Professional Documents
Culture Documents
HSGB Antibiotic Guidelines 2017 PDF
HSGB Antibiotic Guidelines 2017 PDF
INDEX:
DEPARTMENTS PAGE
1 Dental 4
2 Medical 14
Cardiovascular infections 15
Central Nervous Infections 26
Infections In Immunocompromised Patients 31
Non-Surgical Chemoprophylaxis 48
Respiratory Infections 51
Sexually Transmitted Infections 57
Skin & Soft Tissue Infections 64
Tropical Infections 74
Tuberculosis Infections 81
Urinary Tract Infections 85
3 Neurosurgery 89
4 Obstetrics & Gynecology 94
5 Ophthalmology 99
6 Orthopedic 111
7 Otolaryngology 118
8 Paediatrics 127
Cardiovascular Infections 128
Central Nervous System Infections 131
Chemoprophylaxis 134
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Otorhinolaryngology Infections 141
Gastrointestinal Infections 143
Infections In Immunocompromised Patients 146
Neonatal Infections 147
Occular Infections 153
Respiratory Infections 154
Skin And Soft Tissue Infections 155
Surgical Infections 157
Tropical Infections 159
Urinary Tract Infections 161
Vascular Infections 162
9 Plastic Surgery 164
10 Surgical 167
11 Appendix 176
Colistin Dosing Guide 177
Vancomycin Dosing Guide 179
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DENTAL
DEPARTMENT
4|Page
Index:
ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS ANTIMICROBIAL USE FOR FUNGAL INFECTIONS
Infections Of The Teeth And Supporting Structures Oral Candidiasis
- Reversible/ Irreversible Pulpitis (Toothache) - Acute Pseudomembranous Candidiasis
- Localised Dentoalveolar Abscess - Chronic Erythematous Candidosis
- Dry Socket
- Localised Pericoronitis ORAL / DENTAL SURGERY PROPHYLAXIS
- Chronic Gingivitis - Clean Surgery (Class 1)
- Chronic Periodontitis - Minor Clean-contaminated surgery (Class 2)
- Aggressive Periodontitis - Major Clean-contaminated surgery (Class 3)
- Local missed Periodontal Abscess
Infections of the Jaws
- Osteomyelitis of the jaws of dental origin
Spreading Infections and Infections of Fascial Spaces
- Cellulitis±Abscess of dental origin
- Traumatic wound involving skin / Infection of skin origin
Post Implant Infections (“Periimplantitis”)
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Localised Dentoalveolar Systemic antibiotic use not Systemic antibiotic use not Incision and Drainage and Management
Abscess recommended recommended of Cause of Abscess and Symptomatic
Relief of Pain.
If patient medically Penicillin Allergy:
compromised, besides local Clindamycin 150-300mg PO JCan Dent Assoc 2003 Nov 69 (10):660
Clin.Microbiol.Rev.2013,26(2):255
treatment can consider: q6h
Amoxycillin 500mg PO q8h
Dry Socket Systemic antibiotic use not Systemic antibiotic use not Local treatment with saline irrigation
recommended recommended and antiseptic/ analgesic dressings and
symptomatic relief of pain.
Clinical Periodontology-12thed.2014
2ndline treatment-Antimicrobial mouthrinse
Clinical Periodontology-9thed.2002
Chronic Periodontitis Systemic antibiotic use Systemic antibiotic use 1stline treatment-Mechanical plaque
generally not recommended. generally not recommended. control
Can be considered in cases of: Periodontology 2000, Vol. 62, 2013, 218-231
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
1. Unresponsive to conventional CPG Management of chronic periodontitis Nov
2. Episodes of acute infection 2012 MOH, Malaysia
3. Medically compromised
patientstherapy
Aggressive Periodontitis Amoxycillin 500mg PO q8h Azithromycin 500mg q24h Antibiotics are not used alone but are
A. actinomycetemcomitans, P. PLUS for 3 days used as an adjunct to scaling and root
gingivalis, Tannerella Metronidazole 400mg PO q8h debridement
forsythensis, P. intermedia,
Spirochaetes JClin Periodontol.2012;39:284-294
Clin Periodontol.2011;38:43-49
J Clin Periodontol 2008; 35: 696–704
J Periodont Res 2012; 47: 137–148
Local missed Periodontal Systemic antibiotic use not Systemic antibiotic use not Incision and Drainage and management
Abscess recommended recommended of cause of abscess and symptomatic
relief of pain.
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
C. Spreading Infections and Infections of Fascial Spaces (with/without Systemic Signs)
Cellulitis±Abscess of dental Benzylpenicillin 2-4MU IV stat Penicilin Allergy: Empirical antibiotics are started.
origin then 1-2MU IV q4-6h Clindamycin150-450mg IV
Viridans Streptococci, PLUS/MINUS q6h Incision and drainange is advised and
Staphylococci, Prevotella, Metronidazole 500mg IV q8h antibiotics is changed in accordance with
Peptostreptococcus (or 1g q12h) Oral administration: result of culture and sensitivity.
Fusobacterium nucleatum Amoxycillin 250-750mg PO
Clostridium sp OR q8h
PLUS/MINUS
Surgical site infection & Amoxycillin/Clavulanate 1.2gm Metronidazole 400mg PO
Traumatic wound infection IV q6-8h (not more than1.2gm q8-12h
(Infection is usually by in a single dose- max 7.2gm
endogenous organisms rather daily) OR
than exogenous)
Viridans Streptococci OR Amoxycillin/Clavulanate
Staphylococci 625mg PO q8h.
Prevotella, Peptostreptococcus, Cefuroxime 750mg-1.5gm IV
Eubacterium,and q8h If severe, Amoxycillin/
Fusobacterium PLUS/MINUS Clavulanate 625mg PO q8h
Metronidazole 500mg IV OR
q8h(or 1gm q12h)* Cefuroxime 250-500mg PO
q12h
OR OR
Clindamycin 150-450mg PO
If not responding to above q6h
antibiotics,
Ceftriaxone 1-2gm IV q24h
(maybe given up to 4gm per
day)
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Traumatic wound involving Cloxacillin 500mg-1gm IV q6h
skin / Infection of skin origin (inskin involvement- if Staph.
expected)
OR
Clindamycin 150-450mg IV
q6h
Oral administration:
Amoxycillin 250-750mg PO
q8h
PLUS/MINUS
Metronidazole 400mg PO q8-
12h
OR
Clindamycin 150-450mg PO
q6h
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
suggest most effective antibiotic therapy.
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
stomatitis with and without 1:16(2):el 39-43
angular chelitis) Soak dentures in Chlorhexidine Australia Dental Journal 2010; 55:(1 suppl):48-54
mouthwash 2%
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Acyclovir 10mg/kg IV q8h for
10-21 days for varicella zoster
in immunocompromised and
simplex encephalitis
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All oral cancer surgery Ampicillin/Sulbactam 1.5gm
Open reduction and internal IV
fixation of facial bone
fractures
Doses listed are adult doses - for paediatric patients adjust according to age/body weight.
References from KKM CPG: Antibiotic Prophylaxis against Wound Infections for Oral Surgical Procedures 2003 (Reviewed 2014).
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MEDICAL
DEPARTMENT
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Index:
- Streptococcus viridans - HACEK microorganisms
- Nutritionally variant streptococci - Candida
- Staphylococcus aureus and Coagulase-negative staphylococcus - Non-HACEK Gram- negative microorganisms
- Staphylococcal endocarditis in the presence of a prosthetic - Therapy for other microorganisms
valve or other prosthetic material
- Enterococcus species
CARDIOVASCULAR INFECTIONS
Streptococcus viridans
Endocarditis due to penicillin-susceptible viridans group streptococci (VGS) and S gallolyticus (bovis)
Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Penicillin-susceptible VGS and S. gallolyticus (bovis) (MIC ≤ 0.125 µg/ml) – native and prosthetic valve
Benzyl penicillin (Crystalline 3MU* every 4 to 6 hourly or 12-18 4 (native) * MU = mega unit; 600mg = 1MU
penicillin) MU/day as a continuous infusion 6 (prosthetic)
Ampicillin 2 g IV 4 hourly
Ceftriaxone 2 g IV once daily
Vancomycina,b 15-20 mg/kg/dose (actual body Vancomycin therapy is
weight) IV every 8-12 hourly; not to recommended only for patients
exceed 2 g/dose with immediate-type penicillin
hypersensitivity.
Relatively resistant to penicillin VGS and S. gallolyticus (bovis) (MIC > 0.125 to 2 µg/ml) – native valve endocarditis
Benzyl penicillin (Crystalline 4 MU 4 hourly or 24 MU/day as 4 (native) * MU = mega unit; 600mg = 1MU
penicillin) continuous infusion 6 (prosthetic)
OR Cephalosporins may be substituted
Ceftriaxone 2 g IV once daily for penicillin in patients whose
penicillin hypersensitivity is not of
PLUS the immediate type
See notes below on how to monitor
(Low dose) Gentamicinc 3 mg/kg/day IV once daily 2 (native) for gentamicin toxicity
6 (prosthetic)
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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Vancomycina,b 15-20 mg/kg/dose (actual body 4 (native) Vancomycin therapy is
weight) IV every 8-12 hourly; not to 6 (prosthetic) recommended only for patients
PLUS exceed 2 g/dose with immediate-type penicillin
hypersensitivity
(Low dose) Gentamicinc 3 mg/kg/day IV once daily 2 (native) See notes below on how to monitor
6 (prosthetic) for gentamicin toxicity
a. Vancomycin: aim for serum trough level of 10 – 15 mg/l.
b. Vancomycin dose should be adjusted in patients with renal impairment.
c. For patients on gentamicin:
Monitor gentamicin level and renal function weekly. There should be a low threshold for stopping gentamicin in patients with deteriorating renal
function or other signs of toxicity.
When given in a single daily dose give infusion over 30 minutes. Aim for pre-dose (trough) serum level of < 1 mg/l.
Consider biweekly clinical screening for ototoxicity:
Check baseline visual acuity using a Snellen pocket card.
To screen for ototoxicity, have patient shake head and reread the card.
Consider formal audiology test if patient loses 2 lines of visual acuity.
PLUS
(Low dose) Gentamicinc 1 mg/kg IV 8 hourly 2 See notes below on how to monitor
for gentamicin toxicity
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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Ceftriaxone 2 g IV once daily 6 Ceftriaxone is preferred if
PLUS clinically not responding with
(Low dose) Gentamicinc 1 mg/kg IV 8 hourly 2 penicillin
Vancomycina,b 15-20 mg/kg/dose (actual body 6 Vancomycin therapy is
weight) IV every 8-12 hourly; not to recommended only for patients
exceed 2 g/dose with immediate-type penicillin
hypersensitivity
a. Vancomycin: aim for serum trough level of 10 – 15 mg/l.
b. Vancomycin dose should be adjusted in patients with renal impairment.
c. For patients on gentamicin:
Monitor gentamicin level and renal function weekly. There should be a low threshold for stopping gentamicin in patients with deteriorating renal
function or other signs of toxicity.
When given in a single daily dose give infusion over 30 minutes. Aim for pre-dose (trough) serum level of < 1 mg/l.
Consider biweekly clinical screening for ototoxicity:
Check baseline visual acuity using a Snellen pocket card.
To screen for ototoxicity, have patient shake head and reread the card.
Consider formal audiology test if patient loses 2 lines of visual acuity.
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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Absence of metastatic sites of
infection or empyema
Absence of cardiac and
extracardiac complications
Absence of associated
prosthetic valve or left-sided
valve infection
< 20 mm vegetation
Absence of severe
immunosuppression (< 200
CD4 cells/ml) with or without
acquired immune deficiency
syndrome (AIDS)
Regimens for β-lactam allergic patients – both left-sided and right-sided
Cefazolin 2 g IV 8 hourly 4-6 Cephalosporins should be avoided
in patients with immediate-type
hypersensitivity to penicillin.
Cefazolin has inadequate blood-
brain barrier penetrability. In cases
of brain abscesses complicating
MSSA IE, watch out for treatment
failure.
Vancomycina,b 15-20 mg/kg/dose (actual body 4-6 Loading dose of 25-30 mg/kg
weight) IV every 8-12 hourly; not to (actual body weight) may be
exceed 2 g/dose considered for seriously ill
patients.
Vancomycin is inferior to
cloxacillin for treatment of MSSA.
Vancomycin therapy is
recommended only for patients
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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
with immediate-type penicillin
hypersensitivity
Methicillin-Resistant Staphylococci (MRSA) – left-sided and right-sided
Vancomycina,b 15-20 mg/kg/dose (actual body 4-6 Loading dose of 25-30 mg/kg
weight) IV every 8-12 hourly; not to (actual body weight) may be
exceed 2 g/dose considered for seriously ill patients
Daptomycin 10 mg/kg IV daily 4-6 Daptomycin is superior to
Vancomycin for MRSA
bacteraemia with vancomycin MIC
> 1 mg/l
a. Vancomycin: aim for serum trough level of 10 – 15 mg/l.
b. Vancomycin dose should be adjusted in patients with renal impairment.
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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Methicillin-Resistant Staphylococci (MRSA)
Vancomycina,b 15-20 mg/kg/dose (actual body ≥6 For adults, loading dose of 25–30
weight) IV every 8-12 hourly; not to mg/kg (actual body weight) may be
PLUS exceed 2 g/dose considered for seriously ill
patients.
Rifampicin 300 – 450 mg PO 12 hourly ** ≥6
**Rifampicin has better
PLUS penetration. However to avoid the
development of resistance, it
(Low dose) Gentamicinc 1mg/kg IV 8 hourly 2 should be started after 3–5 days of
effective initial vancomycin
therapy and/or once the
bacteraemia has been cleared.
a. Vancomycin: aim for serum trough level of 10 – 15 mg/l.
b. Vancomycin dose should be adjusted in patients with renal impairment.
c. For patients on gentamicin:
Monitor gentamicin level and renal function weekly. There should be a low threshold for stopping gentamicin in patients with deteriorating renal
function or other signs of toxicity.
When given in a single daily dose give infusion over 30 minutes. Aim for pre-dose (trough) serum level of < 1 mg/l.
Consider biweekly clinical screening for ototoxicity:
Check baseline visual acuity using a Snellen pocket card.
To screen for ototoxicity, have patient shake head and reread the card.
Consider formal audiology test if patient loses 2 lines of visual acuity.
Enterococcus species
Endocarditis due to enterococcus- native and prosthetic valve
Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Fully penicillin-susceptible strains (penicillin MIC ≤ 8 mg/l)
Ampicillin 2 g IV 4 hourly 4 or 6 depending on duration of Duration of symptoms < 3 months
symptoms and type of valve; see and native valve:
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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
PLUS comments Ampicillin duration - 4 weeks
Gentamicin duration - 2 weeks
(Low dose) Gentamicinc 1 mg/kg IV 8 hourly 2 or 6 depending on duration of
symptoms and type of valve; see Duration of symptoms > 3 months
comments or prosthetic valves:
Ampicillin duration - 6 weeks
Gentamicin duration - 6 weeks
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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Resistant to penicillin and susceptible to aminoglycosides and vancomycin
Vancomycina,b 15-20 mg/kg/dose (actual body 6
weight) IV every 8-12 hourly; not to
PLUS exceed 2 g/dose
HACEK microorganisms
Therapy for endocarditis due to HACEK microorganisms (Haemophilus Parainfluenza, Aggregatibacter aphrophilus, Aggregatibacter
actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) both native and prosthetic valve
Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Penicillin-susceptible VGS and S. gallolyticus (bovis) (MIC ≤ 0.125 µg/ml) – native and prosthetic valve
Ceftriaxone 2 g IV once daily 4 (native) HACEK-group bacilli produce
6 (prosthetic) beta-lactamases; definitive
OR treatment should be adjusted based
on the cultures.
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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
OR
Candida
Therapy for Candida endocarditis (native and prosthetic valve)
Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Penicillin-susceptible VGS and S. gallolyticus (bovis) (MIC ≤ 0.125 µg/ml) – native and prosthetic valve
Amphotericin B deoxycholate 0.6-1.0 mg/kg IV once daily At least 6 weeks after surgery Step down therapy – Fluconazole
400-800mg (6-12mg/kg) orally
OR daily for susceptible
microorganism in stable patients
Lipid formulation Amphotericin B 3-5 mg/kg IV once daily with negative blood cultures
(clearance of Candida from blood
With or without stream)
Flucytosine 25 mg/kg PO 6 hourly At least 6 weeks after surgery For synergistic effect.
Causes dose related marrow
toxicity.
Avoid using in patients with renal
failure.
Micafungin 150 mg IV daily At least 6 weeks after surgery Step down therapy – Fluconazole
400-800mg (6-12mg/kg) orally
Caspofungin 150 mg IV daily daily for susceptible micro-
organism in stable patients with
Anidulafungin 200 mg IV daily negative blood cultures (clearance
of Candida from blood stream)
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Valve replacement is mandatory. Continue therapy for 6 weeks after replacement or longer in patient with perivalvular abscess.
The duration of therapy will depend on patient response and surgical intervention.
For patients who cannot undergo valve replacement, long-term suppression with fluconazole at a dosage of 400-800 mg (6-12 mg/kg) daily is
recommended.
For PVE, the recommendations above apply, and suppressive therapy should be lifelong if valve replacement is not possible.
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Pathogen Antimicrobial Dosage and Route Duration of Therapy
C. burnetii Doxycycline 100 mg PO 12 hourly 18 – 24 months based on clinical
(agent of Q fever) PLUS and serological response
Hydroxychloroquine 600 mg PO daily or 200 mg PO 8
hourly
Bartonella spp. Doxycycline 100 mg PO 12 hourly 2 weeks
PLUS
Gentamicin 3 mg/kg IV daily
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Index:
MENINGITIS (ACUTE) Viral encephalitis
- Empirical treatment MENINGITIS (CHRONIC)
- Haemophilus influenzae - Tuberculous meningitis
- Streptococcus pneumoniae - Cryptococcal meningitis
- Neisseria meningitidis - Neurosyphilis
- Enterobacteriaceae - HIV related CNS infection
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Duration of treatment: 10-14 Chloramphenicol 1gm IV
days. (very ill patients may q6h for 14 days.
require treatment for 21
days.)
Streptococcus pneumoniae Penicillin-sensitive strains For penicillin resistant Tunkel, et al. Practice Guidelines for the
(Gram +ve cocci) Benzylpenicillin 4MU IV q4- strains Management of Bacterial Meningitis. Clin Inf Dis
2004; 39:1267-84.
6h for 10-14 days. Vancomycin 1gm IV q12h
Prophylaxis for household and Ciprofloxacin 500mg PO as Ceftriaxone 250mg IM as East Kent Hospitals University Foundation Trust
close contacts for single dose; single dose (especially in Antimicrobial Guidelines, 2012.
meningococcal meningitis OR pregnancy);
Rifampicin 600mg PO q12h OR
for 2 days (4 doses) [not Azithromycin 500mg PO as
recommended in pregnant single dose.
women].
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Gram-negative Ceftriaxone 2gm IV q12h. References
Enterobacteriaceae OR Woehrl B, Klein M,Grandgirard D,
Koedel U, Leib S. Bacterial meningitis: current
Cefotaxime 2-4gm IV q8h. therapy and possible future treatment options
Expert Rev Anti Infect Ther 2011; 9(11), 1053–
Duration of treatment: 10-14 1065.
days. (Very ill patients may Tunkel, et al. Practice Guidelines for the
Management of Bacterial Meningitis. Clin Inf Dis
require treatment for 21 2004; 39:1267-84.
days.)
Viral encephalitis IV Acyclovir 10mg/kg q8h Treat for 2-3 weeks if HSV encephalitis
proven by PCR:
Early stages has polymorph
predominance
5-10% normal CSF early stages
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
mg/kg/24h PO to those for HIV-uninfected doses (intravenously initially, then switch
(max: 300 mg/day) adults when the disease is to oral when safe to do so). Alternatively,
PLUS caused by organisms that are oral prednisolone 30-40mg/24h in
Rifampicin (R) 10 (8-12) known or presumed to be tapering doses for 6 weeks.
mg/kg/24h PO susceptible to the first-line
(max: 600 mg/day) drugs. Reference:
PLUS CPG on management of Tuberculosis, 3rd
edition, 2012; 16, 22, 40-42, 56)
Pyrazinamide (Z) 25 (20-30) Daily dosing is WHO Treatment of Tuberculosis Guidelines, 4th ed.
mg/kg/24h PO (max: 2000 recommended rather than 2009
mg/day) intermittent dosing.
PLUS *Requires DG approvals
Streptomycin (S) 15 (12-18) Rifampicin is not
mg/kg/24h IM (max: 1000 recommended in
mg/day) combination with all protease
inhibitors (PIs) and rifabutin
Pyridoxine 10- 50mg PO should be used with PI-based
q24h needs to be prescribed HAART for HIV-TB co-
together with Isoniazid. infected adults.
MDR-TB:
(Streptomycin should replace Combination of one drug
Ethambutol in TB meningitis from each of the groups
as it crosses BBB better than below:-
Ethambutol.) Group 1 – Pyrazinamide,
Ethambutol, Rifabutin*
Treatment is continued for 12 Group 2 – Kanamycin*,
months. Amikacin, Capreomycin* (if
resistant to Kanamycin or
Amikacin)
Group 3 – Levofloxacin,
Moxifloxacin
Group 4 – Ethionamide*,
Cycloserine*, p-
Aminosalicylic Acid (PAS)*
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Group 5 – not routinely used
except in XDR-
TB:Clofazimine*, Linezolid,
Amoxicillin/Clavulanate,
Clarithromycin, Imipenem
Cryptococcal meningitis Induction Therapy: End point of treatment: till at least total of
Cryptococcus neoformans Amphotericin B 0.7-1 1.5-2.0gm of Amphotericin B given and
mg/kg/24h IV CSF shows clearance of fungus by 2
negative C&S one month apart, and CSF
PLUS Cryptococcal antigen titre becomes
negative or at least 1:2 or shows a
5-Flucytosine 100mg/kg/24h fourfold decrease.
PO q6h for 2-4 weeks. Liposomal Amphotericin may be used in
OR cases of severe toxicity to Amphotericin B
Fluconazole 400mg PO e.g. Abelcet 3-5mg/kg/day
q12h.
References:
Consolidation Therapy: Clin Infect Dis. Jul 1 2008; 47(1):123-30.
Clin Inf Dis 2010; 50: 291-322.
Fluconazole 400-800mg PO N Eng J Med 2013; 368: 1291-1302.
q24h for 8 weeks. Antimicrobial Agents And Chemotherapy
2007;51(3): 1038-1042
Neurosyphilis Refer to section (Sexually Treatment same for neurosyphillis in
Transmitted Infections) patients with HIV infection
Reference:
2010 CDC STD Treatment Guidelines; 32-33.
HIV related CNS infection Refer to section (Human
Immunodeficiency Virus)
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Index:
A. HAEMATOLOGY Cytomegalovirus (CMV) Disease
- Potential pathogens in immunocompromised patients - CMV retinitis
- Antifungal agent dosing - Extraocular CMV diseases
- Prophylaxis against bacterial, viral or fungal infections Bacterial enteric infections
- Infections following haematopoietic stem cell transplant - Salmonellosis
- Shigellosis
B. HUMAN IMMUNODEFICIENCY VIRUS (HIV) - Campylobacteriosis
Pneumocystis Pneumonia (PCP) Herpes Simplex Virus (HSV) Infections
- Interstitial pneumonia - Genital or orolabial
- Prophylaxis (primary and secondary) Varicella-Zoster Virus Diseases
Mucocutaneous Candidiasis - Shingles, primary Varicella infection (Chickenpox), progressive
- Oropharyngeal (Oral thrush) outer retinal necrosis (PORN), acute retinal necrosis (ARN)
- Oesophageal Histoplasmosis
- Vulvovaginal - Moderate- to-severe disseminated disease
Cryptococcal Meningitis or Meningoencephalitis - Less severe disseminated disease
- Initial treatment - Chronic suppresive therapy (secondary prophylaxis)
- Maintenance therapy Isospora belli Infection
Toxoplasma Gondii Encephalitis Nocardia Infection
- Acute infection Penicilliosis
- Suppressive/Maintenance therapy - Acute infection
- Primary prophylaxis - Maintenance therapy/secondary prophylaxis
Mycobacterium Avium Complex (MAC) disease Progressive Multifocal Leukoencephalopathy (PML)
- Treatment Cryptosporidiosis
- Mainternance/Secondary prophylaxis
C. SOLID TRANSPLANT
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A. HAEMATOLOGY
1. Any infection in the immunocompromised host is life-threatening and needs immediate attention. Febrile neutropenia is defined as a temperature of
>38.3oC on a single occasion or >38oC over one hour and ANC (Absolute Neutrophil Count) <500cells/uL or <1000cells/uL in those with anticipated
declining counts.
2. Cultures maybe positive in less than 40% of cases. Patients have impaired inflammatory responses and hence may have no localizing signs. The usual
sign is fever>38oC or hypothermia. The common portals of infection include the oral cavity, gastrointestinal tract, perianal region, lungs and IV lines.
4. The choice of antibiotic is based on local organisms and sensitivity patterns. This should be based on sound clinical judgment, the clinical state of the
patient, prior infections with drug resistant bacteria, recent outbreaks e.g. MRSA or multi-drug resistant Enterobacteriaceae, as well as the availability and
cost of the antibiotics. Surveillance for CRE, Stenotrophomonas maltophilia and multi-resistant organisms should be carried out by the infection control
team of the respective hospitals. If this service is not available, the hospital should set up a local surveillance team to monitor these organisms. The
incidence of these organisms must be borne in mind when selecting agents for use in the first line setting
5. Risk assessment for complication of severe infection should be done during triage. Patient are deemed high risk if there is prolonged and profound
ANC< 0.1x109/L, hypotension, pneumonia, new onset abdominal pain or neurological signs, and should be admitted to hospital for IV antibiotics.
6. The administration of the first dose of empirical anti-pseudomonal antibiotic should be done as soon as possible following triage (within the first hour)
after taking blood cultures. The following regimens are suggested:
a. First lline therapy: Piperacillin/Tazobactam 4.5gm IV q6h OR Cefepime 2gm IV q8h. Aminoglycosides e.g Gentamicin or Amikacin may be added
in combination therapy prior knowing sesitivity results. Ceftazidime 2gm IV q8h can be used as an alternative. Duration: until neutrophils count
recovers to > 500 /u or longer if clinically indicated (> 1 x 109/L)
b. Second line therapy: Carbapenem; Imipenem 500mg IV q8h/q6h OR Meropenem 1gm q8h. Imipenem 1gm q8h is used in severe sepsis.
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c. Monotherapy is likely just as efficacious and less toxic. Drugs that can be used as monotherapy are Piperacillin/Tazobactam, Cefepime, Imipenem or
Meropenem
d. Anaerobic infections account for <5% of all cases of bactaeraemia. Metronidazole 500mg IV q8h may be added to cefipime in the presence of severe
mucositis, intra abdominal infections, peri-anal abscesses or colitis. Piperacillin/Tazobactam and Carbapenems have good anaerobic coverage and
therefore do not need additon of metronidazole.
e. Glycopeptide therapy e.g. Vancomycin is not recommended as a standard part of the initial antibiotic regimen. Vancomycin 15mg/kg IV q12h OR
q8h may be added in suspected central device infections, known colonizers by MRSA, severe mucositis, sikin or soft tissue infection suspected
MRSA/MRSE infections and severe sepsis, septic shock or respiratory distress. Consider stopping after 48 hr if no microbiological evidence of
gram positive infection. Linezolid is an alternative in those patients with no clinical response to Vancomycin and in those with suspected or
confirmed VRE, VISA or VRSA.
f. Consider adding antifungal therapy if fever persisted or evidence of new infection after 5 to 7 days of broad spectrum antibiotic therapy or earlier
especially jn the presence of severe mucositis, oral thrush, painful swallowing, suspicious skin infiltrates or pulmonary infiltrates, fundal exudates or
prolonged steroid/antibiotic use more than 2 weeks). Amphotericin B remains the empirical therapy of choice for invasive fungal infections. For
patients who are intolerant, refractory or those with toxicity to conventional Amphotericin B, the lipid formulations of Amphotericin B, Voriconazole
and Echinocandins are alternatives empirical therapy based on local availability and costs. Voriconazole is an alternative to Amphotericin B for
preemptive and directed therapy for invasive aspergillosis. In candidiasis, echinocandins, azoles and ampho B are antifungals of choice.
g. The use of growth factors e.g.G-CSF may be considered as prophylactic use. The prophylactic use of growth factors significantly reduced the
relative risk for severe neutropenia, febrile neutropenia and infection. It should be considered in high-risk patients with ANC<100/uL multiple organ
33 | P a g e
dysfunction syndrome, pneumonia, invasive fungal infections or septic shock. However, there is no evidence that either G-CSF reduced the number
of patients requiring intravenous antibiotics or lowered infection related mortality.
h. The role of granulocytes remains controversial and should be discussed with haematologist. Granulocyte transfusions may be used in patients with
serious bacterial or fungal infections not responding to appropriate treatment and who will likely recover in the neutrophil count in the short term. The
risk of disease transmission e.g. CMV must be borne in mind.
i. The use of oral antibiotics with Ciprofloxacin and amoxicillin / Clavulanate, may be considered after careful assessment of risk factors and a
consult from the haematologist, in an outpatient setting for low risk patients (i.e no evidence of dehydration or hypotension, no evidence of
pneumonia/COAD) and it is important that patients must be able to access prompt medical attention if condition deteriorates.
j. Prophylaxis against bacterial, viral or fungal infections is advised after bone marrow or haematopoietic stem cell transplantation or in high-risk
patient after chemotherapy.
Autologous HSCT
34 | P a g e
Purine Analog therapy At least 3 months after discontinuation of
(fludarabine / cladribine) purine analog.
Anti PCJ therapy Autologous HSCT Allogenic Co-trimoxazole Start when achieved engraftment, continue
HSCT until resolution of immunosuppression.
k. Infections following haematopoietic stem cell transplant are generally similar to that in the solid organ transplant setting. In addition to the usual
bacterial, fungal infections and viral infections especially CMV reactivation and parasitic infections e.g. Pneumocystis jiroveci (PCJ) and Toxoplasma
infection can occur. It is recommended that prophylactic use of Ganciclovir or pre-emptive monitoring for CMV reactivation should be carried out
during the first 100 days. Trimethoprim/ Sulphamethoxazole 480mg once daily or 960mg 3x/week is, also extremely effective in the prevention of
PCJ or toxoplasmosis. It is recommended that these measures be continued in patients with active graft-vs-host disease and in those remaining on
high dose immunosuppressive agents.
1st line Piperacillin/Tazobactam 4.5gm IV q6h Aminoglycosides e.g. Gentamicin or Amikacin may be added in combination
OR
Cefepime 2gm IV q8h
2nd line Imipenem 500mg IV q8h or q6h or Carbapenems are only indicated as first line therapy in seriously ill patient
1gm q8h (severe sepsis) either presenting as septic shock, or with known previous infections with
OR ESBL enterobacteriaceae or gram-negative organisms resistant to narrow
Meropenem 1gm q8h spectrum B-lactams.
Glycopeptides Vancomycin 15mg/kg IVq 12h or q8h Colonization with MRSA or MRSE or suspicion of serious catheter related
infections or skin and soft tissue infection.
Linezolide (dose): alternative and in those suspected or infected with
VRE/VISA/VRSA should be started on
Antifungal agents Conventional Amphotericin B Liposomal Maybe added as empirical therapy from D5-7.
Amphotericin B Echinocandins Voriconazole is the preferable preemptive and directed therapy for invasive
aspergillosis
35 | P a g e
7. Attention must be paid to:
References:
1. NCCN Clinical Practice Guidelines in Oncology V.I2006. Fever and Neutropaenia
2. Hughes W T, Armstrong D, Bodey G P et al. 2002 Guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2002 ; 34 : 730-751
3. Herbrect R, Denning D W, Patterson T F et al. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. NEJM 2002 ; 347: 408-415
4. WalshTJ, Teppler H, Donowitz G R et al .Caspofungin versus liposomal amphotericin B for empirical antifungal therapy in patients with persistent fever and neutropaenia. NEJM
2004;351(14):1391-1402
5. Dellinger RP, Levy MM, Carlet JM et al. Surviving sepsis campaign : international guidelines for management of severe sepsis and septic shock. Intensive Care Med 2008, 34 : 17-60
6. Bohlius J, Herbst C, Reiser M, Schwarzer G, Engert A. Granulopoiesis-stimulating factors to prevent adverse effects in the treatment of malignant lymphoma. Cochrane Database
of Systematic Reviews 2008, Issue 4.
7. Alison GF, Eirc JB, Kent A S et al. IDSA guideline : Clinical Practice guideline for the Use of Antimicrobial Agents in Neutropenic Patients with cancer :2010 update by the
Infectious Diseases Society of America . CID 2011; 52: 56-93.
8. Mica P, Sara B, Abigail F, Liat v and Leonard L. Empirical antibiotics against Gram-positive infections for febrile neutropenia : Systemic review and meta-analysis of randomized
controlled trials. J Antimicrob Chemother 2005; 55: 436-444.
9. Diana A, ChristinaO, Catherine C et al. European guidelines for empirical antibacterial therapy for febrile neutropenic patients in the era of growing resistance: summary of the
2011 4th European conference on the infections in Leukaemia. Haematologica 2013;98(12) :1826-1835
10. Paul M, Yahav D, Fraser A, et al. Empirical antibiotic monotherapy for febrile neutropenia: Systematic review and meta-analysis of randomized controlled trials. J Antimicrob
Chemother 2006;57:176-89.
11. Engelhard D. Akova M, Boeckh MJ et al. Bacterial infection prevention after hematopoietic cell transplantation. Bone marrow Transplant 2009; 44:467-470.
12. Cornely OA, Bohme A, Buchheidt D et al. Primary prophylaxis of invasive fungal infections in patients with hematologic malignancies. Recommendations of the Infectious Diseases
Working Party of the German Society for Haematology and oncology. Haematologica 2009; 94: 113-22.
13. Zaia J, Baden L, Boeckh MJ et al. viral disease protection after hematopoietic cell transplantation. Bone marrow Transplant 2009; 44:471-482.
Important cut-offs for CD4 T cells, above which particular AIDS illnesses are improbable. These CD4 counts are only reference values; exceptions are always
possible.
36 | P a g e
No cut-off Kaposi’s sarcoma, pulmonary tuberculosis, HZV, bacterial pneumonia, lymphoma , HSV
< 250/μl PCP, esophageal candidiasis, PML, , HIV encephalopathy
< 100/μl Cerebral toxoplasmosis, , cryptococcosis, miliary tuberculosis
< 50/μl CMV end organ disease , cryptosporidiosis, atypical mycobacteriosis
The treatment regimes are based on drugs available in the Ministry of Health National Formulary and hence in some instances may vary from
internationally accepted treatments. Some regimes are chosen as preferred regimes due to cost considerations.
Reference:
Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents
Rrecommendations from the CDC, NIH and IDSA, 2013
37 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
300-450mg PO q6h-q8h
PLUS
Primaquine 30mg base PO
q24h for 21 days
OR
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Oesophageal Fluconazole 200-400mg Itraconazole 200mg PO q24h Candidiasis is the most common cause
PO/IV q24h for 14-21 days OR of esophagitis with HIV infection, but
Voriconazole 200mg PO/IV CMV, HSV and aphthous ulcerations
q12h can present with similar complaints.
OR
Amphotericin B 0.6mg/kg IV Endoscopy required with unusual
q24h presentations or lack of response to
azole within several days.
Vulvovaginal Azoles pessary Fluconazole 150mg PO stat Prolonged or refractory episodes is
(Clotrimazole) for 3-7 days OR observed in approximately 10% of
Itraconazole 200mg PO q24h patients and requires antimycotic
for 3 days therapy for >7 days.
CRYPTOCOCCAL MENINGITIS OR MENINGOENCEPHALITIS
Cryptococcus neoformans ƚ The lipid formulations (Amphotericin
B lipid complex 5mg/kg or liposomal 3-
Initial Treatment Amphotericin B Amphotericin B 4mg/kg IV q24h) may be used instead if
Induction therapy (for at least 2 deoxycholateƚ 0.7-1mg/kg IV deoxycholateƚ 0.7-1mg/kg IV available.
weeks) q24h q24h
PLUS PLUS If ICP >250mm or signs & symptoms of
Flucytosine 25mg/kg PO Fluconazole 800mg IV/PO cerebral oedema present, do daily LP to
q6h q24h reduce pressure until patient is
improved.
Consolidation therapy (for 8 Fluconazole 400mg PO q24h Itraconazole 200mg PO q12h If clinical signs of cerebral oedema do
weeks) not improve after about 2 weeks of daily
LPs, consider placement of a lumbar
drain or VP shunt.
Maintenance Therapy Fluconazole 200mg PO Itraconazole 200mg PO q24h Discontinuation:
(continued after consolidation) q24h for patients intolerant or failed Completed initial (induction,
Fluconazole consolidation) therapy, and at least 1
year on maintenance therapy, and
Remains asymptomatic from
39 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
cryptococcal infection, and
CD4 count ≥100 cells/μL for ≥3
months and suppressed HIV RNA in
response to effective ART.
(http://aidsinfo.nih.gov/ contentfiles
/ lvguidelines/ adult_oi.pdf.)
40 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Clindamycin 600mg IV/PO
q6h for at least 6 weeks
Suppressive/ Maintenance Pyrimethamine* 25-50mg Pyrimethamine* 25-50mg PO Discontinuation:
Therapy PO q24h q24h Consider when on HAART, CD4 >200
PLUS PLUS >3 months and viral load well
Clindamycin 600mg PO q8h Folinic acid 10-25mg q24h suppressed
PLUS PLUS
Folinic acid 10-25mg q24h Sulphadiazine* 0.5-1g PO q6h *Requires DG approval
OR
Trimethoprim/
Sulfamethoxazole 160/800mg
PO q12h
Primary Prophylaxis Trimethoprim/ Dapsone 50mg PO q24h All the recommended regimens for
Indications: Sulfamethoxazole PLUS preventing 1st episode of toxoplasmosis
ToxoIgG +ve with CD4<100 160/800mg PO q24h Pyrimethamine* 50mg PO q7d are also effective in preventing PCP
PLUS
Folinic acid 25mg PO q7d *Requires DG approval
OR
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
effective HAART.
PLUS/MINUSƚ
Discontinuation:
1
Amikacin 10-15mg/kg IV Consider if patient is on HAART and
q24h viral load well suppressed, CD4 > 100
OR ≥6 months, asymptomatic of MAC, and
Streptomycin 1gm IM q24h has completed > 12 months of therapy.
OR
Levofloxacin 500mg PO
q24h
OR
Moxifloxacin 400mg
PO q24h
Mainternance/ Same as the treatment Secondary prophylaxis restarted when
Secondary Prophylaxis regimen CD4<100.
CYTOMEGALOVIRUS (CMV) DISEASE
CMV Retinitis Immune recovery is essential for
successful treatment. Start HAART
Initial Therapy Intravitreal injections of Foscarnet* (2.4mg/injection) within 2 weeks if possible.
Immediate Sight-Threatening Ganciclovir (2mg/injection) for 1-4 doses over a period of
Lesions (Adjacent to the Optic 1-4 doses over 7-10 days 7-10 days Discontinuation:
Nerve or Fovea) PLUS PLUS Consider if patient is on HAART and
Ganciclovir 5mg/kg IV q12h Ganciclovir 5mg/kg IV q12h viral load well suppressed, CD4 > 100
for 14-21 days, then 5mg/kg for 14-21 days, then ≥3 months and after 3-6 months of CMV
IV q24h 5–7 times weekly Valganciclovir* 900mg PO treatment.
q24h
For Small Peripheral Lesions Gancyclovir 5mg/kg IV q12h *Requires DG approval
for 14 days
Extraocular CMV diseases Ganciclovir 5mg/kg IV q12h May consider switch to Maintenance therapy is generally not
(Oesephagitis, colitis, interstitial for 21-42 days or until signs Valganciclovir 900mg PO necessary; HAART offers best hope for
pneumonitis, neurological) and symptoms have been q12h once patient can absorb prevention of relapses.
resolved and tolerate orally (in CMV
42 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
oesophagitis and colitis only) *Requires DG approval
Bacteraemia
Ciprofloxacin 500-750mg
PO q12h OR 400mg IV
q12h
PLUS
Aminoglycoside IV
HERPES SIMPLEX VIRUS (HSV) INFECTIONS
Genital or orolabial Acyclovir 400mg PO q8h Duration:
Genital: 5-14 days
Moderate-to-severe Acyclovir 5mg/kg IV q8h Orolabial: 5-10 days
mucocutaneous infections After lesion begins to
regress, change to oral
regime as above and continue
43 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
until lesions have completely
healed
44 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
for 3 days, then q12h for at
least 12 months
Less severe disseminated Itraconazole 200mg PO q8h Fluconazole 800 mg PO q24h Itraconazole oral solution is preferred
disease for 3 days, then 200mg PO OR over capsule because of improved
q12h for at least 12 weeks Voriconazole 400mg PO q12h absorption, but is less well tolerated.
on day 1, then 200mg PO q12h However, this formulation may not be
necessary if itraconazole concentration
is increased by concomitant use of a
CYP3A4 inhibitor such as ritonavir-
boosted PIs
Chronic Suppresive therapy Itraconazole 200mg PO q24h Fluconazole 400mg PO q24h Discontinuation:
(Secondary prophylaxis) Received azole for >1 year, and
Indication: Negative fungal blood cultures, and
severe disseminated or CNS Serum Histoplasma antigen <2
infection after completion of ng/mL, and
at least 12 months of CD4 count >150 for ≥6 months
treatment
relapsed despite appropriate
initial therapy
CD4<150
ISOSPORA BELLI INFECTION
Initial Therapy Trimethoprim/Sulfamethoxaz Pyrimethamine 50-75mg PO
ole 160/800mg PO/IV q6h q24h
for 10 days PLUS
Folinic acid 5-10mg PO q24h
OR
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
NOCARDIA INFECTION
Initial Therapy Trimethoprim/ Imipenem/Cilastatin 500mg IV Use indefinite low dose oral suppression
Sulfamethoxazole q6h in patients with advanced HIV or
(TMP 15mg/kg /SMX PLUS significant immunosuppression to
75mg/kg/24h) IV/PO q6h Amikacin 7.5mg/kg IV q12h prevent relapse with TMP/SMX
for 2-4 weeks or clinical 160/800mg q12h.
May consider decreasing to improvement followed by oral
SMX/TMP (TMP regimen
10mg/kg/24h) after clinical
improvement OR
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY (PML)
Polyoma virus JC virus (JCV) No effective therapy exists With HAART, some patients improve
and others stabilise. Few may deteriorate
due to immune reconstitution
CRYPTOSPORIDIOSIS
Cryptosporidium sp. Symptomatic treatment of Effective HAART (to increase CD4+
diarrhoea >100) can result in complete, sustained
clinical, microbiological and histologic
resolution.
C. SOLID TRANSPLANT
For infections related to renal transplant – please refer to the MOH Renal Replacement Therapy Guidelines.
47 | P a g e
Index:
- Cardiac conditions requiring prophylaxis for dental procedures - Prophylactic regimens for dental, oral, respiratory tract, skin and
- Dental procedures for which prophylaxis is recommended musculoskeletal tissue
- Other procedures for which prophylaxis is recommended - Secondary prevention of rheumatic fever
- Rheumatic fever (type of infections & duration of treatment)
NON-SURGICAL CHEMOPROPHYLAXIS
Maintenance of optimal oral health and hygiene is essential to reduce the incidence of bacteraemia from daily activity. Infective endocarditis prophylaxis
for dental procedures is indicated for the following cardiac conditions:
Prosthetic heart valves, including bio prosthetic and homograft valves
Prosthetic material used for cardiac valve repair
A prior history of IE
Following congenital heart disease
Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
Completely repaired congenital heart defects with prosthetic material or device, whether placed by surgery or by catheter intervention, during the
6 months after the procedure
Repaired congenital heart disease with residual defects at the site or adjacent to the site of the prosthetic device (which inhibit endothelisation)
Cardiac "valvulopathy" in a transplanted heart. Valvulopathy is defined as documentation of substantial leaflet pathology and regurgitation
All dental procedures involve manipulation of gingival tissue or the periapical region of teeth or perforation of gingival mucosa:
Dental Extraction
Periodontal procedure including surgery, scaling and root planning, probing and recall maintenance
Dental implant placement and re-implantation of avulsed teeth
Endodontic (root canal) instrumentation or surgery only beyond the apex
Sub gingival placement of antibiotic fibres or strips
Prophylactic cleaning of teeth prior to implant where bleeding is anticipated
48 | P a g e
Other Procedures for which Prophylaxis is recommended:
Antibiotic prophylaxis may be given to high risk patients who undergo invasive procedure of the respiratory tract that involves incision or biopsy of
respiratory mucosa (level II A):
Tonsillectomy and/or adenoidectomy
Surgical operations that involve respiratory mucosa
For patients undergoing procedure to treat the infection e.g. drainage of empyema, antibiotic regime used to treat must be directed towards Streptococcus
viridans as well as Staphylococcus aureus.
The AHA guidelines 2008 no longer consider any gastrointestinal and genito-urinary procedures high risk and therefore do not recommend routine use of
IE prophylaxis even in patients with the highest risk cardiac conditions defined above.
For patients with established infections of the gastrointestinal and genito-urinary tract that have on-going enterococcal bacteraemia or who are undergoing
genito-urinary procedure, antibiotic prophylaxis is recommended (an agent active against enterococci).
For high risk cardiac patients who undergo surgical procedures that involve the infected skin, skin structure, and musculoskeletal tissue antibiotic
treatment against Streptococcus viridans and Staphylococcus is recommended.
Patients listed in who undergo an invasive respiratory tract procedure to treat an established infection, e.g. drainage of an abscess, should receive an
antibiotic regimen which contains an anti-staphylococcal penicillin or cephalosporin. Vancomycin should be given to patients unable to tolerate a β-
lactam. Vancomycin or another suitable agent should be administered if the infection is known or suspected to be caused by a methicillin-resistant strain
of S. aureus (MRSA).
In the case of an established infection or if antibiotic therapy is indicated to prevent wound infection or sepsis associated with a gastrointestinal or
genitourinary tract procedure in patients, it is reasonable that the antibiotic regimen includes an agent active against enterococci, e.g. ampicillin,
amoxicillin, or vancomycin. Vancomycin should only be administered to patients unable to tolerate β-lactams. If infection is caused by a known or
suspected strain of resistant enterococcus, consultation with an infectious diseases specialist is recommended.
For patients undergoing surgical procedures involving infected skin (including oral abscesses), skin structure, or musculoskeletal tissue, it is reasonable
that the therapeutic regimen contains an agent active against staphylococci and b-haemolytic streptococci, e.g. an anti-staphylococcal penicillin or
cephalosporin. Vancomycin or clindamycin may be used in patients unable to tolerate a β-lactam antibiotic. If the infection is known or suspected to be
caused by MRSA, vancomycin or another suitable agent should be administered.
49 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
PROPHYLACTIC REGIMENS FOR DENTAL, ORAL, RESPIRATORY TRACT, SKIN AND MUSCULOSKELETAL
TISSUE
Prophylactic Regimes for Amoxycillin/Clavulanate Ampicillin 2gm IV single If patient is unable to tolerate PO
Dental, Oral, Respiratory Tract, 2gm PO single dose 1 hour dose 30 minutes before antibiotic.
Skin and Musculoskeletal before procedure procedure
Tissue OR
Cefazolin 1gm IV single dose If patient is unable to tolerate PO
30 minutes before procedure antibiotic or allergic to penicillin.
OR
Ceftriaxone 1gm IV single If patient is unable to tolerate PO
dose 30 minutes before antibiotic or allergic to penicillin.
procedure
OR
Clindamycin 600mg PO If patient has immediate-type penicillin
single dose 1 hour before hypersensitivity).
procedure OR 600mg IV
single dose 30 minutes before
procedure
SECONDARY PREVENTION OF RHEUMATIC FEVER
Secondary Prevention of Penicilin G Benzathine Penicillin V 250mg PO q12h
Rheumatic Fever (Benzathine OR
Penicillin)1.2MU IM every 3 Erythromycin Ethylsuccinate
weeks 800mg PO q12h
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Index:
Community Acquired Pneumonia (CAP) Acute Infective Exacerbation of Chronic Obstructive Pulmonary
- Mild pneumonia Disease (AECOPD)
- Moderate pneumonia - Fulfilled criteria for pneumonia
- Severe pneumonia - No increased purulent sputum
Lung Abscess - Increased purulent sputum
Empyema Early onset HAP (including VAP) and low risk for infection with
multi-drug resistant (MDR) organisms
Early onset HAP with MDR risk factors
Late onset HAP
RESPIRATORY INFECTIONS
(Lower Respiratory Tract Infections)
* If penicillin allergy:
Moxifloxacin 400mg PO
q24h
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Moderate pneumonia Amoxicillin/Clavulanate Ampicillin/Sulbactam 1.5gm If patient had received antibiotics for
(CORB=1, SMART-COP 3-4) 1.2gm IV q8h for 7 days IV q8h current illness prior to admission, consider
PLUS PLUS adding gentamicin or use ceftriaxone as
Streptococcus pneumonia Azithromycin 500mg PO/IV Clarithromycin 500mg PO beta-lactam agent.
Haemophilus influenza q24h for 5 days q12h (see Severe pneumonia)
Klebsiella pneumoniae
Mycoplasma pneumoniae * If penicillin allergy: Criteria (>24 hours) for switching IV to
Chlamydophila pneumonia Moxifloxacin 400mg PO/IV oral antibiotics
Legionella pneumophila q24h - Absence of mental confusion
Staphylococcus aureus - Ability to take oral medication
Other gram negative bacilli - Temperature lower than 38.3°C
- Hemodynamic stability (heart rate
<100 beats/min and systolic blood
pressure >90 mm Hg)
- Respiratory rate lower than 25
breaths/min
- Sp02 > 90% while breathing in normal
room air or return to baseline oxygen
level for patients receiving long-term
oxygen therapy (LTOT)
52 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Other gram negative bacilli - Hospitalization within the last 90 days
- Nursing home resident
- Chronic dialysis
- Home wound care
- Home infusion therapy
If suspect melioidosis Ceftazidime 2gm q8h for 4-6 Meropenem 1gm IV q8h
week (see section on
melioidodsis)
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
(e.g. among IVDU/ elderly/ for 4-6 weeks 12h (if MRSA suspected or
pediatric) allergic to penicillin)
Vancomycin alternative
Empyema
Always investigate as per pleural effusion. Drainage via chest tube required. Tuberculosis must be excluded.
Streptococcus pneumonia Amoxycillin/Clavulanate Ceftriaxone 2gm IV q24h for
Streptococcus pyogenes 1.2gm IV q8h for 4-6 weeks 4-6 weeks
Staphylococcus aureus OR OR
Anaerobes Ampicillin/Sulbactam 1.5gm Cefotaxime 1gm IV q8h
Enterobactereriaceae IV q8h for 4-6 weeks
PLUS
Metronidazole 500mg IV
q8h followed by 400mg PO
q8h for 4-6 weeks
Acute infective exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)
Fulfilled criteria for Refer to CAP treatment *Criteria for pneumonia
pneumonia * guidelines - Fever (≥38°C), cough, purulent
(If no clinical or radiological sputum, pleural pain, dyspnea
evidence of pneumonia, see - New focal chest signs (e.g.
below) crepitation) on examination
- New chest x-ray shadowing for which
there is no other explanation
No increased purulent sputum - No antibiotics
- Symptomatic treatment
- Optimize COPD
treatment
Increased purulent sputum Doxycycline 100mg PO Amoxycillin 500mg PO q8h *No risk factors
q12h for 3-5 days - Age < 65 years
Uncomplicated COPD - FEV1 >50% predicted
*No risk factors - <4 exacerbations/year
- No cardiac disease
54 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Increased purulent sputum Amoxycillin/clavulanate Ampicillin/sulbactam 1.5gm *≥ 1 risk factors
1.2gm IV q8h for 5-7 days IV q8h - Age > 65 years
Complicated COPD - FEV1 <50% predicted
*≥ 1 risk factors - ≥4 exacerbations/year
- Cardiac disease
Early onset HAP (including Amoxycillin/Clavulanate Ceftriaxone 2gm IV q24h S. aureus is more common in diabetes
VAP) and Low risk for 1.2gm IV q8h mellitus, head trauma.
infection with multi-drug OR
resistant (MDR) organisms - Cefuroxime 1.5gm IV q8h Monotherapy is recommended for early
< 5 days onset HAP/VAP/HCAP.
S. pneumoniae
H. influenzae
S. aureus
E. coli
K. pneumoniae
MDR Pseudomonas aeruginosa Piperacillin/Tazobactam Imipenem 500mg IV q6h Use combination therapy if MDR
4.5gm IV q6h OR pathogen is suspected.
OR Meropenem 1gm IV q8h
Cefepime 2gm IV q8h Aminoglycoside can be stopped after 3-5
PLUS days in patients on combination therapy
PLUS who are responding to treatment.
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Amikacin 15mg/kg/24h IV
Amikacin 15mg/kg/24h IV OR
OR Ciprofloxacin 400mg IV q8h
Ciprofloxacin 400mg IV q8h
ESBL producing Klebsiella Ertapenem IV 1gm q24h Imipenem 500mg IV q6h There is lack of adequate data on the
pneumoniae OR pharmacokinetics of once-daily
Meropenem 1gm IV q8h administration of ertapenem in critically
ill patients.
Methicillin-resistant PLUS
Staphylococcus aureus (if MRSA is suspected)
Vancomycin 1gm IV q12h Linezolid 600mg IV q12h
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Index:
Syphilis Chlamydial/Non-specific urethritis (NSU)/Non-specific genital
- Primary, secondary & early latent syphilis infection in women (NSGI)
- Late latent, gummatous and cardiovascular syphilis Chlamydial/Non-specific urethritis (NSU)/Non-Specific genital
- Neurosyphilis infection in pregnancy
Gonorrhoea Recurrent and persistent non-gonococcal urethritis
- Uncomplicated (urogenital, anorectal, pharyngeal Chancroid
- Gonococcal conjunctivitis Lymphogranuloma venereum
- Gonococcal epididymitis/Epididymo-orchitis Granuloma inguinale
- Disseminated gonorrhoea (acral pustules, arthralgia, Trichomoniasis
tenosynovitis, septic arthritis) Bacterial vaginosis
- Gonococcal meningitis Herpes genitalis (Herpes simplex virus 1 and 2)
- Gonococcal endocarditis
Herpes genitalis in HIV
Herpes genitalis in pregnancy
57 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Neurosyphilis Aqueous crystalline Ceftriaxone 2gm IM (with Repeat CSF examinations every 6
penicillin G, 18- Lidocaine as diluent) or IV months. Consider retreatment if cell
24MU/day, administered 3 (with water for injection as count is not decreased in 6 months or
- 4 MU q4h IV for 14 days diluent) for 10-14 days (if no CSF is not entirely normal in 2 years.
anaphylaxis to penicillin) (Ref: MMWR 1998; 47, RR-1)
OR
All patients with neurosyphilis should be
Procaine Penicillin 2.4MU considered for corticosteroid cover at the
IM q24h start of the therapy to prevent the
PLUS Jarisch-Herxheimer reaction
Probenecid 500mg PO q6h (Prednisolone 10-20mg PO q8h for
for 14 days 3 days commencing one day prior to
syphilis treatment).
Reference:
Centre of Disease Control, USA 2013.
Gonorrhoea Ceftriaxone 500mg IM as a Azithromycin 2gm PO stat Contact tracing
Neisseria Gonorrhoeae single dose (for severe cephalosporin
Uncomplicated PLUS allergy) Also treat for non-specific urethritis
(Urogenital, Azithromycin 1gm PO as a (NSU) in view of high incidence of
Anorectal, Pharyngeal) single dose coexisting NSU in patients with
gonorrhea.
OR
Patient to come back 1 week later for
Ceftriaxone 500mg IM as a test of cure if alternative treatment is
single dose used.
PLUS Reference:
Doxycycline 100mg q12h Centre of Disease Control, USA 2013
PO for 7 days
Gonococcal Conjunctivitis Ceftriaxone 500mg IM q24h Azithromycin 2gm PO STAT Reference:
for 3 days PLUS Centre of Disease Control, USA 2013
OR Doxycycline 100mg PO q12h
Ceftriaxone 1gm IM STAT for 7 days
PLUS
58 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Ciprofloxacin 250mg PO q24h
for 3 days
Gonococcal Epididymitis/ Ceftriaxone 500mg IM/IV Contact tracing
Epididymo-orchitis q24h for 7 days
References:
OR British Association of Sexual Health and HIV
Clinical Effectiveness Guidelines 2008.
Centre of Disease Control, CDC 2010 (updated
Ceftriaxone 250mg IM 2013)
STAT
PLUS
Doxycycline 100mg PO
q12h for 10 days
Disseminated Gonorrhoea Ceftriaxone 1gm IM/IV Cefotaxime 1gm IV q8h Admit patient
(Acral pustules, arthralgia, q24h for 7 days
tenosynovitis, septic arthritis) Contact tracing
Reference:
Centre of Disease Control, USA 2013.
Gonococcal Meningitis Ceftriaxone 1-2gm IV q12h Reference:
for 10 to 14 days Centre of Disease Control, USA 2013
Quinolone is contraindicated in
pregnancy and children less than 18
years old.
59 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Chlamydial/Non-Specific Azithromycin 1g PO STAT Erythromycin Ethylsuccinate Reference:
Urethritis (NSU)/Non-Specific OR 800mg PO q6h for 7 days Centre of Disease Control, USA 2013
Genital Infection in Amoxycillin 500mg PO q8h OR
Pregnancy for 7 days Erythromycin Ethylsuccinate
400mg q6h for 14 days
Recurrent and persistent Metronidazole 2gm PO Metronidazole 400mg q12h for Reference:
Non-gonococcal urethritis STAT 5 days Centre of Disease Control, USA 2013
PLUS
Erythromycin Ethylsuccinate
800mg PO q6h for 3 weeks
OR
60 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
OR the first few days to other agents.
Erythromycin Ethylsuccinate
800mg PO q6h for 3 weeks and Duration of treatment should be until
until all lesions completely heal lesions have healed. Healing times vary
OR greatly between patients. A minimum of
Azithromycin 1gm PO weekly 3 weeks treatment is recommended.
for 3 weeks or 500mg PO q24h
for 7 days and until all lesions References:
completely heal Centre of Disease Control, USA 2013.
British Association of Sexual Health and HIV
OR Clinical Effectiveness Guidelines 2008.
Ceftriaxone 1gm IV q24h for 3
weeks and until all lesions
completely heal
Trichomoniasis Refer to Obstetrics &
Trichomonas vaginalis Gynaecology Infections
Section
Bacterial vaginosis Refer to Obstetrics &
Gardnerella vaginalis, Gynaecology Infections
Anaerobes Section
Herpes Genitalis
Herpes Simplex Virus 1 and 2
Reference:
First episodic: Acyclovir 200mg PO 5 Centre of Disease Control, USA 2013
times a day for 5 days (max
10 days)
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
(short course)
62 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
considered for all women, particularly
those developing symptoms after 34
weeks of gestation, as the risk of viral
shedding is very high. If vaginal
delivery is unavoidable, acyclovir
treatment of mother and baby may be
indicated.
References:
Centre of Disease Control, USA 2013
British Association of Sexual Health and HIV
Clinical Effectiveness Guidelines 2008
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Index:
Impetigo - Tinea unguium
Ecthyma - Tinea versicolor
Ecthyma gangrenosum - Candidiasis
Boils/Carbuncles - Subcutaneous fungal infections
Erysipelas - Sporotrichosis
Cellulitis VIRAL INFECTIONS
Diabetic foot infections - Herpes simplex infections
Gas gangrene/Myonecrosis/Necrotizing fasciitis - Chickenpox (Varicella zoster)
- Herpes zoster (Varicella zoster)
MYCOBACTERIAL INFECTIONS
- Hansen’s disease (Leprosy) PARASITIC INFESTATIONS
- Scabies
FUNGAL INFECTIONS
- Head lice
- Tinea capitis
- Body lice/Pubic lice
- Tinea barbae
Peripheral thrombophlebitis
- Tinea corporis/Tinea cruris/Tinea faciei
- Tinea manuum/Tinea pedis
Penicillin Allergy
Erythromycin Ethylsuccinate
800mg PO q12h for 5-7 days
Localised: Topical 2% Fusidic Acid q8- Topical 2% Mupirocin q8- Topical fusidic acid is not
12h for 7 days (Outpatient use 12h for 5 days recommended for inpatients
64 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
only) (Resistance to Mupirocin is
on the rise)
Ecthyma
S. pyogenes Topical mupirocin 2% q8-12h Reference:
Localised for 7 days Lippincott’s Guide to Infectious Disease 2011
Ecthyma gangrenosum Antipseudomonal penicillin e.g Use in combination initially before
Pseudomonas Piperacillin sensitivity results available.
PLUS References:
Aminoglycosides DermNet NZ Update Dec 2013.
Management of Ecthyma gangrenosum
OR MedscapeUpdated june 2013.
Fluoroquinolones
OR
Antipseudomonal
Cephalosporins
Boils/Carbuncles Cloxacillin 500mg PO q6h for Erythromycin Ethylsuccinate Surgical drainage is important in the
S. aureus 7-10 days 800mg PO q12h for 7-10 management
days
OR Reference:
Cefuroxime 500mg PO q12h National Healthcare System UK 2013
for 7-10 days
OR
Amoxycillin/Clavulanate
625mg PO q8h for 7-10 days
Erysipelas Penicillin PO 500mg q6h >2 Cefazolin 1gm IV q8h Reference:
Strep. pyogenes weeks OR Merck Manual 2013
OR Cephalexin 500mg PO q6h
Erythromycin Ethylsuccinate
800mg PO q12h for 10 days
OR
65 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Cloxacillin 500mg PO q6h for
10 days
If severe,
Penicillin G IV 1-3MU q6h
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Severe Benzylpenicillin 2-4MU IV q4h Ampicillin-sulbactam 3gm Add Vancomycin 1gm IV q12h (if high
PLUS IV q6h risk of MRSA)
Grade 4 – sepsis syndrome or IV Clindamycin 600-900mg IV PLUS
severe life threatening infection q8h Clindamycin 600-900mg IV Early aggressive surgical intervention if
such as necrotising fasciitis q8h necrotising process suspected
OR
References:
Piperacillin-tazobactam 4.5g IV IDSA SSTI Practice Guidelines 2014
CREST Guidelines On The management of
q6h Cellulitis In Adults 2005
The Sandford Guide to Antimicrobial Therapy
2017
Johns Hopkins Abx POC-IT Guide 2016
Diabetic Foot Infections Refer to Bone & Joint Infections
Section (Orthopedic)
Gas Gangrene/ Myonecrosis/ Refer to Bone & Joint Infections
Necrotizing Fasciitis Section (Orthopedic)
Streptococci
Clostridium sp. Polymicrobial
MYCOBACTERIAL INFECTIONS
Hansen’s Disease (Leprosy) Paucibacillary Bacterial resistance or Remarks: Second line can only be
Mycobacterium Leprae Rifampicin 600mg PO monthly hypersensitivity to first line initiated by a dermatologist.
(supervised) Can be substituted with one
PLUS of the following:
Dapsone 100mg PO q24h Ofloxacin 400mg PO q24h References:
Duration: 6 months OR Malaysian Clinical practice Guideline on
Management of leprosy 2014
(Completion of 6 doses within 9 Clarithromycin 500mg PO World Health Organisation Health Guidelines
months) q24h
Surveillance: 5 years OR
Ethionamide 250mg PO
Multibacillary q24h
Rifampicin 600mg PO monthly
PLUS
Clofazimine 300mg PO monthly
67 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
PLUS
Dapsone 100mg PO q24h
PLUS
Clofazimine 50mg PO q24h
Duration:
1 year (if initial BI˂4) or 2 years
(if BI≥4)
Completion of 12 doses within
18 months (BI<4)
Completion of 24 doses within
36 months ( BI≥4)
Surveillance: 15 years
FUNGAL INFECTIONS
Tinea capitis Griseofulvin 20-25mg/kg/24h Terbinafine 250mg PO q24h 1) Kerion :Terbinafine 12-16 weeks
Trichophyton, Microsporum (microsized) Griseofulvin 10- OR 2) Contacts of patient may be treated
15mg/kg/day (ultramicrosized) Itraconazole 200mg PO with 2% ketoconazole shampoo 2
PO q24h – 3 times per week for 2 weeks
OR 3) Surgical excision is to be avoided
Griseofulvin 500mg q12h or Duration is based on
q24h for 6 to 12 weeks or longer mycological agent: Reference:
till fungal cultures are negative Trichophyton spp : 2-4 Primary Care Dermatology Society UK 2013.
weeks
PLUS Microsporum spp : 8-12
weeks
2.5% Selenium
sulphide shampoo
OR
2% ketoconazole shampoo ,
2 – 3 times per week for 2
weeks
68 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Tinea barbae Same as treatment of Tinea
capitis (above)
Tinea corporis / Tinea cruris
/ Tinea faciei
Trichophyton,Microsporum, Reference:
Epidermophyton RxFiles Newsletter : Antifungal newsletter (April
2010) Canadian: Bugs and Drugs
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
3 months (toe nails) nails) For 12 months (toe
nails) Reference:
OR RxFiles Newsletter: Antifungal newsletter (April
2010) Canadian: Bugs and Drugs
Fluconazole 150mg PO once
weekly
6-12 months for toenail
≥3 months for fingernail
Tinea versicolor Selenium Sulphide 2% shampoo Itraconazole 200mg PO Reference:
Malassezia Furfur apply to affected areas 10 q24h for 1 week (recurrent Craig G Burkhart et al.Tinea Versicolor
Treatment & Management.medscape. updated
Pityrosporum Orbiculare minutes before bathing cases) Dec 2013.
OR
Dilute to 1:1 with water, apply
and leave overnight (treat for 1-
2 weeks)
For face:
Topical Imidazole for 4-6 weeks
e.g. Miconazole 2% cream,
Clotrimazole 1% cream,
Tioconazole 1% cream
Candidiasis
Candida albicans
Mild cutaneous candidiasis Topical Imidazole q12h till clear Fluconazole 100mg PO q24h Treatment of sexual partner is advisable
e.g. for 1 week (in severe and in case of recurrent infection.
Miconazole 2% cream, immunocompromised
Clotrimazole 1% cream, patients) Reference:
Tioconazole 1% cream RxFiles Newsletter: Antifungal newsletter (April
2010) Canadian: Bugs and Drugs
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Subcutaneous Fungal
Infections
a. Sporotrichosis
i. localized to skin only Itraconazole 200mg PO q24h Fluconazole 400-800mg In some immunocompromised
for 3-6 months for at least 2-4 q24h condition such as AIDS, longer
weeks after recovery. (max OR treatment may be necessary. Refer to
200mg q12h, if no response) Potassium Iodide (saturated Opportunistic Infections In HIV
OR solution 50mg/drop) 5 drops Patients.
Terbinafine 250mg q24h/q12h q8h may increase to 40-50
(max 500mg BD, if no response) drops q8h
Immunosuppressed patients.
Refer to chapter on HIV
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Genitalia:
(Refer to Sexually
Transmitted Infections-herpes
genitalis)
Eczema herpeticum:
Acyclovir 200mg PO 5 times
daily for 7-10 days
Chickenpox
Varicella zoster
Immunocompetent Acyclovir 800mg PO 5 times Advisable to start treatment early
daily for 7 days within 48 hours
Involving face/genitalia
72 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Permethrin 5% cream apply
and leave for 8 hours
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Index:
Typhoid Fever Malaria
Cholera - Plasmodium falciparum (Uncomplicated, new infection)
Scrub typhus - Plasmodium falciparum (Uncomplicated, treatment failure or
Brucellosis relapse)
Leptospirosis - Plasmodium falciparum (Complicated)
Tetanus - Plasmodium vivax/ovale (New infection)
Melioidosis - Plasmodium malariae/ knowlesi
- Mixed Infection
- Chemoprophylaxis
TROPICAL INFECTIONS
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
1. Typhoid Fever
Salmonella Typhi Ciprofloxacin 500mg PO Amoxycillin 75 – Fever clearance is faster with Quinolones
Stable Case q12h for 5-7 days 100mg/kg/day PO in 3-4
Fully sensitive divided doses for 14 days Reference:
OR WHO, 2003
Parry CM et al. Typhoid fever. N Engl J Med 2002;
Trimethoprim/ 347:1770.
Sulfamethoxazole
160/800mg PO q12h for 14
days
Quinolone resistance Ceftriaxone 60mg/kg/day for Azithromycin 500mg PO Reference:
10-14 days q24h for 7 days WHO, 2003
Unstable or complicated cases Ceftriaxone 60mg/kg/day Indication of dexamethasone:
for 10-14 days (discuss with physician)
OR i) Typhoid psychosis
Ciprofloxacin 400mg IV ii) Septic shock
q12h for 10-14 days Dose: 3mg/kg loading, then 1mg/kg q6h
for 2 days
Reference:
WHO, 2003
Paed. Inf. Dis J,1988
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
2. Cholera
Vibrio cholerae Principle of Treatment:
i) Rehydration ORS if tolerating orally
Non Tetracycline resistance Doxycycline 300mg PO stat Ciprofloxacin 1gm PO stat ii) Monitor urine output
(once patient can take orally) iii) Avoid antidiarrhoea agents -
Diphenoxylate HCL/Atropine
Tetracycline resistance Erythromycin Ethylsuccinate Ciprofloxacin 1gm PO stat Sulphate (Lomotil) or Loperamide
800mg PO q12h for 3 days HCL (Imodium)
OR
Azithromycin 1gm PO stat Reference:
WHO Global Task on Cholera Control 2004
Saha D et al. Single-dose azithromycin for the
treatment of cholera in adults. N Engl J Med 2006;
354:2452.
3. Scrub Typhus
Orientia tsutsugamushi Doxycycline 100mg PO Azithromycin 500mg PO ƚ Recommended alternative for pregnant
(rickettsia tsutsugamushi) q12h for 3-7 days statƚ woman
Tetracycline sensitive
Reference:
CID 2004 Nov 1; 39(9):1329-35
4. Brucellosis
B. melitensis, Streptomycin 1gm (15mg/kg) Doxycycline 100mg PO Longer duration (up to 12 weeks) may be
B. abortus, B. suis and B. canis IM q24h for 2 - 3 weeks q12h for 6 weeks required in spodylitis, neurobrusellosis,
PLUS PLUS IE, localized suppurated lesions
Doxycycline PO 100mg Gentamicin 5mg/kg/24h IV
q12h for 6 weeks for 7 days
OR OR
75 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
(15mg/kg) PO q24h for 6 PLUS CPG Brucellosis, MOH 2012
weeks Trimethoprim/ Ariza J et al. Perspectives for the treatment of
brucellosis in the 21st century: the Ioannina
Sulfamethoxazole recommendations. PLoS Med 2007; 4:e317.
160/800mg PO q12h for 6 Mandell, Douglas & Bennett’s Principles &
Practice of Infectioius Diseases. 8th Edition
weeks ƚ
5. Leptospirosis
Mild disease Doxycycline 100mg PO
(No or mild organ dysfunction) q12h 5-7 days
Severe disease C-Penicillin 1.5-2 megaunits Ceftriaxone 2gm IV q24h
(moderate to severe organ IV q6h for 7-14 days (If evidence of pneumonia or
dysfunction) (If no evidence of pneumonia suspected gram negative
or gram negative sepsis) sepsis)
6. Tetanus
Clostridium tetani Metronidazole 500mg IV Benzylpenicillin 2MU IV
q6h-q8h for 7-10 days q6h for 7-10 days
Human Tetanus All patients with tetanus should undergo
Immunoglobulin wound debridement to eradicate spores
3000- 6000 units IM stat and necrotic tissue.e
76 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
divided doses within 72 hours of admission.
PLUS/MINUS
Duration: Look for source of infection.
2 - 3 weeks Trimethoprim/
4 - 8 weeks if severe/ deep Sulfamethoxazole Folic Acid 5mg PO q24h to be given for
focal infection 8/40mg/kg/24h IV/PO in patient on Trimethoprim/
divided doses Sulfamethoxazole.
Duration:
2 - 3 weeks Reference:
4 - 8 weeks if severe/ deep CPG Melioidosis Pahang 2011
focal infection Inglis TJJ. The treatment of melioidosis.
Pharmaceuticals 2010;3:1296-1303
Bart Currie, Nicholas Anstey, Treatment &
Eradication/Maintenance Trimethoprim/ Amoxycillin/Clavulanate
Prognosis of Melioidosis, Wolters Kluwer Health.
Therapy Sulfamethoxazole 1250mg (2 tabs of 625mg)
< 40 kg: 160/800mg q12h; PO q8h
40-60kg:240/1200mg q12h; OR
>60kg:320/1600mg q12h Doxycycline 100mg PO
q12h or 200mg PO q24h
Duration: minimum 3
months Duration: minimum 3
months
In patients with neurological
or osteomyelitis up to 6
months treatment is
recommended.
8. Malaria
WHO recommends the use of Artemisinin Combination Therapy (ACT) as the standard treatment for malaria and discourages the prescription
of monotherapy or sub-standard ACT as this will promote resistant.
Features of severe/complicated Malaria includes at least one of the following clinical or laboratory features:
Clinical manifestation:
Impaired consciousness or unrousable coma
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Prostration (generalized weakness so that the patient is unable to walk or sit up without assistance)
Failure to feed/ not tolerating orally
Convulsion
Deep breathing, respiratory distress (acidotic breathing)
Circulatory collapse or shock
Clinical jaundice and evidence of other vital organ dysfunction
Haemoglobinuria
Abnormal spontaneous bleeding
Pulmonary oedema (radiological)
Laboratory test:
Hypoglycaemia, metabolic acidosis, severe normocytic anaemia, haemoglobinuria, hyperparasitaemia, hyperlactataemia or renal impairment.
Reference:
CPG Malaria, MOH 2013, WHO Guideline on Treatment of Malaria 2010 and WHO A Practical Handbook: Management of Severe Malaria 2012
78 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
OR
79 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Plasmodium vivax/ovale Riamet® Chloroquine 10mg/kg (max G6PD deficiency: Primaquine 0.75mg/kg
New infection (dosing as per Plasmodium 600mg) PO stat, then 5mg/kg PO q7d for 8 weeks. If significant
falciparum treatment) (max 300mg) 6 hours later, haemolysis occurs, should be stopped.
PLUS followed by q24h for 2 days.
Primaquine 0.5mg/kg (max PLUS Pregnancy: Full course chloroquine to be
30mg) PO q24h for 14 days. Primaquine 0.5mg/kg (max given, followed by 300mg q7d till
30mg) PO q24h for 14 days. delivery. Full course of primaquine only
to be given post-delivery.
Plasmodium malariae/ Riamet® Artesunate /Mefloquine If severe P.malariae/knowlesi, treatment
knowlesi (dosing as per Plasmodium (dosing as per Plasmodium is as complicated P.Falciparum.
falciparum falciparum treatment)
OR
Chloroquine 10mg/kg (max
600mg) PO stat, then 5mg/kg
(max 300mg) 6 hours later,
followed by q24h for 2 days
Mixed Infection Treat as Plasmodium
falciparum
Chemoprophylaxis Doxcycline 100mg PO q24h Mefloquine 250mg PO q7d Pregnancy: Only melfoquine can be used
Start: 1-2 days before Start: 2 weeks before
departure departure Refer to the drug resistance pattern and
Stop: 4 weeks after travel Stop: 4 weeks after travel recommended prophylaxis in the
Max duration: 2 years Max duration: 1 year travelling destination.
OR
Atovaquone/proguanil *Requires DG approval
(Malarone®)* 100/250mg
q24h
Start: 1-2 days before
departure
Stop: 7 days after travel
80 | P a g e
Index:
Drugs Management of Tuberculosis in Special Situations
- First-line antiTB drugs - Tuberculosis during pregnancy and lactation
- Fixed-dose combination (FDC) dosing - Tuberculosis and use of oral contraceptive pill
- Second-line antiTB drugs - Tuberculosis in patients with liver impairment
Treatment Regimens - Tuberculosis in patients with renal impairment
- New case of pulmonary tuberculosis (PTB) - Tuberculosis-HIV co-Infection
- Treatment of previously treated cases
- Extra-pulmonary tuberculosis
- Multi-drug resistant tuberculosis (MDR-TB)
TUBERCULOSIS INFECTIONS
(Adapted from the Clinical Practice Guidelines For The Management of Tuberculosis, Ministry of Health Malaysia,3 rd edition 2012)
1. Drugs
1.1 First-line AntiTB Drugs
Recommended Dose
Drug Daily 3 times/week
Dose (range) in mg/kg Max/day in mg Dose (range) in mg/kg Max/day in mg
Isoniazid (H)* 5 (4 - 6) 300 10 (8 - 12) 900
Rifampicin (R) 10 (8 - 12) 600 10 (8 - 12) 600
Pyrazinamide (Z) 25 (20 - 30) 2000 35 (30 - 40)** 3000**
Ethambutol (E) 15 (15 - 20) 1600 30 (25 - 35)** 2400**
Streptomycin (S) 15 (12 -18) 1000 15 (12 - 18)** 1500**
*Pyridoxine 10 – 50mg/day needs to be added.
**Daily treatment is the preferred regimen.
The two FDCs available in MoH Drug Formulary for adults are:-
(i) 4-Drug FDC : Isoniazid 75mg, Rifampicin 15 mg, Pyrazinamide 400mg and Ethambutol 275mg tablet
(ii) 3-Drug FDC: Isoniazid 75mg, Rifampicin 150mg and Pyrazinamide 400mg tablet
81 | P a g e
The recommended dosages for the two FDCs are:
Body weight (kg) Recommended dose
30 - 37 2 tabs daily
38 - 54 3 tabs daily
55 - 70 4 tabs daily
>70 5 tabs daily
*Pyridoxine 10 – 50mg/day needs to be added.
2. Treatment regimens
82 | P a g e
New patients with pulmonary tuberculosis should receive daily 2EHRZ* (2 months of intensive phase), followed by daily 4HR* (4 months of
maintenance phase).
Regimen should contain six months of rifampicin.
Rifampicin should be rounded to higher recommended dose if tolerated.
If ethambutol is contraindicated, streptomycin can be substituted
*The number preceding the treatment regimen refers to the treatment duration in months.
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3. Management of Tuberculosis in Special Situations
3.1 Tuberculosis during pregnancy and lactation
First-line antiTB drugs except streptomycin are safe for pregnancy and lactation.
Standard treatment using Isoniazid, Rifampicin, Pyrazinamide and Ethambutol is used.
Streptomycin should be avoided in pregnancy due to foetal ototoxicity.
Pyridoxine (25mg daily) should be given to all pregnant/lactating women on isoniazid to prevent foetal neurotoxicity.
Once active TB in the baby is ruled out, the baby should be given six months isoniazid prophylaxis, followed by BCG vaccination.
84 | P a g e
Index:
Acute uncomplicated cystitis Acute pyelonephritis in pregnancy
Acute cystitis in pregnancy Asymptomatic bacteriuria
Recurrent urinary tract infections prophylaxis Asymptomatic bacteriuria in pregnancy
Acute uncomplicated pyelonephritis Catheter related bacteriuria
Acute complicated pyelonephritis CAPD peritonitis
85 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Acute Uncomplicated The choice of agents should be based
Pyelonephritis on local culture and susceptibility
E.coli, Enterobacter, Proteus results.
Pseudomonas
May step down to oral antibiotic
For patients not requiring Ciprofloxacin 500mg PO Amoxycillin/Clavulanate following clinical improvement
hospitalization q12hrs for 7 days with/ without 625mg PO q8h for 14 days (afebrile for 48 hours).
an initial Ciprofloxacin 400mg
stat IV
Ciprofloxacin 400mg IV q12h
For patients requiring Ceftriaxone 1-2gm q24h IV for for 7 days
hospitalization 14 days with/without
aminoglycoside.
OR
Amoxycillin/Clavulanate
1.2gm IV q8h for 14 days
Acute Complicated Refer to Surgical Infections
Pyelonephritis Section
Acute Pyelonephritis in Cefuroxime 750mg IV q8h for Amoxycillin/Clavulanate Avoid trimethoprim and
Pregnancy 14 days 1.2gm IV q8h for 14 days fluoroquinolones in pregnancy.
OR
Ceftriaxone 1-2gm IV q24h for
14 days
Asymptomatic Bacteriuria Trimethoprim 100mg PO Cefuroxime 250mg PO q12h The choice of agents should be based
q12hr for 7 days or for 7days on local culture and susceptibility
Recommendation for treatment 300mg PO q24h for 7 days results.
is only for the following OR
conditions:- Nitrofurantoin 50mg PO q6h Avoid trimethoprim in pregnancy.
a) Pregnant women if test for 7 days
results are positive (refer to
Asymptomatic Bacteriuria
in Pregnancy)
b) Patients who undergo
86 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
traumatic urologic
interventions with mucosal
bleeding,and such patients
should be treated prior to
such interventions
c) Before transurethral
resection of the prostate
d) Before renal transplant or
early post-operative period
Asymptomatic Bacteriuria in Nitrofurantoin 50mg PO q6h Cephalexin 500mg PO q12h Avoid trimethoprim and
Pregnancy for 7 days for 7 days fluoroquinolones in pregnancy.
OR OR
Cefuroxime 250mg PO q12hr Amoxycillin/Clavulanate
for 7 days 625mg PO q8h for 7 days
Catheter Related Bacteriuria Antibiotics not recommended Remove or change catheter if possible.
for asymptomatic bacteriuria Only consider antimicrobial treatment
with indwelling urethral if bacteriuria persists 48hrs after
catheter catheter removal.
CAPD Peritonitis Intra peritoneal Cefazolin 15 If patient has been colonized Consider adding the same intravenous
Staph aureus mg/kg per bag once daily with MRSA or is in clinical antibiotics on top of intraperitoneal
CoNS PLUS sepsis or has hypersensitivity to antibiotics in severely ill patients.
Pseudomonas aeruginosa Intra peritoneal Ceftazidime 1- cephalosporins, Vancomycin
Enteric gram negatives 1.5gm per bag once daily can replace Cefazolin at 15-30 If possible, centrifuge removed dialysis
mg/kg every 5-7 days fluid – gram stain and culture directly
into blood culture bottle. .
For hypersensitivity to
Cephalosporins, Ceftazidime If multiple enteric gram negatives are
can be replaced with grown, consider bowel perforation and
Gentamycin 0.6 mg/kg per bag removing catheter.
once daily .
Also consider catheter removal in
relapsing or refractory peritonitis;
refractory exit or tunnel infection and
87 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
for fungal peritonitis.
References:
1. The Sanford Guide To Antimicrobial Therapy 2011
2. Guidelines on Urological Infections, European Association of Urology 2014
3. IDSA Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults 2005
4. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the IDSA and European Society for
Microbiology and Infectious Diseases 2011.
5. Sanford, Australian therapeutic guidelines on antibiotics
88 | P a g e
NEUROSURGICAL
DEPARTMENT
89 | P a g e
Index:
Classification of Types of Neurosurgical Procedures According to Neurosurgery
the Risk of Infection Recurrent urinary tract infections - Cranial trauma
prophylaxis - Skull base fracture without CSF fistula
Chemoprophylaxis for Neurological Surgery - Skull base fracture with CSF fistula
- Clean - Skull fracture with pneumocranium
- Clean + implant - Brain abscess
- Clean contaminated
- Contaminated
- Dirty
NEUROSURGERY
90 | P a g e
Infection / Condition & Suggested treatment
Comments
likely organism Preferred Alternative
Clean
(Craniotomy, burrhole for clean
pathology)
β-Lactam Allergy:
Clindamycin 900mg IV
MRSA colonisation:
Vancomycin 15mg/kg IV
Clean + Implant (CSF Cefuroxime 1.5gm IV single Ceftriaxone 2gm IV single
diversion procedures e.g. Shunt, dose one hour prior to skin dose one hour prior to skin
EVD, omaya, DBS, incision incision
Titanium/acrylic cranioplasty,
artificial dura used) β-Lactam Allergy:
Clindamycin 900mg IV
MRSA colonisation:
Vancomycin 15mg/kg IV
91 | P a g e
Infection / Condition & Suggested treatment
Comments
likely organism Preferred Alternative
Clean Contaminated Cefuroxime 1.5gm IV single Ceftriaxone 2gm IV single
(Transphenoidal, Acoustic dose one hour prior to skin dose one hour prior to skin
neuroma, involving air sinuses) incision, followed by three incision followed by three
repeated doses of 750mg IV repeated doses of 1gm IV
q8h q12h
β-Lactam Allergy:
Clindamycin 900mg IV
MRSA colonisation:
Vancomycin 15mg/kg IV
Contaminated Cefuroxime 1.5gm IV q8h Ceftriaxone 2gm IV q12h
(Skull fracture, previous PLUS/MINUS PLUS/MINUS
surgery, lacerated scalp) Metronidazole 500mg IV Metronidazole 500mg IV
q8h for 72hours q8h for 72hours
β-Lactam Allergy:
Clindamycin 900mg IV
MRSA colonisation:
Vancomycin 15mg/kg IV
Dirty Ceftriaxone 2gm IV q12h Meropenem 2gm IV q8h
(Brain abscess, subdural PLUS/MINUS PLUS/MINUS
empyema, ventriculitis Metronidazole 500mg IV Metronidazole 500mg IV
q8h for 6-8 weeks depending q8h
on response
MRSA colonisation:
Vancomycin 20mg/kg IV
Pseudomonas infection:
Cefepime 2gm IV q8h
OR
Ceftazidime 2g IV q8h
92 | P a g e
Reference:
1. Am J Health-Syst Pharm Vol 70 Feb 1, 2013
2. Scottish Intercollegiate Guidelines Network. Antibiotic prophylaxis in surgery. www.sign.ac.uk/pdf/sign104.pdf (accessed Nov 2014)
3. Nottingham Antibiotic Guidelines Committee, January 2014
4. National Institute for Health and Clinical Excellence. Surgical site infection (clinical guideline 74) 2008. www.nice.org.uk/CG74 (accessed Nov 2014)
5. Tunkel, et al. Practice Guidelines for the Management of Bacterial Meningitis. Clin Inf Dis 2004; 39: 1267-84
6. IDSA 2014
Neurosurgery
Reference:
1. Am J Health-Syst Pharm Vol 70 Feb 1, 2013
2. Scottish Intercollegiate Guidelines Network. Antibiotic prophylaxis in surgery. www.sign.ac.uk/pdf/sign104.pdf (accessed Nov 2014)
3. Nottingham Antibiotic Guidelines Committee, January 2014
4. National Institute for Health and Clinical Excellence. Surgical site infection (clinical guideline 74) 2008. www.nice.org.uk/CG74 (accessed Nov 2014)
5. Tunkel, et al. Practice Guidelines for the Management of Bacterial Meningitis. Clin Inf Dis 2004; 39: 1267-84
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OBSTETRICS
&
GYNEACOLOGIC
AL DEPARTMENT
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Index:
Septic abortion Vaginitis, bacterial vaginosis
Intrapartum prophylaxis for group B strep., positive mothers Candidiasis - uncomplicated infection
Pre-op prophylaxis (emergency caesarean) Candidiasis - complicated infection
Preterm premature rupture of membranes (PPROM) Trichomoniasis (Trichomonas vaginalis)
Chorioamnionitis Acute uncomplicated cystitis (UTI)
Pelvic inflammatory disease IV therapy (moderate to severe Recurrent urinary tract infection
disease)
Pelvic inflammatory disease outpatient therapy (mild disease)
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Preterm Premature Rupture Erythromycin Ethylsuccinate RCOG 2010
of Membranes (PPROM) 400-800mg PO q12h until
delivery
Chorioamnionitis Ampicillin/Sulbactam Cefuroxime 750mg IV q8h
3gm IV q6h PLUS
Metronidazole 500mg IV q8h
Pelvic Inflammatory Disease Ceftriaxone 2g IV stat and OD Clindamycin IV 900mg q8h BASH 2011
IV Therapy (for moderate to PLUS PLUS
severe disease): Doxycycline 100mg IV/PO Gentamicin IV 2mg / kg
q12h loading dose, then IV 1.5
mg.kg q8h
Followed by:
Doxycycline PO 100mg q12h Followed by:
PLUS Clindamycin PO 450 mg q6h
Metronidazole PO 400mg q12h
For total 14days OR
96 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Vaginitis Metronidazole 400mg PO q8h Clindamycin 300mg PO q12h Meta-analysis has not found any
Bacterial vaginosis for 7 days for 7 days relationship between metronidazole
exposure during the first trimester of
pregnancy and birth defects and the
CDC no longer discourage the use of
metronidazole in the first trimester.
Candidiasis Clotrimazole 500mg as a single
Uncomplicated infection vaginal pessary (Stat dose)
Candida albicans OR
Clotrimazole 200mg as vaginal
pessary for 3 nights
Candidiasis
Complicated infection
1.Severe vaginitis symptoms Fluconazole 150mg PO q72h
for 2 or 3 doses
97 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Recurrent Urinary Tract Cephalexin 125 -250mg ON Post coital prophylaxis SOJC 2011
Infection For 3- 12 months ( will need to Ciprofloxacin 125 mg single
>3 episodes/year evaluate after 6 months ) dose
( Continous prophylaxis)
During pregnancy
Cephalexin 250 mg PO single
dose
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OPHTHALMOLOGY
DEPARTMENT
99 | P a g e
Index:
Blepharitis Herpes zoster ophthalmicus
Internal hordeolum with secondary infection Ocular toxoplasmosis
External hordeolum (Stye) Acute retinal necrosis
Bacterial conjunctivitis CMV retinitis
Gonococcal conjunctivitis Ocular syphilis
Chlamydial conjunctivitis Ocular tuberculosis
Gonococcal kerato conjunctivitis Post-operative bacterial endophthalmitis
Bacterial keratitis Post-operative fungal endophthalmitis
Contact lens related bacterial keratitis Endogenous endophthalmitis
Acanthamoeba keratitis Dacryocystitis
Gonococcal kerato conjunctivitis Preseptal cellulitis
Fungal keratitis Orbital cellulitis/abscess
Herpes simplex keratitis
OCULAR INFECTIONS
In the presence of superficial Cloxacillin 500mg PO q6h Amoxycillin 500mg PO q8h No topical antibiotics are indicated.
cellulitis or abscess for 5 days for 5 days
100 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
External Hordeolum (Stye) Epilation of affected eye lash Systemic antibiotics are indicated in the
Staph. aureus and warm compresses presence of superficial cellulitis or
abscess.
No antibiotic recommended
as condition is self-limiting
101 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Chlamydial Conjunctivitis Requires systemic therapy. Topical antibiotics are not indicated
(including neonates) Chlamydial Refer to Sexually
Trachomatis Transmitted Infections &
Neonatal Infection Sections
Gonococcal Kerato Requires systemic therapy. *Ceftazidime 5% Commence a loading dose of one drop
conjunctivitis Refer to Sexually eyedrop q1-2h every 15minutes for 3 hours followed by
Neisseria Gonorrhoea Transmitted Infections & OR hourly drops around the clock. Taper
Neonatal Infection Sections *Gentamicin 0.9% or 1.4% based on clinical response
PLUS eye drop q1-2h
Ciprofloxacin 0.3% eye drop OR *Prepared ready to use extemporaneous
q1-2h Moxifloxacin 0.5% eye drop by using injectable forms
q1-2h
Bacterial Keratitis Commence a loading dose of one drop
No Growth/ Mixed Growth every 15 minutes for 3 hours followed by
hourly drops around the clock. Taper
Non severe keratitis (small Ciprofloxacin 0.3% eye drop based on clinical response. .
peripheral keratitis) may q1-2h
consider monotherapy OR *Prepared ready to use extemporaneous
Moxifloxacin 0 .5% eye drop by using injectable forms
q1-2h
102 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Ciprofloxacin 0.3% eye drop
q1-2h *Prepared ready to use extemporaneous
by using injectable forms. .
Gram-Negative Cocci *Gentamicin 0.9% or 1.4% *Ceftazidime 5% eye drop
eye drop q1-2h q1-2h
OR
Ciprofloxacin 0.3% eye drop
q1-2h
OR
Moxifloxacin 0 .5% eye drop
q1-2h
Contact Lens Related Commence a loading dose of one drop
Bacterial Keratitis every 15 minutes for 3 hours followed by
No Growth hourly drops around the clock. Taper
Non severe keratitis (small Ciprofloxacin 0.3% eye drop based on clinical response. .
peripheral keratitis) may q1-2h
consider monotherapy *Prepared ready to use extemporaneous
by using injectable forms.
Severe bacterial keratitis dual *Gentamicin 0.9% or 1.4%
therapy is advocated eye drop q1-2h
PLUS
*Ceftazidime 5% eye
drop q1-2h
Acanthamoeba Keratitis *Chlorhexidine 0.02% eye Topical therapy tapered with response
Acanthamoeba sp. drop q1-2h over a duration of 6-12 month. .
PLUS
**Propamidine isethionate *Prepared ready to use extemporaneous
0.1% q1-2h by using injectable forms. .
**Requires DG approval
103 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Gonococcal Kerato Requires systemic therapy. *Ceftazidime 5% Commence a loading dose of one drop
conjunctivitis Refer to Sexually eyedrop q1-2h every 15minutes for 3 hours followed by
Neisseria Gonorrhoea Transmitted Infections & OR hourly drops around the clock. Taper
Neonatal Infection Sections *Gentamicin 0.9% or 1.4% based on clinical response. .
PLUS eye drop q1-2h
Ciprofloxacin 0.3% eye drop OR *Prepared ready to use extemporaneous
q1-2h Moxifloxacin 0.5% eye drop by using injectable forms.
q1-2h
Fungal Keratitis *Amphotericin B 0.15%- **Natamycin 5% eye Topical therapy tapered with response
Filamentous Fungi/Yeast 0.2% eye drop q1-2h drop q1-2h
PLUS OR *Prepare ready to use extemporaneous
*Fluconozole 0.2% eye **Voriconazole 1% eye
dropq 1-2h drop q1-2h **Requires DG approval
PLUS
Fluconozole 200mg PO q24h PLUS References:
Sun CQ, Lalitha P, Prajna NV, Karpagam R,
Geetha M, O'Brien KS, Oldenburg CE, Ray KJ,
Ketoconazole 200mg PO McLeod SD, Acharya NR, Lietman TM; Mycotic
q24h Ulcer Treatment Trial Group
Association between In Vitro Susceptibility to
Natamycin and Voriconazole and Clinical
Outcomes in Fungal Keratitis. Ophthalmology
2014 Apr 15. pii:S0161-6420(14)00202-4. doi:
0.1016/j. ophtha. 2014.03. 004.
LohAR, Hong K, Lee S, Mannis M, Acharya NR.
Practice patterns in the management
offungalcorneal ul cers. Cornea. 2009;28(8) :856-
859.
Herpes Simplex Keratitis
Herpes Simplex Type 1 & 2
Epithelial Keratitis Acyclovir 3% eye ointment 5 Acyclovir 3% eye ointment 5 times/day is
times/day used as a prophylactic against epithelial
keratitis.
Non-necrotizing In addition to topical
Stromal Keratitis corticosteroids
104 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Acyclovir 3% eye ointment 5
times/day
105 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Acute Retinal Necrosis Acyclovir 10mg/kg/dose * Valacyclovir 1gm PO q8H * Requires DG approval. .
Herpes Simplex IV q8h for 12 weeks (not
more than 800mg) Systemic steroid is indicated depending
on location or severity of the infection.
FOLLOWED BY
Acyclovir 800mg PO 5 References:
times/day for 6 weeks Patrick MKT, Claire Y H, Susan L. Antiviral
selection in the management of acute retinal
necrosis. Clinical Ophthalmology 2010:4 11–20
Peter R, Jost H, Livia G, et al. Virus Diagnostics
and Antiviral Therapy in Acute Retinal Necrosis
(ARN). Antiviral Drugs – Aspects of Clinical Use
and Recent Advances. Intechopen.
MN Muthiah, M Michaelides, CS Child, et al. Acute
retinal necrosis: a national population-based study
to assess the incidence, methods of diagnosis,
treatment strategies and outcomes in the UK. Br J
Ophthalmol 2007;91:1452–1455
Simon RJT, Robin H, Claire YH, Sue Lightman.
Valacyclovir in the treatment of acute retinal
necrosis. BMC Ophthalmology 2012, 12:48.
Robert WW, Emmett TC et al. Diagnosing and
Managing Acute Retinal Necrosis. Retinal
Physician.
CMV Retinitis Ganciclovir 5mg/kg IV * Valganciclovir: 900mg PO Systemic therapy is indicated in all cases.
Cytomegalovirus q12h for 2-3 weeks q12h for 3 weeks (induction) Intravitreal therapy is indicated in zone 1
followed by 900mg PO q24h and 2 lesions. .
for 1 week
Intravitreal to be tapered according:
Intravitreal Ganciclovir Intravitreal *Foscarnet - To clinical response
2mg/0.1ml biweekly 2.4mg/0.1ml - May need to continue until CD4 count
(1-2weekly) is >150cell/mm3 .
Ganciclovir implant: 4.5gm an option to
intravitreal Ganciclovir. .
*Requires DG approval
106 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Ocular Syphilis Ocular Syphilis (syphilitic Referral to Physician/ID Physician
Treponemap Pallidum uveitis) should be treated as
Neurosyphilis
Refer to Sexually Transmitted
Infections Section
Ocular Tuberculosis Needs systemic therapy Ocular TB: presents as a unilateral/
Mycobacterium Tuberculosis Refer to Tuberculosis bilateral infective uveitis characterized by
Infections Section multifocal choroiditis/ granuloma and
there may be supportive FFA findings of
Ethambutol may cause optic occlusive vasculitis. The diagnosis maybe
neuropathy and should clinical as vitreous sampling for AFB or
avoided depending on the TB PCR may not be very sensitive due to
case small sample size and sensitivity of the
tests. Clinical response to anti-TB is often
diagnostic.
Uveitis secondary to TB Hypersen-
sitivity is an immune response to acid fast
bacilli in the eye and manifests
predominantly as an inflammatory uveitis.
Treatment includes anti-TB in
combination with an immunosuppressive
dose of systemic steroids for at least 6-9
months.
Systemic steroid maybe indicated but is
only for:
- non-active systemic TB
- severe ocular inflammation and vision
threatening condition .
References
Helm CJ, Holland GN. Ocular tuberculosis.Surv
Ophthalmol. 1993 Nov-Dec;38(3):229-56
Bodaghi B1, LeHoang P. Ocular tuberculosis. Curr
Opin Ophthalmol. 2000 Dec;11(6):443-8
107 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Post-Operative Bacterial Intravitreal antibiotic Intravitreal antibiotic Systemic antibiotics are indicated in
Endophthalmitis injections injections: severe, virulent endophthalmitis
Staphylococcus epidermidis Vancomycin 1-2mg in 0.1ml Vancomycin 1-2mg in 0.1ml Repeat intravitreal antibiotics after 48 to
Staphylococcus aureus PLUS PLUS 72 hours if indicated. .
Pseudomonas aeruginosa, Ceftazidime 2mg in 0.1ml Amikacin 0.4mg in 0.1ml
Bacteroids Species Endogenous Endophthalmitis:
Streptococcus pneumoniae, If suspicious of fungal Treatment is based on primary infection
Alpha- Haemolytic streptococci endophthalmitis: (bacterial/fungal etc) and culture and
ADD sensitivity results.
Intravitreal Amphotericin B .
0.005mg in 0.1ml All cases require systemic therapy.
Intravitreal injection is indicated in cases
Topical treatment-options Ceftazidime 5% eye drop, with vitreous involvement and sight
Vancomycin 5% eye drop, threatening lesions. .
Gentamycin 1.2% eye drop Do not use systemic steroids.
Moxifloxacin 0.5% eye drop
(monotherapy or
combination)
108 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Endogenous Endophthalmitis Treatment is based on primary infection
Systemic treatment Ciprofloxacin 750mg PO *Moxifloxacin 400mg PO (bacterial/fungal etc) and culture and
q12h for 10days q24h for 10 days (caution in sensitivity results. .
children)
For culture negative cases OR All cases require systemic therapy.
add: Vancomycin Intravitreal injection is indicated in cases
Clarithromycin 250-500mg and Ceftazidime IV with vitreous involvement and sight
PO q12h for 7-14 days threatening chroidal lesions. .
Topical treatment-options: Ceftazidime 5% eye drop, Topical therapy may supplement therapy.
Vancomycin 5% eye drop, Not to use systemic steroids in these
Gentamycin 1.2% eye drop cases.
Moxifloxacin 0.5% eye drop
(monotherapy or
combination)
Intravitreal antibiotic injections: Vancomycin 1-2mg in 0.1ml Vancomycin 1-2mg in 0.1ml Review antibiotic regimen after
PLUS PLUS microbiology results.Repeat intravitreal
Ceftazidime 2mg in 0.1ml Amikacin 0.4mg in 0.1ml antibiotics after 48 to 72 hours if indicated
If suspicious of fungal
endophthalmitis, ADD
Intravitreal Amphotericin B
0.005mg in 0.1ml
Dacryocystitis Cefuroxime 250mg PO q12h Amoxycillin/ Clavulanic Consider intravenous antibiotics in severe
Strep pneumonia, Staph aureus, for 7 days Acid 625mg PO q8h for 7 infections.
Gram-ve Anaerobes days
Preseptal Cellulitis Cloxacillin 500mg -1gm PO Amoxycillin/Clavulanic Acid Consider intravenous antibiotics in severe
Strep pneumoniae,Staph aureus, q6h for 5 days 625mg PO q8h for 7 days infections.
Strepcoccus sp. OR
Ceftriaxone 1-2gm IV q24h
109 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Orbital Cellulitis/abcess Amoxycillin/ Clavulanic Ceftriaxone 1-2gm q24h IV Periorbital and orbital cellulitis : A 10 year review
Strep pneumoniae, Staph 1.2gm q8h IV for 7-10 days for 7-10 days of Hospitalized children. Eur J Ophthalmol
2010;20(6): 1066-1072.
aureus, Strepcoccus sp. Microbiology and Antibiotic Management of
Gram-ve Anaerobes If Anaerobes suspected: Orbital Cellulitis Pediatrics 2011;127;e56.6
ADD
Metronidazole 500mg IV
q8h for 7-10 days
110 | P a g e
ORTHOPAEDIC
DEPARTMENT
111 | P a g e
Index:
ADULT: SURGICAL CHEMOPROPHYLAXIS - Prosthetic joint infections
- Internal fixation of all closed fracture, total joint - Osteomyelitis
replacement/spine surgery & arthroscopy - Diabetic foot infections
- Amputations for diabetic wounds and ischaemic limbs - Necrotizing fasciitis
ADULT: SURGICAL INFECTION, BONE AND JOINT - Soft tissue infection secondary to gas producing organism
INFECTIONS - Suppurative wound infections, surgical or traumatic
- Compound fractures - Muscular, skeletal and soft tissue trauma, crush injuries and
- Vertebral osteomyelitis (OM), epidural abscess stab wounds
- Septic arthritis
ORTHOPAEDIC
WITH/WITHOUT:
- Temperature >38ºC or <36ºC
- Heart rate >90BPM/
112 | P a g e
Infection/Condition & Suggested treatment
Preferred Alternative Comments
Likely Organism
- Resp rate>20/min
- PaCO2 <32mmHg
- White cell count >12000 or
<4000cells/uL
113 | P a g e
Infection/Condition & Suggested treatment
Preferred Alternative Comments
Likely Organism
Surgical therapy is necessary in
progression of disease despite adequate
antibiotic, spinal cord compression/spinal
instability and/or presence of epidural
abscess.
Septic Arthritis Drainage, debridement and washout of
i. Acute monoarticular Cloxacillin2gm IV q6h Penicillin Allergy: infected joint are important to limit further
no STD risk (Staph/Strep) (immediate hypersensitive damage.
type)
Clindamycin 600mg IV q6- Empirical therapy wherever possible
8h, should be directed by the result of the
followed by oral therapy Gram stain of the joint aspirate.
(same dose)
OR If initial gram stain is gram positive
Vancomycin 15-20mg/kg IV cocciuse Cloxacillin.
q12h
If initial gram stain is gram negative
Cefotaxime 1gm IV q8h bacilli use Ceftriaxone 2gm IV q24h.
Doxycycline 100mg PO
q12h for 7 days
114 | P a g e
Infection/Condition & Suggested treatment
Preferred Alternative Comments
Likely Organism
115 | P a g e
Infection/Condition & Suggested treatment
Preferred Alternative Comments
Likely Organism
Commonest organism: (Removal of deadbone/
S. aureus orthopaedic hardware).
116 | P a g e
Infection/Condition & Suggested treatment
Preferred Alternative Comments
Likely Organism
SOFT TISSUE INFECTION SECONDARY TO GAS PRODUCING ORGANISM
Clostridium spp, Benzylpenicillin 2-4MU IV Ceftriaxone 1-2gm q24h *For Clostridium sp.: Benzylpenicillin
Gram –ve organism q4h PLUS 4MU IV q4-6h is preferred
PLUS Clindamycin 600-900mg IV
Clindamycin 600-900mg IV q6h Early aggressive surgical debridement is
q6h PLUS/MINUS essential.
PLUS/MINUS Gentamicin 5mg/kg IV q24h
Gentamicin 5mg/kg IV q24h Duration: 10 – 28 days
SUPPURATIVE WOUND INFECTIONS, SURGICAL OR TRAUMATIC
Suppurative wound infections, Cefuroxime 1.5gm IV as a Change antibiotics accordingly after C&S
surgical or traumatic loading dose followed by result are available.
750mg IV q8h
Topical antibiotics are not recommended
for treatment of wound infections as it
may result in the emergence of resistant
organisms.
117 | P a g e
OTOLARYNGOLOGY
DEPARTMENT
118 | P a g e
Index:
Chemoprophylaxis Rhinology
- Head and neck surgery - Acute bacterial rhinosinusitis (ABRS)
General Sore Throat Otology
Throat and Upper Respiratory - Acute otitis media
- Tonsillitis/Pharyngitis - Malignant otitis externa/Necrotizing otitis externa
- Acute peritonsillar abscess - Acute diffuse otitis externa
- Diphteria - Chronic suppurative otitis media
- Acute epiglottitis - Otomycosis
- Deep neck space abscess - Perichondritis
- Acute mastoiditis
OTORHINOLARYNGOLOGY INFECTIONS
Chemoprophylaxis
It is the use of antibiotics to prevent infections at the surgical site. It should be considered when there is significant risk of post-operative
infection or where post-operative infection would have severe consequences. Ideally, the prophylaxis when given intravenously should be
given as soon as the patient is stabilized after induction. Usually a single dose is sufficient. A second dose may be required in the following
situations:
Pre-operative dose timing: The optimal time for administration of preoperative doses is within 60 minutes before surgical incision. Some
agents, such as Clindamycin, Fluoroquinolones, Gentamicin, Metronidazole and Vancomycin, require administration over one to two hours;
therefore, the administration of these agents should begin within 120 minutes before surgical incision.
Giving more than 1 or 2 doses postoperatively is generally not advised. The practice of continuing prophylactic antibiotics until
surgical drains have been removed is NOT RECOMMENDED.
119 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
HEAD AND NECK
Clean Antibiotic not required Antibiotic not required
Clean with placement of Ceftriaxone 2g stat IV β -lactam Allergy:
prosthesis Clindamycin 900 mg IV
(excludes tympanostomy tubes)
Clean-contaminated cancer Cefuroxime 1.5gm IV β -lactam Allergy: Redosing:
surgery PLUS Clindamycin 900 mg IV Procedure longer than 4 hours for
Metronidazole 500mg IV Cefuroxime, and 2 hours for
Other clean-contaminated Ampicillin/Sulbactam.
procedures with the exception of OR
tonsillectomy and functional
endoscopic sinus procedures Ampicillin/Sulbactam 3gm
IV
For procedures in which pathogens other than staphylococci and streptococci are likely, an additional agent with activity against those
pathogens could be considered. For example, if there are surveillance data showing that gram-negative organisms are a cause of surgical-site
infections (SSIs) for the procedure, practitioners may consider combining Clindamycin or Vancomycin with another agent (Cefazolin if the
patient is not β -lactam allergic; gentamicin, or single-dose fluoroquinolone if the patient is β -lactam allergic).
References:
1. Am J Health-Syst Pharm. 2013; 70:195-283, 2013@IDSA
2. Weber RS, Callender DL. Antibiotic prophylaxis in clean-contaminated head and neck oncologic surgery. Ann Otol Rhinol Laryngol. 1992; 101:16- 20
3. Johnson JT, Wagner RL. Infection following uncontaminated head and neck surgery. Arch Otolaryngol Head Neck Surg. 1987; 113:368-9.
4. Saginur R, Odell PF, Poliquin JF. Antibiotic prophylaxis in head and neck cancer surgery. J Otolaryngol. 1988; 17:78-80.
5. Simo R, French G. The use of prophylactic antibiotics in head and neck oncological surgery. Curr Opin OtolaryngolHead Neck Surg. 2006; 14:55-61
6. Strauss M, Saccogna PW, Allphin AL. Cephazolin and metronidazole prophylaxis in head and neck surgery. J Laryngol Otol. 1997; 111:631-4.
7. Skitarelić N, Morović M, Manestar D. Antibiotic prophylaxis in clean contaminated head and neck oncological surgery. J Craniomaxillofac Surg.2007; 35:15-20.
8. National Institute for Health and Clinical Excellence. Surgical site infection (clinical guideline 74) 2008. www.nice.org.uk/CG74 (accessed 2012 Dec 9).
9. Fennessy BG, Harney M, O’Sullivan MJ et al. Antimicrobial prophylaxis in otorhinolaryngology/head and neck surgery. Clin Otolaryngol. 2007; 32:204-7.
10. Seven H, Sayin I, Turgut S. Antibiotic prophylaxis in clean neck dissections. J Laryngol Otol. 2004; 118:213-6
11. Slattery WH III, Stringer SP, Cassisi NJ. Prophylactic antibiotic use in clean, uncontaminated neck dissection. Laryngoscope. 1995; 105:244-6.
120 | P a g e
GENERAL SORE THROAT
The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or
empiric antibiotic therapy.
The cumulative score determines the likelihood of streptococcal pharyngitis and the need for antibiotics
Cumulative score
References :
A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CAN MED ASSOC J • JAN. 13, 1998
121 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
THROAT AND UPPER RESPIRATORY
Tonsillitis/Pharyngitis Phenoxymethylpenicillin Amoxicillin 500mg PO q8- Antibiotics should be prescribed in
Group A Streptococcus 500mg PO q12h for 10 days 12h for 10 days suspected/proven bacterial infections
OR only, as sore throats are common viral in
Benzathine Penicillin Penicillin Allergy: origin.
1. 2MU IM, for single dose Azithromycin 500mg
PO q24h for 5 days
OR
Clindamycin 300-450mg PO,
q8h for 10 days
Acute Peritonsillar Abscess Ampicillin/Sulbactam 3 g IV Amoxicillin/Clavulanate 625 Abscess to be drained
Group A Streptococcus q6h mg PO q8h
Staphylococcus aureus
Haemophilus influenza OR OR
Fusobacterium necrophorum
Amoxycillin/Clavulanate Phenoxymethylpenicillin
1.2gm IV q8h 500mg PO q6h
PLUS
OR Metronidazole 500mg PO
q6h
Benzylpenicillin (Penicillin
G) 2 MU IV q6h OR
PLUS
Metronidazole 500mg IV Clindamycin 300-450mg PO
q8h for 10-14 days q6h
Penicillin Allergy:
Clindamycin 600mg IV q8h
122 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Diphteria Antitoxin
Corynebacterium diphtheriae
PLUS
Erythromycin Lactobionate
500mg IV q6h followed by
Erythromycin Ethylsuccinate
800mg PO q12h for total of
14 days
OR
Benzylpenicillin 50,000
units/kg to a maximum of 1.2
MU IV q12h
followed by
Phenoxymethylpenicillin
250mg PO q6h total of 14
days
Acute Epiglottitis Ceftriaxone 2gm IV q24h Penicillin Allergy: Urgent hospitalisation. May present with
Haemophilus influenzae Type b, OR Clindamycin 600-900mg IV life threatening upper airway obstruction,
Streptococcus pneumoniae Ampicillin/Sulbactam 3gm q8h especially in paediatrics.
IV q6h PLUS
Ciprofloxacin 400mg IV
Oral step down q12h
Amoxicillin/Clavulanate
625mg PO q8h for 7 – 14
days
123 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Deep Neck Space Abscess Ampicillin/Sulbactam 3gm
Streptococcus pyogenes IV q6h 10-14 days
Staphylococcus aureus
Fusobacterium necrophorum OR
124 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
OTOLOGY
Acute Otitis Media For severe disease or Penicillin Allergy: Antibiotics should not be routinely
Streptococcus pneumoniae, when risk of complications: Clarithromycin 500mg PO prescribed for uncomplicated AOM.
Haemophilus influenzae Amoxicillin 500mg PO q8h q12h
M.catarrhalis OR
If not responding 48-72hrs; Azithromycin 500mg PO on
Amoxicillin/Clavulanate day 1,
625mg PO q8h for 5 days followed by 250mg PO OD
OR on day 2 through day 5
Cefuroxime 500mg PO q12h
Malignant Otitis Externa/ Ciprofloxacin 400mg IV q8h
Necrotizing Otitis Externa OR
Ceftazidime 2gm IV q8h
Pseudomonas aeruginosa followed by
Ciprofloxacin 750mg PO
q12h for 6 weeks
Acute Diffuse Otitis Externa Ofloxacin 0.3% otic solution Aural toileting required in discharging
P. aeruginosa Instill 10 drops into affected ears
Staph aureus ear(s) once daily for 7 days
OR
Sofradex (Framycetin
sulphate, Gramicidin &
Dexamethasone) ear drop
3 drops q8h for 7 days
Chronic Suppurative Otitis Ofloxacin 0.3% otic solution Aural toileting required in discharging
Media Instill 10 drops into affected ears
P. aeruginosa ear(s) twice daily for 10-14
Staph aureus days
OR
Sofradex (Framycetin
sulphate, Gramicidin &
Dexamethasone) ear drop
125 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
3 drops q8h for 7 days
Otomycosis Clotrimazole 1% ear Aural toileting required.
Aspergillus sp. solution, applied twice daily
for 10 to 14 days
Perichondritis Ciprofloxacin 400mg PO
q12h
Acute Mastoiditis Amoxicillin/Clavulanate 1.2g
IV q8h
OR
Ceftriaxone 1-2g IV q12-24h
126 | P a g e
PAEDIATRICS
DEPARTMENT
127 | P a g e
Index:
Acute Myocarditis - Streptococcus viridans
Acute Pericarditis - Enterococcus
Infective Endocarditis - Staphylococcus
- Empirical Therapy - Culture-negative endocarditis
ACUTE PERICARDITIS
Viral (commonest cause) Treatment mainly supportive Consider surgical drainage if pericardial
empyema detected
Bacterial: Cloxacillin 200 mg/kg/24h Penicillin Allergic:
Staphylococcus aureus IV q4-6h for 6 weeks Cefazolin 100 mg/kg/24h IV
PLUS/MINUS q8h
Gentamicin 1 mg/kg IV/IM OR
q8h for 3 -5 days Vancomycin 40 mg/kg/24h
IV in 2-4 divided doses
INFECTIVE ENDOCARDITIS
Empirical Therapy for Benzylpenicillin 200,000 Vancomycin 15 mg/kg q12h
Infective Endocarditis units/kg/24h IV q4-6h for 4 IV for 4-6 weeks
weeks PLUS
PLUS Gentamicin 1 mg/kg IV/IM
Gentamicin 1 mg/kg IV/IM q8h for 2 weeks
q8h for 2 weeks
128 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Infective Endocarditis Benzylpenicillin 200,000 Ceftriaxone 100mg/kg IV/IM Dosages suggested are for patients with
Streptococcus viridans units/kg/24h IV q4-6h for 4 q24h for 4 weeks normal renal and hepatic function.
Strains fully susceptible to weeks PLUS
penicillin (MIC < 0.125 mg/l) PLUS Gentamicin 1mg/kg IV/IM Maximum dosages per 24 hours:
Gentamicin 1mg/kg IV/IM q8h for 2 weeks Penicillin 18 MU; Ampicillin 12gm;
q8h for 2 weeks Ceftriaxone 4gm, Gentamicin 240 mg.
Penicillin/Ceftriaxone Vancomycin dose adjusted for trough
Allergic: concentration of 15-20
Vancomycin 40mg/kg/24h mg/ml
IV q8-12h for 4 weeks
Infective Endocarditis Benzylpenicillin 300,000 Penicillin allergic:
Enterococcus units/kg/24h IV q4-6h Vancomycin 40 mg/kg/day
OR IV q8-12h
Ampicillin 300 mg/kg/24h PLUS
IV q4-6h for 4-6weeks Gentamicin 1mg/kg IV/IM
q8h for 2 weeks for 4-6
PLUS weeks
129 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Culture-Negative Endocarditis Ampicillin/Sulbactam 300 Patients with culture-negative
mg/kg/24h IV q4-6h for 4-6 endocarditis should be treated in
weeks consultation with an ID specialist
PLUS
Gentamicin 1mg/kg IV/IM
q8h for 4-6 weeks
130 | P a g e
Index:
Meningitis (empirical treatment) Cryptococcal meningitis
Meningitis (Haemophilus influenza, Streptococcus pneumoniae) Herpes Simplex Encephalitis
Neisseria meningitidis Brain Abscess
131 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Neisseria meningitidis Benzylpenicillin 50mg/kg IV Cefotaxime 50mg/kg IV q4- Prophylaxis for all household contacts and
q4-6h for 7 days 6h Health Care Workers involved in
OR intubation and suctioning of airway
Ceftriaxone 50-75mg/kg IV
q12-24h for 7 days.
OR
Chloramphenicol 40mg/kg
stat then 25mg/kg IVq6h
Cryptococcal meningitis Induction Therapy:
Cryptococcus neoformans Amphotericin B
1.0mg/kg/24h IV
PLUS/ MINUS
5-Flucytosine 400-
1200mg/m2 (max 2gm) PO
in q6h for 2-4 weeks.
Consolidation Therapy:
Fluconazole 10-12mg/kg/24h
PO in q12h for 8 weeks.
Herpes Simplex Encephalitis Acyclovir: Duration: for 14-21 days.
<12 weeks old: 20mg/kg IV
q8h
132 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Brain Abscess Cefotaxime 50mg/kg IV q4- If secondary to trauma: Surgical drainage may be indicated if
6h ADD appropriate.
OR Cloxacillin 25-50mg/kg IV
Ceftriaxone 50-75mg/kg IV q4-6h. Duration 6-8 weeks, depending on
q12-24h response as seen from neuroimaging.
PLUS
Metronidazole 15mg/kg IV
stat then 7.5mg/kg IV q8h.
133 | P a g e
Index:
Rheumatic fever Meningococcal exposure
Infective Endocarditis (IE) Neonatal Group B Strep Infection
Postsplenectomy Malaria prophylaxis
- At risk for pneumococcus, meningococcus, haemophilus Pertussis
- Haemophilus influenza b Close contacts Chicken pox
PAEDIATRICS CHEMOPROPHYLAXIS
134 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Genitourinary or perforation of the oral mucosa; this
gastrointestinal does not include routine dental
procedures: cleaning.
IE prophylaxis only if Procedures of the respiratory tract that
ongoing GI or GU tract involve incision or biopsy of the
infection Require activity respiratory mucosa.
against enterococci Procedures in patients with ongoing
(amoxicillin or ampicillin) or gastrointestinal (GI) or genitourinary
vancomycin for penicillin (GU) tract infection.
allergic Procedures on infected skin, skin
structure, or musculoskeletal tissue.
Surgery to place prosthetic heart
valves or prosthetic intravascular or
intracardiac materials.
135 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
immunocompromised
state and asplenia. To seek immediate medical attention
when febrile or to instruct on immediate
(Require ongoing self-directed empiric antibiotics
surveillance for resistant (Amoxicillin/Clavulanate or Cefuroxime
pneumococci) Axetil) before promptly seeking medical
care.
Indications
Household contacts
Household with at least one contact
<4 years who has not received an age-
appropriate number of doses of Hib
conjugate vaccine.
Household with a contact who is an
immunocompromised child (<18
years), regardless of that child's Hib
immunization status.
Nursery Contact
For child-care and preschool contacts
(regardless of age or vaccine status) when
unimmunized or incompletely immunized
children attend the facility and two or
more cases of Hib invasive disease have
occurred among attendees within 60 days,
136 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Others
Close contact for at least 4 hours
during the week before illness onset.
Exposure to index’s nasopharyngeal
secretions (eg kissing, sharing of
toothbrushes, eating utensils).
Airline flights lasting >8 hours:
directly next to case.
Healthcare staff
Routine prophylaxis not recommended,
unless exposure to secretions such as
unprotected mouth to mouth resuscitation,
intubation or suctioning.
137 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Neonatal Group B Strep Intrapartum maternal Ampicillin 2gm IV load then
Infection prophylaxis till delivery 1gm q6h
Treat during labour if previously Penicillin G IV
delivered infant with invasive (5MU load then 2.5MU q6h Penicillin allergy
GBS, GBS bacteriuria or till delivery) Clindamycin 900mg IV q8h
antenatal screening swabs (according to susceptibility)
positive OR
OR if GBS status not known Vancomycin (weight based
AND any of the following: dosing 20mg/kg, max 2gm
Preterm <37 weeks q12h)
PROM >18 hours
Intrapartum temp >38ºC
Malaria prophylaxis Please refer to National
Guidelines on Malaria
Pertussis <1 month : Antimicrobial prophylaxis for close
(Postexposure prophylaxis) Azithromycin 10mg/kg q24h contacts of the index case and for exposed
for 5 days individuals at high risk for severe or
>1 month : complicated pertussis.
Erythromycin Ethylsuccinate
40-50mg/kg/day q6h for 14 Close contact definition:
days Face-to-face exposure within three
feet of a symptomatic patient.
Direct contact with respiratory, oral,
or nasal secretions from a
symptomatic patient.
Sharing the same confined space in
close proximity with a symptomatic
patient for ≥1 hour.
At risk:
Infants younger than one year,
especially <4 months of age.
138 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Persons with immunodeficiency.
Persons with underlying medical
conditions (chronic lung disease,
respiratory insufficiency, cystic
fibrosis).
Because of the risk of severe disease
in infants younger than one year of
age, especially those younger than
four months of age, women in the
third trimester of pregnancy should be
given postexposure prophylaxis.
139 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
immunity.
Varicella zoster immune Premature infants born at <28 weeks
globulin (dose as per product of gestation or who weigh ≤1000 g at
information – weight based) birth and were exposed during their
hospitalization, regardless of their
OR mothers' evidence of immunity to
varicella.
IVIG (400mg/kg)
140 | P a g e
Index:
Tonsillitis/Pharyngitis Acute Otitis Media
Rhinosinusitis Acute Diffuse Otitis Externa
141 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
q12h
OR
Ceftriaxone 50 mg/kg IM/IV
for 1 dose
Penicillin Allergy:
Clarithromycin 7.5mg /kg
PO q12h
OR
Azithromycin 10mg/kg PO
on day 1, followed by
5mg/kg PO q24h on day 2 to
day 5
Acute Diffuse Otitis Externa Ofloxacin 0.3% otic solution Aural toileting required in discharging
P. aeruginosa and Staph. aureus Instill 5 drops into affected ears
ear(s) once daily for 7 days 1-12 years.
> 12 years refer to adult dose
142 | P a g e
Index:
Acute gastroenteritis Cholera
Dysentery Liver abscess
Giardiasis Acute cholangitis
Typhoid fever Peritonitis
143 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Typhoid fever
Salmonella Typhi
S. paratyphi
Mild or uncomplicated Ciprofloxacin 15-20mg/kg/d PO Chloramphenicol 50- *Fluoroquinolones need to be used
in 2 divided doses for 5-7 days 100mg/kg/d PO in q6h for with caution in children due to
minimum 14 days possible arthropathy and rapid
development of resistance. However,
Severe infection or suspected Ceftriaxone 60-80mg/kg IV *Ciprofloxacin IV 10-15mg/kg there is now increasing data on safety
resistant organism q24h for 7-14 days IV q12h for 7-14 days and efficacy of quinolones in children.
144 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Liver abscess (amoebic) Metronidazole 7.5mg/kg IV q8h Amoebic abscess tend to be solitary
Entamoeba histolytica for 10-14 days lesion. Consider surgical drainage if
needed
Liver abscess (pyogenic) Cloxacillin 25-50mg/kg IV q4- Cefotaxime 25-50mg/kg IV q6- Surgical drainage is needed in most
S. aureus, Gram negative, 6h 8h cases
Anaerobes PLUS PLUS
Gentamicin 5mg/kg IV q24h Metronidazole 7.5mg/kg IV q8h
PLUS
Metronidazole 7.5mg/kg IV q8h
for 4-6 weeks
Acute cholangitis Ampicillin 25-50mg/kg IV q6h Cefoperazone 25-50mg/kg IV
Gram negative, anaerobes, PLUS q6-8h
gram positive Gentamicin 5mg/kg IV q24h PLUS
PLUS Metronidazole 7.5mg/kg IV q8h
Metronidazole 7.5mg/kg IV q8h
for 7-14 days
Peritonitis Ampicillin 25-50mg/kg IV q6h Cefotaxime 25-50mg/kg IV q6- May omit metronidazole in primary
Gram negative, anaerobes, PLUS 8h peritonitis
gram positive Gentamicin 5mg/kg IV q24h PLUS
PLUS Metronidazole 7.5mg/kg IV q8h
Metronidazole 7.5mg/kg IV q8h for 7-14 days
for 7-14 days
145 | P a g e
INFECTIONS IN IMMUNOCOMPROMISED PAEDIATRICS PATIENTS
146 | P a g e
Index:
Congenital & Perinatal Infections - Early onset sepsis (<48 hrs)
- Congenital syphilis - GBS infection
- Congenital toxoplasmosis Postnatal Infections
- Herpes simplex - Community acquired infections
- Tetanus neonatorum - Hospital acquired infection
- Gonococcal ophthalmitis - Necrotising enterocolitis (NEC)
- Chlamydia trachomatis conjunctivitis
NEONATAL INFECTIONS
147 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
recommended to repeat CSF FEME and
VDRL at 6 month intervals. Persistent
+VDRL of CSF requires reevaluation and
possible re-treatment.
Congenital Toxoplasmosis Pyrimethamine (initial Fansidar Drug regimen not definitively established.
T. gondii loading dose of 2 mg/kg PO Pyrimethamine (1.25 mg/kg Clinical trials ongoing.
once/day for 2 days followed every 15 days)
by 1 mg/kg PO once/day, PLUS Prednisolone (0.5 mg twice per day) can
max 25 mg) for 6 months, Sulfadoxine (25 mg/kg every be added if cerebrospinal fluid (CSF)
then 3 times a week for 15 d) for 24 months protein is >1 gm/dL or when active
subsequent 6 months PLUS chorioretinitis threatens vision and
PLUS Folinic Acid, 5 mg/week by continued until resolution of elevated CSF
Sulfadiazine (50 mg/kg/dose mouth protein or active chorioretinitis that
PO q12h, maximum 4 gm) threatens vision.
for 1 year
PLUS Clindamycin may be substituted for
Leucovorin (10 mg PO 3 sulfadiazine in children with G6PD
times a week) for 1 year (and deficiency or who develop allergy to
for one week after sulphadiazine.
Pyrimethamine therapy)
Regular FBC recommended: Main
(IV formulation of adverse effect of Pyrimethamine is
Leucovorin may be neutropenia. The folinic acid dose should
considered for oral use) be increased if the ANC falls below 1,000
cells/microL. Pyrimethamine should be
temporarily withheld if the ANC is below
500 cells/microL. Persistent neutropenia
despite withholding of Pyrimethamine
may be caused by Sulfadiazine
Herpes Simplex Acyclovir 60mg/kg/day IV Isolate Ocular involvement requires
Neonatal q8h topical antiviral.
Localized skin, eye, and Screen for other STDs.
mouth (SEM) Duration: For CNS disease.
148 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Central nervous system Skin, eyes, mouth: 14 days Repeat LP at end therapy for HSV PCR
(CNS) with or without SEM CNS/ Disseminated: 21 days and treat till negative.
Disseminated disease Investigate and treat parents.
involving multiple organs Recurrence of HSV can occur and may be
a lifelong problem.
Tetanus neonatorum Metronidazole IV/PO for 10 Penicillin G IV Debridement
days (100, 000U/kg q12h for 1st Human Tetanus IG IM
Neonates (Neofax dosing): week of life and q6h after 1st
Loading dose: 15mg/ week) for 10 days Optimum dose for IM human TIG yet to
kg/dose IV/PO x 1 be established. Traditional
Maintenance dose: recommendations: single dose of 3,000-
7.5mg/ kg/dose IV/PO 6,000U. Limited data suggests doses as
low as 500U as effective.
Metronidazole Dosing
Interval Chart Penicillin-GABA antagonist and
Post- Post- Dosing associated with seizures. Metronidazole
menstrual natal interval recommended as choice.
age age (hours)
(weeks) (days)
≤29 weeks 0-28 d q48h Check maternal immunization.
>28 d q24h
30-36 0-14 d q24h
weeks >14 d q12h
37-44 0-7 d q24h
weeks >7 d q12h
≥45 weeks AL q8h
Gonococcal Ophthalmitis Immediate and frequent Evaluate for signs of disseminated
saline eye irrigation infection (e.g. sepsis, arthritis, and
meningitis).
Non-disseminated disease
Ceftriaxone 50mg/kg IV Screen mother and baby for chlamydial
once (max 125mg) infection.
149 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Ceftriaxone IV (50mg/kg
daily 1st week of life, 12H Investigate and treat parents.
>1week of life) for 7 days
150 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Early onset sepsis (<48 hrs) Penicillin G IV Imipenem IV Suspect in maternal chorioamnionitis,
Sepsis / pneumonia / meningitis) OR sepsis, PROM (>18 hours).
GBS, GNB Ampicillin IV
Do full septic workup, CXR.
PLUS
In babies given antibiotics because of risk
Amikacin IV factors for infection or clinical indicators
of possible infection, review need for
(Till C&S results) continued antibiotics at 48 hours with
- Sepsis 7-10 days culture results.
- G+ meningitis: 2 weeks
- G- meningitis: 3 weeks No evidence from randomised trials to
suggest that any antibiotic regimen may
be better than any other in the treatment of
presumed early neonatal sepsis.
Amikacin IV
151 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
POSTNATAL INFECTIONS
Community Acquired Ampicillin Imipenem IV Inadequate evidence from randomised
Infections OR trials in favour of any particular antibiotic
(Late onset sepsis >48 hrs) Penicillin regimen for the treatment of suspected
Pneumonia, Sepsis late onset neonatal sepsis.
Group B Strep, E. coli, PLUS
Klebsiella, Enterobacter, S Discontinue antibiotics after 48 hours if
aureus Amikacin culture negative or course does not
Possible Listeria support diagnosis.
Hospital Acquired Infection Imipenem IV Cefepime IV
(Pneumonia, sepsis, meningitis) OR
Based on predominant flora and Meropenem IV
susceptibility OR
Coagulase-negative Vancomycin IV if MRSA
staphylococci, Staphylococcus strongly suspected
aureus, E.
coli, Klebsiella, Pseudomonas,
Enterobacter, Candida, GBS,
Serratia, Acinetobacter
Necrotising Enterocolitis Ampicillin IV Amoxicillin/Clavulanate There is insufficient evidence regarding
(NEC) PLUS PLUS choice of antibiotic regimens or duration
Klebsiella, E. coli, Clostridia, Amikacin IV Amikacin of antibiotic treatment of NEC.
coagulase negative PLUS
Staphylococcus, Enterococci, Metronidazole IV Decisions regarding antibiotic choice and
Bacteroides duration might best be guided by culture
Duration results as well as flora & antibiotic
10-14 days resistance patterns present within
nurseries.
(Vancomycin if CoNS
MRSA or VRE suspected) Empiric regimens can be modified based
upon the results of cultures of blood,
peritoneal fluid, or surgical specimens.
152 | P a g e
PAEDIATRICS OCCULAR INFECTIONS
PLUS
153 | P a g e
PAEDIATRICS RESPIRATORY INFECTIONS
PLUS
Erythromycin 15-25mg/kg
IV q6h for 7 days
OR
Azithromycin 15mg/kg IV
loading dose then 7.5 mg/kg
q24h if considering atypical
organisms
154 | P a g e
Index:
Abscess Necrotizing fasciitis
Animal bites Scalded skin syndrome
Cellulitis Scabies
Impetigo
PAEDIATRICS SKIN AND SOFT TISSUE INFECTIONS
155 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Necrotizing fasciitis Benzylpenicillin 50,000 Aggressive surgical debridement;
Group A Streptococcus units/kg IV consider adding IVIG to bind toxin for
Polymicrobial: Gram +ve cocci, q4h streptococcal infection with toxic shock.
Anerobes , Gram-ve rods PLUS Tissues should be gram stained and
Clindamycin 25-40 mg/kg/d cultured.
IV q6-8h
Refer IDSA 2014 guidelines
OR
Piperacillin/Tazobactam 60-
75 mg/kg/dose IV q6h
PLUS
Vancomycin 10-13
mg/kg/dose IV q8h
Scalded skin syndrome Cloxacillin 150 mg/kg/24h
Staphylococcus aureus IV in q6h then, step down
to 50mg/kg/24h PO q6h for 7
days
OR
Cephalexin 50-75mg/kg/24h
PO q8h for 7 days
Scabies Permethrin 5% cream apply For children > 2 years and
Sarcoptes scabeii and leave for 8 hours (not for <12: Benzyl Benzoate
babies less than 2 months) Emulsion (EBB) 12.5%
- two or more applications , apply from neck down and
each a week apart leave for 24 hours for 2 days
156 | P a g e
PAEDIATRICS SURGICAL INFECTIONS
157 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Gram negative enteric organism PLUS on amoxycilin dose) SA in hip and other joints to reduce
Cefotaxime 50mg/kg/dose pressure on growth plate.
q6-8h Optimize antimicrobial
treatment based on C&S *IV antibiotics can be switch to oral if no
concurrent bacterimia when:
Less than 5 yrs: Child afebrile and pain free for at least 24
Staph. aureus. Cefuroxime 50mg/kg/dose Cefazolin 25mg/kg/dose IV hrs and CRP <20mg/L or CRP decreased
Streptococcus pyogens IV q8h (monotherapy) q8h by≥2/3 of highest value
Streptococcus pneumoniae
Non- type able Haemophilus Can be use in children with Duration of antibiotics:
spp. suspected Staph aureus or SA: total of 3-4 weeks
K.Kingae Strep pyogenes; OM: 4-6 weeks
Less hypersensitivity
reaction compared to In complex disease (multifocal,
Cloxacillin and dosing significant bone destruction, immuno -
convenience compromised host and resistant /unusual
pathogens-need prolonged intravenous
*Kingenella kingae- antibiotics and duration might exceed 6
uncommon organism causing weeks
infection in
<5yrs old ;sensitive to β-
lactam antibiotics e.g.
Cefuroxime or
Ampicilin/Clavulanate
158 | P a g e
Index:
Scrub thyphus Leptospirosis
Brucellosis Melioidosis
159 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Leptospirosis L.
icterohaemorrhagiae, L.
canicola
Moderate to severe disease Benzylpenicillin 100,000 Ceftriaxone 80-100mg/kg IV
units/kg IV q6h for 7 days q24h for 7 days
OR
Cefotaxime 150-
200mg/kg/24h IV in 4
divided doses for 7 days
160 | P a g e
PAEDIATRICS URINARY TRACT INFECTIONS
161 | P a g e
Index:
Catheter Related Blood Stream Infection Suppurative Thrombophlebitis
- S. epidermidis (CoNS), S. aureus, MSSA - S. aureus
- Candida albicans or other Candida species
- Gram -ve bacilli
PAEDIATRICS VASCULAR INFECTIONS
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
CATHETER RELATED BLOOD STREAM INFECTION
For infant and children: Indication of catheter removal is
S. epidermidis(CoNS) Vancomycin 10-15 mg/kg/day similar to adult but benefit of catheter
S. aureus IV q6h removal must be weight against the
difficulties of obtaining alternate
MSSA Cloxacillin IV 100-200 venous access.
mg/kg/day q6h Treatment without catheter removal
Candida albicans or Fluconazole 6-12 mg/kg IV For children 3 months-17 years: should be closely monitored clinically
Other Candida species q24h Caspofungin loading dose 70 with additional blood culture;
mg/m³/day IV on day 1 removed catheter if there is persistent
followed by 50 mg/ m³/day or recurrent infection.
thereafter (max 70mg)
Gram –ve bacilli Antibiotic lock therapy should be used
(E.coli, Enterobacter, for catheter salvage in combination
Klebsiella, Pseudomonas, with conventional antibiotic therapy
Acinetobacter) for 10-14 days. S.aures may required
longer course up to 4-6 weeks.
ESBL –ve Cetriaxone/Cefotaxime/
Ceftazidime Exact optimal duration of therapy has
PLUS/MINUS not established in children with or
Aminoglycoside without catheter removal. 10-14 days
after first negative blood culture is
ESBL +ve Imipenem 60-100mg/kg/day IV usually recommended.
q6h Fungaemia: treatment without catheter
OR removal associated with low success
Meropenem 20mg/kg IV q8h rate and higher mortality.
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
SUPPURATIVE THROMBOPHLEBITIS
S. aureus Diagnosis requires positive blood
MSSA Cloxacillin 100-200mg/kg/day culture plus radiographic
IV q6h demonstration of thrombus.
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PLASTIC
SURGERY
DEPARTMENT
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Index:
Plastic Surgery
Burns
Suggested treatment
Wound classification Comments
Preferred Alternative
PLASTIC SURGERY
Clean wounds
e.g.:
Excision of skin lesions Not required Not required
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Suggested treatment
Wound classification Comments
Preferred Alternative
Dirty wounds
e.g.:
Post traumatic wounds with IV Cloxacillin
devitalized tissue 1g (adults)
Avulsion, degloving wounds 25-50mg/kg/dose
with foreign body contamination (paediatrics)
For diabetic & immuno-compromised patients – to cover with IV Ampicillin + Sulbactam 1.5g
Suggested treatment
Wound classification Comments
Preferred Alternative
BURNS
Clean burn wounds Not recommended Not recommended Prophylactic antibiotic are not routinely
given to burn patients as they do not
reduce the risk of infection
Infected burn wounds IV Cloxacillin Penicillin allergies:
1g (adults) IV Cefuroxime
25-50mg/kg/dose (paediatrics) 750mg (adults)
OR 25-50mg/kg/dose
IV Ampicillin + Sulbactam 3g (paediatrics)
Wound debridement IV Amoxicillin + Clavulanate IV Cefuroxime
Skin grafting Acid 750mg (adults)
1.2g (adults) 25-50mg/kg/dose
30mg/kg/dose (paediatrics) (paediatrics)
For diabetic & immuno-compromised patients – to cover with IV Ampicillin + Sulbactam 1.5g
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SURGICAL
DEPARTMENT
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Index:
CHEMOPROPHYLAXIS Bites (penetrating injuries)
- General surgery
- Vascular surgery UROLOGY
Pyonephrosis/Perinephric abscess
GENERAL SURGERY Renal abscess
Appendicitis Acute prostatitis
Perforated appendix, appendicular mass Chronic bacterial prostatitis (CPPS NIH Type II)
Perforated viscus, peritonitis Prostatic abscess
Abdominal trauma Non gonoccocal urethritis
Suspected bowel or solid organ injury Epididymo-orchitis
Breast abscess Testicular abscess
Vascular Fournier’s gangrene
- Mycotic pseudoaneurysm in IVDU Urosepsis (Septicaemia post urological instrumentation or
- Prosthetic graft infection urological infections)
- Ischaemic ulcers
SURGERY
Chemoprophylaxis
It is the use of antibiotics to prevent infections at the surgical site. It should be considered when there is significant risk of post-operative
infection or where post-operative infection would have severe consequences. Ideally, the prophylaxis when given intravenously should be
given as soon as the patient is stabilized after induction. Usually a single dose is sufficient. A second dose may be required in the following
situations:
c. delay in start of surgery
d. in prolonged operations when the time is more than half of the usual dosing interval of the antibiotic
Pre-operative dose timing: The optimal time for administration of preoperative doses is within 60 minutes before surgical incision. Some
agents, such as Clindamycin, Fluoroquinolones, Gentamicin, Metronidazole and Vancomycin, require administration over one to two hours;
therefore, the administration of these agents should begin within 120 minutes before surgical incision.
(Reference: Am J Health-Syst Pharm Vol 70: 195-283, 2013@IDSA.)
Giving more than 1 or 2 doses postoperatively is generally not advised. The practice of continuing prophylactic antibiotics until
surgical drains have been removed is NOT RECOMMENDED.
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
GENERAL SURGERY
Upper GIT oesophagus, stomach Amoxycillin/Clavulanic acid Cefotaxime 1gm IV
& upper small bowel 1.2gm IV OR
Cefoperazone 1gm IV
Distal small bowel colorectal Cefuroxime 1.5gm IV Cefoperazone 1gm IV
PLUS PLUS
Metronidazole 500mg IV Metronidazole 500mg IV
OR
Amoxycillin/Clavulanic acid
1.2gm IV
OR
Ampicillin/Sulbactam 1.5gm
IV
Hernia repair with mesh Cloxacillin 1gm IV Amoxycillin/Clavulanic acid Includes laparoscopic repair
1.2gm IV
OR
Ampicillin/Sulbactam 1.5gm
IV
Breast Cloxacillin 1gm IV Amoxycillin/Clavulanic acid Not recommended for minor excisions
Mastectomy with axillary 1.2gm IV
clearance with/without OR
reconstruction Ampicillin/Sulbactam 1.5gm
IV
VASCULAR SURGERY
Vascular graft implants
a. AVF graft Vancomycin 1gm IV Linezolid 600mg IV
MRSA infection prophylaxis
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
b. Aortic graft / TEVAR / Amoxycillin/Clavulanic acid Ampicillin/Sulbactam 1.5gm
EVAR 1.2gm IV IV
Suspected organism:
Staph. spp. & anaerobic
organism
Ischemic limb Ampicillin/Sulbactam 1.5- Amoxycillin/Clavulanic acid
Suspected organism: 3gm IV 1.2gm IV
Staph. spp. & anaerobic
organism
General Surgery
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Appendicitis 1st gen. Cephalosporins, e.g; -lactam/-lactamase inhibitors, Start upon diagnosis, discontinue after
Enterobacteriaceae Cefazolin 1g IV q8h eg; surgery.
enterococci, Bacteroides PLUS Amoxycillin/Clavulanate 1.2gm
Metronidazole 500mg IV IV q8h
q8h
Perforated appendix, 1st gen. Cephalosporins, e.g; -lactam/-lactamase inhibitors, Duration 7 days.
Appendicular mass Cefazolin 1g IV q8h eg;
PLUS Amoxycillin/Clavulanate 1.2gm
Metronidazole 500mg IV IV q8h
q8h
Perforated Viscus 1st gen. Cephalosporins, e.g; -lactam/-lactamase inhibitors, Duration 7 days.
Peritonitis Cefazolin 1g IV q8h eg;
PLUS Amoxycillin/Clavulanate 1.2gm
Metronidazole 500mg IV IV q8h
q8h
Abdominal trauma 3rd Cephalosporins, e.g. Cefoperazone/Sulbactam 1g IV Duration 7 days.
Suspected bowel or solid Cefotaxime 1g IV q8h q12h
organ injury PLUS PLUS
Gram negative enteric aerobes Metronidazole 500mg IV Metronidazole 500mg IV q8h
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
and anaerobes q8h
OR
-lactam/-lactamase inhibitors,
eg;
Ampicillin/Sulbactam 1.5g IV
q8h
OR
Amoxycillin/Clavulanate 1.2gm
IV q8h
Breast abscess Cloxacillin 1g IV q6h Cefuroxime 1.5g IV q8h Drainage may be required.
Staph aureus Duration 7 days.
VASCULAR
Mycotic Pseudoaneurysm in Cloxacillin 2g IV q6h Based on C&S Initial therapy is high dose IV followed
IVDU by oral therapy once debridement and
ligation done. The duration will depend
on clinical response.
Prosthetic Graft Infection
Non-MRSA 1st gen. Cephalosporins, e.g; Based on C&S Duration may need to be prolonged if
Cefazolin 1g IV q8h Graft salvage considered.
OR Duration 7 days or more.
3rd gen. Cephalosporins, e.g;
Cefoperazone 2-4g/day IV in
divided dose q12h
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Ischaemic Ulcers -lactam/-lactamase Based on C&S Given IV if diabetes present
inhibitors, eg; Duration 7 days
Amoxycillin/Clavulanate
625mg PO q12h
OR
Ampicillin/Sulbactam
375mg PO q12h
BITES (penetrating injuries)
Animal bite Amoxycillin/Clavulanate If severe or allergic to penicillins, Duration 7 days.
Staph aureus, Strep., 1.2g IV TDS Cefuroxime 750mg IV q8h If infected (secondary infection): 10
Gram –ve bacilli, Anaerobes PLUS days
Metronidazole 500mg IV q8h
Human bite Amoxycillin/Clavulanate If allergic to Penicillin, Duration 7 days
Staph aureus, anaerobes, 1.2g IV TDS Clindamycin 300mg PO q6h Delay or do not suture
Eikenella sp
PLUS
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Urology
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Pyonephrosis / Perinephric nd
2 gen. Cephalosporins, e.g Ciprofloxacin 200mg –400mg PLUS Drainage followed by
abscess Cefuroxime 750mg-1.5g IV q8h IV q12h definitive surgery.
E coli, Klebsiella, OR
Proteus,Enterococcus, -lactam/-lactamase
Pseudomonas inhibitors, eg;
Ampicillin/Sulbactam 1.5-3g IV
q8h
Renal abscess 2nd gen. Cephalosporins, e.g 3rd gen. Cephalosporins, e.g; Drainage may be required.
E coli, Klebsiella, Cefuroxime 750mg-1.5g IV q8h Ceftriaxone 1-2g IV q24h
Proteus,Enterococcus, OR Commence oral after temperature
Pseudomonas, Staph aureus -lactam/-lactamase settled.
inhibitors, eg;
Ampicillin/Sulbactam 1.5-3g IV
q8h
PLUS/MINUS
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Chronic Bacterial Prostatitis Ciprofloxacin 500mg PO q12h Trimethoprim/Sulfamethoxazole Pending positive culture on prostatic
(CPPS NIH Type II) for 2 weeks 160/800mg PO q24h for 2 secretion.
Mostly culture negative weeks
Then reassess, if beneficial, to
continue for 4-6 weeks Then reassess, if beneficial, to
continue for 4-6 weeks
Prostatic abscess Ciprofloxacin 200mg – 400mg 3rd gen. Cephalosporins, e.g; Drainage mandatory.
IV q12h Cefoperazone 1g IV q12h
E coli, Klebsiella, Proteus,
Enterococcus, Pseudomonas Followed by, Followed by,
Ciprofloxacin 500mg PO q12h Cefuroxime 500mg PO q12h
minimum of 2 -4 weeks minimum of 2-4 weeks
Non Gonoccocal Urethritis Refer to page (Sexually Transmitted
Infections).
Epididymo-orchitis -lactam/-lactamase Ciprofloxacin 500mg PO q12h
E coli, Klebsiella, Proteus, inhibitors, eg; minimum of 2 weeks
Enterococcus, Pseudomonas Amoxycillin/Clavulanate 1.2g
IV q8h
OR
Ampicillin/Sulbactam 1.5g IV
q8h
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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Testicular abscess -lactam/-lactamase 3rd gen. Cephalosporins, e.g; PLUS drainage
inhibitors, eg; Cefoperazone 1g IV q12h
E coli, Klebsiella, Amoxycillin/Clavulanate 1.2g
Proteus,Enterococcus, IV q8h
Pseudomonas OR
Ampicillin/Sulbactam 1.5g IV
q8h
Fournier’s gangrene Ampicillin/Sulbactam 1.5-3g IV PLUS debridement
E coli, Klebsiella, q8h
Proteus,Enterococcus,
Pseudomonas, Anaerobes OR
PLUS/MINUS
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APPENDIX
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COLISTIN DOSING GUIDE
2. Loading dose is standard for all creatinine clearance and is based on IBW
Maximum 9MU
Loading dose = 2.0 x 2.0 x IBW x 30000
3. Maintenance dose
Dosing Comments
Se CrCl > 50 4.5 MU q12h
CrCl calculated using
Cockcroft Gault
Se CrCL 20 - 50 4.5 MU q24h
formula adjusted to
1.73m2
Se CrCL <20 4.5 MU q48h
In patients with persistent infection/ slow to respond/ deterioration despite above dosing regime, can consider higher dosing regime:
Higher dosing regime for patients with persistent infection/ deterioration/ slow to repond:
Creatinine clearance Maintenance dosing per day
10-19 4 MU
20-29 5 MU
30-39 6 MU
41-49 7 MU
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4. Dosing in patients undergoing various renal replacement therapy
Renal replacement therapy Dosing Comments
2 MU q12h, on non HD day To give the additional
2 MU pre HD/ 3.5 MU post supplemental dosing of 10%/hr
Patients on intermittent HD
HD of baseline dose per day after
Assuming a 4 hr HD session the HD session is over (at the
next regular dosing interval)
Patients on SLED Supplement additional 10%/hr
4 MU q12h
(10 hr session) of baseline dose/day.
Advisable to do SLED at night
6 MU q12h Supranormal doses are required
Patients on CRRT (if unable to achieve to achieve the required PK/PD
clearance, can go up to 8 MU effect.
q12h) Supplement additional 10%/hr
of baseline dose/day.
Patients on Peritoneal dialysis Normal loading dose
(2l exchanges-dwell time 6hrs/ 3 MU q12h To give maintenance dosing
4x/day) 24 hrs later
References:
- Garonzik SM. AAC 2011;55:3284-94,
- Garonzik et al. CID. 2016
- Kift E. S Afr Med J 2014;104(3):183-186
- Dalfino L. et al. CID 2012: 54
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VANCOMYCIN DOSING
General principles:
1. Trough levels should be done pre-HD on the morning of the hemodialysis or if not done can be taken after at least 6 hrs Post HD
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2. Vancomycin administration should be given preferably post hemodialysis unless dialysis is expected to be delayed
3. Residual kidney function will influence the dose (patients may need higher doses if there is residual renal function)
.
First dose: (depends on the timing of the next dialysis session)
Timing of dialysis Dosing Comment
± top up 5 mg /kg if the first
Same day dialysis 15-20 mg/kg
dose was pre HD
Subsequent dosing
Trough level Subsequent dosing post first dose
<10 mg/L Consider redosing as above
1000 mg of IV Vancomycin post HD (40- 75 kg); 1250 mg (75-90 kg);
10-15 mg/L
1500 mg (>90 kg)
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Vancomycin levels Recommendations
<15 mg/L Increase the 12 hourly dose by 250mg
References:
- Heintz. (Pharmacotherapy 2009;29(5):562–577)
- John Hopkins antibiotic guidelines
- Standford antibiotic guidelines
- CID 2011. 15:53(2):124-9
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