PRINCIPLES of ANTIBIOTIC SELECTION

Upper Resp Tract

Upper GI Tract (above the diaphragm)

SKIN
Lower GI Tract (below the diaphragm)

STEP 1.
Where is the
infection?
IMMUNCOMPETENT, COMMUNITY-ACQUIRED INFECTION IN NON-ICU SETTING

LOCATION ORGANISM EMPIRIC ORAL EMPIRIC IV

ANTIBIOTIC COVERAGE ANTIBIOTIC COVERAGE
Skin Strep pyogenes; Linezolid (all cover MRSA)
Staph aureus (abscess); Linezolid
(lines and hardware- Skin anaerobes Clindamycin Clindamycin
associated infections) (Propionibacterium) IV Vancomycin
TMP/SMX DS + beta-lactam (ex, Daptomycin
cephalexin, dicloxacillin, or
amox/clav)

Doxycycline + beta-lactam (Only

beta-lactam if no MRSA suspected)
Upper Resp Tract Haemophilus influenzae; Respiratory Fluoroquinolone Respiratory Fluoroquinolone
Moraxella catarrhalis; (levofloxacin, moxifloxacin)
(sinusitis, Neisseria meningitides; Ceftriaxone + Azithromycin
bronchitis, Strep pneumonia;
pneumonia, Atypicals (Legionella,
meningitis) Chlamydia, Mycoplasma)

Upper GI Tract Strep viridans; Amoxicillin/Clavulanic Acid Ampicillin/Sulbactam

Oral anaerobes
(dental, (Actinomyces. Clindamycin Clindamycin
aspiration) Fusobacterium,
Peptostreptococcus)

Lower GI Tract Enteric Gm Neg Rods; Cipro or levofloxacin + Cipro or levofloxacin + metronidazole
Enterococcus species; metronidazole
(intra-abdominal, Colon anaerobes 3rd or 4th generation cephalosporin + metronidazole
UTI*) (Bacteroides, Clostridium)
Pip/tazo

(*UTI -no anaerobic meropenem

coverage needed)
 STEP 2.
IMMUNOCOMPROMISED, CRITICALLY ILL, RECENT EXPOSURE TO HEALTHCARE
Is expanded coverage necessary?
FACILITY, ABNORMAL STRUCTURAL ANATOMY (ex, bronchiectasis, urethral
strictures, ….), OR HARDWARE add coverage for:

MRSA Pseudomonas

Oral Clindamycin (if not resistant) Oral Ciprofloxacin

Doxycycline Levofloxacin STEP 3. Reassess
Linezolid Fosfomycin (UTI only)
Trimethoprim-Sulfamethoxazole
IV Ceftaroline IV Aminoglycosides IF NO RESPONSE, CONSIDER:
Clindamycin (if not resistant) Aztreonam
1) Coverage of Candida
Daptomycin Cefepime
species (micafungin)
Linezolid Ceftazidime
Vancomycin Ciprofloxacin, Levofloxacin 2) Evaluation for abscess or
Colistin other source control (ex,
Piperacillin/Tazobactam removal of hardware)
Meropenem 3) C difficile infection

Gram Pos Gram Neg Anaerobes Atypical Comments

(* if MRSA) (*if Pathogens
Pseudomonas)
PCN +++ + (oral and + (Treponema) Many Staph isolates are resistant
Clostridia)
Dicloxacillin or +++
Nafcillin
Cephalexin or +++ + + (skin)
Cefazolin
Amoxicillin or +++ + (oral)
Ampicillin
Amox/Clav or +++ ++ ++
Amp/Sulb
Doxycycline +++* ++ (Rickettsia, Does not cover urine;
Chlamydia, Adverse effects: pill esophagitis;
Legionella)
photosensitivity
TMP/SMX +++* ++ Adverse effects: Renal/electrolytes;
pancytopenia, aseptic meningitis
Clindamycin ++* + (oral) Anaerobes above the belt (dental, aspiration)
Metronidazole +++ Anaerobes below the belt (lower GI tract)
Ceftriaxone ++ ++ + (skin)
Ceftazidime + ++* + (skin)
Cefepime + ++* + (skin)
Aztreonam +++*
Pip/Tazo +++ +++* +++
Meropenem +++ +++* +++
Vancomycin +++* + (skin)
Daptomycin +++* + (skin) Does not cover lungs;
Monitor CPK for rhabdomyolysis
Linezolid +++* + (skin) Risk for serotonin syndrome with SSRIs;
Peripheral neuropathy and pancytopenia > 2 wk
Moxifloxacin ++ +++ + ++ Does not cover urine QT prolongation
Levofloxacin ++ ++* ++ Tendon rupture
Ciprofloxacin + (Staph +++* ++
saprophyticus)
Azithromycin ++ + (H. influenzae, ++ QT prolongation
Moraxella)
Aminoglycosides + (synergy only) +++* Ototoxicity, nephrotoxicity