterococcus faecalis
Drugs of Choice: Penicillin, Ampicillin
Alternatives: Vancomycin, Nitrofurantoin (UTI), Gentamicin,
Levofloxacin, Moxifloxacin, Linezolid, Daptomycin, Piperacillin-
tazobactam, Unasyn, Augmentin
Third-Line agents: Imipenem, Meropenem
Comments: (Aerobic Gram Positive Cocci).

Enterococcus faecalis [Vanco-resistant]


Drugs of Choice: Linezolid
Alternatives: Nitrofurantoin (UTI)
Third-Line agents: Quinupristin/dalfopristin: Effective against E
faecium but NOT E. faecalis strains.
Comments: (Aerobic Gram Positive Cocci).

Enterococcus faecium
Drugs of Choice: Linezolid, Synercid
Alternatives: Chloramphenicol, Nitrofurantoin (UTI)
Third-Line agents: Usually resistant: penicillin, ampicillin, imipenem,
Piperacillin-tazobactam
Comments: (Aerobic Gram Positive Cocci).

Enterococcus faecium [Vanco resistant]


Drugs of Choice: Linezolid, Synercid
Alternatives:
Third-Line agents:
Comments: (Aerobic Gram Positive Cocci).
Escherichia coli
Drugs of Choice: Cefazolin, Cephalexin, Cefotaxime, Ceftriaxone,
Gentamicin, Tobramycin
Alternatives: Augmentin, Unasyn, Timentin, Piperacillin-tazobactam,
Aztrenonam, Ceftazidime, Cefepime, Ciprofloxacin, Moxifloxacin,
Levofloxacin
Third-Line agents: Ampicillin, TMP-SMX
Comments: (Enterobacteriaceae (Enteric gram-negative bacilli)).

Hemophilus infuenzae
Drugs of Choice: Augmentin, Cefotaxime, Ceftizoxime, Ceftriaxone,
Azithromycin, Clarithromycin, TMP-SMX, Oral 3rd generation
Cephalosporins
Alternatives: Unasyn, Timetin, Piperacillin-tazobactam, Impenem,
Meropenem, Ertapenem, Cefotetan, Cefoxitin, Oral 2nd generation
Cephalosporins, Ciprofloxacin, Moxifloxacin, Levofloxacin
Third-Line agents:
Comments: (Aerobic Gram Negative Coccobacilli).

Helicobacter pylori
Drugs of Choice: [Omeprazole 40 mg QD + clarithromycin 500 mg TID
x 2 wks, then omeprazole 20 mg QD x 2 wks ] OR

[Lansoprazole 30 mg BID + amoxicillin 1 g BID + clarithromycin 500 mg


TID x 10 days ] OR

[Ranitidine bismuth citrate (RBC) 400 mg BID + clarithromycin 500 mg


TID x 2 wks, then RBC 400 mg BID x 2 wks ] OR

[ Omeprazole 20 mg BID + clarithromycin 500 mg BID + amoxicillin 1 g


BID x 10 days ] OR

[Bismuth subsalicylate (Pepto Bismol) 525 mg QID + metronidazole


250 mg QID + tetracycline 500 mg QID* x 2 wks + H2 receptor
antagonist therapy as directed x 4 wks ]
Alternatives:
Third-Line agents:
Comments: (Aerobic Gram Negative Coccobacilli).
Hemophilus ducreyi
Drugs of Choice: Ceftriaxone
Alternatives: Azithromycin, Erythromycin, Ciprofloxacin, Levofloxacin
Third-Line agents:
Comments: (Aerobic Gram Negative Coccobacilli). Causitive agent in
chancroid

Klebsiella pneumoniae
Drugs of Choice: Cefotaxime, Ceftizoxime, Ceftriaxone, Gentamicin,
Tobramycin
Alternatives: Ciprofloxacin, Moxifloxacin, Levofloxacin, Augmentin,
Unasyn, Timentin, Piperacillin-tazobactam, Imipenem, Meropenem ,
Ertapenem, cefazolin
Third-Line agents:
Comments: (Enterobacteriaceae (Enteric gram-negative bacilli)).

Legionella pneumophilia
Drugs of Choice: Azithromycin, Clarithromycin, Erythromycin,
Ciprofloxacin, Levofloxacin, Moxifloxacin
Alternatives: Doxycycline, TMP-SMX
Third-Line agents:
Comments: (Aerobic Gram Negative Coccobacilli).

Listeria monocytogenes
Drugs of Choice: Ampicillin, TMP-SMX
Alternatives: Augmentin, Unasyn, Timentin, Piperacillin-tazobactam
Third-Line agents: Amikacin, Tobramycin, Erythromycin
Comments: (Aerobic Gram Positive Bacilli).

Moraxella catarrhalis
Drugs of Choice: Augmentin, Azithromycin, Clarithromycin, TMP-SMX
Alternatives: Unasyn, Timentin, Piperacillin-tazobactam, Imipenem,
Meropenem, Ertapenem, 2nd & 3rd generation Cephalosporins,
Quinolones (cipro etc)
Third-Line agents:
Comments: (Aerobic Gram-Negative Cocci).
Mycoplasma pneumoniae
Drugs of Choice: Azithromycin, Clarithromycin, Erythromycin,
Ciprofloxacin
Alternatives: Levofloxacin, Moxifloxacin, Doxycycline
Third-Line agents:
Comments: ().

Neisseria gonorrhoeae
Drugs of Choice: Ceftriaxone, Cefixime
Alternatives: Spectinomycin, Cefotaxime, Cefpodoxime
Third-Line agents:
Comments: (Gram-Negative Cocci). Fluoroquinolones are no longer
recommended.

Neisseria meningitidis
Drugs of Choice: Pencillin G
Alternatives: Ampicillin , Cefotaxime, Ceftriaxone, Ciprofloxacin,
Moxifloxacin, Chloramphenicol
Third-Line agents:
Comments: (Aerobic Gram-Negative Cocci).

Proteus mirabilis
Drugs of Choice: Ampicillin, Amoxicillin, Cefotaxime, Ceftizoxime,
Ceftriaxone, Gentamicin, Tobramycin
Alternatives: Piperacillin, Augmentin, Unasyn, Piperacillin-tazobactam,
1st and 2nd generation Cephalosporins, Ciprofloxacin, Levofloxacin,
Moxifloxacin, TMP-SMX
Third-Line agents:
Comments: (Enterobacteriaceae (Enteric gram-negative bacilli)).

Providencia stuartii
Drugs of Choice: Cefotaxime, Ceftizoxime, Ceftriaxone, Ceftazidime
Alternatives: Timentin, Piperacillin-tazobactam, Aztreonam, Cefepime,
Amikacin, Gentamicin, Tobramycin, Ciprofloxacin, Levofloxacin,
Imipenem, Meropenem
Third-Line agents:
Comments: (Enterobacteriaceae (Enteric gram-negative bacilli)).
Pseudomonas aeruginosa
Drugs of Choice: Piperacillin-tazobactam, Imipenem, Meropenem,
Ceftazidime, Cefepime, Amikacin, Gentamycin, Tobramycin,
Ciprofloxacin
Alternatives: Timentin, Aztreonam, Levofloxacin
Third-Line agents:
Comments: (Gram-negative bacilli). Consider using two agents from
two different classes as empiric treatment in critically ill patients if P.
aeruginosa is suspected. Once susceptibilities known, narrow to one
drug according to susceptibility report.

Pseudomonas cepacia
Drugs of Choice: Meropenem, Imipenem, TMP-SMX
Alternatives: Chloramphenicol
Third-Line agents:
Comments: (gram-negative bacilli). AKA: Burkholderia cepacia

Salmonella spp
Drugs of Choice: Ceftizoxime, Ceftriaxone, Ciprofloxacin
Alternatives: TMP-SMX, Imipenem, Meropenem, Chloramphenicol
Third-Line agents:
Comments: (Enterobacteriaceae (Enteric gram-negative bacilli)).

Serratia spp
Drugs of Choice: Ceftizoxime, Ceftriaxone, Cefepime, Gentamicin
Alternatives: Timentin, Piperacillin-tazobactam, Aztreonam,
Ertapenem, Imipenem, Meropenem, Ceftazidime, Amikacin,
Ciprofloxacin, Levofloxacin, TMP-SMX
Third-Line agents:
Comments: (Enterobacteriaceae (Enteric gram-negative bacilli)).

Shigella spp
Drugs of Choice: Ciprofloxacin, Levofloxacin
Alternatives: Ceftizoxime, Ceftriaxone, Cefepime, Impenem,
Meropenem, Ampicillin, TMP-SMX
Third-Line agents: Doxycycline
Comments: (Enterobacteriaceae (Enteric gram-negative bacilli)).
Staphylococcus aureus
Drugs of Choice: Dicloxacillin, Nafcillin, Oxacillin, Cefazolin,
Cephalexin,
Alternatives: Vancomycin, Augmentin, Unasyn, Timentin, Piperacillin-
tazobactam, Azithromycin, Clarithromycin, Erythromycin, Levofloxacin,
Moxifloxacin, TMP-SMX, Ertapenem, Meropenem, Imipenem
Third-Line agents:
Comments: (Aerobic Gram Positive Cocci).

Staphylococcus aureus [Methicillin-resistant] - MRSA


Drugs of Choice: Vancomycin, Linezolid, Daptomycin
Alternatives: Synercid, Rifampin (never as monotherapy)
Third-Line agents: TMP-SMX
Comments: (Aerobic Gram Positive Cocci).

Streptococcus agalactiae [Group B]


Drugs of Choice: Pencillin, Ampicillin, Amoxicillin
Alternatives: Cephalosporins (1st-3rd), Azithromycin, Clarithromycin,
Erythromycin, Quinolones, Several others
Third-Line agents:
Comments: (Aerobic Gram Positive Cocci).

Staphylococcus epidermidis
Drugs of Choice: Vancomycin +/- Rifampin
Alternatives: Methicillin-sensitive: Nafcillin, Oxacillin.
Third-Line agents: (Ciprofloxacin + Rifampin)
Comments: (Aerobic Gram Positive Cocci).

Staphylococcus epidermidis [Methicillin resistant]


Drugs of Choice: Vancomycin +/- Gentamicin
Alternatives: Linezolid, Daptomycin, telavancin. (+/- Rifampin)
Third-Line agents:
Comments: (Aerobic Gram Positive Cocci).
Streptococcus Group D
Drugs of Choice: Ampicillin, Amoxicillin, Penicillin G or V
Alternatives: Ticarcillin, Piperacillin, Augmentin, Unasyn, Timentin,
Piperacillin-tazobactam, Cefazolin, Cephalexin
Third-Line agents: Imipenem, Meropenem
Comments: (Aerobic Gram Positive Cocci). S. Bovis

Streptococcus pyogenes [Group A]


Drugs of Choice: Ampicillin, Amoxicillin, Penicillin G or V
Alternatives: Unasyn, Timentin, Piperacillin-tazobactam,
Cephalosporins (1st -3rd), Macrolides (Erythromycin, Azithromycin, etc),
Vancomycin, Clindamycin, Levofloxacin, Moxifloxacin, Others
Third-Line agents:
Comments: (Aerobic Gram Positive Cocci).

Streptococcus pneumoniae
Drugs of Choice: Ampicillin, Amoxicillin, Penicillin G or V
Alternatives: Unasyn, Timentin, Piperacillin-tazobactam,
Cephalosporins (1st -3rd), Macrolides (Erythromycin, Azithromycin, etc),
Vancomycin, Clindamycin, Levofloxacin, Moxifloxacin, Others
Third-Line agents:
Comments: (Aerobic Gram Positive Cocci).

Streptococcus pneumoniae [PCN resistant]


Drugs of Choice: Vancomycin, Levofloxacin, Moxifloxacin,
Telithromycin
Alternatives: Imipenem, Ertapenem, Meropenem, Ceftriaxone,
Cefepime, Linezolid, Synercid, Clindamycin
Third-Line agents:
Comments: (Aerobic Gram Positive Cocci).

Streptococcus viridans
Drugs of Choice:
Alternatives: Vancomycin, Unasyn, Timentin, Piperacillin-tazobactam,
Imipenem, Meropenem, Cefazolin, Cephalexin, Ceftriaxone, Cefepime,
Levofloxacin, Moxifloxacin, Clindamycin, TMP-SMX
Third-Line agents:
Comments: (Aerobic Gram Positive Cocci).
Treponema pallidum
Drugs of Choice: Penicillin G
Alternatives: Ceftriaxone, Doxycycline
Third-Line agents: Azithromycin, Erythromycin
Comments: (Spirochete). Causative agent of syphilis. Characteristic
helical shape.

Vibrio cholerae
Drugs of Choice: Doxycycline
Alternatives: Azithromycin, Ciprofloxacin
Third-Line agents: Erythromycin
Comments: (Aerobic gram negative bacilli (ferment-positive)).

Xanthomonas maltophilia
Drugs of Choice: TMP-SMX
Alternatives: Moxifloxacin, Timentin
Third-Line agents: Piperacillin, Ticarcillin, Piperacillin-tazobactam,
Ciprofloxacin, Levofloxacin
Comments: (Aerobic gram negative bacilli (ferment-negative)).

By : Ridha Wahyutomo, MD
Dept. Clinical Microbiology and Infectious Disease
Islamic Universitiy of Sultan Agung Semarang

Source: Global RPH