Antibiotic Guideline BIRDEM 2021

Antibiotic Protocol for BIRDEM General Hospital
Antibiotic Protocol 2021
Published by
Bangladesh Diabetic Somiti

122 Kazi Nazrul Islam Avenue, Dhaka-1000, Bangladesh
Phone: +880-2-58616641-50, 9661551-60
Fax: +880-2-9677772; website: www.dab-bd.org
1st Edition
Co-ordination
Department of Microbiology
Department of Pharmacology
Team-Work
DR. Adeeba Khanduker, MD Resident (Microbiology), BIRDEM Academy
Elizabeth Baroi, Infection Control Nurse, BIRDEM
Md. Rokibul Hasan, Research Assistant, Dept. of Microbiology, BIRDEM
Md. Robiul Islam Rubel, Medical Technologist, Dept of Microbiology, BIRDEM
Composed by
Rofiqul Islam
Co-operation
Mahbubur Rahman
Taposhi Baral
Shahidul Alam
Printed by
BADAS-RVTC Printing Press
Chapter Contents Page
1 Introduction 1-2
Empirical, prophylactic & therapeutic management of

2 common infections used in different departments of
BIRDEM General Hospital
 Dept. of Internal Medicine 3-5
 Dept. of Respiratory Medicine 6
 Dept. of Critical Care Medicine 7-13
 Dept. of Nephrology 14-17
 Dept. of Endocrinology 18-19
 Dept. of Neurology 20-21
 Dept. of Cardiology 22-28
 Dept. of GHPD 29-32
 Dept. of Paediatrics 33-38
39-40
 Dept. Dermatology and Venereology
 Dept. of Obstetrics & Gynaecology 41-47
 Dept. of Surgery 48-50
 Dept. of Orthopaedics & Traumatology 51-53
 Dept. of Ophthalmology 54-59
 Dept. of ENT 60-62
 Dept. of Urology 63-69


 Dept. of Hepato-biliary- Pancreatic Surgery 70-74
3 Antimicrobial options for medically important organisms 75-80
4 Antibiotic resistant pattern of common organism at 81

5 Antibiotic Stewardship program 82-84
Contributors
Antibiotic protocol committee (List according to alphabetic order)

Afsana Karim, Professor of Pharmacology & Course Co-ordinator, BIRDEM Academy.
A K M Shaheen Ahmed, Professor of Internal Medicine, BIRDEM
A M B Safder, Associate Professor, Department of Cardiology, BIRDEM
Amreen Faruq, Assistant Professor, Department of General Surgery, BIRDEM.
A S M Areef Ahsan, Professor of Critical Care Medicine, BIRDEM.
Faria Afsana, Assistant Professor, Department of Endocrinology & Diabetology, BIRDEM.
Farzana Bilkis Ibrahim, Assistant Professor, Department of Plastic Surgery, BIRDEM.
Fatema Ahmed, Associate Professor, Department of Critical Care Medicine, BIRDEM.
Ferdous Akhter Jolly, Associate Professor, Department of Ophthalmology, BIRDEM.
Farhana Afroz, Assistant Professor, Department of Respiratory Medicine, BIRDEM.
Hasna Fahmima Haq, Assistant Professor, Department of Internal Medicine, BIRDEM
Hashim Rabbi, Associate Professor, Department of Hepato-biliary-Pancreatic Surgery, BIRDEM
Hosne Ara Begum, Associate Professor, Department of Skin and VD
Indrajit Kumar Datta, Associate Professor, Department of GHPD, BIRDEM.
Jamal Uddin Ahmed, Associate Professor, Department of Internal Medicine, BIRDEM
Jonaed Hakim, Assistant Professor, Department of Orthopedics & Traumatology, BIRDEM.
K.M. Shahidul Islam, Professor of Microbiology, BIRDEM.
Kaniz Fatema, Associate Professor, Department of Critical Care Medicine, BIRDEM.
Lovely Barai, Associate Professor, Department of Microbiology, BIRDEM.
Md. Abdul Baki, Assistant Professor,Department of Paediatrics, BIRDEM.
Md. Delwar Hossain, Professor of Respiratory Medicine, BIRDEM.
Md. Ashraf Uddin Ahmed, Assistant Professor & Resident Physician (RP), BIRDEM
Md. Zahid Alam, Professor, Department of Cardiology, BIRDEM
M. Golam Azam, Associate Professor, Department of GHPD, BIRDEM
M. Nobi Firoz, Assistant Professor & Resident Surgeon (RS), BIRDEM.
Muhammod Abdur Rahim, Associate Professor, Department of Nephrology, BIRDEM
Rashedul Islam, Assistant Professor, Department of Neurology, BIRDEM.
Sahida Akhter, Professor of Pediatrics, BIRDEM.
S.M.Shefin, Assistant Professor, Department of Endocrinology & Diabetology, BIRDEM.
Samira Rahat Afroze, Assistant Professor, Department of Internal Medicine, BIRDEM
Shawhely Mahbub, Assistant Professor, Department of ENT, BIRDEM.
Shafiqur Rahman, Associate Professor, Department of Urology, BIRDEM.
Tabassum Samad, Assistant Professor, Department of Nephrology, BIRDEM.
Tanzeem Sabina Chowdhury, Assoc. Professor, Department of Gynaecology & Obstetrics, BIRDEM.
Wasim Md. Mohosin Ul Haque, Associate Professor, Department of Nephrology, BIRDEM
Advisor
M. K. I. Qayyum Chowdhury, Professor of Orthopedics & Traumatology & Director General, BIRDEM.
Zafar Ahmed Latif, Professor of Endocrinology & Diabetology, Ex-Director General, BIRDEM
Nazmun Nahar, Professor of Pediatrics & Ex- Director General, BIRDEM
J. Ashraful Haq, Professor of Microbiology & Advisor, Ibrahim Medical College.
Mirza Mahbubul Hasan, Professor of Urology & Director Cilinical Services, BIRDEM
Brig. Gen. Md. Shahidul Hoque Mallik ( Retd), Ex- Director Hospital, BIRDEM
Md. Nazimul Islam, Joint Director (Hospital Admin), BIRDEM
Md. Fazle Rabbi, Additional Director (Hospital Admin), BIRDEM.
Acknowledgement (List according to alphabetic order)

Ashraf Sayeed, Professor of Ophthalmology, BIRDEM.
ATM Mowladad Chowdhury, Professor of Urology, BIRDEM.
Ferdousi Begum, Professor of Gynaecology & Obstetrics, BIRDEM.
Hasina Alam, Assistant Professor, Department of General Surgery, BIRDEM.
Jebun Nahar, Associate Professor, Department of Paediatrics, BIRDEM.
Manash Kumar Goswami, Professor of Ophthalmology, BIRDEM.
M.A. Muttalib, Professor of Biochemistry, BIRDEM.
Mehruba Alam Anannya, Assistant Professor, Department of Nephrology, BIRDEM
Md. Abid Hossain Mollah, Professor of Paediatrics, BIRDEM.
Md. Faruque Pathan, Professor of Endocrinology & Diabetology, BIRDEM
Md. Monwar Hossain, Professor of ENT, BIRDEM
Md. Ezharul Haque, Professor of General Surgery, BIRDEM.
Md. Mamunur Rashid, Professor of Department of Hepato-biliary-Pancreatic Surgery, BIRDEM.
Md. Zahid Alam, Associate Professor of Department of Cardiology, BIRDEM.
Md. Atiqullah, Senior medical Officer, Department of Skin and VD
Mili Rani Saha, Assistant Professor, Department of Microbiology, BIRDEM.
Mohammad Noor-A-Alam, Professor of General Surgery, BIRDEM.
Purabi Rani Devenath, Associate Professor, Department of Ophthalmology, BIRDEM.
Raziur Rahman , Professor of Internal Medicine, BIRDEM.
Rona Laila, Associate Professor, Department of Gynaecology & Obstetrics, BIRDEM.
Rumana Habib, Assistant Professor, Department of Neurology, BIRDEM.
S.M. Ashrafuzzaman, Professor of Endocrinology & Diabetology, BIRDEM.
Sarwar Iqbal, Professor of Nephrology, BIRDEM.
Samiron Kumar Mondal, Professor of General Surgery, BIRDEM.
Shamshed Jahan, Professor of Gynaecology & Obstetrics, BIRDEM.
Sudhanshu Shekhar Biswas, Associate Professor, Department of ENT, BIRDEM
Tapash Kumar Maitra, Professor of General Surgery, BIRDEM.
Tareq Mahmud Bhuiyan, Professor of GHPD, BIRDEM.
Tanjila Rahman, Assistant Professor, Department of Microbiology, BIRDEM
Message
Antimicrobial Resistance has become a matter of great public health concern

globally. The factors for this situation are random use of antimicrobials and
availability of all the antimicrobials without prescription.
I am happy to note that Department of Microbiology in assistance with
Department of Pharmacology & Cell Biology prepared this antibiotic protocol
which will rationalize the use of antimicrobials in the clinical departments in
BIRDEM General Hospital. I hope that the clinicians in BIRDEM, would use
this protocol which might reduce the development of antimicrobial resistance.
I sincerely thank all the clinical departmental heads and their fellow colleagues
for active co-operation in this document.
Prof. Z. A. Latif
Ex-Director General
Message
Emergence of Antimicrobial Resistance (AMR) in pathogens has become a

matter of great public health concern. AMR is a great threat to human health.
Infections caused by antimicrobial resistant micro-organisms in hospitals are
associated with increased morbidity, mortality and healthcare costs. Resistance
has emerged even to newer and more potent antimicrobial agents like
carbapenems and colistin. Irrational use of antimicrobials is the factors which
cause spread of resistant microorganisms.
I really appreciate the sincere efforts put in by the group of experts comprising
Clinicians, Microbiologists and Pharmacologist of BIRDEM General Hospital
who have given their valuable input for the document.
I hope that this effort would bring the desirable effects to reduce AMR burden in
this hospital.
Prof. M.K.I. Qayyum Chowdhury

Director General
Chapter 1: Introduction
Emergence of antimicrobial resistance against pathogens has become a matter of great public health
concern. Antimicrobial resistance is closely linked to inappropriate antimicrobial use. It is estimated that
50% or more of antimicrobial use is inappropriate. The resistance range varies widely depending on the type
of health care setting, availability of antimicrobials in hospitals and over the counter prescribing habits of
treating clinicians. It is emphasized that antimicrobials should be prescribed only when they are necessary in
the treatment following a proper diagnosis.
Since Diabetes Mellitus (DM) is one of the important risk factor for infection, it is a priority to take
appropriate measure for management of infection in DM patients. Previous record data of antimicrobial
resistance (AMR) in BIRDEM General Hospital revealed that more than 60-70% of isolated strain of
Klebsiella and Pseudomonas spp. in ICU were resistant to carbapenem. Overall 50-60% of isolated E.coli
were ESBLs and 25-30% Staphylococcus aureus were MRSA in our hospital.
Currently, there is no accepted national antibiotic guideline to treat infection and to use antibiotics
judiciously in Bangladesh. So, there is earnest need to develop antibiotic protocols for infection in patient
with co-morbidities like DM that we dealt frequently in our hospitals.
These protocol list the recommended empirical and prophylactic treatments for common infectious diseases
that are based on scientific evidence, literature review and are consistent with the already existing
international guidelines and formulated with the collective practice and recommendations of expert
clinicians of different department of BIRDEM General Hospitals.
The contents of this document include empiric treatment choices for commonest infection encountered in
different departments, infection of specific body sites and in certain special settings, antimicrobial choices
for multi drug resistant pathogens, optimizing and monitoring use of antimicrobials by antimicrobial
stewardship program, recent antibiogram report of isolated pathogens in BIRDEM.
We hope this document will be helpful and frequently used by all concerned physicians of BIRDEM
especially junior prescribers and interns to select empirical antibiotics for infections, and for surgical
chemoprophylaxis. The content of these protocols will undergo a process of continuous review.
Chapter 2: Department of Internal Medicine
Likely Empiric antibiotics
Type of Alternative Comments/
Causative (presumptive
Infections antibiotics Remarks
organisms antibiotics)
Respiratory Tract Infections
Azithromycin
Cefuroxime
500mg for 5 days
500mg BD for
Upper Or
10days Modify therapy
respiratory Amoxicillin+
Gr A Streptococcus Or based on
tract clavulanic acid
Levofloxacin sensitivities
infection 625 mg 8 hrly for 7-
500mg once daily
10 days
for 7-10 days
Ceftazidime Meropenem
1gm IVq8h 10- 1gm IV q8h for 10-
14days 14 days
Pneumonia Pneumococcus
Plus Plus
(Community K.pneumoniae Do
Azithromycin Moxifloxacin
acquired) Staph. aureus
500mg/ 400 mg OD
Moxifloxacin
400 mg OD
Pseudo.aeruginosa.
1gm IV q8 h 1gm IV q8 h 10-14
Pneumonia Klebsiella
Plus days
(Hospital pneumoniae. Do
Levofloxacin Plus
acquired) Escherichia coli
500 mg OD 10- Moxifloxacin
Acinetobacter
14days 400 mg OD
Ceftazidime
1-2gm IV q8h
Meropenem
Pneumococcus Plus
1gm IV q8h
Klebsiella. Moxifloxacin
Plus
Lung abscess pneumoniae 400 mg OD Do
Clindamycin
Staph aureus Plus
600 mg q8 h 4-
B.pseudomallei Clindamycin
6weeks
600 mg 8 hrly 4-
6wks
Gastrointestinal Tract Infections
Cefixime 10mg/kg
S. typhi divided doses BD
Ceftriaxone 2gm Modify therapy
S. paratyphi A for 14days
Enteric Fever IV OD/BD for based on
S. paratyphi B Or
14days sensitivities
S. paratyphi C Azithromicin
500 mg for 5days
Azithromicin 1gm
Or
Escherichia coli Ciprofloxacin
Acute Shigella 500mg BD for 5days Ceftriaxone 1gm
Do
gastroenteritis Salmonella Or IV OD for 3-5 days
Nitazoxanide
500 mg BD for
3days
causative (presumptive
Genitourinary Tract Infections
Nitrofurantoin
100mg BD for 7
days
Or
Acute Escherichia coli Modify therapy
Ciprofloxacin Cefuroxime 250
uncomplicated K. pneumonia based on
500mg mg BD for 3-5 days
cystitis S. saprophyticus sensitivities
BD for 3-5 days
Or
Cefuroxime 250
mg BD 3-5 days
Nitrofurantoin
Escherichia coli 100mg BD for 7
Acute
Klebsiella days Cefuroxime 500
complicated Do
P.aeruginosa Or mg BD for 7 days
cystitis
Enterococci Ciprofloxacin500mg
BD for 7days
Ceftazidime
Acute Escherichia coli 1gm IV q8 h Meropenem
uncomplicated S. saprophyticus Or 1gm IV 8 hrly 10- Do
pyelonephritis Amikacin 500mg 14 days
BD IV10-14 days
Ceftazidime 1gm IV
Escherichia coli
Acute 8 hrly
Klebsiella Meropenem
complicated Or, Do
P.aeruginosa 1gm IV q8h 14 days
pyelonephritis Amikacin 500mg
Enterococci
BD IV 14 days
Central Nervous System Infection
N. meningitides Meropenem Modify therapy
Ceftriaxone
Meningitis S. pneumonia 1gm IV 8 hrly 14 based on
2gm IV BD 14 days
H. influenza days sensitivities
Others
1-2gm IV 8 hrly 1gm IV 8 hrly
Staph aureus
Plus Plus
E.coli Modify therapy
Moxifloxacin Clindamycin
Septicaemia Pseudomonas based on
400 mg OD 600 mg 8 hrly 14
Klebsiella sensitivities
Plus days
B.pseudomallei
Clindamycin 600
mg q8h 14 days
Ceftazidime 1gm Meropenem Do
IV q8h 1gm IV 8 hrly
Staph.aureus Plus Or
P. aeruginosa Amikacin500mg Tazobactam+
Neutropenic Acinetobacter BD IV 14 days Piperacillin
sepsis K. pneumonia 4.5gm 6 hrly14
E. coli days
Fucloxacilin Ceftazidime 1gm
Cellulitis or 500mg oral/IV 6hrly IV 8 hrly
Modify therapy
soft tissue Streptococcus 10-14 days Plus
based on
infection or Staphylococcus Or Clindamycin
sensitivities
diabetic foot Clindamycin 600 mg 8 hrly for
600 mg 8 hrly 10-14 days
Fucloxacilin Ceftazidime
Staphylococcus 2 gm IV q 6 h 1gm IV 8 hrly
Streptococcus Or Plus Do
E coli Clindamycin Clindamycin
Septic 600 mg q8 h 600 mg 8 hrly
arthritis Ceftazidime 1-2gm
IV 8hrly for 2-
B. pseudomallei 4weeks then switch
to oral antibiotic for
2-4 weeks
Department of Respiratory Medicine
Upper Respiratory Tract Infections
Azithromycin
500mg for 5 days Cefuroxime
Upper Or 500mg BD for10days Modify
respiratory Amoxicillin+ Or therapy
Gr A Streptococcus
tract clavulanic acid Levofloxacin based on
infection 625 mg 8 hrly for 7- 10 500mg OD for 7-10 sensitivities
days days
Lower respiratory tract infection ( Hospitalized Diabetic patients)
1gm IVq8h 10-14days 1gm IV q8h/Inj
Plus Tajobactum-
Pneumonia Pneumococcus Azithromycin Piperacilline
(Community Klebsiella pneumoniae 500mg/ or Plus Do
acquired) Staph. aureus Moxifloxacin Levofloxacin
400 mg OD 500 mg OD/
/Levofloxacin Moxifloxacin
500 mg OD 400 mg OD
Meropenem
Ceftazidime
Pseudo.aeruginosa. 1gm IV q8h
1gm IV q8h
Klebsiella pneumoniae. Plus
Pneumonia Plus
Levofloxacin
(Hospital Escherichia coli Levofloxacin Do
500 mg OD
acquired) Staph. aureus 500 mg OD
/Moxifloxacin
Acinetobacter /Moxifloxacin
400 mg OD
400 mg OD
Pneumococcus Ceftazidime Meropenem
Klebsiella pneumoniae 1gm IV q8h 1gm IV q8h
Staph aureus Plus Plus
Moxifloxacin Clindamycin
Escherichia coli
400 mg OD 600 mg IV q8h/
Lung abscess B.pseudomallei Metronidazole 500 Do
Plus
Fusobacterium Clindamycin mg IV q8h
Bacteroids 600 mg IV q8h/
Mixed aerobic and Metronidazole
anaerobic organism 500 mg IV q8h
Department of Critical Care Medicine
Likely Empiric antibiotics Comments
Alternative
Type of Infections Causative (presumptive /
antibiotics
organisms antibiotics) Remarks
Pneumonia
Community acquired InjAmoxicillin- Inj Ceftriaxone /
pneumonia clavulanate Cefuroxime
Severe pneumonia Plus Plus
(having 3 or more Inj Clarithromycin InjErythromycin
factors) Or
1.Confusion Inj Amoxicillin
2.Urea > 7mmol/L Plus
3.Resp rate > 30/min Flucloxacillin
4.BP (SBP < 90 mm Hg
or DBP < 60
Strepto. pneumoniae
mm Hg)
H. influenzae
5.Age > 65 years
Staphylococcus
Levofloxacin Ceftriaxone
aureus
750 mg PO daily 1g IV OD
Atypical bacteria (e.g.
Or Plus
Chlamydiapneumonia
Moxifloxacin Macrolide
e,
400mg PO daily
Mycoplasma,
Or Rifampicin
Legionella spp)
Uncomplicated Amoxicillin (600mg BD)
pneumonia (not clavulanate - for atypical
fulfilling severe 2 g PO q12h bacteria
pneumonia criteria) Or
Cefuroxime Flucloxacillin
500 mg PO BD 1-2 g q6h for
Plus Staphylococcus
Macrolide
(Azithromycin or
Clarithromycin)
S. pneumoniae. Co-amoxiclav Beta-Lactam
S. aureus. Plus antibiotics
H. influenzae. Metronidazole (eg.Ceftria
Anaerobes - eg, Or xone/Meropenem)
Peptostreptococcus, Plus
Fusobacterium and Beta-Lactam Clindamycin /
Aspiration Pneumonia
Prevotella spp. antibiotics Vancomycin
(Community
'Streptococcus (eg.Ceftriaxone, /Linezolid
acquired)
milleri' group. Meropenem)
K. pneumoniae - Plus Metronidazole
increasingly seen in
those with a
history of alcohol
misuse.
Alternative Comments/
Type of Infections causative (presumptive
antibiotics Remarks
Oral anaerobes - as
mentioned previous.
Peptostreptococcus, Piperacillin
Carbapenems or
Peptococcus spp. Tazobactam
Aspiration Pneumonia Monobactam
Klebsiellapneumoniae Plus
(Nosocomial) Plus
Escherichia coli, Vancomycin
Clindamycin
Enterobacterspp. /Linezolid
Pseudo.aeruginosa.
MRSA
Tazobactam-
Piperacillin
Or
Cephalosporins(eg. Polymixins
Cefepime, (eg.Collistin)
Ceftazidim) or Or
Meropenem Aztreonam
Plus Plus
Ciprofloxacin or Aminoglycoside
Gm-ve bacilli Levofloxacin (eg.Amikacin or
Pneumonia in immune
and Staphylococcus Plus Gentamycin)
compromised host
aureus Vancomycin or Plus
Linezolid Vancomycin or
Linezolid
Depending on
clinicalcontext, Depending on
antiviral or clinical context,
antifungal antiviral or
antifungal or
Sulfamethoxazole
Trimethoprim
Ventilator associated Organism for early Inj. Meropenem Inj. Cefepime
pneumonia (VAP) onset VAP Plus Or
For High risk group (develops 2-5 days Inj. Moxifloxacin/ Tazobactam-
post intubation) Levofloxacin Piperacillin
1. Suspected MRSA Strepto. pneumoniae. Plus Or
2. Having structural lung Staph. aureus. Inj. Vancomycin Aztronem
disease H. influenzae Plus
(bronchiectasis, fibrosis) Proteus, Klebsiella Inj. Linezolid
3. Prior IV antibiotics pneumoniae Plus
within 90 Serratia, E coli Inj. Colistin/
days Amikacin
4. Septic shock at time
of VAP
Alternative
Type of Infections causative (presumptive /
antibiotics
Organism for late
5. ARDS preceding VAP onset VAP
6. 5 or more days (develops after 5 days
hospitalization prior to post intubation)
VAP Pseudomonas,
7. Acute renal Acinetobacter
replacement prior MRSA, Enterobacter,
to VAP Vancomycin resistant
enterococcus
Inj. Meropenem Inj. Cefepime
Plus Or
InjMoxifloxacin Or Tazobactam-
VAP for low risk group Levofloxacin Piperacillin
(Patients having no risk Or
factors) Aztronem
Plus
Inj. Colistin
Sulphate
Plus Or
Hospital acquired Pseudomonas Inj.Vancomycin/Line Tazobactam-
pneumonia aeruginosa. zolid Piperacillin
(HAP) Staphylococcus Or
For patients not aureus, including Aztreonam
requiring MV support or MRSA Or
no septic shock (but Klebsiella Levofloxacin/Cip
having likelihood of pneumoniae. rofloxacin
MRSA) Escherichia coli. Plus
Inj.Vancomycin/
Linezolid
Or
HAP For patients having
Tazobactam-
no risk factors
Piperacillin
above mentioned
Or
Levofloxacin
Blood Stream Infections
Inj. Vancomycin Inj. Cefepime
1gm q12 h 1gm 8-12 hourly
Plus for7-14 days
Staphylococcus aureus Inj. Meropenem 1gm
Enterococcus q8h for 7-14 days
Gram negative Bacilli Plus
Catheter Related Blood Inj. Amikacin 500
Stream mg q12 h for 7
Infection days
Candida spp. Inj. Fluconazole Echinocandin

100-400 mg daily
Type of Infections Likely Empiric antibiotics Alternative Comments
Causative (presumptive antibiotics /
Neutropenic Sepsis Meropenem Anti-
High risk patients Plus pseudomonal
1) In-door patients with Gentamicin penicillin
fever and neutropenia Or Amikacin (eg.Tazobactum-
2) Out-patients with Plus piperacillin)
uncontrolled cancer Vancomycin (If or Polymixin
(leukemia not in MRSA or coagulase- Plus
remission) ve staphylococcal Gentamicin
3) On sepsis suspected) / Amikacin
immunosuppressive Plus Plus
4) Specific foci of IV Fluconazole Vancomycin (if
infection MRSA or
(intravascular catheter coagulase -
infection, new vestaphy sepsis
pulmonary infiltrate) suspected)
5) Presence of any of the Plus
following – Echinocandins
Abdominal pain, nausea, (eg.Caspofungin
vomiting, diarrhea, orAnidulafungin)
Gm +ve cocci (eg.
mental changes
coagulase -ve
Allogeneic BMT or
staphylococci,
autologousBMT,Pregnan
Staphylococcus
cy,HIV,Renal
aureus,
failure,Hepatic failure,
Viridans streptococci)
Respiratory
or
insufficiency
Gm -ve bacilli (eg.
Haemodynamic
Escherichia coli,
instability
Klebsiella spp,
Inability to take oral
Pseudomonas
medications
aeruginosa
6) Recent treatment with
etc)
antibiotics(within
previous 72 hours)
7) Neutropenia likely to
last for more than 10
days
Ciprofloxacin
Plus Meropenem plus
Co-amoxiclav Gentamicin plus
Vancomycin
Or
Neutropenic Sepsis Tazobactum
Low risk patients piperacillin) /
All those not in the Polymixins plus
above categories Gentamicin/Ami
kacin
Plus
ivFluconazole or
Echinocandins
Likely
Type of Empiric antibiotics Alternative Comment
causative
Infections (presumptive antibiotics) antibiotics /Remarks
organisms
Central Nervous System
Meningitis (Recommendations for empirical antimicrobial therapy for purulent meningitis based on patient
age and specific predisposing condition)
Vancomycin
Plus
N. meningitidis,
Adult <50 years a third-generation
S. pneumoniae
cephalosporin
(ceftriaxone/cefotaxime).
S. pneumoniae, Vancomycin plus ampicillin
N. meningitidis, Plus
>50 years L. monocytogenes, a third-generation
aerobic gram negative cephalosporin.
bacilli (ceftriaxone/cefotaxime)
Vancomycin
S. pneumoniae, H.
Head trauma- Plus
influenzae,
Basilar skull a third-generation
group A ß-hemolytic
fracture cephalosporin
streptococci
(ceftriaxone/cefotaxime)
Staphylococcus
aureus, CoN
Staphylococci Vancomycin plus Cefepime
Head trauma- (especially Or
Penetrating Staphylococcus Vancomycin plus Ceftazidime,
trauma epidermidis), Or
aerobicgram-negative Vancomycin plus Meropenem
bacilli (including
P. aeruginosa
Post
neurosurgery Vancomycin plus Cefepime,
gram-negative bacilli
(Suspected Or
includingP.aeruginosa
Healthcare- Vancomycin plus Ceftazidime
S. aureus,
Associated Or
CoN Staphylococci
Ventriculitis Vancomycin plus Meropenem
and Meningitis)
CSF shunt
CoN Staphylococci
(Suspected
S. aureus,
Healthcare Vancomycin plus cefepime, or
aerobic gram-negative
Associated vancomycin plus ceftazidime or
bacilli including
Ventriculitis vancomycin plus meropenem
P. aeruginosa,
and
Propionibacterium
Meningitis)
Vancomycin 15 mg/kg IV q8h ,
Inj. Ceftriaxone 2 gm IV q12h,
Inj.Cefotaxime2 gm IV q4-6h,
Inj.Ceftazidime 2 gm IV q8h,
Inj. Cefepime 2 gm IV q8h, Inj.
Meropenem 2 gm IV q8h,
Inj. Ampicillin 2 gmIV q4h.
In seriously ill adult patients the vancomycin trough concentration should be maintained at 15–20 μg/mL
Type of Alternative
causative (presumptive /
Infections antibiotics
Viral HSV, Measles, Inj. Acyclovir 5-10
encephalitis Mumps, mg/kg IV q8h ( for HSV)
Rubella,
Vericella zoster
virus, CMV,
Epstein-Barr
virus
Gastrointestinal Infections
Inj.Piperacillin/Tazobactam Inj. Meropenem
4.5 gm 6-8 hourly for 7-14 day 1gm q8h for 7-
Acinatobacter
Plus 1day Plus
Enterococci
Abdominal Inj. Amikacin Inj. Amikacin
faecalis
Sepsis 500 mg q12 h for 7 days 500 mg q12h for
Bacteroides
Plus 7 days.
fragilis
Tab. Metronidazole
500 mg q8h 7 days
Gram negative Inj. Meropenem
Cholangitis
anaerobes 500 mg q8 h
Inj. Meropenem
1 gm q8 h for 7-
Inj. Piperacillin/Tazobactam 4.5 gm 14 days
q6-8 h for 7-14 days Plus
Plus Inj. Amikacin
Necrotizing
Inj. Amikacin 500 mg q12 h
Pancreatitis
500 mg q12 h for 7 days for 7 days
(infected)
Plus Plus
Tab. Metronidazole Inj.
500 mg q8h 7 days Clindamycin
600 mg q8h for
7-14 days
Pseudomem
brenous
colitis by
Tab.
clostridium
Escherichia Ciprofloxacin
difficile
coli 500mg q12 h for
is an
Acute Campylobacter Tab. Azithromycin 7 days
important
gastroenteriti Shigella 500 mg2 tab stat then Plus
cause of
s Salmonella 1 tab for 4 days Tab.
gastroenterit
Clostridium Metronidazole
is
difficile 400mgq 8 h for
following
5-7 days
use of
other
antibiotics.
Severe
disease:
Hospital startVancom
Clostridium Metronidazole
acquired ycin 250 mg
difficile 400 mg oral TDS for 10 days
diarrhea oral 6h
empirically
Cefotaxime 1-2 gm IVTDS
Imipenem
Or
Spontaneous E.coli, 500 mg IV q6h
PiperacillinTazobactam
bacterial Klebsiella or
4.5gm IV q8 h
Peritonitis sp. Meropenem
or Cefoperazone Sulbactam
1gm IV q8h
3gm IV q12h
SSTI non Purulent (Cellulitis/Erysipelas/Necrotizing infection)
Oral
Streptococcus Oral Rx
Mild SSTI Clindamycin or
Staphylococcus Penicillin VK or Cephalosporin
Dicloxacillin
Intravenous Rx Intravenous Rx
Moderate
Penicillin/ Cefazolin or
SSTI
Ceftriaxone Clindamycin
Intravenous Rx
Severe SSTI Vancomycin
Plus Pipercillin-tazobactum
SSTI Purulent (Furuncle/Carbuncle/Abscess)
Streptococcus No Antibiotics.
Mild
Staphylococcus Incision &Drainage,
Moderate Incision & Drainage,
Doxycycline
SSTI Plus Co-trimoxazole
Daptomycin or
Severe SSTI Incision & Drainage, + Vancomycin
Linezolid
Genitourinary system infections
Inj Gentamicin Complicated
14 days dose pyelonephrit
E coli
adjust is
Streptococcus Tab. Ciprofloxacin
according to are common
Acute saprophyticus 500 mg q12 h for 7 days
renal in diabetic
pyelonephritis Klebsiella Tab. Cefalexin
function patient
P. aeruginosa 1gm daily 14 days
Inj.Levofloxacin require
Enterococci
750mg 24 h for prolong
7 days therapy
Department of Nephrology
Likely
Type of Empiric antibiotics Alternative Comments/
causative
Infections (presumptive antibiotics) antibiotics Remarks
organisms
No antibiotics unless the patient
is:
- Scheduled for urologic
procedure
Asymptomatic - Pregnant
Bacteriuria -Kidney transplant recipient
Scheduled urologic procedure:
• Pyuria SMX/TMP DS 1 tablet PO q12h
•Obtainig routine
(urinalysis≥5- OR
cultures in
10 Ciprofloxacin 500 mg PO
asymptomatic
WBC) plus OR
patients is NOT
Positive urine Ciprofloxacin 400 mg IV q12h
recommended
culture OR
• Antibiotics do
(≥ 105cfu/mL) According to sensitivity pattern Meropenem
NOT
initiate within 24 hours prior to
decrease
AND procedure and until foley removed
asymptomatic
Pregnant:
bacteriuria or
• No sign or Amoxicillin 500 mg PO q12h for 3
prevent
symptoms to 7 days
subsequent UTI
including no OR
renal angle Cephalexin 500 mg PO q12h for 3
tenderness E. coli to 7 days
Klebsiella OR
Citrobacter Nitrofurantoin
Acinetobacter 100 mg PO q12h for 5 days
Enterobacter If diabetic- 7 days
Enterococcus Males-7 days, Females-3 days
Symptomatic Pseudomonas Nitrofurantoin • Urine culture
uncomplicated 100 mg PO q12h for 5-7 days should be
cystitis OR performed
• Female & SMX/TMP ONLY
• No criteria for 1 DS tablet PO q12h for 3-5 days If:
complicated UTI - History of
(Clinical Alternative agents should be multiple UTIs or
findings: avoided if possible due to the risk of MDR infections
• Pyuria C. difficile infection & antibiotic • Narrow
Cefuroxime
(urinalysis ≥10 resistance. antibiotic therapy
250 mg
WBC) OR when organism
BD 3-5 days
Positive urine If patient has an &
culture allergy/contraindication to the above susceptibilities
(≥ 105cfu/mL) & antibiotics, alternatives include: are known
• presence of Ciprofloxacin • Follow-up
symptoms- 250-500 mg PO q12h for 3-5 days urine
dysuria, OR cultures or UA
urgency, Cephalexin are only
frequency, 500 mg PO q12h for 3 days warranted for on-
suprapubic pain going symptoms.
Likely
Empiric antibiotics Alternative Comments/
Type of Infections causative
(presumptive antibiotics) antibiotics Remarks
organisms
• Narrow
Outpatient: antibiotic
SMX/TMP 1 DS tablet PO q12h therapy when
Symptomatic
OR organism and
complicated cystitis*
Nitrofurantoin 100 mg PO q12h susceptibilities
≥ 1 of the following:
OR are known
• Male
Ciprofloxacin 250 - 500 mg PO • Follow-up
• Pyelonephritis Piperacillin
q12h urine
•Antibiotic use in Tazobactam
Inpatient: cultures or
previous 1 year 4.5gm IV 6
Ceftriaxone/Ceftazidime urinalysis are
• History of infection hourly
OR only warranted
with MDR organism or
Amoxicillin/clavunalic acid for ongoing
• Amikacin
combination symptoms.
Immunocompromised 1 g OD IV
Known or suspected ESBL+ve They should
• Functional or
bacteria: NOT be
anatomic urologic
Meropenem 1 gm IV q8h obtained
abnormality
Duration of Treatment:7 to 14 routinely to
• Severe sepsis
days monitor
DM -2 weeks response
to therapy
* Clinical findings: Pyuria (Urinalysis ≥ 10 WBC) AND Positive urine culture (≥ 105cfu/ml) AND Presence
of symptoms- Dysuria, Urgency, Frequency, Suprapubic pain AND/OR Presence of signs: Fever (≥
100.4°F), altered mental status, leukocytosis. Raised CRP, Renal angle tenderness
Remove catheter • Obtaining
No antibiotics unless the patient is routine
scheduled for urologic procedure cultures in
and pregnant. asymptomatic
Scheduled Urologic Procedure: patients is
SMX/TMP DS 1 tablet PO q12h NOT
Catheter related
OR recommended
asymptomatic
Ciprofloxacin 500 mg PO • In the
bacteriuria
OR presence of a
Ciprofloxacin 400 mg IV q12h catheter, pyuria
• Positive urine
Initiate within 24 hours prior to (>5-10 WBC)
culture
5 procedure and until foley Cefuroxime in
(≥ 10 cfu/mL of
removed 250 mg BD asymptomatic
≥ 1 bacterial species
Pregnant: 3-5 days patient is
in a single catheter
Amoxicillin 500 mg PO q12h for NOT an
urine specimen)
3 to 7 days indication for
AND
OR Cephalexin 500 mg PO q12h treatment
• No sign or
for 3 to 7 days • Antibiotics do
symptoms
OR Nitrofurantoin 100 mg PO NOT
q12h for 5 days decrease
Known or suspected ESBL asymptomatic
bacteria: Meropenem 1 gm IVq8h bacteriuria or
Duration of Treatment: prevent
Prompt resolution: 7 days subsequent
Delay response: 10-14 days UTI
Likely
organisms
• Remove
catheter
whenever
possible
Outpatient:
• Narrow
SMX/TMP DS
antibiotic
tablet PO q12h
Catheter related therapy
OR
Symptomatic when
Nitrofurantoin
Bacteriuria** organism
100 mg PO q12h (except
≥ 1 of the following: and
pyelonephritis)
• Male susceptibilit
OR
• Pyelonephritis ies are
Ciprofloxacin
• Antibiotic use in Cefepime known
250 - 500 mg PO q12h
previous 1 year Pipercillin/ • Follow-up
Inpatient:
• History of infection tazobactum urine
Ceftazidime
with MDR organism Amikacin cultures or
1 gm IV q8h
• Immuno- urinalysis
OR
compromised are only
Amoxicillin/ clavunalic acid
• Functional or warranted
combination Known OR
anatomic urologic for ongoing
suspected ESBL bacteria:
abnormality Symptoms.
Meropenem 1 gm IV q8h
• Severe sepsis They should
Duration of Treatment:
NOT be
Prompt resolution: 7 days
obtained
delay response: 10-14 days
routinely to
monitor
response to
therapy
3
**Positive urine culture (≥ 10 cfu/mL of ≥ 1 bacterial species in a single catheter urine specimen) AND
Presence of
signs/symptoms, Catheter still in place: Malaise/lethargy, Fever (≥100.4°F)/rigor, altered mental status,
flank pain, pelvic discomfort, acute hematuria, catheter removed within past 48 h: dysuria, urgency,
frequency, suprapubic pain/tenderness
Betalactam
s do not
have
adequate
penetration
into
SMX/TMP 1
prostate
DS
Ciprofloxacin tablet PO q12h
Prostatitis
500 PO q12h for 28 days Levofloxacin
500 mg PO 28
days
Likely
Empiric antibiotics Alternative Comments
(presumptive antibiotics) antibiotics / Remarks
organisms
Ceftazidim and Vancomycin
Meropenem instead of
After
ceftazidime if there is high
sending
CV line associated fever,high TLC, shock, elderly,
blood CS
infection altered sensorium
from
CV line
Linezolide instead of
vancomycin if patient has
AKI
For Prevention of peritonitis:
Peritoneal dialysis Per operative injection
associated infection ceftazidime, IP Vancomycin and
gentamicin stat
Muperocin/G entamicin
Exit site infection
ointment
prevention
Intranasal muperocin
After
Ceftazidime and Vancomycin sending
Sepsis in Meropenem instead of blood CS
haemodialysis ceftazidime if there is high from
patient fever,high TLC,Shock, elderly, CV line
altered sensorium
Ceftazidime
Meropenem instead of
EPN ceftazidime if there is high
fever,high TLC,Shock, elderly,
altered sensorium
Candiduria Usually no Rx, unless indicated

Recurrent Nitrofurantoin, coamoxyclav
UTI(suppressive ) Pivmecillinam
Department Endocrinology
Infections (presumptive antibiotics Remarks
antibiotics)
Urinary tract infection
Upper UTI Pyelonephritis : Ceftriaxone Modify therapy
Meropenam 1 gm 12 hrly 7days based
1gm 8 hrly for 14 days Or on sensitivities
Ceftazidime,1gm 8hrly 14 days
Uncomplicated : Cefixime
Nitrofurantoin 400mg12 hrly for 14 days
100 mg 12 hrly 7-14 days Or
Ciprofloxacin
500 mg BD,
Or Moxifloxacin
400 mg daily-7-14 days
Lower UTI Uncomplicated : Cefixime, Modify therapy
Nitrofurantoin100 mg 12 400mg12 hrly for 14 days Or based
hrly-7-14 days Ciprofloxacin on sensitivities
500mg 12 hrly 7 days Or
Moxifloxacin,
400 mg daily-7-14 days
Complicated: Ceftriaxone,
Meropenam 1 gm 12 hrly 7days Or
1gm 8 hrly for 14 days Ceftazidime,
1gm 8hrly7 days
Urosepsis : Meropenam, Ceftazidime, Modify therapy
1gm 8 hrly for 14 days 1gm 8hrly 14 days Or based
Vancomycin on sensitivities &
500mg 6 hrly 7-14days Or Dose duration
Metronidazole according to
500 mg 8hrly 7days severity
Respiratory tract infection
Upper RTI Coamoxyclav Levofloxacin Dose duration
625 mg 8h for 7 days. 500 mg daily for 7days according to seve
rity
Pneumonia Coamoxyclav Ceftazidime Plus Clarithromycin,
Plus 1gm 8hrly 14 days
Clarithromycin, 625 Ceftazidaime Plus Moxifloxacin 1gm
mg 8hrly for 7 days. 8hrly 14 days
Pneumonitis Coamoxyclav, Moxifloxacin,
625 mg 8hrly for 7 500 mg daily 7days or Ceftazidime
days /Azithromycin
Type of Infections Empiric antibiotics Alternative Comments/
(presumptive antibiotics Remarks
antibiotics)
Foot infection Flucloxacillin, Metronidazole, Dose duration
500 mg 6hrly for 7 500 mg 8 hrly -7days according to
days. Ceftriaxone, 1 gm BD -7days severity or renal
Linezolide+ Coamoxyclav 400mg function status
12hrly-7-14 days
Enteric fever Ceftriaxone, Azithromycin,
2 gm 12hrly -14days 500 mg once daily for 7-14days Or
Ciprofloxacin
500 mg/Levofloxacin 750 mg hrly 7-
14days
Gastroenteritis Azithromycin 2stat+ Ciprofloxacin,
500 mg once daily for 500mg 12 hrly for 3 days
3 days.
Pancreatitis Ceftriaxone, Ceftazidime
1 gm 12 hrly for 7- 1 gm 8 hrly 7-10days or Meropenem
14days 1 gram 8hrly
Department of Neurology
Likely
causative
organisms
Central nervous system infection

Cefotaxime 2 gm 4-
Pathogen is Ceftriaxone
6h/Cefepime 2gm
unidentifiable 2gm 12h, IV
8h/ Meropenem
in most of the Plus
IV 6g/d 8h
cases Vancomycin
Meningitis Plus
Occasionally 15-20 mg/kg/d, 6-12h for 14
(Bacterial) Vancomycin
Pneumococcus days
15-20mg/kg/d, 6-
H. influenzae
12h for 14 days
L.monocytogen
Ampicillin +Metronidazole
es, anaerobes
Herpes virus,
Meningitis (Viral) Self limiting
Enterovirus
Tubercular Mycobacterium According to national
meningitis tuberculosis guideline
Diluted to a
conc.
Acyclovir, IV 10mg/kg, IV 8h
≤7mg/ml,
Encephalitis Herpes simplex for 14-21 days.
Dose
(Viral) virus (VZV encephalitis 10-12
adjustment
mg/kg/dose for 21 days)
in renal
impairment
Ceftriaxone IV
(4 g/d, 12h) Plus
Frontal lobe:
Metronidazole IV
Meropenem
(1.5-2 g/d, 6h)for 6-
(6gm/day 8h IV for 21 days
8 weeks
Plus Metronidazole
Cerebellum:
1.5-2g/d, 6h for 6-8weeks
Gentamicin IV
Temporal lobe:
5mg/kg/d for 6-8
Meropenem
weeks
6gm/day 8h IV
Streptococci, Penetrating head
Plus Metronidazole
Anaerobes, trauma or post-
1.5-2 g/d, 6h for 6-8 weeks
Staphylococci neurosurgery:
Cerebellum
Brain abscess (penetrating CeftazidimeIV
Ceftazidime
head trauma or (6 g/d, 8h) Plus
6g/d, 8h for 6-8 weeks
post Vancomycin IV
Penetrating head trauma or
neurosurgery) (45–60 mg/kg/d, 6–
post neurosurgery
12h)for 6-8 weeks
Meropenem 6g/d, 8h IV plus
Multiple site:
Vancomycin 45-60mg/kg/d,
Benzylpenicillin IV,
6-12h IV for 6-8 weeks
1.8-2.4 g, 6h
Multiple site
(infective
Meropenem 6g/d, 8h IV Plus
endocarditis) for 6-
Metronidazole 1.5-2g/d 6h IV
8 weeks
for 6-8 weeks
Likely
organisms
Streptococci Ceftriaxone, 4g/d, 12h IV Surgical
Spinal Epidural
Anaerobes Plus Metronidazole 1.5-2g/d, drainage
abscess
Staphylococci 6h for 4-6weeks should done
Meropenem 6g/d,
Surgical
Subdural Streptococci Ceftriaxone 4g/d, 12h IV Plus 8h IV Plus
drainage
empyema Anaerobes Metronidazole 1.5-2g/d, IV 6h Vancomycin 45-60
should be
Epidural abscess Staphylococci for 4-6weeks mg/kg/d, 6-12h for
done
4-6 weeks
Venous sinus Meropenem
Meropenem 6g/d,
thrombosis/ 6g/d, 8h IV Plus
8h Plus Linezolid
Cavernous sinus Vancomycin 45-60 mg/kg/d,
for 4-6 weeks
thrombosis 6-12h for 4-6 weeks
Respiratory tract infection
Community acquired Community
Cetriaxone acquired
2g/d, 12h IV plus Quinolone Co-moxiclav IV
IV 1.2g, 8h plus
Klebsiella Aspiration Pneumonia Quinolone IV
pneumoniae Cetriaxone Aspiration
Streptococcus 2g/d, 12h IV plus Pneumonia
Pneumonia
pneumonia Metronidazole IV 500mg, 8h Cetriaxone
S. Aureus Hospital acquired IV, 2g/d, 12h IV
Candida Meropenem+ Vancomycin + plus Clindamycin
Metronidazole IV 600mg, 8h
Atypical pneumonia Hospital acquired
Ceftriaxone IV +Moxifloxacin Meropenem IV+
IV Moxifloxacin IV
Urinary tract infection
E Coli
ESBL positive E
Coli Ceftazidime IV/
UTI Ceftriaxone IV
Pseudomonus Meropenem
Klebsiella
Streptocossus
Blood stream infection
E. coli
Ceftriaxone/
Sepsis Pseudomonus
Meropenem
S. Aureus
Gastrointestinal tract infection
Ceftriaxone
Enteric fever Salmonella typhi
Quinolones
Department of Cardiology
Type of Antibiotic(s) Comments/
Infections Remarks
Infective Endocarditis (Empiric / presumptive antibiotics – according to mode of presentation,

suspected organism, presence of prosthetic valve & presence of penicillin allergy)
Amoxicillin 2gm 4h IV Adjust dose on the
Subacute or indolent
with or without basis of antibiotic
Presentation
Gentamicin 1 mg/kg 12h IV levels
Vancomycin 1g 12h IV Plus (Vancomycin &
Acute presentation Gentamicin).
Gentamicin 1 mg/kg 12h IV
Vancomycin 1gm 12h I/VPlus After identification
True Penicillin allergy of causal organism,
Gentamicin 1 mg/kg 12h I/V determination of
the minimum
inhibitory
Vancomycin 1gm 12hI/VPlus concentration
Suspected prosthetic valve (MIC) for the
Gentamicin 1mg/kg 12h I/VPlus
endocarditis organism,
Rifampicin 300-600mg 12h PO
antibiotic(s) should
be changed / given.
Infective Endocarditis (according to specific organism suspected)

Conditions for the
short-course
treatment of
Duration endocarditis
MIC caused by fully
Antibiotics Native Prosthetic
mg/L sensitive
valve valve
streptococci
Benzylpenicillin -Native valve
≤ 0.12 4 weeks1 6weeks
1.2g 4h IV infect.
-MIC ≤ 0.125
Viridans Streptococci Benzylpenicillin mg/L
and Streptococcus 2.4g 4h IV Plus 4 weeks 6 weeks -No adverse
> 0.12
bovis - ≤0.5 prognostic factors
Gentamicin (heart failure,
1mg/kg 12h2 2 weeks 2 weeks aortic
Vancomycin regurgitation,
1 g 12h IV3Plus 4 weeks 6 weeks conduction defect)
> 0.5 -No evidence of
thromboembolic
Gentamicin 4 weeks 6 weeks disease
1mg/kg 12h2 -No vegetations >
5 mm diameter
-Clinical response
within 7 days
Enterococci Duration
MIC mg/L Antibiotics Native Prosthetic
valve valve
Amoxicillin Amoxicillin 4 weeks 6 weeks
≤ 4 mg/L 2g 4h IV Plus
&
Gentamicin Gentamicin 4 weeks 6 weeks
≤ 128mg/L 1mg/kg 12h2
Amoxicillin Vancomycin 4 weeks 6 weeks
>4 mg/L 1g 12h IV3Plus
&
Gentamicin Gentamicin 4 weeks 2 weeks
≤ 128mg/L 1mg/kg 12h2
Antibiotic(s) Duration
Flucloxacillin
Methicillin- sensitive 4 weeks
Staphylococci-Native 2 g 4-6h IV4
Valve Methicillin- resistant, Vancomycin 4 weeks
Vancomycin 1g 12h IV3Plus
MIC≤2mg/L Rifampicin
Rifampicin sensitive 300-600mg 12h PO 4 weeks
Flucloxacillin 6 weeks
2 g 4-6h IV Plus
Gentamicin IV
Methicillin- sensitive 1mg/kg 12h 6weeks
Staphylococci- IV2Plus
Prosthetic Valve Rifampicin 6weeks
300-600mg 12h PO
Methicillin- resistant, Vancomycin 6 weeks
Vancomycin 1g 12h IV3Plus
MIC≤2mg/L Rifampicin 6weeks
Rifampicin sensitive 300-600mg 12h PO
1
When conditions for short course therapy are met, 2 weeks of benzylpenicillin and gentamicin (1 mg/kg
twice daily) may be sufficient. Ceftriaxone 2 g once daily IV/IM can be used instead of benzylpenicillin for
those with non-severe penicillin allergy.
2
Pre-dose gentamicin level should be ≤ 1 mg/L, post-dose 3–5 mg/L. Adjust dose according to levels and
renal function.
3
Pre-dose vancomycin level should be 15–20 mg/L. Adjust dose according to levels and renal function.
4
Use 6 times daily if weight > 85 kg.
Infections Remarks
Antibiotics Duration Remarks
HACEK^ Microorganisms
(Haemophilus species,
Actinobacillus species,
Cardiobacterium hominis,
Eikenellacorrodens, and Ceftriaxone sodium 4 weeks Dosage
Kingella species) 2gm in 24hIV (adult) or recommended are for
100mg/kg/d IV (children) patients with normal
OR renal function,
Ampicillin-Sulbactam 4 weeks
2gm 6h IV(adult)
200-300 mg/kg/d IV (children)
OR 4 weeks
Ciprofloxacin
500mg 12h PO or 400mg 12h IV
(adult)
10-15mg/kg 12hIV/PO(children)
Doxycycline Dosages
2 gm Once daily PO (adult) 6 weeks recommended are
1-2mg/kg 12h PO (children) for pts with normal
Plus, renal function.
Bartonella culture positive 2 weeks *If gentamicin can‘t
Endocarditis (documented) Gentamicin* sulfate be given, then replace
1mg/kg 8h IV with rifampin 600
mgper 24 h PO/IV in
2 equally divided
doses
Culture Negative Endocarditis
Ampicillin-Sulbactam 4-6 weeks Dosages
3 gm 6h IV (adults) recommended are for
Native Valve
200-300 mg/kg/d IV (children, in patients with normal
(Three independent blood
4-6 equally divided doses) renal function
culture negative for 7 days
Plus,
incubation)
Gentamicin Sulfate 4-6 weeks
1.5 mg/kg 12h IV (adults)
1 mg/kg 8h IV (children)
Vancomycin* 4-6 weeks *Vancomycin
15 mg/kg 12h IV (adults) recommended only
60 mg/kg/d IV (children, in 2-3 for patients unable to
equally divided doses) tolerate penicillins
Plus,
Gentamicin sulfate 4-6 weeks
Native Valve 1 mg/kg 8h IV (adults & children)
(In patient with penicillin Plus,
allergy) Ciprofloxacin
500 mg 12h PO/400 mg 12h 4-6 weeks
IV(adults)
10-15 mg/kgIV/PO 12 h(children)
Infections Remarks
Vancomycin* 6 weeks
15 mg/kg 12h IV (adults)
60 mg/kg/d IV (children, in 2-3
equally divided doses)
Plus,
Prosthetic Valve
Gentamicin sulfate 2 weeks
(Early≤1year)
1 mg/kg 8h IV (adults & children)
Plus,
(Three independent blood
Cefepime
culture negative for 7 days
2 gm 8h IV (adults) 6 weeks
incubation)
50mg/kg 8h IV (children)
Plus,
Rifampicin 6 weeks
300 mg 8h PO (adults)
20mg/kg/d PO (children, in 3
equally divided doses)
Ceftriaxone sodium 6 weeks Dosages
2 gm in 24h IV (adults) recommended are for
100mg/kg/d IV (children) patients with normal
Plus, renal function
Prosthetic Valve
Gentamicin sulfate IV 2 weeks
(Late>1year)
1mg/kg 8h IV(adults / children)
With/without,
Doxycycline
100 mg 12h PO(adults) 6 weeks
1-2 mg/kg 12h PO(children)
Rheumatic Fever
Antibiotics Duration
Benzathine Penicillin Single dose

12 Lac Unit (wt≥ 60lbs); 06 Lac Unit
(wt <60lbs), IM
OR,
Group A beta haemolytic
Phenoxymethyl Penicillin
Streptococcus (BHS) 10 days
250 mg 6h daily (wt ≥ 60lbs); 125
mg 6h daily (wt < 60lbs) PO
OR, 1
In patients who
Erythromycin1 10 days are allergic to
40 mg/kg/day or, penicillin
250 mg 6h PO
Prophylaxis of Infective Endocarditis
Prophylaxis is suggested only in settings associated with the highest risk of an adverse outcome if IE
occurs. This includes patients with:
1) Prosthetic heart valves, including mechanical, bioprosthetic, and homograft valves
(transcatheter-implanted as well as surgically implanted valves are included)
2) Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords
3) A prior history of IE
4) Unrepaired cyanotic congenital heart disease
5) Repaired congenital heart disease with residual shunts or valvular regurgitation at the site or
adjacent to the site of the prosthetic patch or prosthetic device
6) Repaired congenital heart defects with catheter-based intervention involving an occlusion
device or stent during the first six months after the procedure
7) Valve regurgitation due to a structurally abnormal valve in a transplanted heart
Antimicrobial prophylaxis is suggested for patients with the cardiac lesions cited above in the setting of
procedures likely to result in bacteremia with a microorganism that has the potential ability to cause
endocarditis.
i. Dental work - dental procedures that involve manipulation of gingival tissue or the periapical region
of the teeth or perforation of the oral mucosa, such as tooth extractions or drainage of a dental
abscess; this includes routine dental cleaning.
ii. Respiratory Tract procedures - prophylaxis is suggested only for procedures involving incision or
biopsy of the respiratory tract mucosa; examples include tonsillectomy, adenoidectomy, or
bronchoscopy with biopsy.
iii. All endoscopic procedures (Gastrointestinal & Genitourinary) with high risk of bacteremia in
patients with the highest-risk cardiac conditions (e.g., prosthetic heart valve, prior endocarditis) who
have ongoing GI or genitourinary tract (GU) infection.
iv. Skin or soft tissue procedures - Patients undergoing a surgical procedure for management of infected
skin, skin structure, or musculoskeletal tissue.
v. Surgery to place prosthetic heart valves or prosthetic intravascular or intracardiac materials.
Antibiotic regimens for prevention of endocarditis prior to dental and respiratory
procedures
Situations Antibiotic Regimen: Single Dose

- within 60 minutes before procedure
Adults Children
Oral Amoxicillin 2 gm 50 mg/kg
Unable to take oral Ampicillin 2 g IM or IV 50 mg/kg IM or IV
medication OR,Cefazolin 1 g IM or IV 50 mg/kg IM or IV
or,Ceftriaxone
Allergic to penicillins Cephalexin 2 gm 50 mg/kg
and able to take oral OR,Clindamycin 600 mg 20 mg/kg
medication OR,Azithromycin 500 mg 15 mg/kg
or, Clarithromycin
Allergic to penicillins Cefazolin or, 1 g IM or IV 50 mg/kg IM or IV
and unable to take oral Ceftriaxone
medication OR,Clindamycin 600 mg IM or IV 20 mg/kg IM or IV
OR,Vancomycin 15 to 20 mg/kg, not 15 mg/kg to a
to exceed 2 gm / maximum dose of 1
dose gm
Antibiotic regimens for prevention of endocarditis prior to Gastrointestinal and

Genitourinary Tract procedures in high risk patients with ongoing GI or GU tract
infection.
Situations Antibiotic Dose* - within 60 minutes Interval for
before procedure intraoperative re-
Adults Children dose for
prolonged
procedure
Oral Amoxicillin 2 gm 50 mg/kg 2 hours
Unable to take oral Ampicillin 2 g IM or 50 mg/kg IM 2 hours
medication IV or IV
Allergic to penicillins Clindamycin 600 mg 20 mg/kg 6 hours
and able to take oral
medication
Allergic to penicillins Clindamycin 900 mg IV 10 mg/kgIV 6 hours
and unable to take OR,Vancomyc 15 to 20 15 mg/kg to N/A
oral medication in mg/kg, not a maximum
to exceed 2 dose of 1 gm
gm per
dose
*If the preferred agent is vancomycin, administration should begin 120 minutes before
starting procedure because of the prolonged infusion times required.
Procedures on infected Skin & Soft Tissue: Empiric antibiotic therapy with activity
against methicillin-resistant S. aureus and beta-hemolytic streptococci should be
administered (if pathogen is not known).
Antimicrobial prophylaxis for cardiac surgery in adults
Nature of operation Common Recommended Usual adult Re-
pathogens antimicrobials dose* doseinterval¶
Cardiac procedures: Staphylococcus Cefazolin <120 kg: 2 g 4 hours
coronary artery bypass, aureus, IV
cardiac device insertion Staphylococcus ≥120 kg: 3 g
procedures (e.g., epidermidis IV
pacemaker implantation), OR,Cefuroxime 1.5 g IV 4 hours
placement of ventricular OR,Vancomycin§ 15 mg/kg IV N/A
assist devices (max 2 g)
OR,Clindamycin 900 mg IV 6 hours
*Antimicrobial therapy should be administered within 60 minutes before surgical incision to
ensure adequate drug tissue levels at the time of initial incision. If the preferred agent is
vancomycin or a fluoroquinolone, administration should begin 120 minutes before surgical
incision because of the prolonged infusion times required for these drugs.
¶
For prolonged procedures (>3 hours) or those with major blood loss or in patients with
extensive burns, additional intraoperative doses should be given at intervals one to two times
the half-life of the drug for the duration of the procedure in patients with normal renal
function.
§
Use of vancomycin is appropriate in hospitals in which methicillin-resistant S. aureus
(MRSA) and S. epidermidis are a frequent cause of postoperative wound infection.
Prophylaxis of Rheumatic Fever
a. Primary-Earlytreatment of upper respiratory tract infection due to Group A Beta Hemolytic

Streptococci to prevent an initial attack of Rheumatic Fever.
Primary Prophylaxis against Rheumatic Fever
Organism Antibiotic Dosage Duration
Group A Benzathine Penicillin Weight ≥ 60lbs - 12 Lac Single Dose
Beta- UnitIM
Hemolytic Weight < 60lbs - 06 Lac
Streptococcus UnitIM
(BHS) OR,Phenoxymethyl Weight ≥ 60lbs-250 mg 6h PO 10 days
Penicillin Weight < 60lbs - 125 mg 6h
PO
1
OR,Erythromycin 40 mg/kg/day or, 10 days
250 mg 6h PO
1
In patients who are allergic to penicillin
b. Secondary - Regular administration of an antimicrobial agent who have had RF or is already
suffering from Rheumatic Heart Disease (RHD) in order to prevent colonization &/or
infection of upper respiratory tract with Group A Beta HemolyticStreptococci& subsequent
attack of Rheumatic Fever.
Secondary Prophylaxis against Rheumatic Fever
Organism Antibiotic Dosage Duration
Group A Benzathine Weight ≥ 25 Kg 1)Rheumatic Fever with
Beta- Penicillin - 12 Lac Unit IM no Residual Heart
Hemolytic every 4 weeks Disease
Streptococcus Weight <25 Kg • Up to the age of 21
- 06 Lac Unit IM
(BHS) every 4 weeks years.
• It should be extended if
an attack has occurred
OR, Weight ≥ 25 Kg in the last 5 years, or if
Phenoxymethyl - 250 mg 12h daily the patient lives in an
Penicillin PO area of high prevalence
Weight < 25 Kg or has an occupation
- 125 mg 12h daily (e.g. teaching) with
PO high exposure to
OR, Weight < 25 Kg streptococcal infection.
Sulphadiazine1 - 0.5 gm daily PO 2)Rheumatic Fever with
Weight > 25 Kg residual Heart Disease
- 1.0 gm daily PO  Prophylaxis should
OR, 250 mg 12h daily continue until 10 years
Erythromycin2 PO after the last episode or
40 years of age,
whichever is later.
1
In patients who are allergic to penicillin 2In patients allergic to both penicillin &
sulphonamide
Department of GHPD
Likely
Causative
organisms
Infection in Intestine
Antibiotic therapy is
not required in most
Viral or
patients with acute
Bacteria
gastroenteritis.
( Entero-
Rehydration
toxigenic & None None
(oral/IV) essential.
Entero-
Anti-diarrheal agents
pathogenic
(Loperamide,
E.coli)
racecadotril) can
be used
patients with
acute gastroenteritis.
Empirical
Tab. Azithromycin antimicrobial therapy
500 mg 2 tab stat then can be
Acute Escherichia coli
1 tab for 4 days. necessary in certain
gastroenteritis Campylobacter
Ciprofloxacin situations,
Shigella
If severe 500mg BD for such as patients with
Salmonella
Ceftriaxone 3 days febrile diarrhoeal
Clostridium
2 gm IV OD for 5 days illness, with fever
difficile
and bloody
diarrhoea,
symptoms persisting
for >1 week, or
immunocompromise
d
status.
Metronidazole Tinidazole Add diloxanide
E. histolytica 400mg Oral TDS 2gm Oral OD furoate 500 mg
for 7-10 days for 3 days TDS for 10d
Tinidazole 2
Metronidazole
G.lamblia gm oral x
400mg oralTID x 7-10 d
1 dose
Azithromycin Majority of strains
Outpatients: 500 mg BD for are nalidixic acid
Cefixime 20mg/kg/day 7 days. or resistant. Ceftriaxone
S. typhi
for 14 days. Cotrimoxazole to be changed to oral
S. paratyphi A
Enteric fever Inpatients: Ceftriaxone 2 960 mg BD cefixime when
S. paratyphi B
g IV BDfor 2 weeks +/- for 2 weeks or patient is afebrile to
S. paratyphi C
Azithromycin 500 mg Ciprofloxacin finish total duration
BD for 7 days 500mg BD for of 14days.
14 days
Severe disease:
Hospital Metronidazole 400 mg oral startVancomyc
acquired C. difficile TDSfor in 250 mg oral
diarrhoea 10 days 6h empirically
patients with acute
gastroenteritis.
S. aureus,
Food Rehydration
B. cereus, None None
poisoning (oral/IV) essential.
C. botulinum
Anti-diarrheal agents
(Loperamide,
racecadotril) can be
used
Ciprofloxacin
OPD Treatment
Mild Plus
Amoxycillin-Clavulanate
Diverticulitis Metronidazole
625mg TDS for 7 days
for 7 days
Ceftriaxone 2gm IV OD BL-BLI agents
Plus Metronidazole have very good
Moderate Gram-Negative 500 mg IV TDS anaerobic
Diverticulitis Bacteria or cover, so no
Anaerobes Piperacillin-Tazobactam 4.5 need to add
gm IV 8 hourly empirically metronidazole
Meropenem
1gm IV 8hrly Duration based
Severe
Or on
Diverticulitis
Imipenem-Cilastatin 500mg improvement
IV 6 hourly
Infection in Pancreas
Pancreatitis
Mild- No antibiotics
moderate
Imipenem-
Cilastatin
500mg
IV6hourly
Or
Meropenem
1gm IV
Inj.Piperacillin/Tazobactam 8hourly plus Duration of treatment
Infected Entrobacteriacea 4.5 gm 6-8 hourly for 7-14 Inj. Amikacin sometimes based
necrotizing e, days 500 mg12 on source control and
pancreatitis/ Enterococci, S. Plus hourly for 7 clinical
Pancreatic aureus, Inj. Amikacin days plus Inj. improvement.
pseudocyst/ S. epidermidis, 500 mg 12 hourly for 7 days Clindamycin Operation with
Pancreatic anaerobes, +/- 600 mg q8 h necrosectomy or
abscess Candida sp Inj. Metronidazole for 7-14 days drainage of abscess
500 mg 8 hourly 7 days Or needed.
Inj.
Metronidazole
500 mg q8h 7
days
Infection in Liver
Nitazoxanide Ultrasound guided
500 mg 12 hourly drainage indicated
Inj. Metronidazole for 10 days in large abscesses,
Amoebic liver Entamoeba
500 mg 8 hourly for 7-10 Tinidazole, signsof imminent
abscess histolytica
days Orrnidazole rupture andno
2 gm 24 hourly for 5 response to
days medicaltreatment.
Amoxycillin-clavulanate Ultrasound guided

Or 3rdgeneration drainage indicated
cephalosporin Inj. inlarge abscesses,
Pyogenic liver Ceftriaxone Piperacillin- signsof imminent
Polymicrobial
abscess 1 gm plus 12 hourly Tazobactam IV rupture andno
Plus response to
Metronidazole 500mg medicaltreatment.
I.V.TID for 2 weeks
followed by
4-week oral antibiotic.
Drug treatment
alone is appropriate
for
management of a
single compartment
and diameter <5
cm. One to three
months may be
PAIR followedby
appropriate,
Tab. Albendazole (400 Tab. Albendazole
depending clinical
mg) (400 mg)
factors; up to six
Hydatid Surgery followed by 12 hourly for 1
Echinococcus months may be
disease of Tab.Albendazole month
granulosus required.
liver 400 mg 12 hourly for 1 (PAIR is as effective
Indications for
month then 14 days as surgery.)
surgery:
interval, total 3-6 cycles
include
complicated cysts,
cyst diameter
>10 cm, superficial
cyst at risk of
rupture due to
trauma, and
extrahepatic
disease)
Infection of Gall bladder
Escherichia coli Imipenem Surgical or
Piperacillin-
Klebsiella 500mg IV 6hourly endoscopic
Tazobactam (3.375
Cholangitis pneumoniae or intervention to be
gm)
Pseudomonas Meropenem considered if there
6 hourly
Proteus 1gm IV 8hourly. is biliary
Empiric
Likely
Type of antibiotics Alternative
Causative Comments/ Remarks
Infections (presumptive antibiotics
organisms
antibiotics)
obstruction.
De-escalate
For 7-10 days Inj therapy once antibiotic
susceptibility is
known.
Others
We suggest treating most
patients with
SBP for five days rather than
a longer
course of therapy. A longer
course of
Imipenem
therapy is appropriate for
500 mg IV 6hourly
patients who
Or
grow an unusual organism
Meropenem
(eg,
Cefotaxime 1gm IV 8hourly
pseudomonas,
1-2 gm IVbTDS Or
Spontaneous Escherichia coli Enterobacteriaceae), an
or Other third-
bacterial Klebsiella organism resistant to standard
Piperacillin- generation
peritonitis Proteus antibiotic
Tazobactam cephalosporins and
therapy, or an organism
4.5gm IV 8 hourly fluoroquinolones.
routinely
If ceftriaxone is
associated with endocarditis
used, patients
(eg, S.
should be given 2 g
aureus or viridans group
per day
streptococci). In
addition, a longer course of
therapy is
required for patients who fail
to respond
to therapy appropriately
Enterobacteriac Imipenem
Secondary eae (E.coli, Piperacillin- 1g IV 8hourly
bacterial Klebsiella sp.), Tazobactam or
peritonitis Bacteroides 4.5gm IV 8 hourly Meropenem
1gm IV 8hourly
Department of Neonatology & Paediatrics
(General Paediatrics)
Duration
Comment
Infection Likely organisms Name and dose of Antibiotic of
/Remarks
treatment
Pneumonia (Mildly Any one of the following:
ill patient) Oral Amoxycillin. 100 mg/kg q8-12hrly
Oral Cefixime. 8mg/kg /day q12hrs 5-7 days
Oral Amoxycillin + Clavulanate. 30
mg/ kg/dose q8hrs
Severe Pneumonia Inj. Ampicillin. 100 mg/kg/day q12hrs
Fully immunized
against H. influenzae 5-7 days
type b and S.
Pneumoniae
Pneumonia
Severe Pneumonia Inj. Ceftriaxone. 50 mg/kg/day q24hrs
Not fully immunized Or
against H. influenzae Inj. Cefotaxime. 50 mg/kg/dose q8hrs 10 days
type b and S.
pneumoniae
Staphylococcal Inj. Vancomycin Inj. Vancomycin 15
pneumonia mg/kg/dose q6hrs
Or 10 days
Inj. Clindamycin 6-10 mg/kg/dose
q6hrs
Otitis Media S. Pneumoniae Any one of the following 10 days
H. Influenzae Oral Amoxycillin: 90mg/kg q12hrly
Moraxella Oral Amoxycillin+Clavulanate
catarrhalis Inj. Ceftriaxone: 50 mg/kg/day q12hrs 5 days
Group A
streptococcus
Acute Haemophilus Inj. Ceftriaxone 50mg/kg/day once 10 days
Epiglotitis influenzae daily dose
Or
Inj. Meropenem 20mg/kg/day q8hrs
Meningitis S. pneumoniae Ceftriaxone 100mg/kg I/V q24h S.pneumon
N. meningitidis + iae 10- 14
H. influenzae type b Vancomycin 60 mg/kg/day I/V q6 h days
N.meningit
Possibility ofpenicillin/cephalosporin- idis 5–7
resistant pneumococci days
Meropenem 40mg/kg/dose I/V q8 h H.
influenzae
type b 7–
10 days
Encephalitis Herpes simplex virus Acyclovir 10 mg/kg/dose I/Vq8h 14-21 days
Brain abscess S. aureus Ceftriaxone 100mg/kg I/V q24h 6 weeks

S. milleri and other +
streptococci, Vancomycin 60 mg/kg/day I/V q6
Duration
Comment
/Remarks
treatment
Gram negative +
bacteria Metronidazole 1.5 ml/kg I/V q8h
Anaerobes
Enteric Fever Salmonella spp Inj Ceftriaxone- 80-100mg/kg iv q24 2 weeks
hrs
Dysentery Shigella spp Inj. Ciprofloxacin 20mg/kg/day q12hrs 5days
Giardiasis G. lamblia Tinidazol – 50 mg/kg/day, single dose
(>3 years)
Or 3 days
Nitazoxamide
-1-2 year- 100mg q12hrs
-3-12years- 200mg q12hrs
- > 12 year 500mg q12hrs
Or
Metronidazole 15mg/kg/day PO q8hrs 5-7 days
Peritonitis Mixed Bacterial Inj. Ceftriaxone. 50- 10-14 days
infection- 80mg/kg/dayq24hrs
Ecoli +
Anaerobes Inj. Gentamycin. 3mg/kg/day q24hrs
Enterococci +
In.j Metronidazole.1.5ml/kg/day q8hrs
Urinary tract E. coli Before getting culture sensitivity 7 days
infection Klebsiella Trimethoprim-sulfamethoxazole 6-12
Enterobacter mg/kg/dayTMP q12hrs
Or
Nitrofurantoin 5-7mg/kg/day q6-8hrs
Or
Amoxicillin 50mg/kg/dose q8-12hrs
In febrile UTI and pyelonephritis

Inj. Ceftriaxone 50mg/kg/day q24hrs 7-14 days
Or
inj Cefotaxime 100-150mg/kg/day q6-8
hrs
Or
Oral Cefixime10-15mg/kg/day q24hrs
Infective Inj. Vancomycin. 40mg/kg/day q8-12 4-6 wks

hrs Empiric
Endocarditis
+ therapy
Inj. Gentamicin 3 mg/kg/day q24hrs
Strepto. viridans Inj. Ceftriaxone. 100 mg/kg/day q24hrs 2 wks
Streptococcus bovis +
Inj. Gentamicin 3 mg/kg/day q24hrs
If unable to tolerate Ceftraixone
Inj. Vancomycin 40 mg/kg/day q8- 2 weeks
12hrs
Staphylococcus Inj. Vancomycin 40 mg/kg/day q8- 4 weeks
12hrs ±
Inj. Gentamicin 3 mg/kg/day q24hrs 5-7 days
Duration
Comment
/Remarks
treatment
Infective Oral Amoxicillin 50 mg/kg/dose Antibiotic
Endocarditis Unable to take oral medication regimen
(Prophylaxis) Inj. Ampicillin 50mg/kg/dose for dental
Or procedure
Inj. Ceftriaxone 50 mg/kg/dose
Septic Staph. aureus Inj. Vancomycin 15 mg/kg/dose q6hrs 3 wks
Arthritis Streptococci Or
K. kingae Inj. Clindamycin 6-10 mg/kg/dose
q12hr
Osteomyelitis Staphylococcus Inj. Ceftriaxone 80 to 100 mg/kg 3-4 wks
aureus q24hrs
Group A streptococci Or
S. pneumonia Inj. Cefotaxime 150-200mg/kg /day
Haemophylus q8hrs
influenza type b Allergy to Cephalosporin
K.kingae
Salmonella spp. Inj. Clindamycin 6-10 mg/kg/dose
q6hrs
(Neonatal Unit)
Type of infection Antibiotics (name and duration)
Neonatal sepsis Early onset sepsis
Empiric therapy Inj Ampicillin + Inj Gentamicin
Blood c/s : Negative Stop antibiotic at 72 hours
Septic screen : Negative
Baby’s condition : Well baby
Blood c/s : Negative Continue antibiotic for 7-10 days
Baby’s condition : Sick baby
Septic screen : Positive
Improve with empiric therapy
Blood c/s : Negative Inj. Piperacillin and Tazobactum for 7- 10 days,
Septic screen : Positive (may require longer duration of treatment
No improvement with depending upon clinical improvement)
empiric therapy If condition deteriorated – use any of the following
:
Inj. Meropenum
Inj. Vancomycin
Inj. Colistimethate sodium (Colistin)
Blood c/s positive Antibiotic according to c/s report for 7-14 days
Late onset sepsis
Empiric therapy Inj. Ceftazidime / Cefotaxime + Inj Gentamicin /
Amikacin
Blood c/s : Negative Stop antibiotic at 72 hours
Baby’s condition : Well baby
Baby’s condition : Sick baby
Septic screen : Positive
Improve with empiric therapy
Blood c/s : Negative Inj. Piperacillin and Tazobactum ± Inj.
Septic screen : Positive Vancomycin for 7- 10 days
No improvement with empiric (may require longer duration of treatment
therapy depending upon clinical improvement)
If condition deteriorated – use any of the following
antibiotics :
Inj. Meropenum
Inj. Ciprofloxacin
Inj. Colistimethate sodium (Colistin)
Blood c/s positive Antibiotic according to c/s report for 7-14 days
Meningitis Early onset meningitis
Empiric therapy Inj. Cefotaxime/Ceftazidime for 21+ Inj
Gentamicin for 10 days
Culture positive Antibiotic according to c/s report
(Duration of antimicrobial therapy : 21 days)
Late onset meningitis
Empiric therapy Inj. Vancomycin + Inj Cefotaxime for 21 days
Culture positive Antibiotic according to c/s report, duration 21days
Type of infection Antibiotics (name and duration)
Pneumonia Early onset pneumonia InjAmpicilline + Inj Gentamicin for 7-10 days
Late onset pneumonia Inj.Ceftazidime + Inj Gentamicin for 7-14 days
If not improve : use any of the following
Inj. Meropenem
Inj. Vancomycin
Inj. Flucloxacillin
Inj. Claritromycin (for atypical organism)
Necrotizing Enter Triple Antibiotics for 10 days
colitis (NEC) Inj. Vancomycin + Inj. Gentamicin / Ceftazidime +
Inj. Metronidazole
Urinary tract Empiric therapy Inj. Ampicilline + Inj. Gentamicin / Amikacin for
infection 7-10 days
Culture positive UTI Antibiotic according to c/s report for 7-10 days
Cellulitis or Inj. Flucloxacillin + Inj Gentamicin for 7-10 days
Omphalitis
Osteomyelitis/Septic Inj. Cefotaxime + inj. Flucloxacillin for 6 weeks
arthritis
Fungal infection Inj. Fluconazole
Antibiotics Used in Neonatal Unit
Inj Ampicillin (Intravenous over 15 minutes ) InjAmikacin (Intravenous over 30 minutes )
Postnatal age ≤7 days: Neonates 0–4 weeks and <1.2 kg : 7.5

≤2 kg : 50 mg/kg/day q12 hrs. mg/kg/dose q24 hrs.
Meningitis: 100 mg/kg/day q12 hrs. Postnatal age <7 days
>2 kg : 75 mg/kg/day, IV divided q8 hrs. 1.2–2 kg : 7.5 mg/kg/dose q12 hrs.
Meningitis: 150 mg/kg/day q8hrs >2 kg : 7.5–10 mg/kg/dose q12 hrs.
Postnatal age >7 days: Postnatal age ≥7 days
<1.2 kg : 50 mg/kg/day, q12 hrs. 1.2–2 kg : 7.5–10 mg/kg/dose q12 hrs.
Meningitis: 100 mg/kg/day q12 hrs. >2 kg : 10 mg/kg/dose q8 hrs.
1.2–2 kg : 75 mg/kg/day, IV divided every 8
hours.
Meningitis: 150 mg/kg/day q8 hrs.
>2 kg : 100 mg/kg/day, IV q6 hrs.
Meningitis: 200 mg/kg/day q6 hrs.
Inj. Cefotaxime (Intravenous over 30 minutes) Inj. Ceftazidime (Intravenous over 30 minutes)
Neonates 0–4 weeks and <1.2 kg: 100 mg/kg/day Neonates 0–4 weeks and <1.2 kg: 100 mg/kg/day
q12 hrs. q12 hrs.
Postnatal age <7 days Postnatal age <7 days:
1.2–2 kg : 100 mg/kg/day q12 hrs. 1.2–2 kg : 100 mg/kg/day q12 hrs.
>2 kg : 100–150 mg/kg/day q8-12 hrs. >2 kg : 100–150 mg/kg/day q 12hrs.
Postnatal age ≥7 days and Postnatal age ≥7 days and ≥1.2 kg: 150 mg/kg/day
1.2-2 kg : 150 mg/kg/day q8 hrs. q8hrs.
>2 kg : 100–150 mg/kg/day q 8–12 hrs. Meningitis: 150 mg/kg/day q8 hrs.
Meningitis: 200 mg/kg/day q6 hrs
Inj. Flucloxacillin (Intravenous over 15 minutes) Inj. Gentamicin (Intravenous over 15 minutes)
Postnatal age <7 days: ≤29 weeks postmenstrual age (PMA):
≥ 2 kg : 50 mg/kg/day q12 hrs 0–7 days : 5 mg/kg/dose IV q48 hrs.
> 2kg : 75-150 mg/kg/day q8 hrs 8–28 days : 4 mg/kg/dose IVq36 hrs.
Postnatal age ≥ 7 days: ≥29 days : 4 mg/kg/dose IV/q24 hrs.
≥ 2 kg : 75-150 mg/kg/day q8 hrs 30–34 weeks PMA:
> 2kg : 100-150 mg/kg/day q6 hrs 0–7 days : 4.5 mg/kg/dose IVq36 hrs.
>7 days : 4 mg/kg/dose IV/IM q24 hrs.
≥35 weeks PMA: 4 mg/kg/dose IVq24 hrs.
Inj. Meropenem (Intravenous over 30 minutes) Inj. Vancomycin (Intravenous over > 60 min)
Gestational age <32 weeks Postnatal age <7 days:

≤14 days : 20 mg/kg/dose q12 hrs; <1.2 kg: 15 mg/kg/day q24 hrs.
>14 days : 20 mg/kg/dose q8 hrs. 1.2–2 kg: 10–15 mg/kg/dose q12-18 hrs.
Gestational age ≥32 weeks >2 kg: 10–15 mg/kg/dose q8-12 hrs.
≤7 days : 20 mg/kg/dose q12 hrs Postnatal age ≥7 days:
>7 days : 20 mg/kg/dose q8 hrs <1.2 kg: 15 mg/kg/day q24 hrs.
Meningitis: 40 mg/kg/dose q8 hrs. 1.2–2 kg: 10–15 mg/kg/dose q8- 12 hrs.
>2 kg: 15–20 mg/kg/dose q8 hrs.
Inj. Piperacillin and Tazobactum (I/V over 30 Other Antibiotics:

minutes) Colistimethate sodium (Colistin) :15000 – 25000
unit/kg/dose q8h
≤29 weeks postmenstrual age (PMA): Metronidazole: 1.5 ml/kg/dose q8h
0-28 days : 100 mg/kg/day q12hrs
30-36 weeks PMA: Clarithromycin: 7.5 mg/kg/dose q12h
0–14 days : 100 mg/kg/day q12hrs
>14 days : 100 mg/kg/day q8 hrs Ciprofloxacin: 10 mg/kg/dose q12h
37-42 weeks PMA:
0–7 days : 100 mg/kg/day q12hrs
>7 days : 100 mg/kg/day q8 hrs
Inj. Fluconazole
≤29 weeks postmenstrual age (PMA):

0–14 days: 12–25 mg/kg loading dose, then 6–12 mg/kg q48 hrs.
>14 days: 12–25 mg/kg loading dose, then 6–12 mg/kg q24 hrs.
30 weeks PMA and older:
0–7 days: 12–25 mg/kg loading dose, then 6–12 mg/kg q 48 hrs.
>7 days: 12–25 mg/kg loading dose, then 6–12 mg/kg q24 hrs.
Department of Dermatology and Venereology
Skin and soft tissue Infections
Staph. aureus Cephalosporin Amoxicillin , Modify
Strept. pyogen (1st Generation) Flucloxacillin. therapy
Impetigo
500 mg tds 7 days. based on
sensitivities
Cephalosporin Fiucloxacillin
Furunculosis S. aureus (1st Generation) Clindamycin. Do
500 mg qds 7 days.
Strept. pyogen Cephalosporin Dicloxacillin
Ecthyma 500mg tds 7 days. TMP-SMX Do
Staph. aureus Cephalosporin Amoxicillin ,

Folliculitis Strept. pyogen (1st Generation) Flucloxacillin. Do
500 mg tds 7 days.
S. aureus Cephalosporin Flucloxacillin,
Bacterial
S. pyogen 500 mg tds 7 days. Ciprofloxacin. Do
Paronychia
Pseudomonas sp.
Ecthyma- Cephalosporin Penicillin
Do
gangrenosum Pseudomonas (3rd Generation) Fluroquinolone
Staph. aureus Cefixime 400mg bd 7 Cefuoxime axetil.
Strept. pyogen days +
Cellulitis Do
Flucloxacilln
500mg qds 7 days.
Erythomycin Penicillin
Do
Strepto. pyogens 500 mg bd 7-14 days. Amoxicilin
Scarlet fever
Azithromycin
500mg qd 3-5 days.
Corynebacterium Erythomycin Topical
Do
Erythrasma minutissimum 500 mg bd 7-14 days Erythromycin,
clindamycin lotion
Toxic shock Staph. aureus Nafcillin Meropenam
Do
syndrome
Necrotizing Strepto. pyogen Cephalosporin Clindamycin
fascitis (1st Generation)
500 mg tds 7 days Do
Or Flucloxacilln
500mg qds 7 days.
Sexually Transmitted Diseases
Chancroid H.ducreyi Erythromycin 500mg Ceftriaxone
qds for 7 days/ 250 ml i.m. single
Ciprofloxacin 500mg bd dose
Do
for3days/ Azithromycin
1gm single dose/
Doxycycline
Granuloma Klebsiella Azithromycin Doxycycline100m
inguinale Granulomatosis 1gm once weekly for g or Erythromycin
3wks 500mg 6 hrly for
Do
3weeks
Ciprofloxacin
Granuloma
750 mg bd for Do
inguinale
3weeks
Syphilis T.pallidum Benzathine Penicllin Tetracyclin 500
G\1.2-2.4 mu I/M (0.6- mg qds
1.2 mu for children Or
under age 10) Erythromycin 8- Do
10mg/kg 6 hrly for
children for 15
days.
Gonorrhoea N. gonorrhoea Ceftriaxone 1gm/day IV
+
Do
Azithromycin
1gm orally for 1week
Lymphogranulo Chlamydia Doxycycline 100mg bd Erythromycin
ma venerum trachomatis. for 3 weeks 500mg 6 hrly for
Do
21 days
Dept. of Obstetrics and Gynaecology
Alternative
Likely antibiotics
Type of Empiric antibiotics Comments/
Causative (Severe or
Infections (No Penicillin allergy) Remarks
organisms intermediate
penicillin allergy)
Antepartum Infections
A repeat urine should
Nitrofurantoin
Asymptomatic be sent
E.coli 50-100mg QDS PO
bacteriuria Nitrofurantoin after treatment to
Enterococcus Or
and lower 50-100mg QDS PO confirm
sp GBS Cephalexin
UTI clearance of the
500mg BD-TDS PO
organism.
Option 1 Clindamycin
Ceftriaxone 900mg TDS
Oral switch should be
1-2g OD IV Or
considered
Or Vancomycin
once the woman is 48
Cefotaxime 15mg/kg BD (max
hours
1g TDS IV 2g/dose) depending on
afebrile and there is a
(Gentamicin 5mg/kg/day GBSsusceptibility
suitable
IV (max 480mg/day) in AND
oral alternative based
either one single dose of Gentamicin
on
in 3 divided doses may 5mg/kg/day IV (max
E.coli antimicrobial
be added if woman is 480mg/day) in either
Pyelonephritis GBS susceptibility test
systemically one single dose of
Klebsiella results
unwell) in 3 divided doses
In the post-partum
Option 2
setting when the
Co-amoxiclav
woman is not
1.2g TDS IV
breastfeeding,
AND
Ciprofloxacin 750mg
Gentamicin
BD PO
5mg/kg/day IV
may also be
(max480mg/day) in
considered.
either one singledose of
in 3 divided doses
Option 1: Option 1:
Co-amoxiclav Clindamycin
1.2g TDS IV 900mg TDS IV
AND AND
Gentamicin Gentamicin
5mg/kg/day IV 5mg/kg/day IV (max It is important that
(max 480mg/day) in 480mg/day) in either microbiological
E.coli, GBS, either one single dose or one single dose specimens (e.g.
Chorioamnionit
Group A in 3 divided doses of in 3 divided doses blood culture, high
is (including
Streptococcus Option 2: Option 2: vaginal swab) are
septic
, Amoxicillin Vancomycin taken as soon as
miscarriage)
Klebsiella 1g QDS IV 15mg/kg BD (max possible and sent to
AND 2g/dose) the laboratory for
Gentamicin AND analysis.
5mg/kg/day IV Gentamicin
(max 480mg/day) in 5mg/kg/day IV
either one single
Alternative
Likely antibiotics
causative (Severe or
penicillin allergy)
dose or in 3 divided (max
doses 480mg/day) in either
AND one single dose or in 3
Metronidazole 500mg divided doses
TDS IV AND Metronidazole
Option 3: 500mg TDS IV
Benzylpenicillin The choice between Ceftriaxone will be
2.4g QDS IV option 1 & 2 given alternative to
AND depends on the penicillin in case of
Gentamicin susceptibility of penicillin allergy
5mg/kg/day IV Group B patient
(max 480mg/day) in Streptococcus to
either one single dose of clindamycin
in 3 divided doses
AND
Metronidazole
500mg TDS IV
Option 1: Option 1: It is important that
Co-amoxiclav Clindamycin microbiological
1.2g TDS IV 900mg TDS IV specimens (e.g. blood
AND AND culture, high vaginal
Gentamicin Gentamicin swab) are taken as
5mg/kg/day IV (max 5mg/kg/day IV (max soon as possible and
480mg/day) in either one 480mg/day) in either sent to the laboratory
single dose or in 3 one single dose of for analysis. Source
divided doses in 3 divided doses of
Option 2: Option 2: the sepsis is
Any one of Vancomycin 15mg/kg identified quickly
Amoxicillin BD (max and the source of the
1g QDS IV/ 2g/dose) sepsis is controlled
Benzyl penicillin AND The empirical
2.4g QDS IV/ Gentamicin antimicrobial
Sepsis Cefuroxime 5mg/kg/day IV (max regimen should be
(no identifiable 1.5g QDS IV 480mg/day) in either rationalized once
source) AND one single dose of cultures are available
Gentamicin in 3 divided doses and the source of the
5mg/kg/day IV (max AND sepsis has been
480mg/day) in either one Metronidazole 500mg identified.
single dose of in 3 TDS IV
divided doses The choice between
AND option 1 and 2
Metronidazole depends on the
500mg TDS IV susceptibility of
Group
B Streptococcus to
clindamycin
Alternative
Likely antibiotics
penicillin allergy)
Meropenem Vancomycin 15mg/kg If using Vancomycin,
1g TDS IV BD (max consider giving a
AND 2g/dose) loading dose of
Gentamicin AND 25mg/kg (max
5mg/kg/day IV (max Gentamicin 2g/dose) initially
Sepsis 480mg/day) in either one 5mg/kg/day IV (max If MRSA is present,
(Severe) single dose or in 3 480mg/day) in either always give
(e.g. septic divided doses one single dose or in 3 vancomycin in
shock AND divided doses addition to the other
refractory to Clindamycin AND antimicrobials.
initial 1.2g QDS IV Clindamycin Senior obstetric and
resuscitation) 1.2g QDS IV anesthetic staff
Ciprofloxacin should be involved in
500mg BD IV these cases.
may also be added to
improve Gram
negative cover
Intrapartum Infections
Option 1:
Option 1: Clindamycin 900mg It is important that
Benzylpenicillin TDS IV thesusceptibility of
3g stat then 2.4g QDS AND any previously grown
IV AND Gentamicin Group B
Gentamicin 5mg/kg/day 5mg/kg/day IV (max Streptococcus is
IV (max480mg/day) in 480mg/day) in either checked
either one single dose or one single dose of in 3 prior to choosing the
in 3 divided doses AND divided doses antimicrobial
Metronidazole 500mg Option 2: regimen.
TDS IV Vancomycin 15mg/kg The neonatal team
Option 2: BD (max should be informed
Cefuroxime 2g/dose) of cases of
1.5g QDS IV AND AND intrapartum pyrexia
Gentamicin 5mg/kg/day Gentamicin so that
Intrapartum
IV (max 480mg/day) in 5mg/kg/day IV (max they can assess the
pyrexia
either one single dose 480mg/day) in either baby.
ofin 3 divided doses. one single dose or in 3 Institutions should
AND divided doses monitor
Metronidazole 500mg AND their rate of
TDS IV Metronidazole erythromycin/
Option 3: 500mg TDS IV clindamycin
Co-amoxiclav The choice between resistance amongst
1.2g TDS IV option 1 and 2 Group B
AND depends on the Streptococcal isolates
Gentamicin susceptibility of to determine if it is
5mg/kg/day IV (max Group B reasonable
480mg/day) in either Streptococcus to to use clindamycin
one single dose or Clindamycin empirically.
in 3 divided doses
Alternative
Likely antibiotics
penicillin allergy)
Erythromycin Given only if the
Preterm
250-500 mg QDS PO woman is ≥20 weeks’
premature
Or gestation. The
rupture of
Clarithromycin duration of treatment
membrane
500 mg OD PO should be 10 days.
Postpartum Infections
Flucloxacillin
500mg -1g QDS PO
Or
Cephalexin The woman should
Infective Clindamycin
500mg TDS PO be encouraged to
mastitis 300-450mg QDS PO
Or continue tobreastfeed
Amoxycillin-
clavulanate
500mg QDS
Flucloxacillin
1-2g QDS IV
AND Clindamycin
If the woman is
Clindamycin 900mg TDS IV
colonized
Severe 450mg QDS PO For women with
with MRSA or
mastitis Or known clindamycin
thought to
with Cefuroxime resistant S.aureus or if
be at high risk (e.g.
suspected 1.5g QDS IV the woman is
healthcare
breast AND systemically unwell
professional),
abscess Clindamycin consider adding
then discuss with
450mg QDS PO Vancomycin 15mg/kg
Microbiology
Or BD IV (max2g/dose)
Clindamycin
900mg TDS IV
Co-amoxiclav
625mg TDS PO
Or
Endometritis
Cephalexin Clindamycin
(mild)
500mg TDS PO 300-450mg QDS PO
Perineal mild
AND
Metronidazole
400mg TDS PO
Endometritis
(severe) Option 1: Option 1:
OR Co-amoxiclav Clindamycin
Perineal Severe 1.2g TDS/ Cefuroxime 900mg TDS IV
(This includes 1.5gmQDS IV AND See National
women with AND Gentamicin Guideline:
retained products Gentamicin 5mg/kg/day IV (max Management of
of conception 5mg/kg/day IV (max 480mg/day) in Obstetric
who present 480mg/day) in either one single dose Anal Sphincter injury
with sepsis) either one single dose or or in 3 divided doses
in 3 divided doses
Alternative
Likely antibiotics
penicillin allergy)
Option 2: Option 2:
Clindamycin Vancomycin
900mg TDS IV 15mg/kg BD (max
AND 2g/dose)
Gentamicin AND
5mg/kg/day IV (max Gentamicin
480mg/day) in 5mg/kg/day IV (max
either one single dose or 480mg/day) in
Endometritis in 3 divided doses either one single dose
(severe) Option 3: or in 3 divided dose s
OR Amoxicillin AND
Perineal Severe 1g TDS IV AND Metronidazole
Gentamicin 500mg TDS IV
5mg/kg/day IV (max The choice between
480mg/day) in option 1 and 2
either one single dose or depends on
in 3 divided doses AND the susceptibility of
Metronidazole Group B
500mg TDS IV Streptococcus to
clindamycin
If the woman is
Caesarean Option 1: colonized with
section Flucloxacillin MRSA or thought to
wound 500mg-1g QDS PO Clindamycin 300- be at high
infection Option 2: 450mg QDS PO risk (e.g. healthcare
(superficial Co-amoxiclav 625mg professional), then
incisional) TDS PO discuss with
Microbiology
Post C Option 1: Clindamycin If pt is colonized
section Co-amoxiclav 900mg TDS IV with MRSA or
wound 1.2g TDS IV AND AND thought to be at high
infection Gentamicin Gentamicin risk (e.g. healthcare
(deep 5mg/kg/day IV (max 5mg/kg/day IV (max professional), then
incisional 480mg/day) in either 480mg/day) in either discuss with
or organ one single dose one single dose of Microbiologist.
space) of in 3 divided doses in 3 divided doses Radiological imaging
Option 2: should be carried out
Cefuroxime as soon as possible if
1.5g QDS IV AND needed.
Gentamicin Intra
5mg/kg/day IV (max abdominalcollections
480mg/day) in either should be drained to
one single dose achieve source
of in 3 divided doses control and obtain
AND fluid for culture.
Metronidazole
500mg TDS IV
Alternative
Likely antibiotics
penicillin allergy)
Sexual health and sexually transmitted disease
Lactating woman: Mild disease: For women with
Ceftriaxone Ceftriaxone severe disease
500mg IM stat dose 500mg IM stat dose consider changing to
Followed by plus, oral antibiotics once
Erythromycin Doxycycline the woman is
500mg QDS PO 100mg BD 24-48 hours a febrile
AND And An alternative
Metronidazole Metronidazole regimen in
400mg BD for 14 days 400mg BD POfor 14 penicillin allergy and
Or days pregnancy may be
Ceftriaxone Severe disease: Clindamycin
250mg IM/IV stat dose Ceftriaxone 900mg TDS IV
Chlamydia And 2g OD IV with Gentamicin
Pelvic
trachomatis Metronidazole Plus 5mg/kg/day in
inflammatory
Neisseria 400mg BD for 14 days Doxycycline a single dose or 3
disease
gonorrhoeae And 100mg BD PO divided doses
Doxycycline Plus Azithromycin may be
100mg BD for 14 days Metronidazole used instead of
Pregnant woman: 500mg BD IV. erythromycin. See
Ceftriaxone local guidelines for
2g OD IV plus dosing
erythromycin
500mg QDS PO plus
Metronidazole
500mg BD IV.
(Stop IV treatment if
clinically appropriate
after 24-48 hours)
Ensure woman is
Genital Chlamydia Azithromycin 1g stat Azithromycin 1g stat
referred toappropriate
Chlamydia trachomatis dose PO dose PO
STI service
Gonorrhea
Ceftriaxone 250-500mg Ceftriaxone Ensure woman is
(cervix,
Neisseria stat dose 250-500mg stat dose referred to
urethra or
gonorrhoeae IM with azithromycin IM with Azithromycin appropriate STI
rectum,
1g stat dose PO 1g stat dose PO service
pharynx)
Metronidazole High dose
400mg-500mg BD metronidazole
Trichomonas PO for 7 days Metronidazole should be avoided in
Trichomoniasis
vaginalis Or 2g stat dose PO pregnancy,
Tinidazole particularly in the
2 gm oral single dose first trimester
Metronidazole
400mg-500mg BD The sexual partner
PO x 7 days should be
Bacterial Metronidazole
Or Tinidazole treated concurrently
vaginosis 2g stat dose PO
2 gm oral for 3 days
Alternative
Likely antibiotics
penicillin allergy)
Consider IV
treatment if the
lesions are very
Acyclovir 400mg TDS Acyclovir 400mg TDS
severe. See
Or Or
national Mother To
200mg 5 times per day 200mg 5 times per day
Genital Herpes Child
HSV-1, HSV- BASHH recommend 5 BASHH recommend 5
-first Transmission
2 days days treatment
presentation guidelines for
treatment and CDC and CDC recommend
further advice, and
recommend 7- 7-10 days
for
10 days treatment treatment
management of
reactivation in
pregnancy
Prophylactic antibiotic in obstetrics
1. Available evidence does not support the use of prophylactic antibiotics to reduce infectiousmorbidity
following operative vaginal delivery.
2. There is insufficient evidence for or against the use of prophylactic antibiotics to reduce infectious
morbidity for manual removal of the placenta.
3. Available evidence does not support the use of prophylactic antibiotics to reduce infectious morbidity
following elective or emergency cerclage
4. The evidence is not robust for the use of antibiotic prophylaxis to prevent perineal wound complications
following third- or fourth-degree tears
Prophylactic antibiotics in gynecology

There are no recommendations for routine prophylactic antibiotics for the following gynaecological procedures
in healthy women with no risk factors:
1. Insertion of intrauterine contraceptive device (IUCD)
2. Patients undergoing diagnostic laparoscopy
3. Patients having hysteroscopic surgery
4. Hysterosalpingography (HSG) without a prior history of pelvic inflammatory disease
5. Large Loop Excisionof Transformation Zone (LLETZ)
Broad spectrum antibiotics should be used during major abdominal, laparoscopic or vaginal procedures.
Department of Surgery
Alternative Comments
Type of Infections Causative (presumptive
antibiotics / Remarks
A. Skin and soft tissue infections
Amoxicillin-clavulanate
1.2g TDS IV Or
Streptococcus Meropenem
Ceftriaxone
Cellulitis/ pyogens 1 gm TDS IV and
1-2 gm OD IV
Erysepelus Streptococcus Metronidazole
Plus
aureus 500mg IV TDS
Metronidazole
500mg IV TDS
1.2g TDS IV Or
Meropenem Surgical
Ceftriaxone
Staphylococcus 1 gm TDS IV and drainage is
Abscess 1-2 gm OD IV
aureus Metronidazole mainstay of
Plus
500mg IV TDS treatment
Metronidazole
500mg IV TDS
Surgical
Streptococcus Meropenem and incision
Amoxicillin-clavulanate Plus
pyogens Metronidazole and
Carbuncle Metronidazole
Streptococcus (dose mentioned debridemen
(dose mentioned above)
aureus above) t followed
by dressing
Necrotising Streptococcus
Piperacillin
fascitis : pyogens
Tazobactam Incision
MELENEY’S Staphylococcus Meropenem Plus
4.5 gm TDS IV and
synergistic aureus Metronidazole
And drainage
gangrene Anaerobes (dose mentioned above)
Metronidazole fasciotomy
Fournier’s Enterobacteria
500mg IV TDS
gangrene -ceae
Incision,
drainage,
Meropenem debridemen
1gm TDS IV or t and
Colistin dressing.
(according to Most foot
sensitivity) infections
2.5-.5mg/kg/day are mixed
Staphylococcus in 2-3 divided infections
Ceftriaxone or Amocillin-
Klebsiella doses (31,250- and
clavulanate
Pseudomonas 62,500 IU/kg/day) antibiotics
Foot infections Plus
Proteus or 1million units 8 are
Metronidazole
Acinetobacter, hrly changed
Streptococcus PlusMetronidazol according
e to culture
500mg IV TDS and
Piperacillin+Tazo sensitivity
bactum (according
to sensitivity)
B. Breast infections
Amoxicillin- Incision
clavulanate and
Ceftriaxone and
Mastitis Staphylococcus And drainage
Metronidazole
Breast abscess aureus Metronidazole followed
(dose mentioned by
above) antibiotics
C. Hepatobiliary infections
Acute E. coli Meropenem and
Ceftriaxone and
cholecystitis Klebsiella Metronidazole
Metronidazole
Chronic Enterococcus
(dose mentioned
cholecystitis faecalis above)
Meropenem
Ceftriaxone
1 gm TDS
1-2 gm OD IV
Or
E. coli Plus
Piperacillin-
Klebsiella Metronidazole
Cholangitis Tazobactam
Enterococcus 500mg IV TDS
4.5 gm TDS IV
faecalis Plus
Plus
Amikacin
Metronidazole
500mg BD IV
500mg IV TDS
Escherechia
Ceftazidime
Klebsiella Meropenem
Plus
Pseudomonas Plus
Metronidazole
Liver abscess Proteus Metronidazole
Plus
Anaerobes (dose mentioned
Amikacin
Entamoeba above) Drainage of
histolytica abscess
D. Abdominal infections
E. coli., Meropenum
Perforation
Klebsiella sp. Or
of gas Ceftriaxone
Bacteroides Piperacillin-
containing Plus
(colonic Tazobactam
hollow Metronidazole
perforation ) Plus
viscous
Anaerobes Metronidazole
Incision
E. coli.,
Ceftriaxone Meropenum Or and
Intra Klebsiella sp.
Plus Piperacillin- drainage
abdominal Bacteroides
Metronidazole Tazobactam followed
abscess/Perianal (colonic
Plus Plus by
abscesss perforation )
Amikacin Metronidazol antibiotics
Anaerobes
F. Prophylaxis
Gastointestinal
surgery: Ceftriaxone
Above D-J E. coli., Klebsiella Plus Metronidazole
junction sp. etc
E. coli., Meropenem plus
Klebsiella sp. Metronidazole
Ceftriaxone
Bacteroides
Plus
Below D-J (colonic
Metronidazole
junction perforation )
Anaerobes
Meropenem plus
E. coli., Klebsiella Ceftriaxone/Ceftazidime Plus
Biliary surgery Metronidazole
sp. Metronidazole
plus Amikacin
Streptococcus Ceftriaxone Or
Staphylococcus Ceftazidime Or
Hernioplasty Klebsiella Amoxicillin-clavulanate
Pseudomonous Plus
E. coli Metronidazole
Amoxicillin-
Breast surgery Staphylococcus clavulanate/Ceftriaxone/Cefta
zidime
Dept. of Orthopaedics & Traumatology
Empiric
Likely
Type of antibiotics Alternative
causative Comments/ Remarks
Infections (presumptive antibiotics
organisms
antibiotics)
All antibiotics to be given I/V at
Ciprofloxacin least 2 hrs prior surgery or 10
Ceftriaxone I/V
I/V 200mg minutes before application of
Primary 2gm od +
bd + Amikacin tourniquet (if to be used).
Arthroplasty Amikacin I/V
I/V 500mg For high risk patients choice of
500mg tds
tds antibiotic depends on patient`s
condition.
Revision
As above As above As above
Arthroplasty
As above + Metronidazol I/V 500mg tds used
Open spinal As above +
Metronidazol if the surgical site is below
Surgery +/- Metronidazol
I/V 500mg umbilicus or suspicion of soiling
instrumentation I/V 500 mg tds
tds with gut flora.
Ceftriaxone I/V Ciprofloxacin
2gm od + I/V 200mg
Other Metronidazol I/V 500mg tds
Amikacin I/V bd + Amikacin
orthopaedic used if the surgical site is below
500mg tds +/- I/V 500mg
implant surgery umbilicus or suspicion of soiling
Metronidazol tds +/-
(routine) with gut flora
I/V 500 mg Metronidazol
tds I/V500 tds
Open surgery
for As above As above As above
closed fracture
Co-amoxyclav
I/V 1.2 gm tds
Open or + Surgical Toileting / Debridement
Compound Amikacin I/V As above and Closure of wound Skeletal
fractures 500mg tds + stabilization is the first priority.
Metronidazol
I/V 500mg tds
Varies
according to
Meropenum
All Hip the organ
I/V 1 gm -500
Fractures involved or
mg tds +
(Inside Pelvic level of injuries
Metronidazol
Cavity) or
I/V 500 tds
the status of the
patients
Notes:
Antibiotics should be administered as soon as possible after the injury, and certainly within three hours.
Antibiotic-loaded cement is recommened in addition to intravenous antibiotic (SIGN guideline, April 2014).
In every case, either open or close fracture and elective or emergency surgery, special importance is given during
prepping / scrubbing the operative
site andboth chlorhexidine gluconate 0.5% + isopropyle alcohol 70% (e.g., hexisol) and povidon iodine 10% (e.g.,
povisep) are used one after another.
After surgery before wound closure, in almost all cases, irrigation with profuse normal saline (NaCl 0.9%) followed
by wash with povidon iodine 10%
found to be very effective and is practiced routinely.
Type of Alternative
Causative (presumptive Comments/ Remarks
Bursitis Flucloxacillin I/V 1-2 80 % caused by S. aureus
gm qds or and other Gram
Ceftriaxone I/V 1-2 gm positive organisms.
od (diabetic Aspirates should be sent for
Staphylococcus
patients with mixed cultures
aureus
organisms) or (preferably before first dose
Clindamycin I/V 300 of antibiotic).
tds (if penicillin Complete drainage is
resistant) essential.
Teicoplanin I/V 400mg

Better to discuss with
Known MRSA bd for 3
microbiologist
For high risk doses then 400 od
patients
Septic arthritis Staphylococcus Most commonly caused by
Native joints in aureus and - Flucloxacillin I/V 2 gm
Staphylococci
nonrisk patients haemolytic andStreptococci organisms.
qds or
Blood cultures and joint
Clindamycin I/V 450-
aspirate are to be
600 mg qds or
sent for urgent Gram
Cefuroxime I/V 1.5 gm
Native joints in stain/culture &
tds( high risk
highrisk Streptococci sensitivities before initiation
patients of Gram
patients Known MRSA of antibiotic.
negative sepsis)
Or discuss with
Teicoplanin I/V 400mg
microbiologist
bd for 3
Urgent debridement and
doses, then 400mg od
Native joint due Usually washout, and ensure
Seek microbiologist
to polymicrobial samples sent for Gram
advice
penetrating stain/culture and
injury sensitivities.
Ceftriaxone I/V 1-2 gm Can also be contiguous soft
od  tissue infection
Amikacin 500 I/V 500 (usually polymicrobial) or
mg tds haematogenous
Staphylococcus For high risk patients infection (usually
Acute aureus Gram negative monobacterial).
Osteomyelitis Others organisms may be Blood cultures and other
(anaerobes) associated with relevant
osteomyelitis. Advice orthopaedic tissue / pus
from samples should be
microbiologist may be taken before initiation of
taken. antibiotic.
Discuss with Surgical debridement
microbiologist. bone stabilization 
Chronic
As above Duration of treatment vascularization of bony
Osteomyelitis
is longer than in defect is the
acute osteomyelitis. mainstay of treatment.
Type of Alternative
Causative (presumptive Comments/ Remarks
Surgery may be needed if
abscess is formed
Co-amoxyclav I/V 0.6-
in later stage.
Streptococcus 1.2gm tds or
For high risk
pyogens Ceftriaxone I/V 1-2 gm
Cellulitis patientsmay need
Staphylococcus od +
broad
aureus Metronidazol 500mg
spectrum antibiotic.
tds
Advise from
microbiologist is needed.
Staphylococcus Surgery should be the
Abscess As above
aureus main stay of treatment
Streptococcus
pyogens
Carbuncle As above As above
Staphylococcus
aureus
May need ICU support in
Necrotising Streptococcus case of high risk
fasciitis pyogens patients.
Meropenum I/V
MELENEY’S Staphylococcus Surgery / Surgical
500mg-1 gm tds +
synergistic aureus debridement is needed in
Metronidazol I/V 500
gangrene Anaerobes good number of cases.
mg tds
Fournier’s Enterobacteriace Consultation of
gangrene ae microbiologist is needed
in difficult cases.
Staphylococcus
Varies according to the
Surgical site aureus
cases and factors
infection Others
responsible for it.
(anaerobes
Post-operative As above.
wound Staphylococcus Revision surgery may
infection (with epidermidis be needed.
or Staphylococcus Skeletal stability and
without aureus general condition of
Implants / Anaerobes patients are the main
Prosthesis) stay of treatment.
Notes:
High risk patients mean patients having diabetes mellitus, chronic kidney diseases, heart failure, extreme of ages and
having one or more major organ
damage.
This is just a guideline. The main stay of treating patients are clinical judgement of the doctor, condition and
affordability of patients
Physicians are advised to consult with microbiologists or specialists of the major disease suffered by the patients for
choosing the best suitable antibiotic.
Dept. of Ophthalmology
Eyelid infection
*In addition
Topical fusidic acid
Lid hygiene:
or
Unclear Warm
Azithromycin
S. aureus, compress & lid
Artificial tear if associated with
S. epidermidis cleaning with
dry eye
baby shampoo
*
once daily
Tetracycline or
Oral Doxycycline azithromycin
Blepharitis MSSA/S.
100 mg twice daily for 1 week, 500 mg daily for 3
epidermidis
Then once daily for 6-24 weeks days for 3 cycles at
1 week interval
Oral Trimethoprim +
sulphamethoxazole
Artificial tear if
960 mg twice daily
MRSA associated with
Or
dry eye
Linezolide
600 mg twice daily
Oral Doxycycline
100 mg twice daily for 7
days or
Tetracycline 250-500 mg 6
Internal Incision & **In addition
hourly
hordeolum curettage of Hot
S. aureus for 7 days
(infected chalazion after compression +
Plus
chalazion) control of infection lid hygiene
topical antibiotic
(Moxifloxacin/
Ciprofloxacin/Gatifloxacin)
**
Oral Doxycycline
100 mg twice daily for 7days
Or **In addition
Tetracycline Hot
External
Staphylococcal 250-500 mg 6 hourlyfor 7 days compression +
hordeolum
sp Plus lid hygiene
(Stye)
topical antibiotic Epilation of
(Moxifloxacin/ eyelashes
Ciprofloxacin/Gatifloxacin)
**
Conjunctival infection
Highly
contagious. If
associated with
Adenovirus
Viral Self-limiting pain &
Herpes simplex
conjunctivitis No antibiotic required for photophobia
Herpes zoster
(pink eye) treatment suggestive of
virus
keratitis.
Moxifloxacin eye drop 0.5%
Gatifloxacin eye drop 0.3% Uncommon
S. aureus, Levofloxacin eye drop 0.5% causes
Bacterial
S. pneumoniae, 1 drop 2 hourly during day time Chlamydia
conjunctivitis
H. influenzae for 2days, then 4-8 hourly for 7 trachomatis,
days N. Gonorrhoeae
Corneal infections
Topical Aciclovir ointment 3% Trifluridine eye Fluorescein
Or Ganciclovir 0.15% gel 5 drop up to 9 staining
times daily times/day until re- shows topical
Herpes
H. simplex Oral aciclovir 200-400 mg epithelialization, dendritic
simplex
type 1& 2 5times/day for 5-10 days is then 1 drop 4 pattern. 30-50%
keratitis
indicated inimmuno deficient hourly up to 5 recur within 2
patients, in children & with times daily for 21 years.
marked ocular surface disease days.
Intravenous
aciclovir 5-10
Oral aciclovir mg/kg 3 times
800 mg 5 times daily for daily is indicated
Herpes zoster
Varicella zoster 7-10 days or valaciclovir 1 gm for severe
Ophthalmicus
virus 3 times daily Or famciclovir disease & for
(HZO)
250-500 mg 3 moderate to severe
times daily immuno
compromised
patient.
Gatifloxacin 0.3%
Acute S. aureus,
Moxifloxacin 0.5% eye drop- 1 eye drop 1 hourly Treatment may
bacterial S. pyogenes
drop 1hourly for first 48 hours, for first 48 hours, fail
keratitis (no Haemophilus
then reduce as per response. then reduce as per against MRSA.
comorbidities) spp
response.
Corneal infection
Acute Tobramycin 0.3% or
Ciprofloxacin eye
bacterial Fortified Gentamicin 1.5% - 1
drop 0.3% or
keratitis P. aeruginosa drop 2 hourly for first 3 days,
Levofloxacin eye
(contact lens then slowly reduce the
drop 0.5%.
users) frequency as per response
Natamycin eye drop 5% Plus

Clotrimazol eye drop 1%- 1
drop 1 to 2 hourly at
Amphotericin B
day time for several days
0.15% eye drop
depending on
Aspergillus Or
response Plus
Fungal Fusarium Voriconazole eye
Clotrimazol eye ointment at
keratitis Candida drop- 1 drop 2
bed time Plus
and others hourly for several
oral ketoconazole 200 mg
days depending
twice daily for 10 days
on response
Optimum regimen uncertain.
Polyhexamethylene biguanide
0.02% and Chlorhexidine
Uncommon.
0.02% eye drop- 1 drop every Voriconazole Or
Protozoa (soft Trauma
Acanthemoeba 1 hourly during day time Or other azole
contact and soft lenses
spp Hexamidine 0.1% Or antifungals may be
lens users) are risk
Propamidine 0.1%- 1 drop effective.
factors.
every 1 hourly during day
time. Taper the dose according
to clinical response.
Orbital infection
Oral Co-amoxyclav 250- Severe infection
Preceptal S. aureus 500mg/ 125 mg 2-3 times may require
cellulitis S. pyogenes daily or 875/125mg BD intravenous
depending on severity antibiotics
If Penicillin/
Cephalosporin
Ceftriaxone 2 gm I/V once If MRSA is
S. pneumoniae allergy:Vancomycin
daily Plus suspected
H. influenzae 1 gm I/V 12 hourly
Orbital Linezolid 600mg BD Plus then
M. catarrhalis Plus
cellulitis drainage of orbital abscess / vancomycin is
Anaerobes Levofloxacin 750
infected sinus at an the
Group A strep mg I/V once daily
early stage if present drug of choice
Plus Linezolid
600mg bd
I/V Liposomal
AmphotericinB 0.5-
Correction of
1mg/kg/day Plus
underlying
Rhino-orbital Rhizopus Debridement of devitalized
metabolic
mucor Absidia and necrotic tissue Plus daily
defect(uncontro
mycosis Mucor packing with Amp B soaked
lled DM
gauze Plus
and ketosis)
adjunctive therapy with iron
chelator Deferasirox
Endophthalmitis
Immediate core vitrectomy
Plus intravitreal antibiotics
Bacterial (Inj. Vancomycin 2 mg in
(Post-ocular 0.1 ml + Inj. Ceftazidime 2
surgery) mg in0.1ml) Plus S/C Inj.
S. epidermidis Vancomycin 50 mg Plus Intravitreal Vancomycin
S. aureus Ceftazidime 125 mg Or Inj.Amikacin 0.4 mg address
Streptococci Amikacin 50mg, if allergic to in 0.1 ml , Gram positive
Enterococci penicillin Plus Topical alternative to cocci
Gram negative antibiotic (Vancomycin 5% or Ceftazidime including
organisms Ceftazidime 5%) 4-6 times MRSA
daily Plus OralAntibiotics
(Ciprofloxacin 750mg BD
or Moxifloxacin 400mg OD
for 10days
Clarithromycin 500 mg BD
forculture negative infections)
Plus
Oral steroid
(Prednisolone1mg/kg/day) in
severe cases after 12-24 hours
provided fungal infection has
been excluded from culture
Intravitreal antibiotics (Inj.
Vancomycin Plus
Haematogenous
Inj. Ceftazidime) Plus
S. pneumonae
Systemic antibiotics (Inj.
N. meningitidis
Vancomycin1 gm I/V BD
Bacterial S. aureus
Plus Inj. Ceftriaxone 2 gmI/V
Group B .
OD)
Streptococcus
K. pneumonae
Intra vitreal Amphotericin B Duration of

0.005- 0.01mg in 0.1ml Plus treatment 4-
Candida sp. Voriconazole/
Systemic therapy – 6 weeks or
Fungal / Aspergillus sp. Liposomal
Amphotericin B 0.7-1mg/kg longer
Mycotic Coccidioides Amphotericin B 3-5
Plus depending upon
immitis mg /kg Plus PPV
Flucytocin 25mg/kg 4 times clinical
daily response.
Lacrimal sac infection
Dacryocystorhi
nostomy
Oral flucloxacillin 500 mg 6
(DCR)
hourly for 7 days Or
Acute Staphylococcal operation after
Co-amoxiclav 500mg/125 mg
dacryocystitis Streptococci control of acute
2-3 times
infection
daily for 7 days
according to
protocol.
Protozoal & Parasitic Retinochoroidal infection
Oral Azithromycin
500 mg 1 tab daily for 7
days Plus
Co-trimoxazole
(trimethoprim 160
mg/sulfamethoxazole 800 mg)
1 tab twice Pyrimethamine +
Toxoplasmosis daily 6 weeks Plus Sulfadiazine +
Toxoplasma Cat is the
(protozoal Prednisolon 1mg/kg body Clindamycin
gondii definitive host
infection) weight only after 24-48 hours along with oral
of steroid
antimicrobial therapy. Topical
steroid may be given for
anterior uveitis
Toxocariasis Mebendazole and
(roundworm Toxocara canis Thiabendazole Plus
infection) Steroid in all routes
Onchocerciasis Ivermectin kills microfilariae.
(parasitic Single dose
helminth of it needs to be taken Simulium
Onchocerca
infection)/Rive annually to be blackfly is the
Volvulus
rblindness effective. vector
Doxycycline 100-200 mg/day
for 6 wks
Human Immunodeficiency Virus (HIV) infection
HAART Plus
Valganciclovir 900 mg BD
for 3 wks & 900 mg daily as PPV + SOI +EL in Screening of
Cytomegalo Cytomegalo/ maintenance Plus CMV related patients
Virus retinitis Herpes virus Ganciclovir induction with 5 RD with low CD4
mg/kg/day I/V12 hrly for 14 counts
days, then 5 mg/kg/day as
maintenance Plus
Intravitreal 2 mg in 0.1 ml
Foscarnet 60 mg/kg I/V 8 hrly
for 7days, then 90-120
mg/kg/day as maintenance
Plus Cidofovir 5mg/kg I/V
once wkly for 2wks, then 5
mg/kg once every other wk
Plus Steroid -intravitreal and
systemic
Progressive HAART Plus
retinal VZV Intravitreal & I/V PPV for RD
necrosis Ganciclovir &Foscarnet
High doses of I/V Aciclovir
Intravitreal
Acute retinal HSV in (10 mg/kg 8 hrly for 10-14 Vitrectomy for
ganciclovir or
necrosis younger days), RRD with
foscarnet
& VZV in older Oral aciclovir 800 mg 5 silicone oil
may enhance the
patients times/day for 6-12 wks or oral tamponade
prognosis
Famciclovir
Bacterial infections (Posterior segment):
4 drugs (Isoniazid +
Tuberculosis Mycobacterium Rifampicin + Pyrazinamide + LASER may be
tuberculosis Ethambutol) for 2 applied to
months and 2 drugs (Isoniazid ischaemic retina
+ Rifampicin)
for 10 months Plus
topical & systemic steroids
Acquired Treponema I/V Penicillin + topical & Doxycycline or
syphilis pallidum systemic steroids Tetracycline
Transmitted by
Oral Doxycycline, amoxicillin tickbites, deer
Borrelia
Lyme disease or erythromycin in early acute are imp.
burgdorferi
disease, Vectors
but in established disease I/V
Penicillin or Ceftriaxone Plus
topical & systemic steroids
Brucella
Combined Streptomycin &
Brucellosis melitensis &
Doxycycline + Steroid
B.abortus
Co-trimoxazole,
Cat scratch Bartonella Azithromycin,
disease hensellae Rifampicin or Ciprofloxacin.
Steroids in some cases.
Dapson + Rifampicin +
M. leprae & M. Clofazimine
Leprosy
lepromatosis Plus
Topical steroid
Department of ENT
Alternative Comments/
antibiotics Remarks
External ear infections
Amoxiclave 625 mg
IV Meropenem
8 h for 14 days Modify therapy
Staphylococcus 1gm 8 h for 14
Diffuse Otitis Or based
aureus days/
Externa Ciprofloxacin on sensitivities
Pseudomonas IV Amikacin 500
500mg 12 h for 14
mg 8 hfor 14 days.
days
Ciprofloxacin
Secondary
500mg 12 h for 7 Cefixime 400 mg Add Antibiotic if
infection:
Seborrhoeic Otitis days Or 12 h for 7 days + secondary
Staphylococcus
Externa Cefuroxime 500 steroid. infection
aureus/
mg12 h for 7 days
Pseudomonas
Plus steroid.
Ciprofloxacin IV Meropenem
750mg 12 h for 3 1gm 8h Modify therapy
months Plus for1month/ based
Pseudomonas/ IV Gentamicin IV Amikacin 500 on sensitivities
Malignant Otitis
+ Staphylococcus 80 mg 8 h 1 month. mg 8 h for 1
Externa
aureus. month followed by
Ciprofloxacin
750mg 12 h for 3
month.
Ciprofloxacin Cefixime
500mg 12 h for 14 400mg12 h for 14
Perichondritis Pseudomonas days Or days do
Flucloxacillin 500
mg 6 h for 14 days
Ciprofloxacin
Staphylococcus Flucloxacillin 500
Furunculosis 500mg 12 h for 7 do
aureus. mg 6 h for 7 days.
days
Middle and Internal ear infections

IV Meropenem 1gm
Cefuroxime 500 mg
Streptococcus/ 8h for 14 days/
12 h for 14 days Or
Acute Mastoiditis Staphylococcus/ IV Amikacin 500 do
Cefixime 400mg12
Pneumococcus mg 8
h for 14 days.
hourly for 14 days.
Cefuroxime 500 mg Amoxiclav 625 mg
Acute 12 h for 7 days Or 8h for 7 days.
Haemophilus/
Suppurative Otitis Azithromycin 500 do
Streptococcus
Media mg once daily for 5
days.
Ciprofloxacin Amoxiclav 625 mg
500mg 12 h for 14 8h for 14 days.
Chronic Proteus/
days Or
Suppurative Otitis Pseudomonas / do
Cefuroxime
Media E.coli.
500 mg 12 h for
14days
Fungal infection Antifungal Plus Cefuroxime 500 mg12
Add Antibiotic
+Secondary Ciprofloxacin hourly for 7 days
Otomycosis if secondary
infection:S.aureus 500mg 12 h for 7 days
infection.
/Pseudomonas
Antiviral Plus steroid Antiviral+steroid+ IV
Plus Cefuroxime Meropenem 1gm 8
Herpes Zoster Viral infection +
500 mg12 h. for h./ IV Amikacin do
Oticus Secondary infection
14days 500 mg 8 hourly for 14
days
Steroid Plus
Bullous Viral infection + Amoxiclav 625 mg 8
Cefuroxime 500 mg12 do
Myringitis Secondary infection h for 7 days.
h for 7 days
Nose infections
Haemophilus Cefuroxime 500 mg12 IV Ceftriaxone 1gm 12
Acute
/Streptococcus / h for 7 days Or h for 7 days/IV
Sinusitis/ do
Staphaureus/pneum Ciprofloxacin meropenem 1 gm 8 h
Acute Rhinitis.
ococcus 500mg 12 h for 7days for 7 days.
Chronic
Pseudomonas/E.coli
Sinusistis/ Ciprofloxacin 500mg Cefuroxime 500mg12
/ do
chronic 12 h for 14 days h for 14 days
Proteus
Rhinitis
Cefuroxime 500 mg12 Amoxiclav 625 mg 8 h
Atrophic h for 7 days Or 7 days/
Klebsiella ozaenae do
Rhinitis Ciprofloxacin cefixime 400 mg 12h
500mg 12 h for 7 days for 7 days.
IV Ceftriaxone 1gm
Streptococcus / IV Meropenem 1gm
12 h for 10 days/
Staphylococcus 8h for 7 days/
Septal Abscess IV Ciprofloxacin do
aureus/ IV Amikacin 500 mg
500mg 12h for 14
pneumococcus 8h for 7 days
days
Flucloxacillin 500 mg Cefuroxime 500 mg
Staphylococcus 6 h for 7 days Or 12h for 7days/
Vestibulitis do
aureus Ciprofloxacin Cefixime 400 mg 12 h
500mg 12 h for 7days for 7 days
Throat infections
Penicillin 500 mg 6 h Amoxiclave 625 mg 8 h
Acute for 7days Or for 7 days.
Streptococcus do
Tonsillitis Cefuroxime 500 mg 12
h for 7days
Chronic Penicillin 500 mg 6 Ciprofloxacin 500mg 12
Streptococcus do
Tonsillitis hourly for 14 days hourly for 14 days.
Penicillin 500 mg 6 Amoxiclave 625 mg 8
Acute hourly for 7 days Or hourly for 7 days.
Streptococcus do
Pharyngitis Cefuroxime 500 mg 12
hourly for 7 days
Cefuroxime 500 mg 12 h
Pneumococcus /
Chronic Penicillin 500 mg 6 h for 14 days /
Streptococcus/ do
Pharyngitis for 14 days Ciprofloxacin
Haemophilus
500mg 12 h for 14 days
Empiric
Likely
Type of antibiotics Alternative Comments/
causative
Infections (presumptive antibiotics Remarks
organisms
antibiotics)
Throat infections
IV Meropenem 1gm
Streptococcus/ IV Ceftriaxone 1gm Modify therapy
8 hourly +
Peritonsillar Haemophilus/ 12 hourly Plus
IV Metronidazole based on
Abscess Staphylococcus IV Metronidazole 500
500 mg 8 sensitivities
aureus mg 8h for 14 days
hourly for 14 days.
IV Meropenem 1gm
Streptococcus/ IV Ceftriaxone 1gm
Acute 8 hourly +
Haemophilus/ 12 hourly Plus
retropharyngeal Staphylococcus IV Metronidazole 500
IV Metronidazole do
Abscess. 500 mg 8
hourly for 14 days.
IV Meropenem 1gm
Streptococcus/ IV Ceftriaxone 1gm
8 hourly +
Parapharyngeal Haemophilus/ 12 hourly Plus
IV Metronidazole do
Abscess Staphylococcus IV Metronidazole 500
500 mg 8
hourly for 14 days.
Other infections
IV Meropenem do
1gm 8 hourly/
IV Ceftriaxone 1gm
IV Amikacin 500
Streptococcus 12 houlry Plus IV
mg 8
viridians/ Flucloxacillin 500
hourly
Ludwig’s Angina Streptococcus/ mg6h Plus IV
+Flucloxacillin
Pseudomonas/ Metronidazole
500mg 6 hourly +
Klebsiella 500 mg 8 hourly for
Metronidazole 500
14 days
mg 8
hourly for 14 days.
Clindamycin 600 do
Cefuroxime 500
mg 8 h
mg12 hfor 14 days
Staphylococcus for 14 days/IV
Parotid Abscess Or Ciprofloxacin
aureus Meropenem
500mg 12 h for 14
1gm 8 hourly for
days
14 days.
IV Ceftriaxone 1gm IV Meropenem do
12 h Plus IV 1gm 8 h
Flucloxacillin 500 +
Streptococcus
Neck Abscess mg6h Plus IV IV Metronidazole
viridans
Metronidazole 500 mg 8 h/IV
500 mg 8 h for 14 Amikacin 500 mg
days. 8 h for 14 days
IV Ceftriaxone 1gm IV Meropenem do
Streptococcus 12 h Plus IV 1gm 8 h/IV
viridians/ Flucloxacillin 500 Amikacin 500 mg
Necrotizing
Streptococcus/ mg 6h Plus IV 8h + Flucloxacillin
Fascitis
Pseudomonas/ Metronidazole 500mg 6 h +
Klebsiella 500 mg 8 h for 14 Metronidazole 500
days mg 8h for 14 days.
Department of Urology
Uncomplicated cystitis
defined as acute, sporadic or recurrent cystitis ( in women limited to non-pregnant stage) with no known
anatomical and functional abnormalities within the urinary tract or comorbidities
Cephalosporins (e.g.
cefadroxil)
500mg q12h for 3days
Fosfomycin
Or
trometamol
In Woman Nitrofurantoin macrocrystal
3g SD for 1day
Or
Pivmecillinam
400mg q8h for 3-5 days
fluoroquinolones
Trimethoprim- can also be
prescribed in
In Man sulphamethoxazole
accordance with
160/800mg q12h for 7days local susceptibility
testing
Uncomplicated pyelonephritis
defined as pyelonephritis (limited to non-pregnant, pre-menopausal women) with no known urological
abnormalities or comorbidities.
Ciprofloxacin 500-750mg q12h for 7-
Fluoroquinolone resistance
10days should be < 10%
Levofloxacin 750mg q24h for 5days
Trimethoprim/sulphamethoxazol If such agents are used
Oral antimicrobial therapy 160/800mg q12h for7-14d empirically, an initial
intravenous dose of a long
Cefpodoxime 200mg q12h for 10days acting parenteral
Ceftibuten 400mg q24h for 10days antimicrobial (e.g.
ceftriaxone) should be
administered
Ciprofloxacin 400 mg q12h
Levofloxacin 750mg q24h
Cefotaxime 2gm q8h
Not studied as monotherapy
Ceftazidime 1-2 gm q8h in acute uncomplicated
pyelonephritis.
Co-amoxiclav 1.5gm q8h
Ceftriaxone 1-2gm q24h Lower dose studied, but
Cefepime 1-2gm q12h higher dose recommended.
Same protocol for acute un
Piperacillin/tazobactam 2.5-4.5gm q8h complicated pyelonephritis
Parenteral antimicrobial therapy and complicated UTI
(stratification not always
possible).
Ceftolozane/tazobactam1.5gm q8h
Ceftazidime/avibactam 2.5gmq8h
Gentamicin 5mg/kg q24h Not studied as monotherapy
Amikacin 15mg/kg q24h in acute uncomplicated
pyelonephritis.
Ertapenem 1g q24h Same protocol for acute
Imipenem/cilastatin 0.5/0.5gm q8h uncomplicated
Meropenem 1gm q8h pyelonephritis and
Doripenem 0.5gm q8h complicated UTI

Complicated UTIs
Occurs in an individual in whom factors related to the host (e.g. underlying diabetes or immuno suppression)
or specific anatomical or functional abnormalities related to the urinary tract (e.g. obstruction, incomplete
voiding due to detrusor muscle dysfunction) are believed to result in an infection that will be more difficult
to eradicate than an uncomplicated infection.
amoxicillin plus an aminoglycoside
Or
a second generation cephalosporin plus an
aminoglycoside
Complicated UTI with systemic symptoms
Or
a third generation cephalosporin
intravenously as empirical treatment of
complicated UTI
 Do not use amoxicillin, co-amoxiclav, and trimethoprim/sulphamethoxazole for empirical treatment.
 Only use ciprofloxacin provided that the local resistance percentages are < 10% when: the entire
treatment is given orally; patients do not require hospitalisation; patient has an anaphylaxis for beta-
lactam antimicrobials.
 Do not use ciprofloxacin and other fluoroquinolones for the empirical treatment of complicated UTI in
patients from the urology department or when patients have used fluoroquinolones in the last six months.
 Use an initial one-time intravenous dose of a long-acting antimicrobial, such as a third generation
cephalosporin or an aminoglycoside if the prevalence of fluoroquinolone resistance is thought to be
>10% and resistance data are pending.
 If the prevalence of fluoroquinolone resistance is thought to be > 10% and the patient has
contraindications for third generation cephalosporins or an aminoglycoside, ciprofloxacin can be
prescribed as an empirical treatment in women with uncomplicated pyelonephritis.
 In the event of hypersensitivity to penicillin, a third generation cephalosporin can still be prescribed,
with the exception of systemic anaphylaxis in the past
 In patients with a UTI with systemic symptoms empirical treatment should cover ESBL in the initial
treatment only in patients who are colonised with ESBL-producing microorganisms. The resistance
pattern of the ESBL strain should guide empirical therapy
Urosepsis
(defined as a systemic, deleterious host response to infection originating from the urinary tract and/or male
genital organs. Urosepsis is accompanied by signs of systemic inflammation, presence of symptoms of organ
dysfunction and persistent hypotension associated with tissue anoxia)
Cefotaxime 2gm q8h
Ceftazidime 1-2 gm q8h
Ceftriaxone 1-2gm q24h
Cefepime 1-2gm q12h 7-10 days Longer
Piperacillin/tazobactam 2.5-4.5gm q8h courses are
Ceftolozane/tazobactam1.5gm q8h appropriate in
Parenteral antimicrobial therapy
Ceftazidime/avibactam 2.5gmq8h patients who have
Gentamicin 5mg/kg q24h a slow clinical
Ertapenem 1g q24h response
Imipenem/cilastatin 0.5/0.5gm q8h
Meropenem 1gm q8h
Doripenem 0.5gm q8h
Likely Empiric antibiotics Commen
Type of Alternative
causative (presumptive t/Remar
organisms antibiotics) k
Urethritis
(Inflammation of the urethra presents usually with symptoms of the lower urinary tract (LUT) and must be
distinguished from other infections of the LUT. From a therapeutic and clinical point of view, gonorrhoeal
urethritis must be differentiated from non-gonococcal urethritis)
Cefixime 400mg orally
single dose Or
Ceftriaxone
Azithromycin
Gonococcal infection 1gm i.m., single dose in
1-1.5gm, orally single dose
complex situations
Or Ciprofloxacin
1gm, orally single dose
Doxycycline
Azithromycin
Non gonococcal infection 100mg q12h orally Or
500mg orally in day1
(nonidentified pathogen) Quinolones Or oral
250mg orally day2-5
cephalosporin for 3- 10days
Doxycycline
Azithromycin
Chlamydia trachomatis 100mg q12h orally for
1-1.5gm orally single dose
7days
Moxifloxacin
400mg q24h for5days
Azithromycin
however, because of
Mycoplasma genitalium 500mg orally in day1
reported failures, some
250mg orally day2-5
experts recommend 10 -
14d
Azithromycin
Doxycycline 1-1.5gm orally single dose
Ureaplasma urealiticum
100mg q12h orally 7 days Or Clarithromycin
Metronidazole In case of persistence 4gm
Trichomonas vaginalis
2gm orally single dose daily for 3-5 days
Bacterial Prostatitis
Levofloxacin500mgeveryday All of these All
Or Ciprofloxaacin500mg antimicrobials can be treatment
Acute febrile bacterial prostatitis q12h Or Ceftriaxone 2gm administered in should be
with symptoms and fever q24h Or conjunction with given
Piperacillin/tazobactam aminoglycosides e.g. parenterall
4.5gm q8h Or Cefepime 2gm Gentamicin 5 mg/kg q.d y until
q12h
or Amikiacin15 mg/kgqd defervesce
nce
Levofloxacin500mgeveryday/Ciprofloxacin500mg
Acute afebrile bacterial prostatitis q12h/Trimethoprim 200mg q12h/Cotrimoxazole
with symptoms or after 960mg q12h for 2-4 weeks
defervescence Doxycycline 100mg q12h for 10days (only for Chlamydia
and Mycoplasma infection)
Levofloxacin 500mg everyday/ Ciprofloxacin 500mg
q12h/Trimethoprim 200mg q12h/Cotrimoxazole
Chronic bacterial prostatitis 960mg q12h for 2-4 weeks
Doxycycline 100mg q12h for 10days (only for Chlamydia
and Mycoplasma infection)
Perioperative antibacterial prophylaxis in urology
The aim of antimicrobial prophylaxis in urology is to prevent infectious complications resulting from
diagnostic and therapeutic procedures. However, evidence for the best choice of antimicrobials and
regimens is limited.
The duration of surgical antimicrobial prophylaxis should extend throughout the period in which bacterial
invasion is facilitated and/ or is likely to establish an infection.
 Begin infusion of the first dose within 60 minutes of the surgical incision (with the exception of 120
minutes for intravenous fluoroquinolones and vancomycin).
 Do not extend prophylaxis beyond 24 hours after a procedure except when a prosthetic material is
being placed, an external urinary catheter is present prior to or is placed at the time of the procedure
in patients with certain risk factors, or with documented bacteriuria.
 With an existing infection, a therapeutic course of antimicrobials should be administered in an
attempt to sterilize the field or at least to suppress the bacterial count. If urine culture shows no
growth, prophylaxis can be omitted.
Patient-related Factors Affecting Host Response to Surgical Infections
Factor Result
Impair natural defense mechanisms
Advanced age ↓ natural defense mechanisms of the urinary
Anatomic anomalies of the urinary tract tract and immune system
Poor nutritional status
Smoking
Chronic corticosteroid use
Immunodeficiency
Increase local bacterial concentration and/or spectrum of flora
Externalized catheters ↑ local bacterial concentration and/or
Colonized endogenous/exogenous material spectrum
Distant coexistent infection
Prolonged hospitalization
Prophylaxis for Lower Tract Instrumentation

Procedure Prophylaxis Antimicrobial(s) of Choice2 Alternative
(organisms)1 Indicated Antimicrobial(s)2
Removal of Patients with Fluoroquinolone, Aminoglycoside ±
external urinary risk factors5 Trimethoprim/sulfamethoxazole Ampicillin 1st/2nd gen.
catheter,3,4 (GU Cephalosporin
tract) Amoxicillin/Clavulanate
Cystography, Patients with Fluoroquinolone, Aminoglycoside ±
urodynamic study risk factors5 Trimethoprim/sulfamethoxazole Ampicillin 1st/2nd gen.
or simple Cephalosporin
cystourethroscopy Amoxicillin/Clavulanate
(GU tract)
Cystourethroscopy All patients Fluoroquinolone, Aminoglycoside ±
with manipulation6 Trimethoprim/sulfamethoxazole Ampicillin 1st/2nd gen.
(GU tract) Cephalosporin
Amoxicillin/Clavulanate
Transrectal prostate All patients Fluoroquinolone, 1st/2nd/3rd TMP-SMX
biopsy (Intestine) gen. Cephalosporin Aminoglycoside
(Aztreonam)
(Use rectal cleansing with
povidone-iodine in men prior to
transrectal prostate biopsy)
Key: gen., generation; GU, genitourinary.
1
Organisms common to the GU tract − E. coli, Proteus sp., Klebsiella sp., Enterococcus; Intestine − E. coli,
Klebsiella sp., Enterobacter, Serratia sp., Proteus sp., Enterococcus, and Anaerobes; Skin − S. aureus,
coagulase negative Staph. sp., Group A Strep. sp.
2
Order of agents is not indicative of preference.
3
If urine culture shows no growth prior to procedure, antimicrobial prophylaxis is not necessary.
4
Or full course of culture-directed antimicrobials for documented infection (treatment not prophylaxis).
5
Risk factors-see Table
6
Includes transurethral resection of bladder tumor and prostate, and any biopsy, resection, fulguration,
foreign body removal, urethral dilation or urethrotomy, or ureteral instrumentation including catheterization
or stent placement/removal.
Prophylaxis for Upper Tract Instrumentation

Procedure Prophylaxis Antimicrobial(s) of Choice2 Alternative
(organisms)1 Indicated Antimicrobial(s)2
Shock-wave If risk factors Fluoroquinolone, Aminoglycoside ±
lithotripsy (GU trimethoprim/sulfamethoxazole Ampicillin 1st/2nd gen.
tract) Cephalosporin
Percutaneous All patients 1st/2nd gen. Cephalosporin, Aminoglycoside/
renal surgery (GU Aminoglycoside + Sulbactam
tract and skin) Metronidazole or Clindamycin Fluoroquinolone
Ureteroscopy (GU All patients Fluoroquinolone, Aminoglycoside ±
tract) trimethoprim/sulfamethoxazole Ampicillin 1st/2nd gen.
Cephalosporin

1
2
Prophylaxis for Open or Laparoscopic Surgery:
Procedure Prophylaxis Antimicrobial(s) Alternative Antimicrobial(s)2
(organisms)1 Indicated of Choice2
Involving entry All patients 1st/2nd gen. Ampicillin/Sulbactam Fluoroquinolone
into the urinary Cephalosporin
tract (GU tract Aminoglycoside +
and skin) Metronidazole or
Clindamycin
Without entering Patients with risk 1st gen. Clindamycin (single dose)
urinary tract factors3 Cephalosporin
(skin) (single dose)
Involving All patients 2nd/3rd gen. Ampicillin/Sulbactam
intestine4 (GU Cephalosporin, Ticarcillin/ClavulanatePipercillin/Tazobactam
tract, skin, and Aminoglycoside + Fluoroquinolone
intestine) Metronidazole or
Clindamycin
Involving All patients Aminoglycoside + Ampicillin/Sulbactam
implanted 1st/2nd gen. Ticarcillin/ClavulanatePipercillin/Tazobactam
prosthesis (GU Cephalosporin or
tract and skin) Vancomycin
1
2
3
If urine culture shows no growth prior to procedure, antimicrobial prophylaxis is not necessary.
4
For surgery involving colon, bowel preparation with oral neomycin plus either erythromycin base or
metronidazole can be added to or substituted for systemic agents.
Antimicrobial Agents and Doses for Periprocedural Use
Fluoroquinolones Levofloxacin: 500 mg PO single dose
Ciprofloxacin: 500 mg PO [q12h]
Ofloxacin: 400 mg PO [q12h]
Aminoglycosides Gentamicin: 5 mg/kg IV single dose
Tobramycin: 5 mg/kg IV single dose
Amikacin: 15 mg/kg IV single dose
1st Generation Cephalexin: 500 mg PO [q6h]
cephalosporins Cephradine: 500 mg PO [q6h]
Cefadroxil: 500 mg PO [q12h]
Cefazolin: 1 g IV [q8h]
2nd Generation Cefaclor: 500 mg PO [q8h]
cephalosporins Cefprozil: 500 mg PO [q12h]
Cefuroxime: 500 mg PO [q12h]
Cefoxitin: 1 - 2 g IV [q8h]
3rd Generation Ceftizoxime: 1 g IV [q8h]
cephalosporins Ceftazidime: 1 g IV [q12h]
Ceftriaxone: 1 - 2 IV single dose
(oral agents not listed) Cefotaxime: 1 g IV [q8h]
Others Amoxicillin/clavulanate: 875 mg PO [q12h]
Ampicillin: 1 - 2 g IV [q6h]
Ampicillin/sulbactam: 1.5 - 3 g IV [q6h]
Aztreonam 1 - 2 g IV [q8h]
Clindamycin: 600 mg IV [q8h]
Erythromycin base (for bowel preparation): 1 - 2 g PO
[variable]
Metronidazole: 1 g IV [q12h]; (for bowel preparation) 1 - 2 g
PO [variable]
Neomycin(for bowel preparation): 1 - 2 g PO [variable]
Pipercillin/tazobactam: 3.375 g IV [q6h]
Ticarcillin/clavulanate: 3.1 g IV [q6h]
Trimethoprim/sulfamethoxazole: 1 double-strength tablet PO
[q12h]
Vancomycin: 1 g IV [q12h]
g: gram; h: hour; IV: intravenous; kg: kilogram; mg: milligram; PO: orally; q: every.
References:
 EAU Guidelines on Urological Infections (Limited Text Update March 2018)
 AUA Best Practices Statements: Urologic Procedures and Antimicrobial Prophylaxis (2019)
Department of Hepato-biliary-Pancreatic Surgery

Comment
Type of Infections Causative (presumptive Alternative antibiotics
/ Remarks
A. Skin and soft tissue infections
1.2g TDS IV Or Surgical
Meropenem
Streptococcus Ceftriaxone drainage is
1 gm TDS IV and
pyogens 1-2 gm OD mainstay of
Metronidazole
Streptococcus IV treatment
500mg IV TDS
Surgical wound aureus Or
+
Abscess /Cellulitis Escherichia coli Clindamycin
Amikacin
Klebsiella spp. 150 -600 mg
Or
Pseudomonas IV 8 hourly
Quinolones
spp +
Metronidazole
500mg IV TDS
B. Hepatobiliary infections
Acute / Acute on E. coli Meropenem and Source
chronic Klebsiella Ceftriaxone and Metronidazole (dose control is
Cholecystitis Enterococcus Metronidazole mentioned above) the key
faecalis (dose mentioned above)
event
Cefuroxime 750 mg IV 8 Meropenem
h 1 gm TDS Source
Or Or control is
Ceftriaxone Tigacycline 100 mg iv the key
2 gmIV bolus then 1 gm- bolus then 50 mg 12 event
Escherichia coli 2gm IV daily in devided hourly
Klebsiella spp. dose or
Cholangitis Pseudomonas Plus PiperacillinTazobactam
Enterococcus Amikacin 250 mg or 4.5 gm TDS IV
faecalis 500mg IV 12 hourly +
Or Metronidazole
quinolones 500mg IV TDS
+
Metronidazole
500mg IV TDS
Meropenem
Escherechia 1 gm TDS Drainage of
Klebsiella Or abscess is
Pseudomonas Ceftazidime Tigacycline 100 mg iv the main
Proteus Plus bolus then 50 mg 12 stay of
Anaerobes Amikacin hourly treatment
Entamoeba Or or
Liver abscess
histolytica Quinolones PiperacillinTazobactam4
+ .5 gm TDS IV
Metronidazole Or
(500 mg iv 8 hourly)
Causative (presumptive Comment
Type of Infections Alternative antibiotics
organisms antibiotics) / Remarks
Linazoide
+
Amikacin
Or
Quinolones
+
Metronidazole
500mg IV TDS
+
Fluconazole IV 200 mg
daily
C. Abdominal infections
Meropenem1 gm TDS
E. coli., Meropenem Or
Klebsiella sp. 1 gm TDS Tigacycline 100 mg iv
Bacteroides Or bolus then 50 mg 12
Pseudomonas Tigacycline 100 mg iv hourly
Anaerobes bolus then 50 mg 12 or
hourly PiperacillinTazobactam
or 4.5 gm TDS IV
Biliary or GI
PiperacillinTazobactam Or
Perforation
4.5 gm TDS IV Linazolide
+ +
Metronidazole Amikacin
500mg IV 8 hourly Or
Quinolones
+
Metronidazole
500mg IV TDS
Meropenem
Ceftriaxone or 1 gm TDS Surgical
Co-amoxiclav or Or drainage
Ceftazidimeor Tigacycline 100 mg iv followed is
Plus bolus then 50 mg 12 key event
Amikacin hourly
Or or
Quinolones PiperacillinTazobactam
E. coli., + 4.5 gm TDS IV
Acute
Klebsiella sp. Metronidazole +
Pancreatitis
Bacteroides (500 mg iv 8 hourly) Metronidazole
with collection /
Pseudomonas 500mg IV TDS
abscess
Anaerobes +
daily
Comment
Type of Infections Causative (presumptive Alternative antibiotics
/ Remarks
E. coli. Ceftriaxone or Meropenem 1 gm TDS
Klebsiella sp. Co-amoxiclav or Or
Pseudomonoassp Ceftazidime or Tigacycline 100 mg iv
Bacteroides Plus bolus then 50 mg 12
Enterococcus Amikacin hourly
Peptostreptococc Or or
Acute
us Quinolones PiperacillinTazobactam
necrotizing
+Anaerobes + 4.5 gm TDS IV
Pancreatitis
+Fugus Metronidazole +
(500 mg iv 8 hourly) Metronidazole
500mg IV TDS
+
daily
D. Additional procedure
Gastointestinal Ceftriaxone
surgery: E. coli., Plus Metronidazole Meropenem plus
Above D-J Klebsiella sp. etc Metronidazole
junction
E. coli.,
Klebsiella sp.
Ceftriaxone
Bacteroides
Below D-J Plus
(colonic
junction Metronidazole
perforation )
Anaerobes
E.coli., Meropenem plus
Ceftriaxone/Ceftazidime Metronidazole plus
Biliary surgery Klebsiella sp.
Plus Metronidazole Amikacin
Pseudomonas sp
Antimicrobial susceptibility
The antimicrobial susceptibility pattern observed in recent study in 2019 revealed, Gram-negative isolates
showed highest sensitivity to meropenem, imipenem, netilmicin, and amikacin.
I. Most of the Escherichia coli were susceptible to imipenem (88.89%), meropenem (88.89%),
ertapenem (77.78%), piperacillin–tazobactam (55.56%), amikacin (77.78%), netilmicin (89%),
gentamicin (88.89%), and cefepime (55.56%).
II. Moreover, most of the Klebsiella pneumonia were sensitive to imipenem (89%), meropenem (89%),
ertapenem (89%), Piperacillin–tazobactam (67%), amikacin (89%), netilmicin (78%), and gentamicin
(89%).
III. Pseudomonousaeruginosa isolates were also sensitive to imipenem, meropenem, piperacillin–
tazobactam, amikacin, netilmicin, and gentamicin and cefepime,
IV. Among the Gram-positive isolates, Enterococcus faecalis isolated from stented patient sensitive to
teicoplanin, linezolid and vancomycin
V. Studies also showed high level of resistance to aminoglycosides.
Restricted Antibiotic Policy:

The policy is to reserve for Multi drug resistant (MDR) proven organisms, to reduce the empirical use of
higher antibiotics and to prevent further resistance to higher antibiotics. The List comprises of
Vancomycin is recommended to cover Enterococcus spp. for grade III community-acquired acute
cholangitis and cholecystitis, and healthcare-associated acute biliary infections. Linezolid is recommended
in vancomycin-resistant Enterococcus (VRE) infection. Besides, Colistin, Polymyxin-B, Teicoplanin,
Vancomycin, Tigecycline, Antifungals, Azoles – Voriconazole, Amphotericin B, Echinocandins –
Caspofungin, Micafungin, Anidulafungin may be added in special circumstances like liver transplant.
Preoperative Screening and Decolonization

Staph. aureus is the most common pathogen causing SSIs, accounting for 30% of SSIs in the United
States. It’s colonization primarily in the nares, occurs in roughly one in four persons and increases the risk
of SSI by 2 to 14 folds. So, decolonization is important in immunocompromised and immunosuppressed
individuals like Liver transplant.
Recommendations
Infection is very common in surgery of liver biliary tree and pancreas, due to biliary tract obstruction by
stone, stricture, tumor, intervention or surgery.Major risk factor revealed the blood loss. Surgical site
infection (SSI) is more frequent after hepatobiliary surgery. The primary goal is to limit both the systemic
septic response and local inflammation, to prevent SSI and to prevent intrahepatic abscess formation.
Drainage of obstructed biliary tree also termed as source control, is recognized as the corner stone
management strategy.
Recommendations for the use of antimicrobial prophylaxis are graded according to the strength of
evidence available. Studies supporting the recommendations for the use of antimicrobial therapy were
classified as follows:
i. Bile cultures should be obtained at the beginning of any procedure performed. Gall bladder bile
should be sent for culture in all cases of acute cholecystitis except those with grade I severity.
(Recommendation 1, level C)
ii. We suggest cultures of bile and tissue when perforation, emphysematous changes, or necrosis of
gall bladder are noted during cholecystectomy
iii. Blood cultures are not routinely recommended for grade I community-acquired acute cholecystitis.
(Recommendation 2, level D)
iv. When selecting antimicrobial agents, targeted organisms, pharmacokinetics and
pharmacodynamics, local antibiogram, a history of antimicrobial usage, renal and hepatic function,
and a history of allergies and other adverse events should be considered. (Recommendation 1,
level D).
v. We suggest anaerobic therapy in all biliary-enteric anastomosis is present. (Recommendation 2,
level C)
vi. Once the source of infection is controlled, antimicrobial therapy for patients with acute
cholangitisis recommended for the duration of 4 to 7 days.(Recommendation 1, level C)
vii. Antimicrobial therapy for patients with Grade I and II acute cholecystitis is recommended only
before and at the time of surgery. (Recommendation 1, level B)
viii. Once the source of infection is controlled, antimicrobial therapy for patients with Grade III acute
cholecystitis is recommended for the duration of 4to 7 days. (Recommendation 2, level D)
ix. In patients with pericholecystic abscesses or perforation of the gallbladder, treatment with an
antimicrobial regimen as listed in Table 3 is recommended. Therapy should be continued until the
patient is afebrile, with normalized white cell count and without abdominal findings.
(Recommendation1, level D)
Each recommendation was categorized according to the strength of evidence that supports the use or
nonuse of antimicrobial prophylaxis as category A (levels I–III), category B (levels IV–VI), or category C
(level VII). When higher-level data are not available, a category C recommendation represents a
consensus of expert panel members based on their clinical experience, extrapolation from other
procedures with similar microbial or other clinical features, and available published literature.
Chapter 4: Antibiotic resistance among bacteria isolated from 2011 to 2014
at BIRDEM General Hospital
Organism Pattern of % Antibiotic Resistance

antibiotic
resistance 2011 2012 2013 2014
3rd generation 70.3 68.7 69.7 70.67

cephalosporin
E.coli resistant
Fluoroquinolone 83.1 80.9 74.7 71.1

resistant
3rd generation 66.3 63.5 63.6 67.1

cephalosporin
Klebsiella sp. resistant
Carbapenem 11.6 16 19.2 20.0

resistant
Pseudomonas sp. Carbapenem 51.1 68.4 60.0 53.7

resistant
Salmonella sp. Nalidixic acid 94.3 98.2 95.6 81.6

resistant
Staphylococcus aureus Methicillin 36.9 27.35 37.3 30.5

resistant
Reference: Barai L, Saha MR, Rahman T, Khandaker T, Dutta S, Hasan R, Haq JA. Antibiotic resistance: Situation
analysis in a tertiary care hospital of Bangladesh. Bangladesh J Microbiol. 2017; 34(1):15-19.
Chapter 3: Antimicrobial options for medically important organisms
Name of Category Antimicrobials

Microorganism
Gram Positive Cocci

Staphylococcus aureus Penicillin sensitive Penicillin G
isolates Amoxicillin
Cephalexin
Penicillin resistant Cloxacillin
isolates Flucloxacillin
Clindamycin
Erythromycin
MRSA Clindamycin
Vancomycin
Linezolid
Daptomycin
Tetracycline
Cotrimoxazole
D test positive Cloxacillin
(clindamycin resistance) Flucloxacillin
Vancomycin
(according to c/s)
Staphylococcus Penicillin sensitive Penicillin G
epidermidis isolates Amoxicillin
Cephalexin
MRSE Vancomycin plus
aminoglyside
Streptococcus pyogenes All isolates are Penicillin G
(Group A) penicillin sensitive Amoxicillin
Ampicillin
Streptococcus Penicillin G
agalactiae (Group B) Ampicillin
Enterococcus faecalis Penicillin sensitive Penicillin
Ampicillin
High level gentamycin Penicillin plus
resistant (HLGRE) aminoglycoside or
Vancomycin plus
aminoglycoside
Vancomycin resistant Linezolid
Quinopristin-
dalfopristin
Daptomycin
Microorganism
Streptococcus Penicillin sensitive Penicillin G
pneumoniae strain Erythromycin
Penicillin resistant strain Ceftriaxone
Levofloxacin
Vancomycin
Streptococci viridians Penicillin G with or
group without
aminoglycosides
Gram Negative Cocci
Neisseria meningitidis Penicillin G
Ceftriaxone/cefotaxi
me
Chloramphenical
Neisseria gonorrhoeae Penicillin sensitive Cefixime
Ceftriaxone
Spectinomycin
Neisseria gonorrhoeae Penicillin resistant Ciprofloxacin
(PPNG)
Quinolone resistant Spectinomycin
Gram Positive Bacilli
Bacillus anthracis Penicillin G
Corynebacterium Penicillin G
diphtheriae Erythromycin
Listeria monocytogenes Cotrimoxazole
Ampicillin with or
without gentamycin
Gram Negative Bacilli
Escherichia coli Non beta lactamase Ampicillin
Amoxyclav
Cephalosporin
Cotrimoxazole
ESBLs Aminoglycoside
Carbapenem
Cotrimoxazole
Nitrofurantoin (UTI)
Ciprofloxacine
Tigecycline
Piperacillin-
Tazobactum (choice
according to c/s
report)
Microorganism
Salmonella typhi Nalidixic acid sensitive Quinolone
Ampicillin
Azithromycin
Nalidixic acid resistant Ceftriaxone
Cefixime
Azithromycin
(choice according to
c/s)
Shigella sp. Ciprofloxacin
Vibrio cholerae Tetracycline
Haemophilus spp Amoxicillin, Co-
amoxiclav
Cephalosporin,
Ciprofloxacin,
Macrolid
Helicobacter pylori Amoxicillin
Metronidazole
Bismuth
Campylobacter jejuni Erythromycin
Klebsiella spp Non beta lactamase Cephalosporins

Enterobacter spp Aminoglycosides
Serratia spp Quinolones
Proteus spp
Morganella spp
Providenciaspp
Klebsiella spp ESBLs Aminoglycoside
Enterobacter spp Carbapenem
Serratia spp Cotrimoxazole
Proteus sp Nitrofurantoin (UTI)
Morganella spp Quinolones
Providenciaspp (choice according to
c/s report)
Pseudomonas Piperacillin-
aeruginosa tazobactam
Ceftazidime,
cefepime
Quinolones
Carbapenem
Aztreonam
(choice according to
c/s report)
Microorganism
Burkholderia Ceftazidime
pseudomallei Carbapenem
Cotrimoxazole
Amoxyclav
Leginella Azithromycin,
Levofloxacin,
doxycycline
Chlamydia trachomatis Azythromycin,
doxycycline
Rickettsia Tetracycline
Treponema pallidum Penicillin,
Doxycyclin
Nocardia Cotrimoxazole
Mycoplasma Erythromycin,
Tetracyclin
Anaerobes
Bacteroides Metronidazole,
Coamoxyclav
Clindamycin
Carbapenem
Clostridium tetani Penicillin
Clostidium difficile Metronidazole

Vancomycin
Actinomyces PenicillinG
Virus
Herpes Simplex Virus Acyclovir
Varicella Zoster Virus No antiviral therapy
needed
Cytomegalovirus Gancyclovir
Human papilloma virus Podophyllin
Liquid Nitrogen
Alpha interferon
Influenza virus Oseltamivir
Zanamivir
Hepatitis B virus Pegylated α-IFN
Lumivudin
Hepatitis C virus Pegylated α-IFN
Plus ribavirin
Microorganism
HIV virus Zidovudin
Lamivudin
Nevirapine
Indinavir
Fungi
Dermatophytes Miconazole
Clotrimazole
Histoplasma Itraconazole
capsulatum Amphotericin B
Coccidioides immitis Itraconazole
Amphotericin B
Blastomyces Itraconazole
dermatitidis
Candida albicans Topical nystatin or
clotrimazole
Fluconazole
Ketoconazole
Amphotericin B
Cryptococcus Amphotericin B plus
neoformans flucytosine
Aspergillus sp Amphotericin B
Mucor &Rhizopus sp Amphotericin B
Parasites
Entamoeba histolytica Metronidazole
Tinidazole
Ornidazole
Secnidazole
Diloxanide furate
Giardia lamblia Metronidazole
Nitozoxanide
Trichomonas vaginalis Metronidazole
Plasmodium sp. Chloroqine sensitive Chloroquine phosphate
strain
Chloroqine resistant Artemether
strain Artemether with
lumefantrine
Artesunate
Quinine
Mefloquine
Toxoplasma gondii Sulfadiazine plus
pyrimethamine
Pneumocystis jiroveci Cotrimoxazole
Microorganism
Leishmania donvani Sodium stibogluconate
Liposomal
Amphotericin B
Miltefosin
Echinococcus Albendazole
Taenia sp Praziquantel
Schistosoma Praziquantel
Ascaris lumbricoides Mebendazole
Pyrantel pamoat
Hook worm Mebendazole
Pyrantel pamoat
Pinworm Mebendazole
Pyrantel pamoat
Strongyloides Ivermectin
stercoralis
Trichuris trichiura Mebendazole
Wuchereria bancrofti Diethylcarbamazine
Dracunculus Thiabendazole
medinensis Metronidazole
Onchocerca volvulus Ivermectin
Chapter 5: Antibiotic Stewardship Program
Antibiotic stewardship program (ASP) is defined as ‘co-ordinated interventions designed to improve and
measure the appropriate use of [antibiotic] agents by promoting the selection of the optimal [antibiotic] drug
regimen including dosing, duration of therapy, and route of administration’. 1 It can be explained as an
activity of giving the appropriate antimicrobial at right dose for optimal duration to eradicate infection and
minimize collateral damage. The high antibiotic resistance observed in hospital patient population increases
their mortality, morbidity, length of stay in hospital and cost of care. It also contributes in emergence and
dissemination of resistant strains of microbes. Main aim of ASP is improvement of antimicrobial use and
reduction of emergence and spread of antimicrobial resistance.
The stewardship team should consist of members from all levels in a hospital. This interdisciplinary team
should compose of Infectious disease specialist, Clinical Pharmacist with training in infectious disease,
Clinicians, Heads of all departments, Microbiology and laboratory staffs, hospital epidemiologist,
information system specialist and nurses.
Recommendations for Implementing an ASP1:

1. Use of preauthorization for certain broad spectrum antibiotics and/or prospective audit and feedback
interventions to improve antibiotic utilization and patient outcomes.
2. Didactic educational activities, like lectures, informational pamphlets etc, should be used to
complement ASP activities. Principles of ASP should be included in preclinical and clinical
curricula.
3. ASPs should develop facility-specific clinical practice guidelines along with dissemination and
implementation strategy.
4. ASPs may implement interventions for specific infectious diseases syndromes to improve antibiotic
use and clinical outcomes.
5. Antibiotic stewardship interventions should be designed to reduce the use of antibiotics associated
with Clostridium difficile infection.
6. Strategies (eg, antibiotic time out, stop orders etc) may be used to encourage prescribers for routine
review of antibiotic regimens.
7. Computerized clinical decision support, if available, may be incorporated at the time of prescribing.
8. Use of antibiotic cycling as a stewardship strategy is not recommended.
9. Pharmacokinetic monitoring and adjustment programs for aminoglycosides and Vancomycin should
be implemented in all hospitals.
10. Alternative dosing strategies may be used instead of standard dosing for broad spectrum β-lactams.
11. Appropriate use of oral antibiotics should be increased with timely transition of patients from IV to
oral antibiotics.
12. ASPs may promote allergy assessments and penicillin skin testing if there is history of β-lactam
allergy.
13. ASPs should implement guidelines and strategies to reduce antibiotic therapy to the shortest effective
duration.
14. Stratified antibiograms may be developed for empiric therapy.
15. During reporting of antibiotic susceptibility test results by Microbiology laboratory, selective and
cascade antibiotics may be reported only.
16. To reduce inappropriate use of antibiotics, rapid viral testing for respiratory pathogens may be used.
17. Rapid diagnostic test on blood specimens (eg; PNA-FISH, MALDI-TOF etc) may be used in
addition to conventional culture.
18. Serial procalcitonin measurement may be done in adults in ICUs with suspected infection.
19. Nonculture based fungal markers (eg; Galactomannan, fungal PCR, 1,3 β D glucan assay etc) may be
used in patients with hematologic malignancy with risk of invasive fungal disease.
20. ASP must be implemented in Neonatal ICU (NICU) to reduce inappropriate antibiotic use and/or
resistance.
21. Care providers of terminally ill patients should be supported in decisions related to antibiotic
treatment.
Core elements of Hospital ASP2:

1. Leadership commitment: Hospital authority should support the stewardship team to monitor
antibiotic prescribing. Authority should assure that involved staffs have adequate time, authority and
accountability. Financial support should be provided for training and IT support.
2. Accountability: Stewardship team should have a single leader who will be responsible for program
outcomes. Clinicians are highly effective in this role. ASP is a teamwork which requires involvement
of all team members.
3. Drug expertise: A clinical pharmacist with training in Infectious diseases and/or ASP should be
involved. He/she can monitor the use of antimicrobials and identify areas of improvement.
4. Action implement policies and interventions: Policies and protocols that support optimal antibiotic
prescribing should be implemented. These protocols should be based on national guideline and local
susceptibility pattern (antibiograms).
5. Tracking: Antibiotic prescribing and resistance patterns must be monitored properly by ASP team.
6. Reporting: All doctors, nurses and relevant staffs of hospital should be regularly reported about
antibiotic use and antimicrobial resistance pattern.
7. Education: Clinicians must have fundamental knowledge of ASP. Informational pamphlets, lectures
etc may be used to strengthen ASP activities.
As widespread use of antibiotics has compromised their values leading to a crisis of antimicrobial resistance,
ASP must be implemented in all hospitals for solving this man-made crisis. Stewardship is a group effort
among multiple disciplines. By adopting ASP, organizations can improve use of antibiotics and slow down
the rise of infections with drug-resistant organisms.
References:
1. Barlam TF, Cosgrove SE, Abbo LM et al. Implementing an antibiotic stewardship program: Guidelines by the
Infectious Diseases Society of America, and the Society for Healthcare Epidemiology of America. Clin Infect
Dis 2016; doi:10.1093/cid/ciw118.
2. http://www.cdc.gov/getsmart/healthcare/pdfs/core-elements.pdf

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Antibiotic Guideline BIRDEM 2021

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Antibiotic Protocol for BIRDEM General Hospital

Antibiotic Protocol 2021

Bangladesh Diabetic Somiti

Empirical, prophylactic & therapeutic management of

 Dept. of Respiratory Medicine 6

 Dept. of Critical Care Medicine 7-13

 Dept. of Nephrology 14-17

 Dept. of Endocrinology 18-19

 Dept. of Neurology 20-21

 Dept. of Cardiology 22-28

 Dept. of GHPD 29-32

 Dept. of Paediatrics 33-38

 Dept. of Surgery 48-50

 Dept. of Orthopaedics & Traumatology 51-53

 Dept. of Ophthalmology 54-59

 Dept. of ENT 60-62

 Dept. of Urology 63-69

3 Antimicrobial options for medically important organisms 75-80

4 Antibiotic resistant pattern of common organism at 81

Antibiotic protocol committee (List according to alphabetic order)

Acknowledgement (List according to alphabetic order)

Antimicrobial Resistance has become a matter of great public health concern

Emergence of Antimicrobial Resistance (AMR) in pathogens has become a

Prof. M.K.I. Qayyum Chowdhury

Lower respiratory tract infection ( Hospitalized Diabetic patients)

Candida spp. Inj. Fluconazole Echinocandin

Candiduria Usually no Rx, unless indicated

Central nervous system infection

Infective Endocarditis (Empiric / presumptive antibiotics – according to mode of presentation,

Infective Endocarditis (according to specific organism suspected)

Benzathine Penicillin Single dose

Situations Antibiotic Regimen: Single Dose

Antibiotic regimens for prevention of endocarditis prior to Gastrointestinal and

Prophylaxis of Rheumatic Fever

a. Primary-Earlytreatment of upper respiratory tract infection due to Group A Beta Hemolytic

Amoxycillin-clavulanate Ultrasound guided

Brain abscess S. aureus Ceftriaxone 100mg/kg I/V q24h 6 weeks

In febrile UTI and pyelonephritis

Infective Inj. Vancomycin. 40mg/kg/day q8-12 4-6 wks

Antibiotics Used in Neonatal Unit

Inj Ampicillin (Intravenous over 15 minutes ) InjAmikacin (Intravenous over 30 minutes )

Postnatal age ≤7 days: Neonates 0–4 weeks and <1.2 kg : 7.5

Gestational age <32 weeks Postnatal age <7 days:

Inj. Piperacillin and Tazobactum (I/V over 30 Other Antibiotics:

≤29 weeks postmenstrual age (PMA):

Staph. aureus Cephalosporin Amoxicillin ,

Prophylactic antibiotics in gynecology

Teicoplanin I/V 400mg

Natamycin eye drop 5% Plus

Intra vitreal Amphotericin B Duration of

Middle and Internal ear infections

Likely Empiric antibiotics

Prophylaxis for Lower Tract Instrumentation

Prophylaxis for Upper Tract Instrumentation

Key: gen., generation; GU, genitourinary.

Likely Empiric antibiotics

Restricted Antibiotic Policy:

Preoperative Screening and Decolonization

at BIRDEM General Hospital

Organism Pattern of % Antibiotic Resistance

3rd generation 70.3 68.7 69.7 70.67

Fluoroquinolone 83.1 80.9 74.7 71.1

3rd generation 66.3 63.5 63.6 67.1

Carbapenem 11.6 16 19.2 20.0