Antibiotics Booklet 2021

‫شكر و عرفان‬
‫جزيل الشكر لسيادتكم للدعم و المساندة في اتمام هذا العمل‪.‬‬
‫السيد اللواء طبيب‪ /‬أحمد عبد الرؤوف بالسي‬

‫مدير مجمع الجالء الطبي ق‪.‬م‪.‬‬
‫‪1‬‬
‫‪Clinical Pharmacy Department‬‬ ‫‪Pediatrics & Gynecology Hospital‬‬
‫جزيل الشكر لمدير مستشفى األطفال و النساء التخصصي‬
‫السيد اللواء طبيب‪ /‬حسام الدين عبد هللا‬
‫بالتعاون مع السادة المستشارين و رؤساء األقسام‪:‬‬

‫لواء طبيب‪ /‬مصطفى السيوفي (مدير الشئون العالجية بالمجمع)‬
‫لواء طبيب‪ /‬وائل أحمد ماهر (مساعد المدير للشئون الطبية)‬
‫لواء طبيب‪ /‬أسامة قاسم (رئيس قسم األطفال)‬
‫عقيد طبيب‪ /‬أحمد طلعت (رئيس قسم الجراحة)‬
‫مقدم طبيب‪ /‬أيمن صبري (رئيس قسم جراحة قلب و صدر أطفال)‬
‫أستاذ طبيب‪ /‬وائل عطية – أستاذ طب األطفال – جامعة القاهرة (أستشاري رعاية جراحة قلب و صدر أطفال)‬
‫قسم المعامل‪:‬‬
‫عميد طبيب‪ /‬أحمد فاروق (مدير قسم المعامل)‬
‫د‪ .‬شروق عبد المنعم الدمنھوري ( أخصائي تحاليل طبية)‬
‫قسم األمداد الطبي‪:‬‬

‫عقيد صيدلي‪ /‬محمود محمد يوسف (رئيس قسم االمداد الطبي بالمجمع)‬
‫قسم الصيدلة األكلينيكية‪:‬‬

‫مقدم صيدلي‪ /‬سارة يوسف أبراهيم (رئيس قسم الصيدلة األكلينيكية بالمجمع)‬
‫نقيب صيدلي‪ /‬سارة سمير المنشاوي (رئيس قسم الصيدلة األكلينيكية بمستشفى األطفال)‬
‫نقيب صيدلي‪ /‬شيماء علي (أخصائي صيدلة أكلينيكية)‬
‫صيدلي‪ /‬ساندي سامي رياض (أخصائي صيدلة أكلينيكية)‬
‫صيدلي‪ /‬ايناس سعيد (أخصائي صيدلة أكلينيكية)‬
‫صيدلي‪ /‬أميرة مصطفى (أخصائي صيدلة أكلينيكية)‬
‫صيدلي‪ /‬ميري رضا (أخصائي صيدلة أكلينيكية)‬
‫صيدلي‪ /‬ناردين عصمت (أخصائي صيدلة أكلينيكية)‬
‫صيدلي‪ /‬أريج شامل (أخصائي صيدلة أكلينيكية)‬
‫‪2‬‬
‫‪Clinical Pharmacy Department‬‬ ‫‪Pediatrics & Gynecology Hospital‬‬
Index
Topic Page
Introduction
Guidelines & Principles 4
Antibiotic Allergy 5
Restricted Antibiotics 6
Neonatal Policy
Neonatal Antibiotic Policy 7-8
Neonatal Fungal Prophylaxis 8
Pediatric Policy
Upper Respiratory Tract Infections 9
Lower Respiratory Tract Infections 10-11
Urinary Tract Infections 12
Bloodstream Infections 13
Bone and Joint Infections 14
Feverish illness in Children 14
Central Nervous System Infections 15
Intra-abdominal Infections 16-17
Skin & Soft Tissue Infections 18
Infective Endocarditis & Cardiovascular System Infections 19
Surgical Site Infections 20-22
Antibiotics Susceptibilities 23
Antibiotics Guide
Renal Adjustment of IV Antibiotics 24-36
Hepatic Adjustment of IV Antibiotics 37-38
Antibiotics Data 39-50
References 50
3
Clinical Pharmacy Department Pediatrics & Gynecology Hospital
Introduction
 Introduction to Galaa Military Pediatric and Gynecology Hospital Antibiotic Guidelines:
These antibiotic guidelines are designed to guide clinicians in the empiric use of antibiotics.
Empiric treatment is the choice of an antibiotic prior to sensitivity results being available.
These guide will help to choose agents that are active against the likely pathogens and can
adequately penetrate the site of infection.
When selecting an antibiotic it is important to weigh up the benefits of treatment against the
risks such as drug related adverse effects and the contribution of antibiotic use to development
of antimicrobial resistance.
The control of antimicrobial prescribing is a crucial part of our strategy to limit the
development of resistance. As a general rule, the broader the antibacterial spectrum of an
antibiotic and the longer the treatment coarse, the greater the risk of resistance developing.
Therefore, it is very important to prescribe antibiotics only when clinically indicated and for
as short a period as possible and to use a narrow spectrum antibiotic if possible.
 Principles of Antibiotic prescribing in critically ill patients:
1. Antibiotics should be prescribed only when there is clinical evidence of infection or a clear
indication for prophylaxis.
2. Ensure that appropriate microbiological specimens are taken prior to starting antibiotic.
3. In case of fever of unknown origin and in the absence of systemic response, replacement
and/or withdrawal of catheters may be sufficient to solve the infectious process.
4. Colonization or contamination should not be treated.
5. Targeted therapy (narrow spectrum) should be used in preference to broad spectrum
antibiotics unless there is a clear clinical reason.
6. Broad spectrum antibiotics should be reviewed as soon as possible and switched to narrow
spectrum agents when sensitivity results are available.
7. Intravenous antibiotic should be changed to oral antibiotic as soon as clinically appropriate.
8. Avoid unnecessarily prolonged courses of antibiotics, the course should be reviewed
within 5 days.
9. Avoid repeated courses with the same antibiotic unless necessary and revised by the
clinical pharmacist.
10. The indication for prescribing the antibiotic should be documented in the patient medical
notes.
11. The start date and the stop or review date of antibiotics should be recorded in the patient
medical notes.
4
Antibiotic Allergy
The allergy status of the patient should always be checked before prescribing antibiotics. If a
patient is allergic to an antibiotic, the nature of the allergy, the name of the drug causing the
reaction, and the date should be documented clearly in the front of the drug chart.
Pharmacists and nurses must check whether a patient has any allergies before dispensing or
administering an antibiotic.
 Penicillin Hypersensitivity:
Allergic reactions to penicillins occur in 1-10% of exposed individuals. Anaphylactic reactions
occur in fewer than 0.05% of treated patients. Patients with a history of atopic allergy (e.g.
asthma, eczema, hay fever) are at a higher risk of anaphylactic reactions to penicillins. About
0.5-6.5% of patients allergic to penicillins will also be allergic to cephalosporins.
 Types of Hypersensitivities:
1. Type 1 - Immediate hypersensitivity: Patients with a history of anaphylaxis, urticaria or
rash immediately after penicillin administration are at risk of an immediate hypersensitivity
reaction to a penicillin; these patients should not be given a penicillin, cephalosporin or
carbapenem.
2. Minor Rash: For patients with a history of a minor rash i.e. a non-confluent, non-pruritic
rash restricted to a small area of the body, or a rash that occurs more than 72 hours after
penicillin administration; these patients can be given a cephalosporin or carbapenem.
Penicillins can be used for a serious infection with caution and under supervision.
 Skin Test:
Skin test is a reliable method for detecting immediate allergic reactions to beta-lactams.
A small amount (0.02-0.05 ml) of the beta-lactam is injected
intradermally with a tiny needle. A positive reaction to the test will cause
a red, itchy, raised bleb measuring 3 mm in diameter after 15-20 minutes.
A positive result indicates a high likelihood of penicillin allergy.
A negative test result usually means that the patient is not at high risk of an allergy to
penicillin. But a negative result is more difficult to interpret because some kinds of drug
reactions cannot be detected by skin tests.
 Vancomycin Red Man Syndrome:

Vancomycin may cause red man syndrome if the infusion is too rapid. It is not an allergic
reaction, but may be characterized by hypotension and/or a maculopapular rash appearing on
the face, neck, trunk and/or upper extremities.
If this occurred, slow the infusion rate to administer dose over 90-120 minutes and increase the
dilution volume. Administration of antihistamines just before the infusion may also prevent or
minimize this reaction. The reaction usually dissipates in 30-60 minutes.
5
Restricted Antibiotics
Restricted Antibiotics Culture based Antibiotics
Gentamicin Colistin
Ciprofloxacin Tygacil (Tigecycline)
Tienam (Imipenem/Cilastatin) Zavicefta (Ceftazidime/Avibactam)
Maxipime (Cefepime)
Zyvox (Linezolid)
Targocid (Teicoplanin)
Their use should be approved by the head of Their use should be restricted only according
department with illustration of the indication to cultures and the duration of administration
and duration of administration. should be illustrated.
The clinical pharmacist signature is a must. The clinical pharmacist signature is a must.
Restricted Antibiotics Order Form
6
Neonatal Antibiotic Policy
Condition Organism Suitable Antibiotics Notes

Cefotaxime may be added
to or substituted for the
Early-Onset Neonatal Group B streptococci Ampicillin/Sulbactam + aminoglycoside if
Sepsis Escherichia coli Amikacin meningitis caused by a
(It usually presents in the first Listeria monocytogenes gram-negative organism
72 hours after birth) is suspected. Antibiotics
may be changed as soon
as an organism is
identified.
Community Group B streptococci Ampicillin/Sulbactam +

acquired Gram negative bacteria Cefotaxime Or Amikacin Stop antibiotics if blood
Late- Listeria monocytogenes culture yields negative
Onset Coagulase negative staph results after 36–48
Neonatal hours, and the infant
Sepsis Vancomycin + Amikacin shows no subsequent
(It occurs clinical evidence of
after 72
Hospital Gram positive bacteria
acquired Coagulase negative staph If suspected Pseudomonas sepsis or other neonatal
hours of
birth) Gram negative bacteria aeruginosa, add Ceftazidime infections.
Fungus Or Cefepime Or
Piperacillin/Tazobactam
(add on or instead of
Amikacin)
Adding Acyclovir if:
Vesicular rash, CSF
pleocytosis, seizures or
elevated AST.
Ampicillin/Sulbactam +
Streptococcus agalactiae Cefotaxime Or Amikacin There are insufficient data
Neonatal Meningitis Escherichia coli on the use of adjunctive
Listeria monocytogenes 2nd Line: dexamethasone in
Klebsiella species Meropenem + Vancomycin neonates with bacterial
meningitis.
Duration: 2 weeks
beyond the first sterile
CSF culture or 3 weeks
whichever is longer.
Gram negative bacteria
Neonatal Necrotizing Staphylococcus epidermidis Ampicillin/Sulbactam + For confirmed NEC,
Enterocolitis (NEC) Anaerobes Amikacin add Metronidazole.
7
Escherichia coli Meropenem Or If atypical organisms is a
Hospital acquired Klebsiella pneumonia Piperacillin/Tazobactam concern, add Macrolides
Pneumonia Proteus + Vancomycin (Azithromycin or
Staphylococcus aureus Clarithromycin).
gram-positive cocci
If MRSA is a concern,
add Vancomycin.
If anaerobes is a concern,
Staphylococcus aureus add Metronidazole.
Neonatal Osteomyelitis Group B streptococci Amoxicillin/Flucloxacillin +
or Septic Arthritis Gram negative bacteria Amikacin Duration:
Anaerobes Septic Arthritis: 4-6 weeks
Osteomyelitis: 6 weeks
Longer duration for 6-8
weeks in severe cases.
Gentamicin maximum
duration is 2 weeks, so
shift to 3rd Generation
Cephalosporin.
Gram negative bacilli
Ampicillin/Sulbactam +
Urinary Tract Infection Group B streptococci Duration: 7-14 days
Cefotaxime Or Amikacin
Staphylococci
If Gonococcal Conjunctivitis:
Single IM Ceftriaxone Or
Ophthalmia Chlamydia trachomatis Cefotaxime + Local treatment Local treatment with
Neonatorum Neisseria gonorrhoeae antibiotic ointment (e.g.
(Neonatal If Chlamydial Conjunctivitis: Tetracycline) 4 times/day
Conjunctivitis) Oral Azithromycin (3 days)
Or Oral Erythromycin (14
days) + Local treatment
 Neonatal Fungal Prophylaxis:

Prophylactic use of antifungal should be considered in the following neonates:
1. Neonates < 750 gm.
2. Neonates with multiple lines in situ.
3. Neonates with a prolonged length of stay.
Fluconazole: 1st line in fungal UTI.

2nd line in systemic fungal infections.
Amphotericin B: 1st line in systemic fungal infections.

Liposomal Amphotericin: in systemic fungal infections.
8
Pediatric Antibiotic Policy
 Upper Respiratory Tract Infections:
Infection Organisms Suitable Antibiotics Notes
Viral (Mostly)
Co-amoxiclav Or Cefuroxime Or
Streptococcus pneumonia
Ceftriaxone
Otitis Media Haemophilus influenza Duration: 5-10 days
Moraxella catarrhalis If Pen-allergy:
Group A streptococcus Clarithromycin Or Azithromycin
Co-amoxiclav
Streptococcus species Duration: 10 days
If Pen-allergy:
Pharyngitis (commonly Group A) (except for
Cephalexin Or Cefadroxil Or
Neisseria gonorrhea Azithromycin 5 days)
Azithromycin Or Clarithromycin
Chlamydia trachomatis
Or Clindamycin
Co-amoxiclav
2nd Line:
Doxycycline (12-17 years) Or
Sinusitis Haemophilus influenza Duration: 5-14 days
Cefixime Or Ceftriaxone
Moraxella catarrhalis
Or Cefotaxime + Clindamycin
Anaerobes If Pen-allergy:
Clarithromycin
Duration: 5-10 days
Usually viral Co-amoxiclav
Severe FeverPAIN criteria:
(Respiratory viruses,
Tonsillitis 1.Fever (during
Epstein-Barr virus) If Pen-allergy:
previous 24 hrs)
Group A streptococcus Clarithromycin Or Clindamycin
2.Purulence (pus on
tonsils)
3.Attend rapidly
Tonsillitis
(within 3 days after
onset of symptoms)
IV Co-amoxiclav 4.Severely Inflamed
then step down to PO Co-amoxiclav tonsils
Peri- Anaerobes 5.No cough or coryza
tonsillar/ Group A streptococcus If Pen-allergy: (Inflammation of
retro- Staphylococcus aureus IV Clindamycin mucus membranes in
pharyngeal +/- coliforms then step down to PO Clindamycin the nose)
abscess Score 0-1: Unlikely to
Drainage is the essential part of the benefit from AB
treatment Score 2-3: More likely
to benefit from AB
Avoid Co-amoxiclav if Epstein-Barr Score 4-5: Most likely
virus is suspected as it may cause benefit from AB
rash.
If viral, no need for AB
9
 Lower Respiratory Tract Infections:
1. Community Acquired Pneumonia (CAP):
Patients must NOT have the following characteristics:
a. Hospitalization 2 days or more in the past 90 days.
b. Residence in a long-term care facility.
c. Receipt of intravenous antibiotic therapy, chemotherapy, or wound care in the past 30 days.
d. Attendance at a hospital or hemodialysis clinic.
2. Nosocomial Pneumonia:
A. Hospital Acquired Pneumonia (HAP):
Pneumonia that occurs 48 hours or more after admission and patient is not intubated.
B. Ventilator Associated Pneumonia (VAP):
Pneumonia that arises more than 48-72 hours after endotracheal intubation.
C. Health Care Associated Pneumonia (HCAP):
Pneumonia developing in a patient with the following characteristics:
a. Hospitalization for 2 days or more in the past 90 days.
b. Residence in a long-term care facility.
c. Receipt of intravenous antibiotic therapy, chemotherapy, or wound care in the past 30 days.
d. Attendance at a hospital or hemodialysis clinic.
Oral Co-amoxiclav Duration:
Non- Respiratory Viruses  5-7 days if Bronchiolitis
Bronchiolitis severe If Pen-allergy:  7-10 days if
with Secondary bacterial Oral Macrolides (Azithromycin Uncomplicated CAP
secondary infection may be caused by Or Clarithromycin)  14 days if S.
bacterial Streptococcus pneumonia IV Cefotaxime aureus/MRSA
infection Severe Haemophilus influenza  2-3 weeks if Atypical
Moraxella catarrhalis If Pen-allergy:
IV Clindamycin If < 6 months of age, treat
as severe.
≤ 5 years: If viral, no need for AB.

Oral Co-amoxiclav +/- Macrolides If there is a clear clinical
(added if no response) diagnosis of bacterial
Respiratory Viruses pneumonia, treat with
Uncomplicated Streptococcus pneumonia 5-18 years: antibiotics.
Community Haemophilus influenza Oral Co-amoxiclav + Macrolides Consider obtaining blood
acquired Moraxella catarrhalis cultures in suspected
Pneumonia (CAP) Staphylococcus aureus If Pen-allergy: pneumonia.
In school ages, also Oral Macrolides
Mycoplasma suggested
Atypical bacteria by:
If S. aureus suspected, add
(Mycoplasma pneumonia, 1. Age >5 years
Amoxicillin/Flucloxacillin Or
Chlamydia)
Clindamycin 2. Subacute onset
3. Prominent cough
4. +/- headache
5. +/- sore throat
10
Cefotaxime or Ceftriaxone +
Respiratory Viruses
Clarithromycin Or Azithromycin
Severe Community If MRSA is a concern,
Haemophilus influenza
acquired If Pen-allergy: add Vancomycin.
Moraxella catarrhalis
Pneumonia (CAP) Levofloxacin
Staphylococcus aureus
Duration: 2-3 weeks
In school ages, also
If S. aureus suspected, add
Atypical bacteria
Amoxicillin/Flucloxacillin Or
(Mycoplasma pneumonia,
Clindamycin (stop Clarithromycin)
Chlamydia)
If no risk factors for MDR If onset < 5 days after

Respiratory Viruses bacteria: hospital admission (Early
Streptococcus pneumonia Meropenem Or onset), treat as CAP
Haemophilus influenza Piperacillin/Tazobactam +/-
Hospital acquired Moraxella catarrhalis Vancomycin If MRSA is a concern, add
Pneumonia (HAP) Staphylococcus aureus Vancomycin.
If risk factors for MDR bacteria:
Tendency towards more Ceftazidime Or Meropenem Or If the patient is
resistant organisms such as Piperacillin/Tazobactam neutropenic, add
Enterobacteriaceae and + Levofloxacin Or Amikin antifungal.
Pseudomonas aeruginosa + Vancomycin
Duration: 2-3 weeks
Risk factors for MDR

If no risk factors for MDR
bacteria:
bacteria:
1.Prior AB use in the past
Meropenem Or
Streptococcus pneumonia 90 days.
Piperacillin/Tazobactam +/-
Ventilator Haemophilus influenza 2.Current hospitalization
Vancomycin
associated Klebsiella pneumoniae exceeding 5 days.
Pneumonia (VAP) Pseudomonas aeruginosa 3.High frequency of
If risk factors for MDR bacteria:
Acinetobacter species MDR in the hospital.
Ceftazidime Or Meropenem Or
4.Immunosuppressive
disease or therapy.
+ Levofloxacin Or Amikin
+ Vancomycin
Duration: 2-3 weeks
Co-amoxicalv Or
Anaerobes Piperacillin/Tazobactam Or
Aspiration Staphylococcus aureus Ceftriaxone + Metronidazole
Pneumonia Streptococcus pneumonia Duration: 7 days
Coliforms If Pen-allergy:
Clindamycin
11
 Urinary Tract Infections (UTI):
Add Amikacin if:
Child < 3 months with Gram negative bacilli Co-amoxiclav + Cefotaxime Sever sepsis, suspected or
possible UTI Group B streptococcus +/- Amikacin confirmed UTI or likely
Staphylococcus aureus resistant organism such as
pseudomonas.
Asymptomatic bacteriuria
Oral Co-trimoxazole (used if low shouldn’t be treated with
Child > 3 months with Gram negative bacilli risk of resistance) antibiotics. Only use AB in
Cystitis or (E. coli 80%) Or Oral Nitrofurantoin (used only high risk patients.
Uncomplicated Lower Klebsiella species when GFR ≥ 45 ml/min)
UTI Proteus Duration:
2nd line: Co-trimoxazole: 3 days
Oral Co-amoxiclav Or Cefalexin Nitrofurantoin: 3 days
Co-amoxiclav: 7 days
If Outpatient:
Oral Co-amoxiclav Or Cephalexin
If Pen-allergy:
Acute Pyelonephritis Gram negative bacilli Oral Ciprofloxacin
(Child with systemic E. coli
If Septic:
upset, fever, vomiting, Proteus Duration: 7-14 days
IV Ceftriaxone Or Cefuroxime,
poor feeding and Klebsiella
then after 72 hrs step down to Oral
inability to tolerate Enterococci
Cefalexin
oral fluids) Pseudomonas aeruginosa
If Pen-allergy:
IV Amikacin then after 72 hrs step
down to Oral Co-trimoxazole
Oral Co-trimoxazole Or
Nitrofurantoin
UTI Prophylaxis Once daily at bedtime
2nd line:
(if Recurrent UTI)
Oral Cefalexin
Rotate antibiotics monthly
Or Co-amoxiclav (if ≤ 2 months of
age)
Give IV if:
Vomiting, unable to take
Enterobacteriaceae Oral Co-trimoxazole Or Cefalexin oral AB or severly unwell.
Pseudomonas aeruginosa Or Co-amoxiclav
Catheter associated Acinetobacter Duration: 10 days
UTI Enterococci IV Co-amoxiclav Or Cefuroxime Review after 48 hrs to step
MSSA Or Ceftriaxone Or Amikacin down to Oral
MRSA AB treatment is not
Candida routinely needed for
asymptomatic bacteriuria in
people with catheter.
12
 Bloodstream Infections (Septicemia):
Add Amikacin if:
1. Severe sepsis requiring
inotropes/critical care
Group B streptococcus Cefotaxime Or Ceftriaxone 2. Suspected or confirmed
< 3 months Staphylococcus aureus + Co-amoxiclav urinary tract infections
Gram negative bacilli +/- Amikacin 3.Likely resistant organisms
Listeria monocytogenes (such as pseudomonas)
Add Acyclovir if:
Sepsis of < 2 months old with raised
unknown ALT, seizure, suspected
origin, CNS infection, maternal
Community primary HSV.
acquired Duration: 7-10 days
Longer if Staphylococcus
Neisseria meningitides Ceftriaxone Or Cefotaxime
aureus, slow response,
Streptococcus pneumoniae +/- Amikacin
undrainable foci, immune
Haemophilus influenza
deficiency.
≥ 3 months Group A streptococcus If Pen-allergy:
Staphylococcus aureus Levofloxacin + Vancomycin Treatment of sepsis must be
Gram negative bacilli started immediately within
60 minutes of presentation.
Obtain appropriate
cultures before starting
antibiotic treatment.
Staphylococci
Suspected Septicemia, Streptococci Piperacillin/Tazobactam Add Vancomycin if
no focus of infection, Gram negative bacilli +/- Amikacin Or MRSA infection or line
Child 1 month-18 years Pseudomonas aeruginosa Meropenem +/- Amikacin infection.
Hospital acquired Gram negative bacilli
Suspected Septicemia, Streptococci Piperacillin/Tazobactam Add Vancomycin if central
no focus of infection, Gram negative bacilli + Amikacin venous catheter related
with Neutropenia Pseudomonas aeruginosa Or Meropenem + Amikacin infection suspected.
Enterococcus species Two positive blood
Staphylococcus species cultures with the same
Klebsiella species organism are highly
Suspected Central Line Enterobacter species Vancomycin + Amikacin suggestive of central
associated Bloodstream E. coli + Ceftazidime Or venous catheter infection.
Infection (CLABSI) Proteus mirabilis Piperacillin/Tazobactam Or
Pseudomonas species Meropenem If suspected Candida,
Serratia species consider adding
Stenotrophomonas maltophilia Fluconazole Or
Streptococcus species Amphotericin B Or
Candida species Echinocandin.
13
 Bone and Joint Infections:

If MRSA is a concern,
Cefotaxime Or Ceftriaxone add Vancomycin.
<3 Staphylococcus aureus
months Group B streptococcus If Pen-allergy: If anaerobes is a concern,
Coliforms Clindamycin add Metronidazole.
If Prosthesis:
Amoxicillin/Flucloxacillin
Osteomyelitis + Rifampicin
and Septic Staphylococcus aureus Cefuroxime Or Ceftriaxone
Arthritis 3 months Kingella kingae If Sickle cell:
– 5 years Streptococcus pneumoniae If Pen-allergy: Add Ciprofloxacin
Haemophilus sp. Clindamycin
E. coli Step down to PO Co-
amoxiclav Or Cefalexin if:
1. Afebrile and pain free
Amoxicillin/Flucloxacillin minimum 24 hours
2. CRP < 20 or decreased
Staphylococcus aureus by ≥ 2/3 highest value
> 5 years If Pen-allergy:
Streptococcus pneumoniae Clindamycin
Duration:
14-21 days IV, treat for 4-6
weeks total
If MRSA is a concern, add
Staphylococcus aureus Vancomycin.
Open Fracture Gram negative bacilli Cefuroxime + Metronidazole
Anaerobes Duration:
Until wound debridement
 Feverish Illness in Children:

Give IV antibiotics to
infants < 1 month, infants
Viral aged 1-3 months who
Fever of unknown Streptococcus pneumoniae Co-amoxiclav +/- Cefotaxime appear unwell or with
origin for investigation Neisseria meningitidis Step down to Oral Co-amoxiclav WBC <5 or >15 *109/L.
Consider adding Acyclovir

if viral.
14
 Central Nervous System Infections:

Streptococcus pneumoniae Cefotaxime Or Ceftriaxone Do not use corticosteroids
1-23 months Neisseria meningitides + Vancomycin in children < 3 months.
Streptococcus agalactiae
Meningitis Haemophilus influenza 2nd Line: Add Dexamethasone if:
Escherichia coli Meropenem + Vancomycin lumbar puncture shows
any of the following:
Neisseria meningitides Cefotaxime Or Ceftriaxone 1. CSF is very purulent
≥ 2 years Streptococcus pneumoniae + Vancomycin 2.CSF WBC count
>1000/microliter
Coagulase negative
Cefepime Or Ceftazidime 3.Raised CSF WBC count
Staphylococci
CSF Shunt + Vancomycin and protein >1 gm/litre
4. Bacteria on gram stain
2nd Line: Give dexamethasone (0.15
Pseudomonas aeruginosa
Meropenem + Vancomycin mg/kg, max 10 mg Q 6 hrs
Propionibacterium acnes
for 4 days) preferably
Coagulase negative Cefepime Or Ceftazidime before or with first dose of
Staphylococci (especially + Vancomycin antibiotics or within 4
Post Neurosurgery S.epidermidis) hours (if missed, do not
Staphylococcus aureus 2nd Line: start 12 hours or later after
Gram negative bacilli Meropenem + Vancomycin starting antibiotics).
(Pseudomonas aeruginosa)
Streptococcus pneumoniae Avoid Dexamethasone if:
Basilar skull Haemophilus influenza Cefotaxime Or Ceftriaxone 1. Septic shock
fracture Group A beta hemolytic + Vancomycin 2.Meningococcal
streptococci septicemia
Head Coagulase negative Cefepime Or Ceftazidime 3. Immunocompromised
Trauma Staphylococci + Vancomycin 4. Meningitis following
Penetrating ( especially S.epidermidis) surgery
Staphylococcus aureus nd
trauma 2 Line:
Gram negative bacilli Meropenem + Vancomycin Add IV Vancomycin if:
(Pseudomonas aeruginosa) recent multiple antibiotics
exposure or overseas
Meropenem Or travel or suspected MRSA
Brain Abscess Respiratory tract, Skin & Ceftriaxone + Metronidazole
Bowel flora (For 2 to 3 weaks after Add IV Acyclovir if:
successful drainage, If no signs of herpes simplex
surgery for 3 to 6 weaks) encephalitis for 21 days
Treatment Duration:
1. Neisseria meningitidis: 7 days.
2. Haemophilus influenza: 7-10 days.
3. Streptococcus pneumoniae: 10-14 days.
4. Streptococcus agalactiae: 14-21 days.
5. Gram negative bacilli: 21 days.
6. Listeria monocytogenes: Co-amoxiclav for ≥ 21 days + Amikacin for at least the first 7 days.
15
 Intra-abdominal Infections:

No need unless septicemic,
Diarrhea and Vomiting Mostly Viral Antibiotics are not indicated blood/mucus in stool or
immunocompromised
Cefotaxime Or Ceftriaxone Consider adding Amikacin
+ Metronidazole +/- Amikacin if hemodynamically
Post-operative intra- Coliforms Or Co-amoxiclav if not septic unstable.
abdominal infections Enterococci
(e.g. Appendicitis) Anaerobes If Pen-allergy: Duration: 7-10 days
Metronidazole + Amikacin + Step down to Oral after 3-7
Teicoplanin days
Consider adding Amikacin
if ESBL or Pseudomonas is
Spontaneous Bacterial Enterobacteriaceae Ceftazidime Or Cefepime + a concern.
Peritonitis (SBP), (E.coli, Klebsiella sp.) Metronidazole
Intra-abdominal abscess, Bacteroides (colonic Or Piperacillin/Tazobactam Or Consider adding
GI perforation perforation) Meropenem Vancomycin if MRSA is a
Anaerobes concern.
Duration: 7-10 days

Staphylococci
Necrotizing Enterocolitis Streptococci Cefotaxime Or Ceftriaxone Duration: 5 days
(NEC) Gram negative bacilli + Metronidazole
Clostridium perfringens
Cefotaxime Or
Biliary Tract Infections Enterobacteriaceae Piperacillin/Tazobactam Or Duration: 7-10 days
(Cholangitis, Cholecystitis) (E.coli, Klebsiella sp.) Meropenem
PO Amoxicillin/Flucloxacillin
Wounds at gastrostomy Staphylococci
sites Streptococci If Pen-allergy:
PO Clindamycin
Staphylococci IV Co-amoxiclav Duration:
Perianal abscess Group A streptococcus 5 days IV then shift to Oral
Anaerobes If Pen-allergy: (Post drainage up to 2
IV Clindamycin weeks)
Hospital acquired IV Metronidazole
diarrhea (Clostridium Clostridium difficile Or Oral Vancomycin Duration: 7-10 days
difficile)
Ceftriaxone + Metronidazole
Liver Abscess Polymicrobial Or Duration: 14 days
16
Must be based on cultures,
Usually self-limiting.
Campylobacter, Macrolides (Azithromycin Or Only consider antibiotics if
Salmonella (non- Clarithromycin) immunocompromised or
typhoidal), Shigella Or Ceftriaxone Or Cefotaxime severe disease.
enteritis Or Cefixime
Duration: 7 days
(3-5 days if Macrolides)
Macrolides (Azithromycin Or
Bacterial Shigella Clarithromycin) Duration: 7 days
Campylobacter Ceftriaxone Or Cefotaxime Or (3-5 days if Macrolides)
Dysentery Salmonella Cefixime
Amoebic Entamoeba histolytica Metronidazole Or Tinidazole Duration: 7-10 days
(3 days if Tinidazole)
Giardiasis Giardia lamblia Metronidazole Or Tinidazole Duration: 7-10 days
(1 dose if Tinidazole)
Oral Ciprofloxacin Or Oral
Uncomplicated Salmonella Typhi Duration: 14 days
Enteric Azithromycin Or Oral Cefixime
Salmonella Paratyphi A (7 days if Azithromycin)
fever Severe Ceftriaxone
Mild Co-amoxiclav
Gram negative rods Ceftriaxone + Metronidazole Duration of treatment is

Diverticulitis Moderate Or Piperacillin/Tazobactam
Anaerobes based on the clinical
improvement.
Severe Meropenem
17
 Skin & Soft Tissue Infections:
Oral Amoxicillin/Flucloxacillin
Staphylococcus aureus Or Co-amoxiclav Add 1% hydrogen peroxide
Impetigo Group A Streptococcus topically.
If Pen-allergy:
Oral Macrolides
Mild
If Pen-allergy:
Duration: 5-10 days based
Oral Macrolides
Erysipelas Group A Streptococcus on clinical decision.
Staphylococcus aureus IV Amoxicillin/Flucloxacillin
Severe
If Pen-allergy:
IV Clindamycin
Or Cefalexin If MRSA is susceptible, add
Clindamycin in mild cases,
Mild If Pen-allergy: and add Vancomycin or
Oral Clindamycin Or Teicoplanin in severe cases.
Cellulitis Streptococcus species Macrolides
Staphylococcus aureus IV Amoxicillin/Flucloxacillin Duration: 5-10 days based
If severe sepsis, add IV on clinical decision.
Clindamycin Step down to Oral if good
Severe response.
If Pen-allergy: (If MRSA 10-14 days)
IV Clindamycin
Streptococcus species IV Co-amoxiclav
Peri-Orbital (Pre-Septal) Staphylococcus aureus Duration: 14 days
Cellulitis Haemophilus influenza If Pen-allergy: Step down to Oral if good
Anaerobes IV Clindamycin response.
Streptococcus species Cefotaxime Or Ceftrixone Duration: 14 days
Staphylococcus aureus If no improvement within
Orbital Cellulitis Haemophilus influenza If Pen-allergy: 48 hrs, Consider adding IV
Anaerobes Clindamycin Metronidazole Or
Clindamycin.
Streptococcus species Pipracillin/Tazobactam
Staphylococcus aureus Or Ceftriaxone + Clindamycin Surgical debridement is
Necrotizing Fasciitis Anaerobes essential.
Coliforms If Pen-allergy:
Teicoplanin + Clindamycin +
Amikacin
Staphylococcus aureus Co-amoxiclav
Streptococcus species Check immunization status.
Bites Pasteurella multocida If Pen-allergy:
(Human or Animal) Eikanella corrodens Ciprofloxacin + Clindamycin Duration: 5-7 days
Anaerobes Or Metronidazole +
Macrolides
18
 Infective Endocarditis (IE) & Cardiovascular System Infections:

Ampicillin/Sulbactam
Staphylococcus aureus Or Co-Amoxiclav
IE if Native Valve Streptococcus species + Amikacin Duration: 4-6 weeks
Enterococcus species (Amikacin for 2 weeks only)
Gram negative rods If Pen-allergy:
Vancomycin + Amikacin
Early IE if Prosthetic Valve Streptococcus species Vancomycin + Amikacin + Duration: 6 weeks
(<12 months post-surgery) Enterococcus species Rifampin (Amikacin for 2 weeks only)
Gram negative rods
Staphylococcus aureus or Co-Amoxiclav
Late IE if Prosthetic Valve Streptococcus species + Amikacin Duration: 4-6 weeks
(>12 months post-surgery) Enterococcus species (Amikacin for 2 weeks only)
Gram negative rods If Pen-allergy:
Vancomycin + Amikacin
19
 Surgical Site Infections:
 Surgical Wound Classification:

1. Class I / Clean:
This class describes an uninfected operative wound in which no inflammation is encountered and the
respiratory, alimentary, genital or uninfected urinary tract is not entered. Operative incisional wounds that
follow non penetrating trauma should be included in this category if they meet the criteria.
2. Class II / Clean-Contaminated:
This class describes an operative wound in which the respiratory, alimentary, genital or urinary tract is
entered under controlled conditions and without unusual contamination. Specifically, operations involving
the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of
infection or major break in sterile technique is encountered.
3. Class III / Contaminated:
This class contains open, fresh, accidental wounds, as well as operations with major breaks in sterile
technique or gross spillage from the gastrointestinal tract, and incisions in which acute, non-purulent
inflammation is encountered. Open traumatic wounds that are more than 12-24 hours old also fall into this
category.
4. Class IV / Dirty-Infected:
This class describes an incision created during an operation in which the viscera are perforated or when
acute inflammation with pus is encountered during the operation, as well as delayed presentation of
traumatic wounds with existing contaminated and devitalized tissue.
 Surgical Prophylaxis:
 Time of Administration:
Administration of the first dose of antimicrobial beginning within 60 minutes before surgical incision is
recommended. Administration of vancomycin and fluoroquinolones should begin within 120 minutes
before surgical incision because of the prolonged infusion times required for these drugs.
 Antibiotics used According to the procedure:
Type of Procedure First line Alternative for B-lactam allergy

Cardiac
(Coronary artery bypass, Cardiac Cefazolin Or Cefuroxime Clindamycin Or Vancomycin
device insertion procedures)
Clindamycin Or Vancomycin
Gastroduodenal Cefazolin
+ Aminoglycoside
Biliary tract Cefazolin Or Cefoxitin Or

Clindamycin Or Vancomycin
(Open procedure, Laparoscopic Ceftriaxone Or Ampicillin
+ Aminoglycoside
procedure with high risk) /Sulbactam
Clindamycin + Aminoglycoside Or
Fluoroquinolone
Appendectomy for Cefazolin Or Cefoxitin +
Or Metronidazole +
uncomplicated appendicitis Metronidazole
Aminoglycoside Or
Fluoroquinolone
20
Clindamycin + Aminoglycoside
Nonobstructed Cefazolin
Small Or Fluoroquinolone
Intestine Cefazolin + Metronidazole Metronidazole + Aminoglycoside
Obstructed
Or Cefoxitin Or Fluoroquinolone
Clindamycin + Aminoglycoside Or
Cefazolin + Metronidazole Or
Fluoroquinolone
Cefoxitin Or Ampicillin
Colorectal Or Metronidazole +
/Sulbactam Or Ertapenem Or
Aminoglycoside Or
Ceftriaxone + Metronidazole
Fluoroquinolone
Clean with placement
Cefazolin, Cefuroxime Clindamycin
of prosthesis
Head &
Neck Cefazolin + Metronidazole Or
Clean-contaminated Cefuroxime + Metronidazole Clindamycin
Or Ampicillin /Sulbactam
Neurosurgery
(CSF shunt or implantation of Cefazolin Clindamycin Or Vancomycin
intrathecal pumps)
Ophthalmic Topical Neomycin – Polymyxin B – Gramicidin – Moxifloxacin
Orthopedic
(spinal procedures, hip fracture
Cefazolin Clindamycin Or Vancomycin
repair, implantation of internal
fixation, total joint replacement)
Lower tract Cefazolin Or Fluoroquinolone Or
Aminoglycoside +/- Clindamycin
instrumentation Co-trimoxazole
Clean without entry
Cefazolin +/- Aminoglycoside Clindamycin Or Vancomycin
into urinary tract
Implanted Cefazolin +/- Aminoglycoside Clindamycin Or Vancomycin
Urologic prosthesis Or Ampicillin/Sulbactam +/- Aminoglycoside
Clean with entry Fluoroquinolone Or
Cefazolin +/- Aminoglycoside
into urinary tract Aminoglycoside +/- Clindamycin
Fluoroquinolone
Cefazolin + Metronidazole Or
Clean-contaminated Or Aminoglycoside +
Cefoxitin
Metronidazole Or Clindamycin
Vascular Cefazolin Clindamycin Or Vancomycin
Heart, lung, Heart-Lung
Cefazolin Clindamycin Or Vancomycin
Transplantation
Piperacillin/Tazobactam Clindamycin Or Vancomycin +
Liver Transplantation Or Ampicillin/Sulbactam + Aminoglycoside Or
Cefotaxime Flouroquinolone
Cefazolin Or Fluconazole (for Clindamycin Or Vancomycin +
Pancreas, Pancreas-Kidney
patients at high risk of fungal Aminoglycoside Or
Transplantation
infection) Flouroquinolone
Cefazolin Or
Plastic Surgery Clindamycin Or Vancomycin
21
 Re-dosing: Intraoperative re-dosing is needed to ensure adequate serum and tissue concentrations of the
antimicrobial if the duration of the procedure exceeds two half-lives of the antimicrobial or there is
excessive blood loss.
Antimicrobial Dose Re-dosing interval from time
of initial preoperative dose
Ampicillin/Sulbactam 75 mg/kg 2
Cefazolin 30 mg/kg 4
Cefuroxime 50 mg/kg 4
Cefotaxime 50 mg/kg 4
Ceftriaxone 50 mg/kg N/A
Clindamycin 10 mg/kg 6
Gentamicin 2.5 mg/kg N/A
Levofloxacin 10 mg/kg N/A
Metronidazole 15 mg/kg
N/A
(7.5mg/kg in neonates weighting <1.2 kg )
Piperacillin/Tazobactam 2-9 months : 90 mg/kg
2
> 9 months :112.5 mg/kg
Vancomycin 15 mg/kg N/A
 Duration: The duration of antimicrobial prophylaxis should be less than 24 hours for most procedures.
Cardiothoracic procedures for which a prophylaxis duration of up to 48 hours has been accepted without
evidence to support the practice is an area that remains controversial.
 Post-Operative Prophylaxis:
Procedure Antibiotic Notes
Cefazolin Or Amoxacillin/Flucloxacillin If MRSA is a concern, Add
Or Cefuroxime Vancomycin.
Cardiothoracic If Pen-allergy: If Reopened, add 3 doses of

Surgery Clindamycin Vancomycin.
2nd line without sepsis:
Co-amoxiclav + Amikin If Open sternum,
Ceftazidime + Vancomycin
2nd line with sepsis: (continue till closure then for
Piperacillin/Tazobactam 3 more doses after closure)
Or Meropenem
Clean GI Ceftriaxone (Q12 hrs) + Metronidazole Duration: 48 hrs
Surgery surgeries
likely to be UT Ceftriaxone (Q 12 hrs) Duration: 48 hrs
contaminated surgeries
Ceftriaxone (Q12 hrs) + Metronidazole +
Contaminated/dirty Amikacin
Surgery or Peritonitis
2nd line :
Piperacillin/Tazobactam + Vancomycin
22
23
Neonatal & Pediatrics Renal Dose Adjustment for IV Antibiotics
 Glomerular Filtration Rate by Schwartz:
GFR (ml/min/1.73m²) = Muscle Factor * Height (cm)
Serum Creatinine (mg/dl)
Muscle Factor:
Premature infant up to 1 year = 0.33
Term infant up to 1 year = 0.45
Child or adolescent girl = 0.55
Adolescent boy = 0.7
 Serum BUN/Creatinine Ratio:

1. If BUN/SCr> 20:1  Pre-renal Acute Kidney Injury.
2. If BUN/SCr< 15:1  Intrinsic or Post-renal Acute Kidney Injury.
24
Medication Age Normal GFR = 50-30 GFR = 30-10 GFR < 10 PD IHD CRRT
HSV: GFR <10 or
< 30 weeks: 20 mg/kg/dose GFR 25-50 or GFR 10-25 or SCr >1.5 or
Q 8-12 hrs SCr 0.8-1.1: SCr 1.2-1.5: Urine Output <
Neo ≥ 30 weeks: 20 mg/kg/dose Usual dose Q Usual dose Q 24 1 ml/kg/hr:
Q 8 hrs 12 hrs hrs 50% of usual
Zoster Virus: dose Q 24 hrs
Aciclovir 10-15 mg/kg/dose Q 8 hrs
Child 1-2 months:
10-20 mg/kg/dose Q 8 hrs GFR 25-50: GFR 10-25: 50% of usual 5 mg/kg/dose Q 5 mg/kg/dose Q 10 mg/kg/dose
Ped 3 months – 11 years: Usual dose Q Usual dose Q 24 dose Q 24 hrs 24 hrs 24 hrs Q 12 hrs
250-500 mg/m2 Q 8 hrs 12 hrs hrs (after dialysis)
12-17 years:
5-10 mg/kg/dose Q 8 hrs
Postmenstrual age dosing
GA Days Dose Interva
l
0-7 14 48
Amikin Neo ≤ 29 8-28 12 36 Either prolong the interval or reduce the dose
≥29 12 24
30-34 0-7 12 36
≥8 12 24
≥ 35 All 12 24
15-22.5 mg/kg/day Q 8 hrs
Or 5-7.5 mg/kg/dose 5-7.5 mg/kg/dose 5-7.5 mg/kg/dose 5 mg/kg/dose as 5 mg/kg/dose as 7.5 mg/kg/dose
Ped 15-20 mg/kg/day Q 24 hrs Q 12-18 hrs Q 18-24 hrs Q 48-72 hrs indicated by serum indicated by serum Q 12 hrs
(not for endocarditis or conc. conc. Monitor serum
meningitis) conc.
25
150-300 mg/kg/day
GA Days Interval
≤ 29 0-28 12
>28 8
Neo 30-36 0-14 12
Ampicillin/ >14 8
Sulbactam 37-44 0-7 12
>7 8
≥ 45 All 6
Ped 150-300 mg/kg/day Q 6 hrs Normal Dose 50-75 mg/kg/dose 50-75 mg/kg/dose 50-75 mg/kg/dose 50-75 mg/kg/dose 50-75 mg/kg/dose
Q 12 hrs Q 24 hrs Q 24 hrs Q 24 hrs Q 8 hrs
Neo 30 mg/kg/dose Q 12 hrs
30 mg/kg/dose Q
< 40 kg: < 40 kg: 24 hrs (1200 mg
Child 1-2 months: 30 mg/kg/dose Q 30 mg/kg/dose Q if > 40 kg)
Amoxicillin/ Ped 30 mg/kg/dose Q 12 hrs Normal Dose 12 hrs 24 hrs (At the end of
Clav acid Child 3 months-17 years: ≥ 40 kg: ≥ 40 kg: dialysis session,
30 mg/kg/dose (max 1.2gm) 1200 mg LD then 1200 mg LD give an additional
Q 8 hrs 600 mg Q 12 hrs then 600 mg Q dose of 15
24 hrs mg/kg/dose (600
mg if > 40 kg))
0.25 mg/kg/dose once daily If SCr increases > 0.4 mg/dl from baseline during
initially, then inc by 0.25 therapy, hold dose for 2-5 days.
Neo mg/kg increments on each Alternate day dosing is recommended over decreasing
day till reaching therapeutic daily dose in patients experiencing renal toxicity.
Amphotericin dose: (1-1.5 mg/kg/dose Q 48 hrs)
B 1-1.5 mg/kg/dose Q 24 hrs Discontinue if BUN > 40 mg/dl, SCr >3 mg/dl.
If renal dysfunction is due to the drug, decrease the dose
Ped 1-1.5 mg/kg/dose Q 24 hrs by 50% or the dose can be given every other day Normal Dose Normal Dose Normal Dose
(1-1.5 mg/kg/dose Q 48 hrs)
26
Gonococcal:
25 mg/kg/dose Q 12 hrs
Meningitis: < 7 days: 100-
Neo 150 mg/kg/day Q 8-12 hrs
≥ 8 days: 150-200
mg/kg/day Q 6-8 hrs
Cefotaxime Sepsis: 50 mg/kg/dose
GA Days Interval
All weeks <7 12
< 32 ≥7 8
≥ 32 ≥7 6
50 mg/kg/dose Q 8-12 hrs 50 mg/kg/dose Q 50 mg/kg/dose Q 50 mg/kg/dose Q 50 mg/kg/dose Q 50 mg/kg/dose Q 50 mg/kg/dose Q
Ped (inc to Q 6 hrs in severe inf) 8-12 hrs 12 hrs 24 hrs 24 hrs 24 hrs 12 hrs
(Max 12 gm/day)
30 mg/kg/dose
GA Days Interval
≤ 29 0-28 12
>28 8
Neo 30-36 0-14 12
>14 8
37-44 0-7 12
Ceftazidime >7 8
≥ 45 All 8
Meningitis: < 7 days: 100-
150 mg/kg/day Q 8-12 hrs
≥ 8 days: 150 mg/kg/day Q 8
hrs
90-150 mg/kg/day Q 8 hrs
Ped (Max 3 gm/day) 50 mg/kg/dose Q 50 mg/kg/dose Q 50 mg/kg/dose Q 50 mg/kg/dose Q 50 mg/kg/dose Q 50 mg/kg/dose Q
Sever Inf: 200 mg/kg/day 12 hrs 24 hrs 48 hrs 48 hrs 48 hrs 12 hrs
Q 8 hrs (Max 6 gm/day)
27
Sepsis:
Meningitis: Normal Dose Normal Dose Normal Dose Normal Dose
100 mg/kg LD, then 80
mg/kg/dose Q 24 hrs
Gonococcal:
Ceftriaxone 25-50 mg/kg/dose Q 24 hrs
1 mo – 11 yrs (up to 50 kg):
11-17 yrs (≥ 50 kg):
Ped 1-2 gm Q 24 hrs Normal Dose Normal Dose Normal Dose Normal Dose Normal Dose Normal Dose
(Max 4 gm/day)
Severe infection or
meningitis:
25 mg/kg/dose
GA Days Interval
≤ 29 0-28 12
Neo >28 8
30-36 0-14 12
Cefazolin >14 8
37-44 0-7 12
>7 8
≥ 45 All 6
25-100 mg/kg/day Q 8 hrs GFR 40-70: GFR 20-40: GFR 5-20:

(Max 6 gm/day) 60% of usual 25% of usual 10% of usual daily 25 mg/kg/dose Q 25 mg/kg/dose Q 25 mg/kg/dose Q
Ped Severe infection: daily dose Q 12 daily dose Q 12 dose Q 24 hrs 24 hrs 24 hrs 8 hrs
100-150 mg/kg/day Q 6-8 hrs hrs hrs
(Max 12 gm/day)
28
50 mg/kg/dose
Weight Postnatal age Interva
l
Neo <1 ≤ 14 days 12
kg 15-28 days 8-12
Cefuroxime 1-2 ≤ 7 days 12

kg 8-28 days 8-12
>2 ≤ 7 days 12
kg 8-28 days 8
75-100 mg/kg/day Q 8 hrs Normal Dose 25-50 mg/kg/dose 25-50 mg/kg/dose 25-50 mg/kg/dose 25-50 mg/kg/dose 25-50
(Max 1500 mg/dose) Q 12 hrs Q 24 hrs Q 24 hrs Q 24 hrs mg/kg/dose Q 8
Ped Severe infection: hrs
100-200 mg/kg/day Q 6-8 hrs
Term & preterm ≤ 28 days:
Neo Term & preterm > 28 days:
Cefepime 50 mg/kg/dose Q 12 hrs
Severe infection or
meningitis:
50 mg/kg/dose Q 8-12 hrs 50 mg/kg/dose Q 25-50 mg/kg/dose 25-50 mg/kg/dose 50 mg/kg/dose Q 25-50 mg/kg/dose 25-50
Ped (Max 2 gm/dose) 12-24 hrs Q 24 hrs Q 24 hrs 24 hrs Q 24 hrs (After) mg/kg/dose Q 12
(Max 2 gm/dose) (Max 2 gm/dose) (Max 1 gm/dose) (Max 1 gm/dose) hrs
Cipro-
10 mg/kg/dose Q 8 hrs 10-15 mg/kg/dose 10-15 10-15 10-15 10-15
floxacin
Ped (max 400 mg/dose) Normal Dose Q 18 hrs mg/kg/dose Q 24 mg/kg/dose Q 24 mg/kg/dose Q 24 mg/kg/dose Q
hrs hrs hrs 12 hrs
29
5-7.5 mg/kg/dose
GA Days Interval
≤ 29 0-28 12
>28 8
Neo 30-36 0-14 12
>14 8
Clindamycin 37-44 0-7 12
>7 8
≥ 45 All 6
3.75-6.25 mg/kg/dose Q 6 hrs

Ped (inc up to 10 mg/kg/dose Q 6 Normal Dose Normal Dose Normal Dose Normal Dose Normal Dose Normal Dose
hrs in severe infection)
GFR 50-79:
37,500-57,000
IU/kg/dose Q 12
Neo 25,000 – 50,000 IU/kg/dose hrs 45,000 IU/kg/dose
Q 8 hrs GFR 30-49: Q 36 hrs
Colistin 75,000 IU/kg/day
Once or divided
into 2 doses
< 41 kg:
25,000 – 50,000 IU/kg/dose 37,500 37,500 IU/kg/dose 45,000 45,000 75,000
Ped Q 8 hrs IU/kg/dose Q 12 Q 12 hrs IU/kg/dose Q 36 IU/kg/dose Q IU/kg/dose Q
≥ 41 kg: hrs hrs 24-48 hrs 24-48 hrs
9 million IU/day Q 8-12 hrs
30
Prophylaxis:
< 1.5 kg: 3-6 mg/kg/dose Normal LD, then Normal LD, then Normal LD, then 100% of dose 100% of dose 100% of dose
twice weekly for 6 weeks 50% of normal 50% of normal 50% of normal after each after each after each
Neo Treatment: dose with normal dose with normal dose with normal dialysis session, dialysis session, dialysis
LD: 12-25 mg/kg/dose interval interval interval and adjust and adjust session, and
MD: 6-12 mg/kg/dose according to according to adjust
Fluconazole GA Days Interval GFR on non- GFR on non- according to
≤ 29 0-14 48 dialysis days dialysis days GFR on non-
>14 24 dialysis days
≥ 30 0-7 48
>7 24
LD: 6-12 mg/kg/dose 50% of normal 50% of normal 50% of normal 50% of normal 50% of normal LD: 6-10
Ped MD: 3-12 mg/kg/dose Q 24 dose at normal dose at normal dose at normal dose Q 48 hrs dose after 3 hrs of mg/kg/dose Once
hrs interval interval interval session MD: 6-12
max daily dose: 800 mg mg/kg/dose Once
< 7 days:
7-21 days:
>21 days:
Flumox 25 mg/kg/dose Q 6 hrs
(Amoxicillin/ Doses may be doubled in
Flucloxacillin) severe infection
12.5-25 mg/kg/dose (max 1
gm) Q 6 hrs (may be
Ped doubled in severe infection) Normal Dose Normal Dose Normal Dose Q 8 Normal Dose Q 8 Normal Dose Q 8 Normal Dose Q
Meningitis: hrs hrs hrs 8 hrs
50 mg/kg/dose (max 2 gm)
Q 6 hrs
31
GA Days Dose Interval
0-7 5 48
≤29 8-28 4 36
Neo ≥29 4 24
30-34 0-7 4.5 36 Increase the dose interval
Gentamicin ≥8 4 24
≥35 All 4 24
2.5 mg/kg/dose Q 8 hrs
Ped (Once Regimen not for 2.5 mg/kg/dose Q 2.5 mg/kg/dose 2.5 mg/kg/dose Q 2 mg/kg/dose as 2 mg/kg/dose as 2-2.5
endocarditis or meningitis: 12-18hrs Q 18-24 hrs 48-72 hrs indicated by serum indicated by serum mg/kg/dose Q
7.5 mg/kg Q 24 hrs) conc. conc. 12-24 hrs
< 7 days:
20-25 mg/kg/dose Q 12 hrs Use is not recommended in pediatric patients weighing
Imipenem/ Neo 7-28 days: <30 kg with impaired kidney functions
Cilastatin 20-25 mg/kg/dose Q 8 hrs
1-2 mo: 20 mg/kg/dose Q 6 hrs 7-13 mg/kg/dose 7.5-12.5 7.5-12.5 7.5-12.5 7.5-12.5 7-13
Ped 3 months - 18 yrs: Q 8 hrs mg/kg/dose Q 12 mg/kg/dose Q 24 mg/kg/dose Q 24 mg/kg/dose Q 24 mg/kg/dose Q
15 mg/kg/dose (max 500) Q hrs hrs hrs hrs 8 hrs
6 hrs
Neo Not Recommended ____ _____ ______ ____
6 months – 5 years:
8-10 mg/kg/dose Q 12 hrs 5-10 mg/kg/dose 5-10 mg/kg/dose 5-10 mg/kg/dose 5-10 mg/kg/dose 10 mg/kg/dose
Levofloxacin Ped ≥ 5 years: Normal Dose Q 24 hrs Q 48 hrs Q 48 hrs Q 48 hrs Q 24 hrs
(max 750 mg daily)
< 7 days:
Neo 10 mg/kg/dose Q 12 hrs Normal Dose Normal Dose Normal Dose
> 7 days:
Linezolid 10 mg/kg/dose Q 8 hrs
1 month – 12 years:
Ped 10 mg/kg/dose Q 8 hrs Normal Dose Normal Dose Normal Dose 10 mg/kg/dose Q 10 mg/kg/dose Q Normal Dose
12-18 years: 12 hrs 12 hrs
600 mg/dose Q 12 hrs
32
20-40 mg/kg/dose
GA Days Interval
< 32 < 14 12
Neo ≥ 14 8
Meropenem ≥ 32 < 14 8
≥ 14 8
10-20 mg/kg/dose Q 8 hrs Normal dose Q 50% normal 50% normal 50% normal dose 50% normal dose Normal dose Q
Ped Meningitis: 12 hrs dose Q 12 hrs dose Q 24 hrs Q 24 hrs Q 24 hrs 12 hrs
40 mg/kg/dose Q 8 hrs (after Dialysis)
LD 15 mg/kg
MD 7.5 mg/kg/dose
GA Interval
Neo 24-27 24
Metro- 28-33 12
nidazole 34-40 8
≥ 40 6
1-2 mo: LD 15 mg/kg then MD
7.5 mg/kg/dose Q 12 hrs Normal Dose Normal Dose 4 mg/kg/dose Q 4 mg/kg/dose Q 6 4 mg/kg/dose Q Normal Dose
Ped 2 months – 17 years: 6 hrs hrs 6 hrs
100 mg/kg/dose
GA Days Interval
≤29 0-28 12
Neo >28 8
30-36 0-14 12
Piperacillin/ >14 8
Tazobactam 37-44 0-7 12
Ratio 8:1
>7 8
≥ 45 All 8
270-337 mg Tazocin/kg/day 40-56 mg 40-56 mg 40-56 mg 56-85 mg 56-85 mg 40-56 mg
Ped Q 6-8 hrs Tazocin/kg/dose Tazocin/kg/dose Tazocin/kg/dose Tazocin/kg/dose Tazocin/kg/dose Tazocin/kg/dos
(max 4.5 gm/dose Q 6 hrs) Q 6 hrs Q 8 hrs Q 8 hrs Q 12 hrs Q 12 hrs e Q 8 hrs
33
≤ 7 days:
30–60 mg/kg/day Q 12 hrs
Sulperazone Neo > 7 days: Normal Dose Normal Dose Normal Dose Normal Dose
(Cefoperazone/ 30–60 mg/kg/day Q 6-12 hrs
Sulbactam)
Ratio 2:1 (increased to 240 mg/kg/day)
30–60 mg/kg/day (increased
Ped to 240 mg/kg/day) Q 6-12 hrs Normal Dose Normal Dose Normal Dose Normal Dose Normal Dose Normal Dose
Max sulbactam: 80 mg/kg/day
Neonates & Infants < 2
months:
Neo LD: 16 mg/kg/dose for one
dose
MD: 8 mg/kg/dose Q 24 hrs
Teicoplanin 2 months - 12 years: GFR 80-30: Normal regimen on Normal regimen on
LD: 10 mg/kg/dose Q 12 hrs Normal regimen on days 1-4, then: days 1-4, then:
Ped for 3 doses days 1-4, then: 6-10 mg/kg/dose Q 6-10 mg/kg/dose Q
MD: 6-10 mg/kg/dose Q 24 6-10 mg/kg/dose Q 72 hrs 72 hrs
hrs 48 hrs
____ ____ ____ ___ ___ ___
Neo Not Recommended
< 8 yrs:
LD: 1.5-3 mg/kg once
MD: 1-2 mg/kg/dose Q 12
Tigecycline
hrs ( max 50 mg/dose)
Ped If no LD: MD 2 mg/kg/dose Normal Dose Normal Dose Normal Dose Normal Dose Normal Dose Normal Dose
Q 12 hrs (max 50 mg/dose)
8-11 yrs:
1.2-2 mg/kg/dose Q 12 hrs
(max 50 mg/dose)
≥12 yrs:
50 mg/dose Q 12 hrs
34
LD: 20 mg/kg once, then MD:
10-15 mg/kg/dose GA Sr Cr Dose
GA Days Interval < 0.5 15 mg/kg/dose Q 12 hrs
≤29 0-14 18 0.5-0.7 20 mg/kg/dose Q 24 hrs
Neo >14 12 ≤ 28 weeks 0.8-1 15 mg/kg/dose Q 24 hrs
30-36 0-14 12 1.1-1.4 10 mg/kg/dose Q 24 hrs
>14 8 > 1.4 15 mg/kg/dose Q 48 hrs
Vancomycin 37-44 0-7 12 > 0.7 15 mg/kg/dose Q 12 hrs
>7 8 0.7-0.9 20 mg/kg/dose Q 24 hrs
≥ 45 All 6 > 28 weeks 1-1.2 15 mg/kg/dose Q 24 hrs
1.3-1.6 10 mg/kg/dose Q 24 hrs
> 1.6 15 mg/kg/dose Q 48 hrs
10 mg/kg/dose 10 mg/kg/dose 10 mg/kg/dose 10 mg/kg/dose 10 mg/kg/dose 10 mg/kg/dose Q

Ped 45-60 mg/kg/day Q 6-8 hrs Q 12 hrs Q 18-24 hrs Redose according Redose according Redose according 12-24 hrs
to serum conc. to serum conc. to serum conc.
35
(doses up to 24 mg/kg/day
Neo have been used)
(Earlier data describes lower
doses of 4-8 mg/kg/day Q 12
hrs)
< 2 years:
2-11 years:
LD: 9 mg/kg/dose Q 12 hrs
for 2 doses
Voriconazole MD: 8 mg/kg/dose Q 12 hrs
12-14 years: Due to accumulation of the IV vehicle, it is
< 50 kg: recommended to use oral voriconazole unless risk
Ped LD: 9 mg/kg/dose Q 12 hrs benefit justifies the use of IV voriconazole.
for 2 doses If IV therapy is used, closely monitor Sr Cr and change
MD: 4-8 mg/kg/dose Q 12 hrs to oral when possible.
≥ 50 kg:
for 2 doses
MD: 3-4 mg/kg/dose Q 12 hrs
≥ 15 years:
for 2 doses
MD: 3-4 mg/kg/dose Q 12 hrs
36
Hepatic Dose Adjustment for IV Antibiotics
 Child Pugh Classification:

Encephalopathy:
None (1 point)
Grade 1: Altered mood/confusion (2 points)
Grade 2: Inappropriate behavior, impending stupor, somnolence (2 points)
Grade 3: Markedly confused, stuporous but arousable (3 points)
Grade 4: Comatose/unresponsive (3 points)
Ascites:
Absent (1 point)
Slight (2 points)
Moderate (3 points)
Bilirubin:
< 2 mg/dl (1 point)
2-3 mg/dl (2 points)
> 3 mg/dl (3 points)
In Case of Primary Biliary Cirrhosis, Bilirubin point values are sometimes considered
differently:
1-4 mg/dl (1 point)
4-10 mg/dl (2 points)
> 10 points (3 points)
Albumin:
> 3.5 g/dl (1 point)
2.8-3.5 g/dl (2 points)
< 2.8 g/dl (3 points)
Prothrombin time prolongation:
Less than 4 seconds above control/INR < 1.7 (1 point)
4-6 seconds above control/INR 1.7-2.3 (2 points)
More than 6 seconds above control/INR > 2.3 (3 points)
5-6 points: Child class A

7-9 points: Child class B
10-15 points: Child class C
37
Medication Class A Class B Class C
Aciclovir No dose adjustments
Amikacin No dose adjustments
Ampicillin/Sulbactam No dose adjustments
No dose adjustments, Use with caution (Monitor Liver Functions)
Amoxicillin/Clav acid Contraindicated in patients with a history of amoxicillin/clavulanate- associated
hepatic dysfunction
Amphotericin B No dose adjustments
Cefotaxime No dose adjustments
Ceftazidime No dose adjustments, Use with caution in severe impairment
No dose adjustments, Use with caution in severe impairment
Ceftriaxone If concurrent renal and hepatic dysfunction, a reduced maximum daily dose should
be considered
(In adults, maximum daily dose should be ≤ 2,000 mg/day)
Cefazolin No dose adjustments
Cefuroxime No dose adjustments
Cefepime No dose adjustments
Ciprofloxacin No dose adjustments, Use with caution in severe impairment
Clindamycin No dose adjustments, Use with caution in severe impairment
( Monitor Liver Functions if treatment more than 10 days )
Colistin No dose adjustments
Fluconazole No dose adjustments, Use with caution in severe impairment
Flumox Use with caution including those with risk factors for hepatic reactions
Gentamicin No dose adjustments (does not undergo hepatic metabolism)
Imipenem/Cilastatin No dose adjustments
Levofloxacin No dose adjustments (limited hepatic metabolism)
Linezolid No dose adjustments, Use with caution in severe impairment
Meropenem No dose adjustments
Metronidazole No dose adjustments Use with caution
Decrease 50% of the
normal dose
Pipracillin/Tazobactam No dose adjustments
No dose adjustments Decrease 25-50% of the
Sulperazone normal dose
In case of renal and hepatic dysfunction, dose shouldn’t exceed 2 gm/day
Teicoplanin No dose adjustments
Use with caution
Tygacil No dose adjustments Decrease 50% of the
normal dose
Vancomycin No dose adjustments
Use normal loading dose, then half maintenance dose Should only be used if
Voriconazole benefit outweighs risk,
monitor closely for toxicity
38
Antibiotics Data
Age Max. Infusion Passing BBB Notes

Medication Dose Preparation Diluent
Conc. Rate
HSV:
< 30 weeks: 20 mg/kg/dose Q Monitoring Parameters:
8-12 hrs - Urinalysis, BUN, serum
Neo ≥ 30 weeks: 20 mg/kg/dose Q 8 creatinine, urine output, Liver
hrs 500mg/10ml enzymes, CBC.
Zoster Virus: → take the - Monitor for neurotoxicity and
Aciclovir 10-15 mg/kg/dose Q 8 hrs dose then NS - 5 mg/ml 1 hr Pass nephrotoxicity when using high
Child 1-2 months: further D5W dose therapy.
10-20 mg/kg/dose Q 8 hrs dilution - Neutrophil count at least twice
Ped 3 months – 11 years: weekly in neonates receiving 60
250-500 mg/m2 Q 8 hrs mg/kg/day IV.
12-17 years:
Postmenstrual age dosing
GA Days Dose Interval - IV / IM
0-7 14 48 - Can’t be used for asthmatic
≤ 29 8-28 12 36 patient (NA metabisulphite).
Neo ≥29 12 24 500mg/2ml→ Poor
30-34 0-7 12 36 take the dose penetration Monitoring Parameters:
Amikacin ≥8 12 24 then further NS - 5 mg/ml 30-60 into BBB - Urinalysis, urine output, BUN
≥ 35 All 12 24 dilution D5W min even when and serum creatinine.
meninges are - Peak and tough serum amikacin
15-22.5 mg/kg/day Q 8 hrs inflamed concentration be alert to ototoxicity.
Or
Ped 15-20 mg/kg/day Q 24 hrs (not
for endocarditis or meningitis)
39
150-300 mg/kg/day
GA Days Interval
≤ 29 0-28 12
>28 8
Neo 30-36 0-14 12
>14 8 1500mg/10ml
37-44 0-7 12 → take the 15-30 Pass if
Ampicillin/ >7 8 dose then NS 45 mg/ml min inflamed - IV / IM
Sulbactam ≥ 45 All 6 further dilution
Monitoring Parameters:
Mild to Moderate infection: - Renal, hepatic and hematologic
150 mg/kg/day Q 6 hrs (Max functions.
Ped single dose 1500 mg) - Change in bowel frequency.
Severe infection: - Observe for signs and symptoms
300 mg/kg/day Q 6 hrs of anaphylaxis during the first
(preferred to be 225mg/kg/day in dose.
order not to exceed maximum
daily sulbactam dosage
80mg/kg/day)
- Used within 20 min of
Neo 30 mg/kg/dose Q 12 hrs reconstitution.
600mg/10ml - Do not mix with dextrose.
Or NS - 10-20 mg 30 mins Pass if
Amoxacillin/ 1-2 months 1200mg/20ml SWFI amoxacillin/ inflamed Monitoring Parameters:
Clav acid Ped 30 mg/kg/dose Q 12 hrs take the dose ml - Renal, hepatic and hematologic
Child 3 months - 17 years →then further functions.
30 mg/kg/dose (max 1.2gm) Q dilution - Observe for signs and symptoms
8 hrs of anaphylaxis during the first
dose.
40
- Protected from light.
- Flush the line with D5W before the
dose or use separate line.
0.25 mg/kg/dose once daily - If rigors occurred during infusion,
Neo initially, then inc by 0.25 mg/kg Preterm meperidine may be administered.
increments on each day till 0.1 mg/ml neonate:
Pre-medications:
reaching therapeutic dose: 50mg/10ml (In volume variable (40-
Perfalgan + Hydrocortisone 20-30
1-1.5 mg/kg/dose Q 24 hrs SWFI→ take restricted 90% of serum
min before the dose, then bolus
Amphotericin the dose then D5W patients: 0.25 2-6 hrs conc.)
infusion of NS immediately before
B further mg/ml Pediatric
the dose (may reduce drug-induced
dilution through a patients:
nephrotoxicity).
central line) Highly variable
adult: poor Monitoring Parameters:
Ped 1-1.5 mg/kg/dose Q 24 hrs - Hepatic function tests.
- Renal function tests every other day
during dose increases and at least
weekly thereafter.
- CBC, electrolytes, PT and PTT.
Gonococcal:
25 mg/kg/dose Q 12 hrs - IV / IM
Meningitis: - Protect from light.
< 7 days: 100-150 mg/kg/day Q
8-12 hrs Monitoring Parameters:
≥ 8 days: 150-200 mg/kg/day Q 1000mg/10ml - Observe for signs and symptoms of
Neo 6-8 hrs → take the NS - 60 mg/ml 20-60 Pass if anaphylaxis during the first dose.
Cefotaxime Sepsis: 50 mg/kg/dose dose then D5W min inflamed - Monitor infusion rate for
GA Days Interval further dilution extravasation.
All weeks <7 12 - With prolonged therapy: monitor
< 32 ≥7 8 renal, hepatic and hematologic
≥ 32 ≥7 6 function periodically.
50 mg/kg/dose Q 8-12 hrs - Number and type of stools/day
Ped (increase to Q 6 hrs in severe for diarrhea.
inflammation) (Max 12 gm/day)
41
Neo 30 mg/kg/dose
GA Days Interval
≤ 29 0-28 12
>28 8
30-36 0-14 12
>14 8 1000mg/10ml
Ceftazidime 37-44 0-7 12 → take the NS - 40 mg/ml 3-5 min Pass if - IV / IM
>7 8 dose then D5W inflamed or - Protect from light.
≥ 45 All 8 further dilution in high doses
Meningitis: < 7 days: 100-150
mg/kg/day Q 8-12 hrs
≥ 8 days: 150 mg/kg/day Q 8 hrs
Ped 90-150 mg/kg/day Q 8 hrs
(Max 3 gm/day)
Sever Inf: 200 mg/kg/day Q 8 hrs
(Max 6 gm/day)
Sepsis:
50 mg/kg/dose Q 24 hrs 1000mg/10ml 30 min - IV / IM
Neo Meningitis: → take the NS- (60 mins - Don’t mix with any solution
100 mg/kg LD, then 80 dose then D5W 40 mg/ml for Pass containing calcium. Flush the line
mg/kg/dose Q 24 hrs further dilution neonates) between them.
Ceftriaxone Gonococcal:
25-50 mg/kg/dose Q 24 hrs Monitoring Parameters:
1 mo – 11 yrs (up to 50 kg): Full blood count with long
50-80 mg/kg/dose Q 24 hrs treatment
Ped 11-17 yrs (≥ 50 kg): 1-2 gm Q
24 hrs (Max 4 gm/day)
Severe infection or meningitis:
42
25 mg/kg/dose
GA Days Interval - IV / IM
≤ 29 0-28 12 - Protect from light.
>28 8
30-36 0-14 12 Monitoring Parameters:
Neo >14 8 1000mg/10ml CSF - Renal function periodically when
Cefazolin 37-44 0-7 12 → take the NS- 100 mg/ml 10-60 penetration is used with other nephrotic drugs.
>7 8 dose then D5W min poor - Hepatic function tests, CBC,
≥ 45 All 6 further dilution prothrombin time in patient at risk.
- Number and type of stool/day for
Ped 25-100 mg/kg/day Q 8 hrs (Max diarrhea.
6 gm/day) - Monitor for signs of anaphylaxis
Severe infection: during first dose.
(Max 12 gm/day)
50 mg/kg/dose
Weight Postnatal age Interva
l - IV / IM
Neo <1 ≤ 14 days 12 1500mg/10ml
kg 15-28 days 8-12 → take the NS- 100 mg/ml 3-5 Pass Monitoring Parameters:
dose then D5W mins - Renal, hepatic and hematologic
1-2 ≤ 7 days 12 further dilution function.
Cefuroxime kg 8-28 days 8-12 - Prothrombin time.
- Number and type of stool/day for
>2 ≤ 7 days 12 diarrhea.
kg 8-28 days 8 - Monitor for signs of anaphylaxis
during first dose.
75-100 mg/kg/day Q 8 hrs
(Max 1500 mg/dose)
Ped Severe infection:
43
Term & preterm ≤ 28 days:
Neo Term & preterm > 28 days:
50 mg/kg/dose Q 12 hrs 1000mg/10ml NS-
Cefepime Severe infection or meningitis: → take the D5W 40 mg/ml 30 min Pass - IV / IM
50 mg/kg/dose Q 12 hrs dose then
further dilution
Ped 50 mg/kg/dose Q 8-12 hrs

(Max 2 gm/dose)
200mg/20ml→ - Protect from light

Neo 10 mg/kg/dose Q 12 hrs take the dose CSF
then further penetration is Monitoring Parameters:
Ciprofloxacin dilution NS- 2 mg/ml 60 min 10% if - Renal, hepatic and hematopoietic
Or D5W noninflamed function.
10 mg/kg/dose Q 8 hrs 200mg/100ml (14-37% if - Number and type of stool/day for
Ped (max 400 mg/dose) → take the inflamed) diarrhea.
dose
5-7.5 mg/kg/dose
GA Days Interval
≤ 29 0-28 12 10-60 - IV / IM
>28 8 300mg/2ml NS- min - Never administered as Bolus.
Clindamycin Neo 30-36 0-14 12 Or D5W 18 mg/ml (not Doesn’t pass
>14 8 600mg/ml→ exceed Monitoring Parameters:
37-44 0-7 12 take the dose 30mg/ Liver and kidney functions if
>7 8 then further min) treatment exceeds 10 days and in
≥ 45 All 6 dilution neonates.
3.75-6.25 mg/kg/dose Q 6 hrs
Ped (inc up to 10 mg/kg/dose Q 6
hrs in severe infection)
44
- IV / IM
Neo 25,000 – 50,000 IU/kg/dose Q 8 Monitoring Parameters:

hrs -CBC with differential.
1 million < 12 years: -Renal function test and urine output.
IU/10ml→ take NS- 90000 IU/ml 30-60 CSF -Number and type of stool/day foe
Colistin the dose then D5W min penetration is diarrhea.
< 41 kg: further dilution > 12 years: 5%
25,000 – 50,000 IU/kg/dose Q 8 200000 - For Inhalation Therapy: Pre-and
Ped hrs IU/ml post-treatment spirometry and
≥ 41 kg: signs of Bronchospasm.
9 million IU/day Q 8-12 hrs If Bronchospasm occurs in patient
not using a bronchodilator, repeat
test using bronchodilator before
the dose of colistin.
Prophylaxis:
< 1.5 kg: 3-6 mg/kg/dose twice
weekly for 6 weeks 1-2 hrs
(max rate
Neo Treatment: 200mg - Do not refrigerate.
LD: 12-25 mg/kg/dose /hr) - Used immediately. Any unused
MD: 6-12 mg/kg/dose 200mg/100ml infusion should be discarded.
Fluconazole → Administer - 2 mg/ml Doses up Pass
GA Days Interval without further to 8-10 Monitoring Parameters:
≤ 29 0-14 48 dilution mg/kg Liver functions
>14 24 infused
≥ 30 0-7 48 over 2 hrs
>7 24
LD: 6-12 mg/kg/dose

Ped MD: 3-12 mg/kg/dose Q 24 hrs
max daily dose: 800 mg
45
< 7 days: 25 mg/kg/dose Q 12 hrs
7-21 days: 25 mg/kg/dose Q 8 hrs - IV / IM
>21 days: 25 mg/kg/dose Q 6 hrs
Flumox Neo Doses may be doubled in severe 1000mg/10ml Monitoring Parameters:
(Amoxacillin/ infection → take the NS- 30-60 - Liver functions.
Flucloxacillin) 12.5-25 mg/kg/dose (max 1 gm) dose then D5W min - Accumulation of electrolytes can
Q 6 hrs (may be doubled in further dilution occur with high doses.
Ped severe infection) - Risk of kernicterus in jaundiced
Meningitis: 50 mg/kg/dose neonates when high doses given
(max 2 gm) Q 6 hrs parenterally in neonates.
GA Days Dose Interval - IV / IM
0-7 5 48
Monitoring Parameters:
≤29 8-28 4 36
-Urinalysis, urine output, BUN
Neo ≥29 4 24 40 mg/ml→ Minimal
take the dose NS- ˂ 10 mg/ml 30 min penetration and serum creatinine.
30-34 0-7 4.5 36
-Peak and tough serum gentamicin
Gentamicin ≥8 4 24 then further D5W to CSF
concentration.
≥35 All 4 24 dilution
-Hearing test especially for patient
2.5 mg/kg/dose Q 8 hrs. at risk for ototoxicity or who will
Ped (Once Regimen not for be receiving prolonged therapy
endocarditis or meningitis: (>2 weeks)
7.5 mg/kg Q 24 hrs.) -CBC with differential.
< 7 days:
20-25 mg/kg/dose Q 12 hrs Monitoring Parameters:
Neo 7-28 days: - Periodic renal, hepatic and
Imipenem/ 20-25 mg/kg/dose Q 8 hrs 500mg/100ml NS 5 mg/ml 30-60 hematologic function tests.
Cilastatin 1-2 months: → take the min - Bowel movement frequency.
20 mg/kg/dose Q 6 hrs dose - Monitor for signs of anaphylaxis
Ped 3 months-18 years: during first dose.
15 mg/kg/dose (max 500)
Q 6 hrs
46
- Protect from light.
Neo Not Recommended - used undiluted.
- Avoid administration through IV
500mg/100ml NS- 5 mg/ml 60-90 Pass line with a solution containing
Levofloxacin 6 months – 5 years: → take the D5W min multivalent cations.
8-10 mg/kg/dose Q 12 hrs dose
Ped ≥ 5 years: Monitoring Parameters:
10 mg/kg/dose Q 24 hrs - Periodic renal, hepatic and
(max 750 mg daily) hematologic function tests.
- The possibility of crystalluria.
- Signs & symptoms of tendonitis.
< 7 days:
> 7 days: 600mg/300ml 2 mg/ml 30-120 Pass Monitoring Parameters:
Linezolid 10 mg/kg/dose Q 8 hrs → take the mins CBC due to the risk of
1 month – 12 years: dose thrombocytopenia.
Ped 10 mg/kg/dose Q 8 hrs
12-18 years:
600 mg/dose Q 12 hrs
20-40 mg/kg/dose
GA Days Interval
< 32 < 14 12 500mg/10ml
Neo ≥ 14 8 → take the
Meropenem ≥ 32 < 14 8 dose then NS 20 mg/ml 15-30 Pass Monitoring Parameters:
≥ 14 8 further min Liver functions
10-20 mg/kg/dose Q 8 hrs dilution
Ped Meningitis:
47
LD 15 mg/kg - Protect from light.
MD 7.5 mg/kg/dose
GA Interval Monitoring Parameters:
Neo 24-27 24 - CBC with differential at baseline,
28-33 12 during and after prolonged or
34-40 8 500mg/100ml repeated courses of therapy.
Metronidazole ≥ 40 6 → take the 5 mg/ml 20-30 Pass - Liver functions.
dose mins - Observe carefully if neurologic
1-2 mo: LD 15 mg/kg then MD
symptoms occur and consider
discontinuation of therapy.
Ped 2 months – 17 years:
100 mg/kg/dose
GA Days Interval
≤29 0-28 12 Monitoring Parameters:
Neo >28 8 - Serum electrolytes.
30-36 0-14 12 4500mg/45ml - CBC with differential.
Piperacillin/ >14 8 → take the NS - 20-80 mg 30 min Pass if - Periodic renal, hepatic and
Tazobactam 37-44 0-7 12 dose then D5W piperacillin inflamed hematologic function tests.
>7 8 further dilution /ml - Bowel movement frequency.
≥ 45 All 8 - Monitor for signs of anaphylaxis
during first dose.
270-337 mg Tazocin/kg/day Q
Ped 6-8 hrs
(max 4.5 gm/dose Q 6 hrs)
≤ 7 days:
30–60 mg/kg/day Q 12 hrs
Neo > 7 days: 1500mg/10 - IV / IM
Sulperazone 30–60 mg/kg/day Q 6-12 hrs ml→ take the NS - 75 mg/ml 15-60 - Protect from light.
(Cefoperazone/ (increased to 240 mg/kg/day) dose then D5W min - Highly protein bound.
Sulbactam) 30–60 mg/kg/day (increased to further dilution
Ped 240 mg/kg/day) Q 6-12 hrs
Max sulbactam: 80 mg/kg/day
48
Neonates & Infants < 2 - After the first 3 doses, subsequent
months: doses can be given by IM.
Neo LD: 16 mg/kg/dose for one dose 200mg/3ml→ - IV route is preferable.
MD: 8 mg/kg/dose Q 24 hrs take the dose NS- 5-30 Doesn’t pass
Teicoplanin D5W min Monitoring Parameters:
2 months - 12 years: (can be used -Serum concentration after LD.
LD: 10 mg/kg/dose Q 12 hrs for 3 undiluted) - CBC with differential and
Ped doses platelet count.
MD: 6-10 mg/kg/dose Q 24 hrs - Kidney functions, liver functions.
Neo Not Recommended - Reconstituted solution should be

yellow-orange, Discard if not this
Tigecycline < 8 yrs: LD: 1.5-3 mg/kg once 50 mg/5.3ml → 30-60 color.
MD: 1-2 mg/kg/dose Q 12 hrs ( take the dose NS - 1 mg/ml min
max 50 mg/dose) then dilute to a D5W Monitoring Parameters:
If no LD: MD 2 mg/kg/dose Q max conc. of - Hypersensitivity reactions.
Ped 12 hrs (max 50 mg/dose) 1mg/ml - Hepatic function.
8-11 yrs: 1.2-2 mg/kg/dose Q 12 - Coagulation parameters.
hrs (max 50 mg/dose)
≥12 yrs: 50 mg/dose Q 12 hrs
10-15 mg/kg/dose Monitoring Parameters:
GA Days Interval - Periodic testing of auditory
≤29 0-14 18 function may be helpful to minimize
>14 12 500mg/10ml 5 mg/ml risk of ototoxicity.
Vancomycin Neo 30-36 0-14 12 → take the NS - (In volume 90-120 Pass - Blood count, urinalysis, hepatic and
>14 8 dose then D5W restricted min renal function.
37-44 0-7 12 further patients: 10 - Leucocyte count regularly.
>7 8 dilution mg/ml) - When used by inhalation measure
≥ 45 All 6 lung function before and after initial
dose of vancomycin and monitor for
Ped 45-60 mg/kg/day Q 6-8 hrs bronchospasm.
49
12-20 mg/kg/day Q 8-12 hrs (up - Don’t infuse concomitantly into
to 24 mg/kg/day have been used) same line or cannula with other
Neo (Earlier data describes lower drug infusions or TPN.
doses of 4-8 mg/kg/day Q 12 hrs)
< 2 years: 9 mg/kg/dose Q 12 hrs Monitoring Parameters:
2-11 years: 200 mg/19ml 1-2 hrs CSF - Hepatic function (transaminases
LD: 9 mg/kg/dose Q 12 hrs for SWFI → NS - 5 mg/ml (not to concentration and bilirubin) test weekly during
Voriconazole 2 doses take the dose D5W exceed 3 is 50% of first month and monthly during
Ped MD: 8 mg/kg/dose Q 12 hrs then further mg/kg/hr) plasma course of treatment.
12-14 years: dilution concentration - Monitor visual acuity, visual
< 50 kg: LD: 9 mg/kg/dose Q . field and color perception if
12 hrs for 2 doses treatment course continues >28
MD: 4-8 mg/kg/dose Q 12 hrs days phototoxic (higher incidence
≥ 50 kg: LD: 6 mg/kg/dose Q 12 in pediatric patients).
hrs for 2 doses - Serum electrolytes prior to
MD: 3-4 mg/kg/dose Q 12 hrs initiation and during therapy.
≥ 15 years: - Periodic renal function test.
LD: 6 mg/kg/dose Q 12 hrs for - ECG in selected patients.
2 doses - Pancreatic function in patients at
MD: 3-4 mg/kg/dose Q 12 hrs risk for acute pancreatitis.
References:
IDSA Guidelines – NICE Guidelines – NHS Guidelines
Neofax, 2020 - BNF, 2019-2020 - Lexicomp online - Drug Prescribing in Renal Failure, ACP - Medication package insert
Presented by:
Clinical Pharmacist Team, Pediatrics & Gynecology Hospital, Galaa Military Complex
March 2021
50

Antibiotics Booklet 2021

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‫شكر و عرفان‬

‫جزيل الشكر لسيادتكم للدعم و المساندة في اتمام هذا العمل‪.‬‬

‫السيد اللواء طبيب‪ /‬أحمد عبد الرؤوف بالسي‬

‫بالتعاون مع السادة المستشارين و رؤساء األقسام‪:‬‬

‫قسم األمداد الطبي‪:‬‬

‫قسم الصيدلة األكلينيكية‪:‬‬

 Vancomycin Red Man Syndrome:

Restricted Antibiotics Order Form

Condition Organism Suitable Antibiotics Notes

Community Group B streptococci Ampicillin/Sulbactam +

 Neonatal Fungal Prophylaxis:

Fluconazole: 1st line in fungal UTI.

Amphotericin B: 1st line in systemic fungal infections.

≤ 5 years: If viral, no need for AB.

If no risk factors for MDR If onset < 5 days after

Risk factors for MDR

Infection Organisms Suitable Antibiotics Notes

 Feverish Illness in Children:

Infection Organisms Suitable Antibiotics Notes

Consider adding Acyclovir

Infection Organisms Suitable Antibiotics Notes

Infection Organisms Suitable Antibiotics Notes

Duration: 7-10 days

Gram negative rods Ceftriaxone + Metronidazole Duration of treatment is

Infection Organisms Suitable Antibiotics Notes

 Surgical Wound Classification:

 Antibiotics used According to the procedure:

Type of Procedure First line Alternative for B-lactam allergy

Biliary tract Cefazolin Or Cefoxitin Or

Cardiothoracic If Pen-allergy: If Reopened, add 3 doses of

 Serum BUN/Creatinine Ratio:

25-100 mg/kg/day Q 8 hrs GFR 40-70: GFR 20-40: GFR 5-20:

Cefuroxime 1-2 ≤ 7 days 12

3.75-6.25 mg/kg/dose Q 6 hrs

10 mg/kg/dose 10 mg/kg/dose 10 mg/kg/dose 10 mg/kg/dose 10 mg/kg/dose 10 mg/kg/dose Q

 Child Pugh Classification:

5-6 points: Child class A

Age Max. Infusion Passing BBB Notes

Ped 50 mg/kg/dose Q 8-12 hrs

200mg/20ml→ - Protect from light

Neo 25,000 – 50,000 IU/kg/dose Q 8 Monitoring Parameters:

LD: 6-12 mg/kg/dose

Neo Not Recommended - Reconstituted solution should be

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