Antibiotic Guidelines

4th Edition,
2010
Antimicrobial Guidelines
Preface to the Fourth Edition
It gives me great pleasure to present to you the 4th edition of the “AKUH Antimicrobial Consensus Guidelines”. Since its
inception by the Antibiotic Subcommittee (of the Pharmacy and Therapeutics committee), the AKUH antibiotics guidelines have
been welcomed by all healthcare workers involved in caring for patients with infections.
From the last revision about 5 years ago, many changes have occurred in the infectious diseases. We now have newer drugs in our
antimicrobial armamentarium while some older drugs are being phasing out. The bacteria have also evolved and resistance in the
hospital and outside continues to rise sharply. This is especially worrying for the gram negative bacteria for which antibiotic
options are rapidly diminishing and no new drugs are on the horizon. The ESKAPE organisms (Enterococcus, Staphylococcus,
Klebsiella, Acinetobacter, Pseudomonas and Enterobacter) therefore represent a major threat which is likely to get worse unless
Infection Prevention practices and Antimicrobial Stewardship principles are followed.
This edition contains major changes from the previous one to reflect this shift in epidemiology of our pathogens and as a result
most of the empiric antibiotic recommendations have now been updated. We have also incorporated new recommendations from a
number of updated guidelines published in the interim. There are also new sections including those devoted to viral and fungal
infections, antimicrobial spectra and the hospital antibiogram as well as vaccines. Through this, we have tried to keep the
guidelines locally relevant not only for AKUH but also for other tertiary care hospitals in the region and hope that this will
provide readily available quick access to information in order to better treat your patients with infections.
I would like to thank the entire antibiotic subcommittee for their help in designing and reviewing the guidelines. I would also like
especially point out the hard work of Ms. Salwa Ahsan who spearheaded this project and ensured that we were on schedule. I look
forward to hearing your thoughts and suggestions for future guidelines and anticipate your cooperation in helping us streamline
antimicrobial use at AKUH.
Dr S. Faisal Mahmood, Chair Antibiotic Subcommittee
Acknowledgement
We are thankful to all members of the Antibiotic Subcommittee for drafting, reviewing and putting together the “AKUH
Consensus Antibiotic Guidelines”.
We appreciate efforts of the Chairman and members of Pharmacy and Therapeutic Committee to provide constant guidance, input
and finally approving the guidelines.
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Members of Antibiotic Subcommittee
Dr Faisal Mahmood, Chair Antibiotic Subcommittee; Asst. Prof. Infectious Diseases, Department of Medicine
Dr Nawal Salahuddin, Associate Professor Medicine and Chair P & T committee
Dr Farheen Ali, Assistant Professor Infectious Diseases, Department of Medicine
Dr Anita Zaidi, Professor Paediatrics and Paediatric Infectious Diseases/Microbiology
Dr Asad Ali, Assistant Professor Paediatrics and Paediatric Infectious Diseases
Dr Afia Zafar, Professor Clinical Microbiology
Dr Erum Khan, Assistant Professor Clinical Microbiology
Dr Salman Naseem Adil, Associate Professor Heam-Oncology
Dr Tabish Chawla, Assistant Professor General Surgery
Salwa Ahsan, Assistant Manager, Department of Pharmacy Services
Abdul Latif Sheikh, Consultant, Department of Pharmacy Services
Comments or Suggestions?
Please send us your feedback trough email at: drug.information@aku.edu

Or call us on 021-34861504, 1506
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Contents
Preface
Acknowledgement
Members of Antibiotic Subcommittee
Chapter 1: Empiric Antibiotic Regimens
1. Skin, soft tissue, bone/joint infections

2. Central nervous system infections
3. Cardiovascular system infections
4. Gastrointestinal tract infections
5. Genitor-Urinary tract infections
6. Obstetrics/gynecological infection
7. Upper and lower respiratory tract infections
8. Ophthalmic infections
9. Otic Infections
Chapter 2: Surgical Prophylaxis
1. Cardiothoracic surgery
2. Gastrointestinal surgery
3. Obstetrics/Gynaecological surgery
4. Head and neck surgery
5. Orthopaedic surgery
6. Neurosurgery
7. Ophthalmic surgery
8. Urological surgery
9. Plastic surgery
10. Miscellaneous
Chapter 3: Treatment Guidelines and Protocols
1. Febrile Neutropenia
2. Malaria (treatment and prophylaxis)
3. Helicobacter pylori
4. Community Acquired Pneumonia (CAP)
5. Tuberculosis (TB)
6. Management of Urinary Tract Infection
Chapter 4: Treatment of Miscellaneous Infections
Viral infections
Fungal infections and Amphotericin B administration protocol
GI Infestations (Helminths)
Chapter 5: Antimicrobial Coverage & Sensitivity
1. AKUH Antibiogram
2. Antibiotic Spectrum
Chapter 6: Drug Dosing, Pharmacokinetic and Safety
1. Normal adult doses and cost of therapy

2. Pregnancy and lactation status
3. Safety of vaccines in pregnancy and lactation
4. Renal adjusted doses
5. Supplemental doses in dialysis
6. Cerebrospinal Fluid (CSF) penetration of antibiotics
7. Intraventricular doses
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Chapter 7: Antibiotic Utilization Criteria
a. Vancomycin
b. Carbapenem
c. Polymyxin B
d. Piperacillin/Tazobactam
e. Linezolid
Chapter 8: Annexure
1. Carbapenem Interchange Policy
2. IV to Oral Switch Criteria
3. Standard volume of IV antibiotics in children
4. Antimicrobial Eye preparations (commercial and compounded)
5. Topical Antimicrobials (commercial and compounded)
6. Routine Immunization Schedule
7. Catch-up Immunization Schedule
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Chapter 1: Empiric Antibiotic Regimens
All treatments must be reviewed after 48 – 72 hours
Obtain appropriate cultures before starting antibiotics
Important Note: For Infections requiring treatment with carbapenem, please follow the “Carbapenem Interchange
Policy” (page # 50)
Skin and Soft Tissue/ Bone/ Joints Infections

Antibiotic recommended
Indication
First line Alternative
Acute recurrent boil/frunculosis Cloxacillin Amox/Clav
Hidradenitis suppurativa Amox/Clav Clindamycin + Ciprofloxacin
Cellulitis, erysipelas
Cloxacillin Cefazolin or Amox/Clav
(extremities or facial)
Cloxacillin
Acute Osteomylitis (adults) (Add Ciprofloxacin if any suspicion for gram Clindamycin
negative organisms)
Acute Osteomylitis (Paeds) Ceftriaxone + Cloxacillin Amox/Clav
Chronic Osteomylitis Antibiotics based on cultures
Impetigo Cloxacillin Cefazolin or Clindamycin
Diabetic foot ulcer
Amox/Clav Ciprofloxacin + Clindamycin
Non-limb/life threatening
Diabetic foot ulcer
Piperacillin/ Tazobactam Imipenem
Limb/life threatening
(Add Vancomycin, if suspicion for MRSA is high or previously documented colonization)
Necrotizing fasciitis / Gas
Piperacillin/Tazobactam+ Clindamycin -
gangrene
Add Vancomycin if suspected MRSA
Pyomyositis Cloxacillin Cefazolin
Add Metronidazole if anaerobes suspected and Vancomycin if documented MRSA
Infected wound post-operative - (Not involving GI or female GU tract)

Vancomycin if already on a β-
Without sepsis Cloxacillin
lactam antibiotic
Add Vancomycin if suspecting
With sepsis Piperacillin/ Tazobactam
MRSA
Septic arthritis (Paeds) Cloxacillin + Ceftriaxone Clindamycin + Ceftriaxone
Septic Arthritis (adults) Ceftriaxone Amox/Clav
Prosthetic joint, post op or
infection post intra-articular Vancomycin + Ceftriaxone -
injection
Septic bursitis Cefazolin Cloxacillin
Dog/cat/human/rat bite Amox/Clav Clindamycin + Ciprofloxacin
Infected Decubitus/
venous/arterial insufficiency Piperacillin/Tazobactam Imipenem
ulcer with sepsis
Vancomycin if already on a β-
Phlebitis Cloxacillin
lactam antibiotic
Central Nervous System Infection
Indication
First Line Alternative
Meningitis
-
Neonates Meropenem
Children and adults up to 50yrs Ceftriaxone + Vancomycin -
> 50 years Ceftriaxone + Vancomycin Meropenem + Vancomycin
Ventriculitis/meningitis due
Vancomycin + Meropenem ±
to infected VP or Atrial shunt, Post -
Polymyxin B
OP Neurosurgery
Ventriculitis/meningitis due
Vancomycin + Meropenem
to Post-head trauma, CSF leak
Ampicillin+ Chloramphenicol +
Brain abscess Ceftriaxone + Metronidazole
Metronidazole
Acyclovir 10 mg/kg IV q 8 hourly
Herpes encephalitis -
for 14 – 21 days
Rifampin + INH + PZA +
Tuberculous meningitis -
Ethambutol + Dexamethasone
Cryptococcal meningitis (HIV -ve) Amphotericin B 0.6 mg /kg x 4 – 6 weeks
Amphotericin B 0.7 mg/kg x 2 weeks followed by Fluconazole 400
Cryptococcal meningitis (HIV +ve)
mg PO daily for 8-10 weeks
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Cardiovascular System Infections
Indication
First line Alternative
Native valve Endocarditis
ID consult is recommended for Endocarditis
Ampicillin (q4hrly) + Cloxacillin
Empiric while awaiting cultures Ceftriaxone + Gentamicin
(q4hrly) + Gentamicin
Streptococcus species with Ceftriaxone (2 wks) + Gentamicin
Ceftriaxone x 4 weeks
penicillin MIC <0.1 1mg/kg q8hrly (2 wks)
Streptococcus species with
penicillin Pen G (4wks) + Gentamicin (2 wks) -
MIC > 0.1 to < 0.5
Streptococcus species with
penicillin MIC >0.5 or ID consult recommended -
Enterococcus
IV Cloxacillin q4hrly (4-6 wks) +
Cefazolin (4-6wk) +
MSSA aortic/mitral valve Gentamicin 1mg/kg q8hrly (3- 5
Gentamicin (3-5 days)
days)
IV Cloxacillin q4hrly (2 wks)+
MSSA tricuspid valve Cefazolin + Gentamicin
Gentamicin (2 wks)
MRSA Endocarditis Vancomycin (4- 6 wks) Teicoplanin (4- 6 wks)
Ampicillin + Gentamicin (4
Endocarditis due to HACEK Ceftriaxone (4 wks)
wks)
Prosthetic valve Endocarditis
ID and Surgery consult is recommended
Vancomycin + Gentamicin +
Empiric while awaiting cultures -
Rifampicin
Vancomycin + Rifampicin (6 wks)
MRSE or MRSA + -
Gentamicin (2 wks)
Cloxacillin + Rifampicin (6 wk) + Vancomycin + Rifampicin +
MSSE
Gentamicin (2 wks) Gentamicin
Cloxacillin + Rifampicin (6 wk)+ Cefazolin + Rifampicin +
MSSA
Gentamicin (2 wks) Gentamicin
Candida Amphotericin B -
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Gastrointestinal Tract Infections
Indication
Antibiotic associated diarrhea Vancomycin PO (if severely ill
Metronidazole PO/IV
(C. difficile diarrhea/colitis) and failure on Metronidazole)
Neutropenic enterocolitis Piperacillin/Tazobactam +
Imipenem
(typhlitis) Amikacin
Diverticulitis/ Perirectal
Ceftriaxone + Metronidazole Piperacillin/Tazobactam
abscess/ Peritonitis
Piperacillin/Tazobactam +/-
Intra-abdominal sepsis Imipenem
Amikacin
Cholecystitis/ cholangitis
Piperacillin/Tazobactam +/-
/biliary sepsis/ CBD Imipenem
Amikacin
obstruction
SBP (Spontaneous Bacterial
Peritonitis) Ceftriaxone Piperacillin/Tazobactam
(primary/mono-microbial)
Secondary Peritonitis
(polymicrobial) Piperacillin/Tazobactam Cefoperazone/Sulbactam
(post- operative/ perforation)
Ciprofloxacin PO
Bacterial dysentery Cefixime
Amoebic dysentery Metronidazole -
Acute watery diarrhea (not Ciprofloxacin (for severe diarrhea
No antibiotics
cholera) with fever and toxicity)
Ciprofloxacin
Cholera Doxycycline (over age 9 yrs)
Metronidazole (additional
Amoebic liver abscess Metronidazole/Diloxanide therapy -
required for eradication)
Pyogenic liver abscess Ceftriaxone + Metronidazole Amox/Clav
Enteric fever ( Inpatient) Ceftriaxone -
Acute pancreatitis
No Antibiotic Recommended
(Alcoholic/ without necrosis)
Pancreatic abscess/
Infected pseudocyst or Imipenem -
necrosis
Genito-Urinary Tract Infection
Antibiotics Recommended
Indication
Acute uncomplicated UTI
See algorithm (page # 26)
(cystitis-urethritis)
Acute uncomplicated
See algorithm ( page # 26)
pyelonephritis
Complicated UTI/ Catheter
See algorithm (page # 26)
related UTI
Perinephric abscess Piperacillin/Tazobactam Cefoperazone/Sulbactam
Asymptomatic bacteriurea
(treat in pregnancy/pre GU Treat according to culture -
procedure only)
Prostatitis Ciprofloxacin TMP- SMX
Ceftriaxone + Doxycycline
(adults)
Epididmo-orchitis Cefixime + Doxycycline (adults)
Ceftriaxone + Amikacin
(Pediatrics)
Gonorrhea (simultaneous
treatment for non-gonococcal Cefixime single dose Ceftriaxone single dose
infection recommended)
Non-gonococcal /
post gonococcal urethritis/ Doxycycline -
cervicitis
Syphilis Penicillin G -
UroSepsis: Piperacillin/Tazobactam +/-
Imipenem +/-Amikacin
Life threatening sepsis Amikacin
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Obstetrics/Gynaecological Infections
Antibiotic Recommended
Indication
Endometritis/ Clindamycin + Ceftriaxone
septic pelvic phelibitis or Piperacillin/Tazobactam
(post partum) Amox/Clav
Also inform neonatal team if mother has endometritis
PID/ salpingitis/ tubo-ovarian Ceftriaxone + Metronidazole +
Amox/Clav + Doxycycline
abscess Doxycyline
Septic abortion Piperacillin/Tazobactam + Doxycycline Imipenem + Doxycycline
Candida vaginitis Clotrimazole vaginal pessaries Fluconazole 150mg single dose
Upper Respiratory Tract Infections

Antibiotic Recommended
Indication
Acute rhinosinusitis
Usually symptomatic care. No antibiotics needed
(< 10 days)
Acute rhinosinusitis Levofloxacin (in adults) or
Amox/Clav
(> 10 days, or facial pain) Azithromycin
Chronic sinusitis
Amox/Clav Clindamycin
(Symptoms > 3 months)
Nosocomial sinusitis (nasotracheal/ Piperacillin/Tazobactam +/-
Imipenem +/- Vancomycin
nasogastric intubation) Vancomycin
Acute pharyngitis (bacterial)
(exudative or diffuse erythema or Amoxicillin Clarithromycin
petechiae)
Peritonsiller/ tonsiller abscess Amox/Clav Clindamycin
Vincent’s angina (anaerobes) Clindamycin Amox/Clav
Parapharyngeal space infection Amox/Clav Clindamycin
Jugular vein septic phlebitis Amox/Clav Clindamycin
Perimandibular actinomycosis Penicillin G Or Amox/Clav Clindamycin or Chloramphenicol
Parotitis (adults) Cloxacillin Clindamycin
Lower Respiratory Tract Infections
Acute bronchitis
Antibiotics usually not indicated
Tracheo-bronchitis
Paediatric Community Acquired Ampicillin (inpatient)
Ceftriaxone
Pneumonia (non severe) Amoxicillin (outpatient)
Paediatric Community Acquired
Ceftriaxone Cloxacillin + Ceftriaxone
Pneumonia (severe/ICU)
Adult Atypical pneumonia/ CAP
See Algorithm (page number 21)
(non- hospitalized)
Adult Community Acquired
Pneumonia See Algorithm (page number 21)
(Hospitalized, non ICU)
Adult Community Acquired
Pneumonia See Algorithm (page number 21)
(Hospitalized, ICU)
Imipenem
Nosocomial Pneumonia (including
Piperacillin/Tazobactam (Add Polymyxin B if suspicion of
VAP)
MDR Acinetobacter high)
Aspiration Pneumonia
Ceftriaxone + Clindamycin Amox/Clav
(Community Acquired)
Imipenem
Aspiration pneumonia
Piperacillin/Tazobactam (Add Polymyxin B if suspicion of
(>3 days in hospital)
MDR Acinetobacter high)
Lung abscess Amox/Clav Clindamycin
Acute Empyema Amox/Clav Ceftriaxone
Chronic/subacute empyema Treat according to cultures -
Acute bacterial exacerbation
Amox/Clav Levofloxacin
of COPD (severe)/ bronchiectasis
Cystic fibrosis Ciprofloxacin Piperacillin/Tazobactam
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Eye
infections
Orbital cellulitis Ceftriaxone + Clindamycin
Dacryocystitis Amox/Clav; alternate Clindamycin
Endophthalmitis Vancomycin + Ceftriaxone along with intravitreal antibiotics
(hematogenous) (If suspicion of candida infection, systemic and local antifungal agents may be needed)
Cavernous sinus Ceftriaxone + Vancomycin
thrombosis Alternate Imipenem + Vancomycin
Ear
Infections
Indication Initial choice Alternate
Malignant otitis
Pip/Tazo (q6hrly) Imipenem
externa
Otitis media Amoxicillin (80-90 mg/kg/day) Cefpodoxime
Acute mastoiditis Amox/Clav Ceftriaxone
Chronic mastoiditis
(Surgery often Based on cultures -
required)
Acute parotitis Cloxacillin If nosocomial use Vancomycin
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Chapter 2: Surgical Prophylaxis Guidelines
Important Note:
Timing of Antimicrobial Prophylaxis:

1. First dose of Antimicrobial for surgical prophylaxis should be administered within 60 minutes before incision. However if fluoroquinolone
is indicated, the duration recommended is within 120 minutes before incision.
2. When a proximal tourniquet is required, however, the entire antimicrobial dose should be administered before the tourniquet is inflated.
3. Prophylactic antibiotics should preferably be discontinued 24 hrs after the end of surgery
4. Antimicrobial prophylaxis after wound closure is unnecessary
5. Administration should be repeated intraoperatively if the operation is still in progress 2 half-lives after the first dose to ensure adequate
antimicrobial levels until wound closure.
Non-Antimicrobial methods of preventing infection:
Recent data suggest that attention to intraoperative temperature control and supplemental oxygen administration along with aggressive fluid
resuscitation may reduce infection rates. Proper glycemic control before operating is also known to reduce surgical site infections.
Note: If the patient is already on antibiotic, there is no need to initiate a new antibiotic for surgical prophylaxis. However if the dose time is due,
there is a need to administer the due dose before the procedure.
Cardiovascular Surgery
Indications First line Alternate
Alternative: preop Vancomycin/ Clinda if
Cefazolin 1-2 g preop 30 min before surgery
documented allergy to beta lactam, start 30
then Q8 hour x 48 hours)3
Coronary bypass; valve surgery minute before the procedure for 24-48 hrs
Some recommend a 2nd dose at the time of
*Duration up to 72 hrs for high risk surgeries
removal from bypass.
only
Pace maker insertion, defibrillator
Same as above
implant
Peripheral vascular surgery,
vanco2 15 mg/kg or Clinda + gent
Abdominal aorta, and legs or any
or Cephalosporins with groin incision q 12
procedure involving a prosthesis, Cefazolin 1- 2 g preop, q 8 hrly x 3 doses1, 3
hours x 2 doses
including coronary stents and grafts
or Amoxicillin/clavulanic acid
for hemodialysis
Carotid or brachial artery None -
Thoracic surgery
Cefazolin 1-2 g pre op (+/-) 1 g q 8 hours x48 Alternative Vancomycin2 1 g IV pre-op over
Lobectomy, pneumonectomy 1
hours) , 60 min
Gastrointestinal surgery
Alternative Clindamycin 600 mg IV +
Gastric surgery (high risk only) Cefazolin 1- 2 g IV pre-op
Gentamicin 1.7 mg/kg
Alternative; Amox/Clav or Gentamicin 1.7
Biliary tract (high risk only) ERCP Cefazolin 1- 2 g IV pre-op
mg/ kg pre-op and q8 hrly x 3 doses
Bowel preparation +/- Amox/Clav 1.2 g IV q 8 Alternative Metronidazole 1 g IV plus
hours Note: If patient has history of prior Cefazolin 1- 2 G IV (some advocate 3
Colorectal
antibiotic use, then start subsequent doses of parental agent at 8 hours
Piperacillin/Tazobactam 4.5 gm q8hrly interval)
Alternative is Clindamycin 900 mg IV +
Gentamicin 1.7 mg /kg immediately, then q 8
hour
Penetrating trauma abdomen Amox/Clav 1.2 g stat and q8 hour + Gentamicin
(Patients with intestinal perforation should
receive antibiotics for 2 to 5 days; if no bowel
injury, one dose is adequate).
Alternative: Clindamycin 600 IV +
Gentamicin 1.7 mg /kg immediately and then q
8 hour (for perforated gangrenous appendix
Appendicectomy Amox/Clav 1.2g IV
continue antibiotics for 3 to 5 days and for
non-perforated appendix 1 to 4 doses are
adequate).
Laprotomy, lysis of adhesion,
splenectomy, etc. Without GI tract None -
surgery
Important Note:
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In cases of b-lactam allergy, the workgroup recommends the use of one of the following regimens: Clindamycin combined with
Gentamicin, Aztreonam, or Ciprofloxacin; Metronidazole combined with Gentamicin or Ciprofloxacin; or Clindamycin monotherapy. A
single 750-mg dose of Levofloxacin can be substituted for Ciprofloxacin
Gynaecological and Obstetrics Surgery

Alternative is Amox/Clav, Clindamycin, or
Metronidazole IV pre-op, and q 8 hrly x 2 if Doxycycline may be used.
Vaginal and abdominal hysterectomy
needed) (Single dose appears to be as effective as
multiple doses).
Radical hysterectomy Cefazolin 1-2 g pre-op
Alternative is Amox/Clav, Clindamycin, or
Caesarian section (high risk only) Cefazolin IV pre-op, (and q 8 hrly x 2 if needed)
Doxycycline may be used.
Doxycycline 100 mg PO before and 200 mg PO
Abortion (1st trimester, high risk
30 min after or aqueous penicillin G 2 million -
only)
units IV
Alternative: Doxycycline 300-400 mg PO;
Metronidazole 500 mg PO x 3 doses in
Abortion (Second trimester) Cefazolin 1 g IV perioperative period. (For patients with N.
gonorrhea and C. trachomatis, treat STD with
minimal delay in abortion cases)
Hysterosalpingography Doxycycline 200 mg pre-procedure -
Cystocele and rectocele repair None -
Tubal ligation None -
In cases of b-lactam allergy, the workgroup recommends the use of one of the following regimens: clindamycin combined with gentamicin,
aztreonam, or ciprofloxacin; metronidazole combined with gentamicin or ciprofloxacin; or clindamycin monotherapy. A single 750-mg
dose of levofloxacin can be substituted for ciprofloxacin
Head and Neck Surgery

Clean None -
Clean with placement of prosthesis Cefazolin 1 g IV at induction of anesthesia -
Cefazolin 2 g IV at induction of anesthesia and
q 8 hour for 24 hour or Clindamycin 600 mg IV
Clean- contaminated -
at induction of anesthesia and q 8 hour for 24
hour.
Addition of Gentamicin 1.7 mg /kg IV to Clindamycin regimen or of Metronidazole 500 mg q8 hour to Cefazolin regimen is controversial.
Rhinoplasty None
Tonsillectomy +/- adenoidectomy None
Major surgery with entry via oral Clindamycin 600- 900 mg IV +/- Gentamicin Cefazolin 1-2 g IV pre-op and q 8 hour x 2
cavity or pharynx 1.7 mg /kg IV pre-op and q 8 hour for 48 hours doses3 or Amox/Clav
Orthopaedic surgery
Clean* None
*Not involving implantation of foreign material (laminectomy, knee, hand, and foot surgeries, also arthroscopies, carpel tunnel release etc)
Other orthopedic surgeries Cefazolin + Gentamicin
Alternative: Vancomycin 1g IV or
Joint replacement Cefazolin 2 g IV pre-op (+/- second dose)1, 2, 3
Clindamycin 600 mg q 8 hour
Open reduction of fractures/ internal 3
Cefazolin 1 – 2 g IV (+/- 1g q 8 hour x 3 doses) Vancomycin2 1 g IV
fixation
Ciprofloxacin 400 mg q 12 hour + Clindamycin
Vancomycin2 1 g IV q 12 hour or Clindamycin
Compound fracture 600 mg q8hrly for 5- 10 days (consider
600 mg q 8 hour for 5 to 10 days.
switching to PO as per IV to PO switch criteria)
Amputation of the leg Cefazolin 1- 2 g IV within 1 hour Amox/Clav 1.2 g IV
Neurosurgery
Elective craniotomy Cefazolin 1 g IV at induction of anesthesia Vancomycin2 1 g IV over 60 min pre op
CSF fluid shunting Cloxacillin +/- Rifampicin for 1- 2 days Alternative is Vancomycin2
If involving foreign material may use
Spinal surgery None
Cefazolin + Gentamicin
Vascular Surgery
Including including aneurysm repair, Vancomycin with or w/o Gentamicin, or
thromboendarterectomy, and vein Cefazolin Clindamycin if patient has documented beta
bypass) lactum allergy
Miscellaneous
for elective procedures; Ciprofloxacin eye drops Topical [Neomycin-Polymyxin B-
Eye surgery QID preop, For 1 day, then QID post op and Gramicidin] 1-2 drops or Tobramycin 0.3% or
tapered over 1 month Gentamicin 0.3% 2 drops instilled before the
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procedure.
Urologic Surgery (high risk patients only):
Continue agent active in vitro or give single
Prostatectomy Infected urine preoperative dose. Sterilization of urine before -
surgery is preferred.
Prostate biopsy and Dilatation of
None -
ureathera
Plastic Surgery
Skin grafting/flaps Operating in Amox/Clav -
oropharyngeal region
Inguinal hernia repair Cefazolin 1 g IV pre op -
Mastectomy
(Greatest risk with radical
Cefazolin 1 g IV pre op -
mastectomy and axillary node
dissection)
Traumatic wound Amox/Clav or Cefazolin IV q 8 h -
1 Pre- op usually indicates administration with induction of anesthesia. Intra-op often given with long procedures. Optimal duration is usually unclear,
but most studies show a single dose is adequate. With Cefazolin, obese patients should receive 2 g.
2 Vancomycin preferred in hospitals with high rate of wound infections with MRSA/ MRSE and for patients allergic to penicillin and Cephalosporins.
3 Use of more than a single preoperative dose is arbitrary and usually discouraged.
13
Chapter 3; Treatment Guidelines and Protocols
Febrile Neutropenia Guidelines
Empirical Parenteral
Therapy
Imipenem: 500 mg q6h
or
Meropenem: 1 g q8h (See
carbapenem Interchange
policy) or
Piperacillin/Tazobactam:
4.5g q 6h + Aminoglycosides
Vancomycin: 15mg/kg q12h
Empirical Antifungal Therapy

Amphotericin B (0.5-1.5
mg/kg/day)
A general approach to patients with fever and neutropenia without a clinically or microbiologically documented infection.
14
Fever and Neutropenia
Fever: A single oral temperature of greater than 38.3°C (101°F) or 38.0°C (100.4°F)or greater for over 1 hour.
Neutropenia: Absolute neutrophil count less than 500 mcL or less than 1,000 mcL with predicted rapid decline.
Findings Evaluation and Modifications
Initial neutropenic fever Complete history and physical examination with special attention to the mouth, skin, catheter exit site, and
perianal region.
Complete blood count and differential, serum chemistry including liver function tests, MP-ICT, at least
two sets of blood cultures, a urine culture, a chest radiograph and potential sites of infection should be
sampled prior to instituting antibiotics.
Initiate empirical antibiotic therapy promptly.
Persistent neutropenic fever Look for invasive fungal infection.
(4–7 d) Add empirical antifungal therapy in patients not receiving mold-active prophylaxis.
Consider MP x 3 to rule out malaria.
Recurrent neutropenic fever Signs of breakthrough sepsis (e.g., hypotension, rigors, tachypnea, decline in urine output) should prompt
without a source after initial empirical modification of antibacterial regimen.
response to empirical antibiotics Repeat blood cultures and a chest radiograph.
Consider chest CT scan to evaluate for signs of mold infection. If a nodule or infiltrate is present, consider
bronchoscopy or percutaneous biopsy depending on location.
Consider other laboratory tests and imaging studies to investigate fever.
Persistent or recurrent fever Infections are diagnosed infrequently.
without a source after ANC Consider chronic disseminated candidiasis.
recovery
Antibiotic Regimens
The IDSA and the NCCN have published evidence-based guidelines on antibiotic therapy for neutropenic patients with fever.
• The cornerstone of the management of fever in neutropenic hosts is the prompt empirical administration of a broad-spectrum β-lactam antibiotic with
activity against P. aerugionsa.
• The agents recommended are imipenem, and meropenem.
• Piperacillin/Tazobactam is an acceptable alternative but in combination with aminglycosides.
• The addition of an aminoglycoside otherwise, should be limited to patients with hemodynamic instability.
• In neutropenic febrile patients with allergies to β-lactams, Vancomycin plus aztreonam is an acceptable regimen.
• Empirical Vancomycin should be used for specific settings during neutropenia, which include
• clinically apparent, central venous catheter-related infection.
• blood culture positive for a Gram-positive bacterium prior to identification and susceptibility testing.
• known colonization with methicillin-resistant S. aureus (MRSA) or penicillin-resistant Streptococcus pneumonia(PRSP).
• hypotension or septic shock without an identified pathogen.
• prior quinolone prophylaxis.
• severe mucositis.
Empirical Vancomycin should be discontinued after 2 to 3 days if the initial cultures are negative or show a pathogen such as methicillin-susceptible S. aureus for
which other antibiotics can be used.
Modification of the Antibiotic Regimen

Daily evaluation of the patient is essential to search for new findings (tachypnea, tachycardia, hypotension, new skin lesions, pain or tenderness) that may suggest
persistent or breakthrough infection. Antibiotics need to be adjusted depending on positive culture.
Duration of Treatment
The standard recommendation is to continue antibiotics until resolution of neutropenia. If the neutropenia persists, classic studies showed that 7 days of treatment may
not be enough, but 2 weeks may be adequate. In contrast to the neutropenic period, empirical antibiotics can be discontinued after resolution of neutropenia in patients
who are stable with fever without apparent source and negative cultures. If a source of infection is identified, then antibiotic therapy targeted to the specific pathogen(s)
is advised.
Colony-Stimulating Factors (CSF)

CSF may be considered in selected cases of profound neutropenia (absolute neutrophil count less than 100 mcL), uncontrolled primary disease, and in serious
infections, such as pneumonia, hypotension, multiorgan dysfunction, and invasive fungal infection.
Risk Assessment
Multinational Association for Supportive Care in Cancer (MASCC) index is the tool for the stratification of risk for complications in febrile neutropenic patients which
identified the following independent factors;
1. Burden of illness: no or mild symptoms, +5; moderate symptoms, +3.
2. no hypotension, +5.
3. no chronic obstructive pulmonary disease, +4.
4. solid tumor or no previous fungal infection, +4.
5. no dehydration, +3.
6. outpatient status, +3.
7. age < 60 years, +2.
A score of 21 or greater identified low-risk patients with a positive predictive value of 91%, specificity of 68%, and sensitivity of 71%.
Outpatient Management of low-risk Febrile Neutropenic Patients

In adults, Ciprofloxacin plus Amoxicillin/Clavulanate is recommended with inpatient observation for 24 hours. In patients allergic to Penicillin, the NCCN guidelines
recommend substituting Amoxicillin/Clavulanate with Clindamycin.
References
DeVita, Hellman, and Rosenberg's Cancer: Principles & Practice of Oncology, Eighth Edition, 2008.
15
Prevention and treatment of cancer-related infections. NCCN Guidelines 2008. World Wide Web URL: www.nccn.org.
Hughes WT, Armstrong D, Bodey GP, et al. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2002;34:730.
16
Malaria Treatment Guideline
MP: Trophozoites of P.vivax

MPICT: Mixed +ve only
Assess for the presence of any of the following
-Severe anemia -Severe thrombocytopenia -Acute renal failure

-Cerebral malaria -ARDS -Splenic rupture
No Yes
Chloroquine phosphate Treat as severe malaria

(See Figure 3)
Consider MP daily for 72 hours
In 48 hours, MP -ve for trophozoites Consult ID

No
Yes
Complete course of Chloroquine
G6PD Deficient or
Pregnant
No Yes
Primaquine 30 mg ID consult
QD adults and 0.2-0.3
mg/kg/day for children x14 days
17
Figure 2; Malaria Guidelines
MP: Trophozoites of P. falciparum

MPICT: Mixed & Falciparum +ve
Assess for the presence of any of the following
-Prostration -Impaired consciousness/coma -Respiratory distress -Multiple convulsions

-Circulatory shock -Pulmonary edema -ARDS -Abnormal bleeding -Jaundice -Severe anemia
-Acute renal failure -DIC -Acidosis -Hemoglobinuria -Parasitemia >5%
No Yes
Co-Artemether 40/240mg* Treat as severe malaria

(See Figure 3)
Consider MP daily for 72 hours
-Development of signs of severe malaria in the presence

of parasitaemia
-Increase in parasite count in 48 hours Yes
-Less than 75% reduction in parasite count at 72 hours Consult ID
-Any trophozoites after 72 hours with an axillary
temperature of ≥ 37.5 °C
No
Continue Co-Artemether to
complete the course
*complete dose guide Co-Artemether - Treatment of uncomplicated falciparum malaria:

• Adult and Child over 12 years and body weight over 35 kg:
Initially 2 tablets (40/240mg) followed by 5 further doses of 2 tablets each at 8, 24, 36, 48 and 60 hours (total 24 tablets over 60 hours);
• body weight 25–34 kg, initially 1.5 tablets followed by 5 further doses of 1.5 tablets each at 8, 24, 36, 48 and 60 hours (total 18 tablets over 60 hours)
• body weight 15–24 kg, initially 1 tablet followed by 5 further doses of 1 tablet each at 8, 24, 36, 48 and 60 hours (total 12 tablets over 60 hours);
• Child body weight 5–14 kg, initially 1/2 tablet followed by 5 further doses of 1/2 tablet each at 8, 24, 36, 48 and 60 hours (total 6 tablets over 60 hours);
Patient Advice. Take tablets with food; repeat dose if vomiting occurs within 1 hour of administration
18
Figure 3; Malaria Guideline
MP: Trophozoites of P. falciparum or P.vivax

MPICT: Falciparum & /or Mixed +ve
Severe Malaria is defined by the presence of any of the following
-Prostration -Impaired consciousness/coma -Respiratory distress -Multiple convulsions

-Circulatory shock -Pulmonary edema -ARDS -Abnormal bleeding -Jaundice -Severe anemia
-Acute renal failure -DIC -Acidosis -Hemoglobinuria -Parasitemia >5%
Yes
-Support airway, breathing, circulation

-Admit in SCU/ICU
-Consider ID consult
IV Quinine (20mg/kg over 4 hrs, followed by 10mg/kg q8hrs)

+
Clindamycin (900mg IV q8hrs)
For at least 48 hours
Check MP’s daily -Monitor blood glucose every 2-4 hourly Evaluate and monitor for
-Monitor ECG secondary bacterial infections
Development of signs of severe malaria in the presence of

parasitaemia
-Increase in parasite count in 48 hours
-Less than 75% reduction in parasite count at 72 hours Yes ID consult
-Any trophozoites after 72 hours with an axillary temperature
of ≥ 37.5 °C
No
Continue IV for 48 hours then switch to oral therapy;

If <72hrs on Quinine, start Co-Artemether
If >72hrs on Quinine and Clindamycin continue same as oral regimen
for 7 days
19
Helicobacter pylori Treatment Guideline
Indications of Therapy
Treatment is highly recommended: Treatment is advised:
• Duodenal/gastric ulcer or complicated • Functional dyspepsia
peptic ulcer (active or inactive) • GERD (patients requiring long term acid
• MALT lymphoma suppression)
• Atrophic gastritis • NSAIDs use
• Recent resection of gastric cancer
1st line Treatment Options – Adults

Duration
Regimen Eradication rates
[days]
Standard dose PPI b.i.d. (Esomeprazole is q.d.),
7 70–85%
Clarithromycin 500 mg b.i.d., Amoxicillin 1 g b.i.d.
Standard dose PPI b.i.d., Clarithromycin 500 mg b.i.d.,
7 70–85%
Metronidazole 500 mg b.i.d.
Bismuth subsalicylate 525 mg q.i.d. Metronidazole
200 mg q.i.d., Tetracycline 500 mg q.i.d., Ranitidine 150 mg 7 75–90%
b.i.d. or standard dose PPI q.d. to b.i.d.
PPI + Amoxicillin 1 g b.i.d. followed by:
5 days each >90%
PPI, Clarithromycin 500 mg, Tinidazole 500 mg b.i.d.
Salvage therapy (persistent infection)1
Bismuth 2 tablets qid + Metronidazole 200 mg bid +
Tetracycline 500 mg qid + Ranitidine 150 mg bid or standard 7 68%
dose PPI*
Levofloxacin triple therapy
7 87%
PPI*, Amoxicillin 1 g b.i.d., Levofloxacin 500 mg q.d.
1
avoid using antibiotics that were previously utilized
Treatment Options – Paediatric

st Dosage x 7-14 days up to 3
1 line option Medications
weeks
50 mg/kg/day up to 1 gm bid
1 Amoxicillin + Clarithromycin + Omeprazole 15 mg/kg/day up to 0.5 gm bid
1 mg/kg/day up to 20 mg bid
2 Amoxicillin + Metronidazole + Omeprazole 20 mg/kg/day up to 0.5 gm bid
15 mg/kg/day up to 0.5 gm bid
3 Clarithromycin +Metronidazole + Omeprazole 20 mg/kg/day up to 0.5 gm bid
nd Dosage x 7-14 days up to 3
2 line option Medications
weeks
2 tablets qid
Bismuth + Metronidazole + Omeprazole +
4 1 mg/kg/day up to 20 mg bid
Amoxicillin OR Clarithromycin
Note: Omeprazole can be substituted by comparative dose of any other PPI (e.g. Esomeprazole 40 mg qd, Pantoprazole 40 mg bid). Esomeprazole has once a day
dosing.
20
Community Acquired Pneumonia (Adult)
Management
General management
• Oxygen therapy (to maintain PaO2 60 mm Hg and SaO2 92%).
• In patients with pre-existing COPD controlled oxygen therapy is recommended.
• Intravenous fluids in volume depleted patients.
• Early nutritional support should be given in prolonged illness.
Switch to oral Therapy
• Resolution of fever for >24 hours
• Pulse rate <100 beats/min
• Resolution of tachypnea
• Clinically hydrated and taking oral fluids
• Resolution of hypotension
• Absence of hypoxia
• Improving white cell count
• Non-bacteremic infection
• No concerns over gastrointestinal absorption
Duration of antibiotic therapy

Minimum therapy required for CAP should be for 5 days; before discontinuing the therapy patient should be afebrile for 48–72h, and should have at least 1 sign of
clinical stability. Usual duration of therapy is:
1) Non severe pneumonia (microbiologically undefined) 7 - 10 days

2) Severe Pneumonia (microbiologically undefined) 10 – 14 days
3) Legionella, Staphylococcal and 14 – 21 days
Gram negative bacilli infection
REFERENCES:
Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults. Clinical Infectious Diseases
2007; 44:S27–72
British Thoracic Society guidelines for the management of adults with community acquired pneumonia. Thorax 2001; 56 (suppl IV).
American Thoracic Society guidelines for the management of adults with community acquired pneumonia. Am J Respir Crit Care Med 2001; 163: 1730-1754.
Halm EA, Teirstein AS. Management of community acquired pneumonia. N Engl J Med 2002 Dec 19; 347(25): 2039-2045.
File Jr TM. Community acquired pneumonia. Lancet 2003 Dec 13; 362: 1991-2001.
21
Algorithm for Severity assessment and Management of CAP
Consider ‘CURB 65’ clinical adverse prognostic features:

• Age > 65 years
• New mental confusion
2 or more features
• Renal failure : BUN > 30 mg/dl
• Respiratory rate 30/min or more
• Systolic BP ≤90 mm Hg or diastolic BP ≤60 mm Hg
None 1 feature
Consider “pre-existing” Consider “additional”

adverse prognostic features: YES adverse prognostic features:
• Age 60 years or over or • PaO2 ≤ 60mmHg or
• Any coexisting chronic illness (COPD, SaO2 <92% (any FiO2)
Diabetes, CHF, Renal failure) • CXR: bilateral/ multilobar infiltrates
NO
Clinical judgment
Manage as Manage as
Outpatient Manage in Severe CAP in SCU/ICU
Hospital
PO Amox/Clav (2 gm bid) or IV B-lactam (Ceftriaxone 2g QD) Without risk of Pseudomonas

3rd Generation Cephalosporin (Cefpodoxime + IV B-lactam (Ceftriaxone 2 g
200mg bid PO) + Macrolide (Clarithromycin 500 bid) QD) +
Macrolides (Clarithromycin 500 bid/Azithromycin OR only Fluoroquinolone (Levofloxacin
500 mg stat and 250mg QD) or Resp. Fluoroquinolone 750/ day)
Respiratory Fluoroquinolone alone (Levofloxacin 750/day)
(Levofloxacin 750mg/day)
Risk factors for P.aeruginosa: With risk of P. aeruginosa

IV Pip/Tazo (4.5g q6h) or Carbapenem (Imipenem*) + Aminoglycosides +
Structural lung disease (Bronchiectasis),
Resp. Fluoroquinolone (Levofloxacin)
Corticosteroid therapy, Malnutrition, Broad
spectrum antibiotic >7d in past month.
*follow carbapenem interchange policy
22
Treatment Protocol for Tuberculosis
Case Definitions
Classification by site
Pulmonary tuberculosis (PTB)

A case of TB involving the lung parenchyma
Smear-positive PTB case

The presence of one acid fast bacillus (AFB+) in at least one sputum sample
Extrapulmonary tuberculosis (EPTB)

A patient with one bacterial culture positive specimen from an extra-pulmonary site or a patient with histological and or clinical evidence consistent with active extra
pulmonary tuberculosis.
Patient Registration Groups
New Patient
Never had treatment for TB, or has taken anti-TB drugs for less than 1 month.
New patients may have positive or negative bacteriology and may have disease at any anatomical site.
Previously Treated
Has received 1 month or more of anti-TB drugs in the past.
Previously treated patients may have positive or negative bacteriology and may have disease at any anatomical site.
Previously treated patients may have relapsed, defaulted or failed
Relapsed
Patient with positive AFB smear or culture or other newer means of identifying M. tuberculosis who have previously been declared cured or treatment completed (see
below)
Defaulted
A patient who completed at least 1 month of treatment and returns after at least 2 months’ interruption of treatment.
Failure
While on treatment, remains or becomes smear positive again 5 or more months after starting treatment. There may be cases that while smear-negative, remain culture-
positive at the end of treatment
Treatment outcomes
Cure
A patient whose sputum smear or culture was positive at the beginning of the treatment but who was smear- or culture-negative in the last month of treatment and on at
least one previous occasion
Treatment completed
A patient who completed treatment but who does not have a negative sputum smear or culture result in the last month of treatment and on at least one previous occasion
(i.e. testing not available or not done)
Treatment failure
A patient whose sputum smear or culture is positive at 5 months or later during treatment. Also included in this definition are patients found to harbor a multidrug-
resistant (MDR) strain at any point of time during the treatment, whether they are smear-negative or -positive.
Treatment regimens
New patient
2 months of RHEZ followed by 4 months of RH

(6 months total)
Defaulted or relapsed patient
Send sputum/bronchial wash for AFB C/S and start ATT

Consult ID or pulmo for the ATT regimen required.
23
Doses
Normal Doses for Adults and Children
Drug Adults/children Daily dose Available as

Adults (max.) 5 mg/kg (300mg) Tab; 100 mg
Isoniazid
Children (max.) 10-15 g/kg (300mg) Syp.: 50 mg/5ml
Adults (max.) 10 mg/kg (600mg) Tab; 300, 450 mg
Rifampicin
Children (max.) 10-20 mg/kg (600mg) Syp.: 100 mg/5ml
Adults (max.) 20–30 mg/kg (2g) Tab; 500 mg
Pyrazinamide
Children (max.) 15-30 mg/kg (2 g) Syp.:250 mg/5ml
Adults (max.) 15–20 mg/kg (1.6 g) Tab; 400 mg
Ethambutol
Children (max.) 15-20 mg/kg (1 gm) Syp.100 mg/5ml
Pyrazinamide and Ethambutol doses for adults weighing 40–90 kilograms
40-55 kg 56-75 kg 76-90 kg

Pyrazinamide 2 tablets (1g) 3 tablets (1.5g) 4 tablets (2g)
Ethambutol 2 tablets (800 mg) 3 tablets (1200 mg) 4 tablets (1600 mg)
Fixed Dose Combinations (FDCS)
FDCs have the advantage of improving patient compliance. Always calculate dosage according to weight of the patient. Use of separate drugs is advised in case of
weight-dosage discrepancy with FDCs.
Any FDCs with Rifampicin must have a certificate of bioavailability by a WHO recommended reference laboratory.
Initial Phase Continuation Phase

patient body weight (kg) 02 Months 04 Months
RHZE HR
30-39 02 tablets 1.5
40-54 03 Tablets 02 Tablets
55-70 04 Tablets 02 Tablets
(RHZE) R= 150 mg, H= 75mg, Z= 400mg, E= 275.
(HR) H= 150mg, R= 300mg.
Managing Side effects
Side-effects Drug(s) probably responsible Management

Major Stop responsible drug(s) and refer to clinician urgently
Skin rash with or without Streptomycin, Isoniazid,
Stop anti-TB drugs
itching Rifampicin, Pyrazinamide
Deafness (no wax on otoscopy) Streptomycin Stop streptomycin
Dizziness (vertigo and
Streptomycin Stop streptomycin
nystagmus)
Jaundice (other causes Isoniazid, Pyrazinamide,
Stop anti-TB drugs
excluded), hepatitis Rifampicin
Confusion (suspect drug-
induced acute liver failure if Most anti-TB drugs Stop anti-TB drugs
there is jaundice)
Visual impairment (other
Ethambutol Stop Ethambutol
causes excluded)
Shock, purpura, acute renal
Rifampicin Stop Rifampicin
failure
Decreased urine output Streptomycin Stop streptomycin
Minor Continue anti-TB drugs, check drug doses

Give drugs with small meals or just before bedtime, and
advise patient to swallow pills slowly with small sips of
Anorexia, nausea, abdominal Pyrazinamide, Rifampicin,
water. If symptoms persist or worsen, or there is protracted
pain Isoniazid
vomiting or any sign of bleeding, consider the side-effect to
be major and refer.
Aspirin or non-steroidal anti-inflammatory drug, or
Joint pains Pyrazinamide
paracetamol
Burning, numbness or tingling
Isoniazid Pyridoxine 50–75 mg daily (3)
sensation in the hands or feet
Drowsiness Isoniazid Reassurance. Give drugs before bedtime
Reassurance. Patients should be told when starting
Orange/red urine Rifampicin
treatment that this may happen and is normal
Flu syndrome (fever, chills, Intermittent dosing of Change from intermittent to daily Rifampicin
malaise, headache, bone pain) Rifampicin administration (3)
24
Monitoring Pulmonary TB
Treatment monitoring calendar for new patients

Month 1st 2nd 3rd 4th 5th 6th
Start X
End X X
If Next Step
At the end of the 2nd month patient
is sputum smear-negative (true for Continue with the treatment as planned until the end of regimen
vast majority)
• Prolong the initial phase of regimen for a 3rd month
• If at the end of the 3rd month sputum smear negative, continue as
At the end of the 2nd month patient planned
is sputum smear-positive • If at the end of the 3rd month sputum smear positive, start
continuation phase, perform culture and susceptibility tests and
adjust as needed
• Consider case treatment failure
• Do drug susceptibility test
• Re-register patient as treatment failure
At the start of the 5th month patient
• Start retreatment regimen as treatment failure
is sputum smear-positive
• Obtain result of sensitivity test
• Adapt treatment to susceptibility of bacilli and continue with the
treatment
At the start of the 5th month patient
Continue with the treatment as planned until the end of regimen
is sputum smear-negative
At the end of the 6th month patient
Patient is considered cured
is sputum smear-negative
At the end of the 6th month patient Follow the same steps as at the start of 5th month if sputum smear -
is sputum smear-positive positive
Treatment monitoring calendar for defaulted/relapsed patients

Month 1st 2nd 3rd 4th 5th 6th 7th 8th
Start
End X X X
If Next Step
A case is a “treatment failure”,
“treatment after default” and
sputum smear-positive or Obtain the results of sensitivity test
“relapse of TB” and sputum
smear-positive
• Treat according to susceptibility of bacilli
• If susceptibility test is not available:
1. Extend initial phase of treatment with 4 drugs by one
additional month
At the end of the 3rd month
2. Start continuation phase after extended initial phase
patient is sputum smear-positive
• Sensitivity test results show sensitivity to Rifampicin and Isoniazid,
then: continue patient on Re-treatment regimen
• Sensitivity test results show resistance to 2 or 3 drugs employed in
continuation phase, then: refer patient to a centre specialized in
treatment with second-line anti-TB drugs for DR TB treatment
At the end of 5th month patient is sputum smear
• Obtain a specimen for culture and continue patient on same regimen.
negative
th
At the end of 5 month patient is sputum smear • Obtain a specimen for culture and DST and continue patient in same
positive regimen.
At the end of the 8th month • Review the result of culture and DST done at the end of 5th month.
patient is sputum culture-positive • The patient might be drug resistant. Refer to a national specialist
(smear-negative) centre for DR TB treatment/ Empiric MDR TB treatment regimen
At the end of the 8th month patient
Patient is considered cured
is sputum smear and culture - negative
Remember: Never add a single drug if the patient is not responding well to treatment.
Follow-up
Subsequent relapse is rare when patients complete the prescribed course of chemotherapy. They should be told to report for re-examination if symptoms recur.
25
Guidelines for the Management of Urinary Tract Infections (UTIs) for Adults
Definitions:
• Bacteriuria – presence of bacteria in urine.
– Significant bacteriuria - ≥105 bacteria/ml (100,000 CFU/ml).
• In dysuric men ≥103 CFU/ml can be significant.
– Asymptomatic bacteriura – significant bacteriuria without symptoms. Asymptomatic bacteriuria should only be
treated in:
• Pregnant females
• Patients undergoing urologic procedures
• Children with vesico-ureteric reflux
• Pyuria – For a centrifuged specimen >5-10 leucocytes/HPF is abnormal. Pyuria is non-specific i.e., patients with pyuria may
or may not have infection.
Therefore for the diagnosis of a UTI, the presence of symptoms is vital.

A positive urine D/R or urine culture alone does not signify a UTI.
• Uncomplicated UTIs – infection in a structurally and neurologically normal urinary tract (non-pregnant young adult females).
• Complicated UTIs – infection with functional and structural abnormalities (including obstruction, indwelling catheters, and
reflux). Infections in hospitalized patients, immunocompromised patients, men and pregnant women are also considered to be
complicated UTIs.
• Relapse – recurrence of infection with the same organism, usually within 1- 2 weeks of completion of therapy.
• Reinfection – new infection with a different organism, usually >2 weeks after the end of therapy.
26
Algorithm 1 Uncomplicated UTI’s
-Dysuria, urgency, frequency -Fever, flank pain ± lower tract symptoms

-Young non-pregnant female -Young non-pregnant female
- No recent hospitalizations or antibiotics - No recent hospitalizations or antibiotics
No further investigation Urine D/R, Urine C/S, Blood C/S
Nitrofurantoin 100mg PO q12h x 7days

Ceftriaxone 2g IV QD + Amikacin 15mg/kg/day
or
Or
Ciprofloxacin 500mg PO q12h x 3 days
Piperacillin/Tazobactam 4.5g IV q8h
-Once afebrile can switch to oral antibiotic as per C/S reports

to complete 14 days
-If no oral alternative, treat IV for 14 days
Symptoms resolved
No follow up cultures Yes No

required Refer to Algorithm 3
Algorithm 2 Complicated UTI

Fever, flank pain ± lower tract symptoms
plus any one of the following
Male or post menopausal female
Any urological abnormality
Send Urine D/R & C/S, Blood C/S
Assess for sepsis

Two or more of the following
(1) Temperature, >38°C or <36°C; (2) pulse > 90 beats/min; (3) respiratory rate > 20/min or PacO2 < 32 mm Hg;
(4) WBC count >12,000/mm3, <4,000/mm3
Present No
Admit and do imaging Treat as outpatient
Assess for possible resistant organisms

History of any antibiotics or hospitalization in the last 3 months
Yes No
Piperacillin/Tazobactam 4.5g IV q8h Ceftriaxone 2g IV QD

+/- Amikacin 15mg/kg/day + Amikacin 15mg/kg/day
OR Or
Imipenem 500mg q6h Piperacillin/Tazobactam 4.5g IV q8h
Once afebrile can switch to oral antibiotic as per culture and sensitivity report to complete 2-3 weeks
If no oral alternative, treat IV for 2-3 weeks
If relapse or recurrence See Algorithm 3
27
Algorithm 3 Recurrent Infection
Recommend ID consult
Relapse Reinfection
Urine D/R, C/S

Evaluate for structural/functional abnormality,
bacterial prostatitis Frequent
Infrequent
(>3/year)
Treat each episode as a Consult ID

Obstruction No Obstruction Chronic
new infection as per
Prostatitis
algorithm 1 and 2
Surgical Treat for 2 Treat for 6-8

intervention + weeks weeks
Treat for 2-3
weeks
Relapse
Consult ID
28
Chapter 4: Treatment for Miscellaneous Infections
Viral Infections
Infection Therapy
Dengue Fever No antiviral recommended
Crimean-Congo Hemorrhagic Fever Ribavirin 30mg/kg PO loading dose then
15 mg/kg q6h x4 days then
7.5 mg/kg x 6 days
CMV
Retinitis Ganciclovir 5mg/kg IV q12h x 14-21 days
Colitis Ganciclovir 5mg/kg IV q12h x 3-6 weeks
HSV
Bell’s palsy 1) Prednisolone 1mg/kg PO divided twice daily x 5 days then taper to 5mg BD
over next 5 days (10 days total)
2) Valacyclovir 500 mg BD x 5 days
Encephalitis Acyclovir 10mg/kg IV q8h for 14-21 days
Primary genital Acyclovir 400 mg PO TID x7-10 days
herpes OR
Valacyclovir 1g BID x 7-10 days
Genital herpes Acyclovir 800 mg PO TID x 2 days
episodic recurrences OR
(Non-HIV) Acyclovir 400 mg PO TID x 5 days
OR
Valacyclovir 500g BID x 3 days
OR
Valacyclovir 1g once
Genital herpes Acyclovir 400 mg PO TID x 5-10 days
episodic recurrences OR
(HIV) Valacyclovir 1g BID x 5-10 days
Oro-labial (“Fever Acyclovir 400 mg PO TID x 5 days
Blisters”) OR
Valacyclovir 2g BID x 1 day
VZV
Chickenpox- No antiviral treatment
Child (2-12 years)
Chickenpox- Acyclovir 800 mg PO 5 times/day x 5-7 days
adolescent, young OR
adults Valacyclovir 1g TID x 5 days
Chickenpox- Acyclovir 800 mg PO 5 times/day x 5 days
pneumonia or 3rd OR
trimester Acyclovir 10mg/kg IV q8h for 5 days
Chickenpox- Acyclovir 10- 12 mg/kg (500 mg/m2) IV q8h x 7 days
Immunocompromised
host
Zoster- Valacyclovir 1g TID x 7 days
Normal Host OR
Acyclovir 800 mg PO 5 times/day x 7-10 days
Add Prednisolone if patient >50 years at 30 mg PO BID days 1-7, 15 mg BID

days 8-14 and 7.5 mg BID days 15-21
Zoster - Acyclovir 800 mg PO 5 times/day x 7days
Immunocompromised OR
Host (Not severe) Valacyclovir 1g TID x 7 days
Zoster - Acyclovir 10- 12 mg/kg (500 mg/m2) IV q8h x 7 days
Immunocompromised
Host (Severe)
29
Fungal Infections
Infection Therapy (doses for adults unless specified)
Aspergillosis
Allergic Bronchopulmonary Itraconazole 200 mg QD x16 weeks or longer
Aspergillosis (ABPA) Treat asthma attacks with steroids
Amphotericin B* OR OR (for less severe
1- 1.5 mg/kg/day Voriconazole1 disease or continuation
400 mg q12h on day 1 then therapy)
Also see Amphotericin B Weight ≥ 40kg: 200 mg q12h Itraconazole
Invasive aspergillosis administration protocol Weight < 40kg: 100 mg q12h 200 mg q8h for 3 days
1
non formulary then
200 mg q12h
Take with fatty meals and
acidic liquids (cola drinks)
Candidiasis
Fluconazole 800 mg once then 400 mg q24h
Blood stream infection
OR
Non-neutropenic
(in moderate to severe disease) Amphotericin B* 0.5-1 mg/kg q24h
Amphotericin B* 0.5-1 mg/kg q24h
Blood stream infection
OR
Neutropenic
(If no exposure to azoles) Fluconazole 800 mg once then 400 mg q24h
Neonatal Disseminated Amphotericin B* 1 mg/kg q24h
candidiasis
Fluconazole 400 mg q24h
Prophylaxis (during chemotherapy induction and duration of neutropenia as well as SCT for duration of
neutropenia)
Fluconazole 100-200 mg once daily x 2 weeks
OR
Thrush Itraconazole 200 mg q24h on empty stomach x 1 week
OR
Nystatin 500,000 units (5ml) swish and swallow q6h x 2 weeks
Esophageal Candidiasis Fluconazole 200-400 mg once daily x 2-3 weeks
Fluconazole 150 mg single dose
Vaginitis-Sporadic Clotrimazole Pessaries 200 mg x 3 nights or 100 mg x 6 nights
Clotrimazole Vaginal cream 5 gm single dose – may be repeated if required
Vaginitis-Recurrent (≥ 4
Fluconazole 150 mg q12h x 3 doses then 150 mg every week for 6 months
episodes/year)
No treatment unless symptoms of UTI, high risk of dissemination or undergoing urologic
Urinary manipulation
Fluconazole 200mg q24h x7-10 days
Apply topical Clotrimazole, Miconazole or Ketoconazole. OR
Cutaneous
Use PO Ketoconazole 400 mg QD for 2 weeks
Cryptococcus
Non-meningeal, Non AIDS Fluconazole 400 mg q24h x 2- 6 months
Amphotericin B* 0.5-0.8 mg/kg q24h till afebrile and culture negative (approx 6 weeks)
Meningitis, Non AIDS then
Fluconazole 200 mg once a day
Amphotericin B* 0.7 mg/kg q24h x 2 weeks
Non-meningeal or Meningitis-
Then consolidation therapy
AIDS
Fluconazole 400mg q24h to complete 10 weeks or till culture negative
Dermatophytes
Terbinafine 250 mg q24h x 6 weeks OR
Itraconazole 200mg q24 hr x 3 months OR
Onychomycosis
Itraconazole 200mg BID once a week/month x 2 months OR
Fluconazole 150-300 mg once weekly x 3-6 months
Topical antifungals
OR
Tinea corporis, cruris or pedis Terbinafine 250 mg q24h x 2 weeks
OR
Fluconazole 150 mg once weekly x 8-12 weeks
Terbinafine 250 mg q24h x 4 weeks
Tenia capitis Or
Itraconazole
Mucormycosis Amphotericin B* 1.5 mg/kg q24h
*Cumulative total dose of Amphotericin B is 3.6 gm for severe infections
30
Amphotericin B Administration Protocol
S# Amphotericin B Description Comments

0.25-1.5 mg/kg IV Common side effects are fever, chills, hypokalemia,
1. Normal dose
Max. cumulative dose 2-3.6 gm nephrotoxicity, head ache and weight loss.
Dose in renal Increase interval to 48 hrly in ESRD
2. Avoid concomitant use of nephrotoxic drugs
failure (end stage renal disease)
• 1 mg / 20 ml D5W over 20-30 minutes
IV. • Test dose is not mandatory
3. Test dose • Monitor for fever +/- rigors, chills, • Patients exhibiting side effects should be treated
hypotension and anaphylaxis for 4 hrs with pre-medications according to the symptoms
post administration
• Recommended diluent: D5W
0.25 mg/ml is recommended for fluid restricted
4. IV dilution • Concentration: 0.1-0.25 mg/ml
patients and should be administered via central line.
• Duration of infusion: 4-6 hours
Reconstituted solution in WFI 10 ml is stable
for 7 days at 2-8 ◦C
5. Stability • Light protection is not needed
Diluted solutions in D5W are stable for
24hours at room temperature
Paracetamol for fever:
650-1000 mg PO/PR ½ hr before infusion • Pre-medications are not routinely indicated
Hydrocortisone for severe rigors: • Should be given to only those patients
Adults: 25-50 mg IV ½ hr. before infusion experiencing infusion related ADR after test dose
Pre-medications Children: 2.5mg/kg (up to 50mg) IV or 1st dose.
6. (not routinely Ibuprofen or Pethidine: • Tolerance to side effects is developed over time,
indicated) Use for persistent fever and chills despite therefore pre-medications need should be
conventional pre-medications evaluated weekly.
Diphenhydramine or clemastine can also be • Consider withholding pre-medications after
used for infusion related adverse events several days if side effects have resolved
(IRAEs)
7.
Alternate day May double the normal dose and administer • This helps in reducing severe nausea and
dosing every alternate day anorexia
• Do not administer to patients with strict fluid or
sodium restriction
Adults: 250-500 ml NS 0.9% pre and post • This method helps to reduce the nephrotoxicity of
administration of Amphotericin B the drug
8. Saline loading • If azotemia of 3mg/dl occurs, dose of
Children: Correct Fluid or serum sodium Amphotericin B should be reduced and risk vs
level disturbances benefit ratio should be assessed regarding
continued use.
• Avoid concomitant use of nephrotoxic drugs
Reference:
• Recommendations for the administration and dosing of the Amphotericin B – University of Pennsylvania Medical Center Guidelines for Antibiotic Use
• Pretreatment regimens for adverse events related to infusion of Amphotericin B; Clin Infect Dis, vol 20, iss 4, p 755-61, 1995
• Introduction to antifungal drugs; Clin Infect Dis, vol 30, iss 7, 2000
• AJHP; #7, vol 49, iss 5, 1992
• The Sanford Guide to Antimicrobial Therapy 2008
31
Parasitic Infections
Protozoa – Intestinal
Blastocystis hominis No treatment required Metronidazole PO 800 mg tid
Metronidazole PO 500mg-800 mg tid x 10 days
Dientamoeba fragilis -
(30 mg/kg/day in children)
Entamoeba histolytica; amebiasis
Asymptomatic cyst passer Diloxanide furoate 500 mg tid x 10 days -
Metronidazole PO 500mg-800 mg tid +
Mild diarrhea/dysentery, PO Rx possible -
Diloxanide furoate 500 mg tid x 10 days
Metronidazole IV or PO 800 mg tid x 7 days,
Severe or extraintestinal disease, hepatic
followed by Metronidazole 400 mg + Diloxanide -
abscess
furoate 500mg PO tid x 7 days
Giardia lamblia; Giardiasis Metronidazole PO 500mg-800 mg tid x 5 days -
Protozoa – Extraintestinal
Malaria See Algorithm (page number 17)
Amebic meningoencephalitis
Amphotericin B 1.5 mg/kg/ d ay q12h for 3 days
then 1 mg/kg/day IV +
1.5 mg given Intrathecal for 2 days then 1 mg/d
Naegleria fowleri every other day intrathecal for 8 days + -
Azithromycin 10mg/kg once daily +
Rifampicin 10mg/kg q24hr+
Fluconazole 800 mg q24 hours
Leishmeniasis
Amphotericin B 1 mg/ kg /d IV for 21
Antimony (Meglumine antimonite or
Visceral – Kala Azar days
Stibogluconate) 20 mg/kg in 2 divided doses
Miltifosine* 50 mg PO BID for 21 days
IV/IM x 28 days
(not in pregnant)
Warning: Avoid combining Amphotericin and Antimony compounds
Cutaneous (most resolve spontaneously) Fluconazole 200 mg QD PO for 6 weeks Antimony as for visceral
Pneumocystis jiroveci pneumonia (PCP)
Clindamycin 300-450 PO q6hrly +
Not acutely ill (PO Rx possible) TMP/SMX-DS 2 tabs q8hrly x 21 days Primaquine 15 mg base PO QD x 21
days
TMP/SMX at 15mg/kg/day of TMP component
Acutely ill (PO Rx not possible, PaO2 < 70 divided q6-8h with Prednisolone 40 mg BID x5
mmHg) days, 40 mg qd x5 days and then 20 mg qd x11
days
Nematodes – Intestinal
Mebendazole 100 mg bid x 3 days or
Ascariasis Albendazole 400 mg x 1 dose
500 mg x 1 dose
Albendazole 400 x 1 dose, repeat in 2 weeks or Pyrantal pamoate 11mg/kg (max 1 gm) x
Pinworm
Mebendazole 100 mg x1 dose repeat in 2 weeks 1 dose repeat every 2 weeks x 2
Albendazole 400 x 1 dose or Mebendazole 100 Pyrantal pamoate 11mg/kg (max 1 gm) x
Hookworm
mg bid x 3 days 3 days
Strongyloidiosis Albendazole 400 mg bid x 2 days (max 10 days)
Whipworm Albendazole 400 mg QD x 3 days Mebendazole 100 mg bid x 3 days
Cestodes (Tapeworm)
Albendazole <60kg: 15 mg/kg/day q12h
Systemic (Echinococcus) >60kg: 400 mg q12h PAIR procedure recommended
Use for 28 days
Niclosamide* 500 mg qd x 3 days for
Intestinal Niclosamide (non formulary) 2 gm x 1 dose
H.nana
Ectoparasites
Benzyl benzoate lotion; apply for 24 hours and
Pediculosis (head lice) then wash. Note: children may require dilution of -
lotion prior to administration
Permethrin 5% cream; apply on entire skin from
chin to toe, leave on 8-10 hours, and repeat in 1
Benzyl benzoate lotion; apply and leave
Scabies week.
for 24 hours, may repeat after 2 days.
Note: safety not established less than 2 months of
age.
*nonformulary
32
Chapter 5: Antibiotic Coverage & Sensitivity
Antibiogram (July to December 2009)

AKUH Inpatient Percent Resistance
Organism AMP ATM CEF CXM CRO CAZ TZP MEM AMK GEN OFX/CIP SXT
Acinetobacter group NT 14 NT NT 86 88 85 88 85 87 21 86
E. coli 92 78 78 78 78 NT 16 2 6 47 73 81
Enterobacter species 98 74 74 74 74 NT 9 0 14 52 26 58
Klebsiella pneumoniae 100 75 75 75 75 NT 10 3 16 50 60 69
Pseudomonas aeruginosa NT 26 NT NT NT 30 19 47 24 29 38 NT
Proteus mirabilis 33 44 44 44 44 NT 0 0 8 42 17 42
AMP CLR CLOX FD PEN ERY CLI SXT TET VAN GEN OFX/CIP
Enterococcus species 58 10 NT NT NT NT NT NT 71 30 52 70
Staphylococcus aureus NT 4 48 13 99 49 45 24 63 0 43 49
Coagulase negative
NT 12 74 66 93 82 51 68 39 0 59 58
Staphylococci
AKUH All Patients Percent Resistance

Organism AMP CLR CEF CRO ERY OFX.CIP SXT TET NA
Aeromonas hydrophila 100 NT 7 7 NT 10 21 NT NT
Campylobacter species 47 NT NT NT 3 55 NT 26 NT
Salmonella typhi, para A,B & C 45 45 0 0 NT 49 46 NT NT
Salmonella spp. 21 5 7 7 NT 35 47 NT NT
Shigella 59 42 8 8 NT 12 90 NT 39
Vibrio cholerae 16 1 NT NT NT 0 70 1 NT
AMP CLR PEN CRO ERY OFX/CIP SXT TET
Haemophilus influenzae 1 6 NT 0 NT 6 71 18
Moraxella catarrhalis 70 5 NT NT 3 8 35 3
Neisseria gonorrhoea NT NT 89 0 NT 91 NT 75
CLI PEN CLR ERY SXT VAN OFX.CIP TET
Beta haemolytic strep. A 27 0 14 31 NT 0 NT NT
Streptococcus pneumoniae NT 1 11 25 78 0 8 49
Abbreviations
NT - Not Tested
AMK - Amikacin
AMP - Ampicillin
ATM - Aztreonam
CAZ - Ceftazidime
CEF - Cefixime
CLI - Clindamycin
CLOX - Cloxacillin
CLR -Chloramphenicol
CTX - Cefotaxime
CRO - Ceftriaxone
CXM - Cefuroxime
EYR - Erythromycin
FD - Fusidic acid
GEN - Gentamicin
MEM - Meropenem
NA - Nalidixic acid
INH - Isoniazid
OFX/CIP - Ofloxacin/Ciprofloxacin
P - Penicillin
SXT - Cotrimoxazole
TET - Tetracycline
VAN - Vancomycin
33
The following tables provide the antibiotic spectrum of selected antibiotics to some commonly encountered pathogens.
When deciding on an antibiotic, please also refer to the AKUH Antibiogram (page 32) which provides the susceptibility patterns of pathogens
isolated at AKUH over the last 1 year.
Black boxes refer to the preferred agent. Empty square denotes lack of data.
Gram Positives
β-lactam drugs and quinolones
Ciprofloxacin
Levofloxacin
Cefoperazone-
Cefpodoxime
Cefotaxime/
Ceftazidime
Meropenem
Cefuroxime
Ceftriaxone
Amox/Clav
Imipenem /
Cloxacillin
Aztreonam
Ertapenem
Ampicillin
sulbactam
Cefazolin
Cefepime
Penicillin
Cefixime
Pip-Tazo
Strept grp A,B,C,G + + + + + + + - + + + + + + + + ± +
S. pneumo + + + + + + + - - + + ± + ± + ± +
S. viridans ± ± ± ± + + + - + + + + - + ± + - +
Enterococcus (not VRE) ± - + + + + + - - - - - - - - - ± -
VRE - - - - - - - - - - - - - - - - ± -
MSSA - + - + + + + - + + + + - + ± + + +
MRSA - - - - - - - - - - - - - - - - - -
Coag negative staph - ± - ± ± ± ± - ± ± ± ± - ± ± ± ± ±
Listeria + - + + + + ± - - - - - - - - - + +
Chlamydia - - - - - - - - - - - - - - - - + +
Mycoplasma - - - - - - - - - - - - - - - - + +
Legionella - - - - - - - - - - - - - - - - + +
Bacteroides fragilis - - - + + + + - - - - + - - - - - -
Clostridium difficile - - - - - - - - - - - - - - - - - -
Clostridium (not difficille) + - + + + + + - + + + + + - ± +
Peptostreptococcus + - + + + + + - + + + + + + + + ± +
Gram Positives
Non β-lactam drugs
Chloramphenicol
Clarithromycin
Metronidazole
Nitrofurantoin
Erythromycin
Azithromycin
Clindamycin
Doxycycline
Vancomycin
Fusidic acid
Teicoplanin
Fosfomycin
Tigecycline
Gentamicin
TMP-SMX
Polymyxin
Amikacin/
Linezolid
Strept grp A,B,C,G - + + ± ± ± ± + + + ± - - - + -

S. pneumo - + + + + + + + + + ± + - - + -
Enterococcus (not VRE) Syn* + - - - - - + + + + - + + - + -
VRE Syn + - - - - - + - ± ± - + + - + -
MSSA Syn ± + ± + + ± + + + + + + - + -
MRSA Syn ± ± ± ± ± ± + + + + + + - + -
Coag negative staph Syn - ± ± ± ± ± + + + + + + - + -
Listeria Syn + + + + + + + + + - - + -
Chlamydia - + - + + + + + - - - - - - - -
Mycoplasma - + - + + + + + - - - - - - - -
Legionella - - + + + + + - - - - - - - -
Bacteroides fragilis - + + - - - ± + - - - - - + - -
Clostridium difficile - - - - - - - - + + - - - - + - -
Clostridium (not difficille) - + ± + + + + + + + - - + + -
34
Peptostreptococcus - + + ± + ± + + + + + - - + + -
*Syn = Synergy with Beta Lactams and Vancomycin

Gram negatives
β-lactam drugs and Quinolones
Ciprofloxacin
Cefpodoxime
Cefperazone-
Levofloxacin
Cefotaxime/
Ceftazidime
Meropenem
Cefuroxime
Ceftriaxone
Amox/Clav
Imipenem /
Cloxacillin
Aztreonam
Ertapenem
Ampicillin
sulbactam
Cefazolin
Cefepime
Penicillin
Cefixime
Pip/Tazo
N. gonorrhoeae - - - - + + + - + ± + ± + + + - -
N. meningitidis + - + + + + + + - + + ± + ± - -
E.coli - - ± + + + + + + + + + + + + + + +
Klebsiella - - - + + + + + - + + + + + + + + +
Enterobacter - - - - + + + + - ± + + + + + + + +
ESBL + GNR - - - + + + + - - - - + - - - - + +
Salmonella - - + + + + + + + + + + + +
Shigella - - + + + + + + + + + + + + + +
Acinetobacter - - - - + + - - - - - + ± ± - - ± ±
Pseudomonas aeruginosa - - - - + + - + - - - ± + + - - + ±
B. cepacia - - - - + - - - - - - + ± - - - -
S. maltophilia - - - - ± - - - - - - - ± - - - - -
Gram negatives
Non β-lactam drugs
Chloramphenicol
Clarithromycin
Metronidazole
Nitrofurantoin
Erythromycin
Azithromycin
Clindamycin
Doxycycline
Vancomycin
Fusidic acid
Teicoplanin
Fosfomycin
Tigecycline
TMP-SMX
Polymyxin
Amikacin
Linezolid
N. gonnorhea - + - ± ± ± ± + - - + ± + + - - -
N. meinigitidis - + - + + + - - + + - - -
E.coli + + - - - - + + - - - + + + - - +
Klebsiella + ± - - - - + + - - - + + + - - +
Enterobacter + - - - - - + + - - - + + + - - +
ESBL + GNR + ± - - - - + + - - - + + + - - +
Salmonella + - - + - ± + - - - + - - - -
Shigella - + - - + - ± + - - - + - - - -
Acinetobacter ± - - - - - - ± - - - - - - - - +
Pseudomonas aeruginosa + - - - - - - - - - - - - - - - +
B. cepacia - + - - - - - ± - - - - - - - - -
S. maltophilia - + - - - - - + - - - + - - - - ±
35
Chapter 6: Drug Dosing, Pharmacokinetics and Safety
Adult Normal Doses and Antimicrobial drug Cost
Cost/Day Cost/Day
Drug Dose Range Strength (Rs) (Rs) Common Adverse Effects
Oral Parenteral
300-750mg q8hrs IV
250 mg, 500 mg IV
Acyclovir 800 mg q5times a day 1400 2568-5286 Dryness, Scaling, Nephrotoxicity
200 mg Tablet
PO
200 mg tab
Albendazole 400 mg stat 18-20 - Abdominal pain, Nausea, Vomiting, Headache
200 mg/5ml Susp.
Amikacin 750-1000mg q24hrs 250 mg, 500 mg - 229-379 Nephrotoxicity, Ototoxicity, Tinnitus, Drug fever.
Ampicillin 1-2g q6hrs 250 mg, 500 mg - 417-709 Rashes, Nausea, Vomiting, Diarrhea.
Chills, Fever, Headache, Rash, Nephrotoxicity, Weight
Amphotericin B 25- 75mg q24hrs 50 mg/vial - 335-670
loss, Hypokalemia.
600mg, 1.2 gm (IV) -
1.2g q8hrs IV 625 mg, 375 mg, 37.5-60
Amox/Clav 375-625 mg TID (PO) 1 gm (tablet) 52 618 Diarrhea, Abdominal discomfort, Rashes, Urticaria.
Or 1 gm q12hrly 125mg/5 ml, 65/bot
250 mg/5 ml (Susp.) 100/bot
200mg/5ml 223/- Abdominal pain, Diarrhea, Nausea and vomiting,
Azithromycin 250-500 mg q24h -
250 mg cap 33.17/- Headache
Aztreonam 1-2g q8hrs 500 mg, 1000 mg - 1098- 2103 Rash, Headache, Confusion.
Cefepime 1-2g q12hrs 1000 mg - 1148-2200 Fever, Headache, Nausea.
Cefotaxime 1-2g q8hrs 250 mg, 1000 mg - 840-1740 Rash, Pruritis, Colitis.
200 mg tab 30/ tab Diarrhea, abdominal pain, nausea, vomiting, skin
Cefpodoxime 200-400 mg per day -
40 mg/5 ml syrup 175/bot eruptions, eosinophilia, dermalmycosis and urticaria.
Diarrhea, Neuromuscular excitability, Steven-Johnson
Ceftazidime 1-2g q8hrs 1000 mg - 927-1710
Syndrome.
Ceftriaxone 1-2g q24hrs 1000 mg - 433-773 Headache, leucopoenia.
1000 mg IV Aplastic anemia, Bone marrow suppression, Gray baby
Chloramphenicol 0.5-1 g q6hrs 16-32 308
250 mg cap. Syndrome.
200 mg IV
Ciprofloxacin 200-400mg q12hrs 26-45 240-480 Restlessness, Rash
250mg, 500 mg tab.
500 mg IV,
Clarithromycin 500mg q12hrs 250 mg, 500 mg Tab, 130-314 160 Headache, Rash, Diarrhea, Abnormal taste, Heartburn.
125mg/5 ml Susp.
600mg q8hrs IV 300 mg, 600 mg IV
Clindamycin 63-96 675 Diarrhea, Rash, Colitis, anemia, hepatotoxicity.
300-450 mg q8hrs PO 150mg, 300 mg cap.
250 mg IV and Cap
Cloxacillin 250-500mg q6hrs 20-25 376 Diarrhea, Abdominal pain, Allergic reactions.
125 mg/5 ml Susp.
Doxycycline 200mg q24hrs 100 mg cap. 11 - Discoloration of teeth in children, Esophagitis, Diarrhea.
250 mg, 500 mg tab 22-44 Abdominal pain, Cramping, Nausea Vomiting, Oral
Erythromycin 0.5-1g q6hrs 236
200 mg/5 ml Susp. 37 candidiasis, Phlebitis at Inj. Site, Cholestatic jaundice.
100 mg IV
Fluconazole 100-200mg q24hrs 50mg, 150 mg, 200 240-609 487-974 Headache, Rash, Abdominal pain, Dizziness.
mg Cap.
500 mg IV
Fusidic Acid 500mg q8hrs 451 2001 Skin rash, Pruritis, Nausea, Thrombophlebitis.
250 mg tab.
44-88
Gentamicin 160-320mg q24hrs 20 mg, 80 mg IV - Neurotoxicity, Ototoxicity, Nephrotoxicity, edema.
129
Erythema multiforme, Stevens-Johnson syndrome, Toxic
epidermal necrolysis, Agranulocytosis, Leukopenia (rare),
Imipenem 500 mg q6hrly 500 mg IV - 3572
Neutropenia, Seizure, Most commonly in patients with CNS
disorders
100 mg tablet, 0.5-1 Nausea, Vomiting, Loss of appetite, Weakness, Peripheral
Isoniazid 300mg q24hrs 1-60
50 mg/5ml Susp. 18 Neuropathy, Jaundice.
500 mg IV,
Levofloxacin 500mg q24hrs 84-95 175 Seizures, hypersensitivity reaction, diarrhea
250 mg, 500 mg tab.
Reversible myelosuppression, lactic acidosis, peripheral
Linezolid 600 mg q12h 600 mg tab 356 -
or optic neuropathy
100 mg tablet, 4
Mebendazole 100 mg stat - Headache, Abdominal pain, Dizziness, fever
20 mg/ml Susp. 30
Meropenem 1-2g q8h 500 mg, 1000 mg IV - 6135 -12135 See Imipenem
Metronidazole 500mg q8hrs 500 mg IV, 3-4 201 Dizziness, Headache, metallic taste.
36
200 mg, 400 mg tab.
200mg/5 ml Susp.
Headache, Insomnia, Dizziness, Fatigue, Pyrexia, Pain,
Ofloxacin 200-400mg q12hrs 200 mg IV and Tab. 60-120 261-1044
Rash.
2-4 million unit Convulsions, Hemolytic Anemia, Positive Coomb's
Penicillin G 1 Million Units - 248-414
q4-6hrs Reaction, Interstitial nephritis
Piperacillin/ Diarrhea, Hypertension, Insomnia, Headache, Rash,
4.5g q8hrs 4.5 gm - 2019
Tazobactam Rhinitis.
1 million unit-2.5 Neurotoxicity (Irritability, Drowsiness, Ataxia, Numbness
Polymyxin B million unit per day AKUH compounded - 1150-1725 of extremities, and Blurring of vision), Nephrotoxicity,
divided by l2hrs1 Respiratory arrest, Neuromuscular blockade.
250 mg tablet 9-36 Stomach cramps, nausea, or vomiting, Diarrhea, Headache,
Pyrantal pamoate 250-1000 mg stat -
50 mg/ml Susp. 24 dizziness, Trouble sleeping
300 mg, 450 mg tab, 7-9 Flushing, Confusion, Hemolysis, Rashes, anorexia, Nausea,
Rifampicin 450-600mg QD 1760
100 mg/5 ml Susp. 32 vomiting, Cramps, visual changes, Behavioral changes.
Neurotoxicity, Ototoxicity, Nephrotoxicity, Skin rash,
Streptomycin 1 g q24hrs 1000 mg - 8
Nausea, Vomiting
Teicoplanin 200-400mg q24hrs 200mg, 400mg - 1600-3160 Thrombophlebitis, Neutropenia, eisonophillia, rash.
Hypotension accompanied by flushing, Erythmatous rash
Vancomycin 1g q12hrs 500 mg - 3334
on face and upper body
Prices quoted are prone to change with the change in brands or price revision by the manufacturer
37
Safety of Antimicrobial in Pregnancy & Lactation
Pregnancy
S# Antibiotics Lactation Status
Category
1. Acyclovir B Compatible
2. Amantadine C Unsafe
3. Amikacin D Compatible
4. Amoxicillin B Compatible
5. Amoxicillin/Clavulanic acid B Compatible
6. Amphotericin B B Unsafe
7. Ampicillin B Caution advised
8. Ampicillin/Sulbactum B Caution advised
9. Azithromycin B Caution advised
10. Aztreonam B Compatible
11. Cefazolin B Compatible
12. Cefixime B Unknown
13. Cefotaxime B Compatible
14. Cefpodoxime B Caution advised
15. Ceftazidime B Compatible
16. Ceftriaxone B Compatible
17. Cephalexin B Caution advised
18. Chloramphenicol C Unsafe
19. Ciprofloxacin C Compatible
20. Clarithromycin C Caution advised
21. Clindamycin B Compatible
22. Cloxacillin B Unknown
23. Cycloserine C Compatible
24. Doxycycline D Unsafe
25. Erythromycin B Compatible
26. Ethambutol C Compatible
27. Ethionamide C Caution advised
28. Fluconazole C Compatible
29. Fusidic Acid C Unknown
C (topical/ophth)
30. Gentamicin Compatible
D injection
31. Imipenem/Cilstatin C Caution advised
32. Isoniazid C Compatible
33. Itraconazole C Unsafe
34. Kanamycin D Unknown
35. Ketoconazole C Unsafe
36. Levofloxacin C Unsafe
37. Linezolid C Caution advised
38. Meropenem B Unknown
B (unsafe in 1st
39. Metronidazole Unsafe
trimester)
40. Minocycline D Unsafe
41. Oxytetracycline D Compatible
42. Penicillin G B Compatible
43. Penicillin G Benzathine B Compatible
44. Piperacillin/Tazobactam B Caution advised
45. Polymyxin B B Caution advised
46. Pyrazinamide C Caution advised
47. Ribavirin X Unsafe
48. Rifampicin C Compatible
49. Streptomycin D Compatible
50. Sulfadoxine/Pyrimethamine C (D at term) Unknown
51. Teicoplanin B Unknown
38
B ophth
52. Tobramycin Unsafe
D injection
53. Valacyclovir B Caution advised
54. Vancomycin C Caution advised
Lactation status definition:
Caution advised: Enters in breast milk in significant quantities
Unknown: FDA Pregnancy Category not defined.
Definition of Pregnancy Categories (FDA)

• Category A: Controlled studies in women have failed to demonstrate a risk of the fetus
• Category B: Animal studies have shown no risk but no controlled human studies have been performed, OR animal studies have shown an adverse effect that
has not been confirmed in human studies.
• Category C: Animal studies have revealed adverse effects and there are no controlled studies in women OR studies in women and animals are not available.
Benefit must exceed risk
• Category D: There is evidence of fetal adverse effects but the benefit may outweigh the risks.
• Category X: There is strong evidence of fetal abnormalities in humans; Risk outweighs the benefit.
Use of Vaccines in Pregnancy and/or lactation
Lactation Pregnancy
S# Vaccines Type Comments (Pregnancy)
Status Category
01 BCG live attenuated Safe C Contraindicated
02 DPT toxoid & antigen Unknown C *
03 TD toxoids Unknown - Indicated in 2nd and 3rd trimester
04 Hepatitis B surface antigen Safe C Indicated in Hepatitis B carriers
H. influenza type
05 polysacchrides Unknown C *
b
06 Polio Vaccine live Unknown C Indicated in women at high risk needing immediate protection
07 MMR live attenuated Unsafe C Contraindicated
Women exposed to chickenpox either in first 20 weeks or near
08 Varicella live attenuated Safe C
gestation should receive Varicella Ig**
09 Pneumococcal polysacchride Unknown C *
inactivated
10 Hepatitis A Unknown C Give hepatitis Ig ** with in 1st week of exposure
hep. a virus
Influenza
11 inactivated Safe C *
Vaccine
12 Meningococcal polysaccharide Unknown C *
13 Tetanus Toxoid tetanus toxoid Unknown C See Td
purified protein
14 Tuberculin Unknown C CDC considers it to be safe
derivative
15 Rabies inactivated Unknown C Can be given as post exposure prophylaxis
16 Measels live attenuated Unknown C Contraindicated
17 Typhoid polysaccharide Unknown C If extremely necessary, delay it till 2nd or 3rd trimester
*Not routinely indicated but can be given in certain indications other than
• All Live Vaccines are considered contraindicated during pregnancy
primary immunization
• Pregnancy / Conception should be avoided 1 month after MMR ** Immunoglobulin (Immunoglobulins are usually considered safe)
and 3 months after Varicella vaccination
! Center of Disease Control
39
Dose Adjustments in Renal Failure Patients
For the following drugs, there is no need for the adjustment of dosage in patients with renal impairment: Amphotericin B, Azithromycin, Ceftriaxone, Chloramphenicol,
Clindamycin, Doxycycline, Fusidic acid, Metronidazole, Cloxacillin, Linezolid and Isoniazid
Formula for creatinine clearance calculation:
Different methods recommended for obese (20% over IBW or BMI >30) and non-obese patients
Adult- non obese
CrCl = (140 – Age) x IBW (Kg) (multiply answer by 0.85 for females)
72 x Serum Creatinine
IBW is
• Men: 50 kg plus 2.3kg/inch over 60 inches in height
• Women: 45 kg plus 2.3 kg/inch over 60 inches in height
Adult obese patient

Men: (137-age) x ((0.285 x wt in Kg) + (12.1 x ht in m2))
Women: (146-age) x ((0.287 x wt in Kg) + (9.74 x ht in m2))

Note:
Adjusted doses mentioned are for mild to moderate susceptible infections. For severe infections with moderately susceptible infection, a higher dose may be required.
Dose adjustment Adjustment as per creatinine
Antimicrobials method clearance
(see footnote) (GFR or CrCl, ml/min)
GFR
GFR>50-90 GFR 10-50
<10
Carbapenems
0.5 gm
Meropenem D&I 1 gm Q8hrly 1 gm Q12hrly
Q24hrly
125-250mg
Imipenem D&I 250-500 mg q6-8hrly 250mg q6-12hrly
q12hrly
Cephalosporins
Cefepime D&I 1-2 gm Q12hrly Q16-24hrly Q24-48hrly
1-2 gm
Cefotaxime I Q12-24hrly Q24hrly
Q8-12hrly
Ceftazidime I Q8-12h Q24-48h Q48h
Cefazolin I 1-2 gm Q8hrly Q12hrly Q24-48hrly
Fluoroquinolones
Levofloxacin D&I 100% 50-75% 25-50%
Ofloxacin D&I 100% 50%Q12h 50% Q24h
Ciprofloxacin D 100% 50-75% 50%
Macrolides
Clarithromycin D 100% 75% 50- 75%
Erythromycin D 100% 100% 50- 75%
Penicillins
Ampicillin I Q6hrly Q6-12hrly Q12-24hrly
Ampicillin/Sulbactam I Q6hrly Q8-12hrly Q24hrly
Amoxicillin I Q8hrly Q8-12hrly Q24hrly
250/500 mg
Amoxicillin/Clavulani 250/500 mg Amox component Amox
D&I 500/125 mg q8h
c acid q12hrly component
q24hrly
Aztreonam D 100% 50-75% 25%
Penicillin G D 100% 75% 20-50%
Piperacillin/Tazobacta 2.25gm
D&I 4.5gm Q8hrly 2.25gm Q6hrly
m Q8hrly
Antifungal
Amphotericin I Q24hrly Q24hrly Q24-48hrly
Fluconazole D 100% 50% 50%
40
Itraconazole D Q12hrly Q12hrly Q12-24hrly
Better to
Terbinafine - Q24hrly No reference
avoid
Antivirals
50%
Acyclovir D&I 100% Q8hrly 100% Q12-24hrly
Q24hrly
10mg
Adefovir I 10mg q24hrly 10 mg q48-72hrly
q72hrly
Amantadine I Q12hrly q24-48hrly Q 7 days
0.05mg
Entecavir D 0.5 mg q24hrly 0.15-0.25 mg q24hrly
q24hrly
1.25mg/kg 3
Ganciclovir D&I 5mg/kg q12hrly 1.25-2.5 mg/kg q24hrly
times/week
30-50: 75 mg bid
Oseltamivir I 75 mg bid No data
< 30: 75 mg q48hrly
Use with caution in crcl < 50
Ribavirin - ml/min
>30: 300 mg q48hrly
Tenofovir - 300 mg q24hrly No data
10-29: 300 mg 2x/wk
0.5gm
Valacyclovir D&I 1gm q8hrly 1gm q12-24hrly
q24hrly
Antiparasitic/malaria
l
Quinine I 600 mg Q8hrly 600mg 8-12hrly 600mg QD
Anti T.B
Ethambutol I Q24hrly Q24-36hrly Q48hrly
Ethionamide D 100% 100% 50%
Isoniazid D 100% 100% 100%
12-25mg/kg
Pyrazinamide D 25mg/kg QD 25mg/kg QD
QD
Rifampicin D 600mg QD 300-600mg QD
Miscellaneous
Metronidazole D 100% 100% 50%
1 gm Q4-7
Vancomycin D&I 1 gmQI2h 1 gm Q24-96hrly
day
Teicoplanin I Q24h Q48h Q72h
Nitrofurantoin D 100% Avoid Avoid
Not
Trimethoprim- Based on TMP Based on TMP
D recommende
Sulfamethoxazole 100% 50%
d
Note: normal prophylaxis dose
can be given. Adjustment
required in treatment doses only
Anti Helmintics
Albendazole -
Mebendazole - Dose adjustment not required
Pyrantal pamoate -
Aminoglycosides Dose 24 hrly (mg/kg)
GFR
GFR >80 GFR 60-80 GFR 40-60
30-40
Amikacin/
- 15 12 7.5 4
Streptomycin
Gentamicin - 5.1 4 3.5 2.5
Dose 48 hrly
(mg/kg)
GFR 20-30 GFR 10-20 GFR <10
Amikacin/
- 7.5 4 3
Streptomycin
Gentamicin - 4 3 2
Footnote:
Dose adjustment method:
D = dose adjustment
I = Interval adjustment
D&I = both interval and dose can be adjusted
41
Supplemental Doses for Antibiotics During Dialysis
Supplement Doses (Paediatrics) Supplemental doses (adults)
Antimicrobials
Peritoneal Dialysis Hemodialysis
Adefovir None 10 mg every week AD*
Ampicillin Dose for CrCl < 10ml/min 500-1000 mg AD*
Oral = 375-625mg
Amox/Clav Dose for CrCl < 10ml/min
IV= 600 mg -1.2 gm AD*
Amikacin 15-20 mg/L/day is removed (see footnote 1) ½ of the normal renal function dose AD*
Aztreonam Dose for CrCl < 10ml/min 500 mg AD*
Acyclovir Dose for CrCl < 10ml/min Give adjusted dose AD*
Cefazolin Dose for CrCl < 10ml/min 0.5-1 gm AD*
Cefixime Dose for CrCl < 10ml/min Dose for CrCl < 10ml/min
Ceftazidime Dose for CrCl < 10ml/min 1 gm AD*
1gm AD*
Ceftriaxone Dose for CrCl < 10ml/min (If dialysis session is of 4 hrs and inter-
dialysis duration of no more than 48 hours)
Cefotaxime Dose for CrCl < 10ml/min 1 gm AD*
Ciprofloxacin ½ of the normal renal function dose AD* None
Gentamicin 3-4 mg/L/day is removed (see footnote) ½ of the normal renal function dose AD*
Dose for CrCl < 10ml/min, adjust to 50% of
Isoniazid Dose for CRCL<10 ml/min
normal dose/day for CAPD
Itraconazole - 100-200 mg AD*
Levofloxacin Dose for CrCl < 20 ml/min Dose for CrCl < 20 ml/min
Meropenem Dose for CrCl < 10ml/min Give adjusted dose AD*
Metronidazole Dose for CrCl < 10ml/min Dose for CrCl<10 ml/min
Oseltamivir None 30 mg on non dialysis day
Piperacillin/Tazo
Dose for CrCl < 10ml/min 0.75 gm AD*
bactam
Polymyxin B - Yes 1
Pyrazinamide None 40mg/kg prior to each 3x/wk dialysis
Streptomycin 20-40mg/L/day is removed (see footnote) ½ of the normal renal function dose AD*
Vancomycin As per levels As per levels
1
Literature supports that the drug is removed by dialysis but dosing information not available.
AD* After dialysis
Footnote:
1. e.g. Usual method for CAPD is 2 L replaced qid (8L/day): give 8Lx 20mg lost per L = 160 mg supplement every day
2. Drugs which are not mentioned in the table should be given as their routine adjusted dose preferably after dialysis. Supplemental doses are
not required in this case.
42
Penetration of Antimicrobial in Cerebrospinal Fluid (CSF)
Therapeutic Sub-Therapeutic Concentration

Therapeutic Concentration
Concentration in CSF in CSF with or without
in CSF with inflammation
without inflammation inflammation
Chloramphenicol Aztreonam Amikacin
Isoniazid Acyclovir Amphotericin B
Metronidazole Ampicillin Cefazolin
Rifampicin Cefotaxime Clindamycin
Sulfonamide antibiotics Ciprofloxacin ** Gentamicin
Ceftazidime Itraconazole
Ceftriaxone Polymyxin
Imipenem* Streptomycin
Meropenem
Penicillin G high doses!
Piperacillin/Tazobactam
Vancomycin
Note: No data for Cefepime available

*Avoid for meningitis therapy due to seizure potential
! Does not apply to penicillin resistant S. pneumoniae
** Concentration not good for streptococci
Intra-Ventricular Doses of Antimicrobials
Drug Daily Dose

Amikacin 5-10 mg
Amphotericin B 0.3-1.5 mg
Ampicillin l0-50 mg
Chloramphenicol 1-2 mg/kg
Gentamicin 25-100 mg
Vancomycin 5 mg
43
Chapter 7: Drug Utilization Criteria
Drug Usage Criteria for Vancomycin

Justification of use:
• C/S documented MRSA (Methicillin Resistant Staph.aureaus), or Staph. epidermidis

• C/S documented C. diphtheria susceptible to Vancomycin and patient is allergic to penicillin
• C/S documented Ampicillin Resistant Enterococcus (ARE)
• Patient is allergic to penicillin (cloxacillin) and Clindamycin
• Endocarditis prophylaxis in patients allergic to penicillin
• Prophylaxis in surgical procedures involving implantation of prosthetic materials or devices (as per standard recommendations)
• Empiric therapy of line sepsis in critically ill patients or who are known carriers of MRSA (for 48-72 hours only)
• Antibiotic associated colitis not responding to 10 days therapy of Metronidazole (Oral Therapy only)
Critical (Process) Indicators:

• Must send proper sample(s) for culture prior to administration
• Pretreatment serum creatinine and CBC
• Monitor WBC and Neutrophils at least once a week, temperature 4 times a day and serum creatinine twice weekly
• Adjust doses if renal function is compromised
Dosing & Administration:

1. Dose should be based on actual body weight even for obese patients
2. Seriously ill patients may require a loading dose of 25-30 mg/kg
3. Subsequent dose is 15-20 mg/kg every 8-12 hrly (for normal renal function)
4. If dose is > 1 gm (1.5 or 2 gm) the infusion rate should not be less than 1.5-2 hrs
Serum Levels:
1. Trough levels are recommended for monitoring the optimal dose for Vancomycin
2. To avoid resistance, trough levels should be greater than 10 mg/L
3. For complicated infections, trough levels should be maintained between 15-20 mg/L
Therapeutic Drug Monitoring (TDM):

1. First Trough level should always be taken just prior to the fourth dose so that the steady state is achieved
2. Levels may be monitored weekly for hemodynamically stable patients and even daily for hemodynamically unstable patients
3. Frequency of optimal level monitoring is based upon clinical judgment
4. Monitor serum drug levels in:
i. patients with renal failure,
ii. fluctuating renal status,
iii. patients on dialysis,
iv. patients getting therapy for > 1 week or
v. patient on concurrent nephrotoxic therapy
Toxicity:
A patient should be considered to have Vancomycin-induced nephrotoxicity if multiple (at least 2 or 3 consecutive) high serum creatinine concentrations (increase of
0.5 mg/dL or >50% increase from baseline, whichever is greater) are documented after several days of Vancomycin therapy in the absence of an alternative explanation.
Duration of therapy:
Therapy must be individualized;
Not more than 72 hours Empiric therapy; if it has to be continued for any valid reason, ID consult should be involved
14-28 days C/S documented staphylococcus bacteremia or CNS infection
4-8 weeks Bone/Joint infections
Not more than 14 days Skin & soft tissue Infection
44
Complications:
• Nephrotoxicity evident from a rise of > 0.4mg/dl from baseline serum creatinine excluding other causes
• Cutaneous reaction; Red Man’s Syndrome
Outcome Measures:
• Fever reduction within 3 days of initiation of therapy (decrease of at least 1 oC from peak temperature
• Normalizing WBC and neutrophil count
• negative cultures 24hrs after stopping Vancomycin
Drug Usage Criteria for Carbapenems (Imipenem and Meropenem)

Justification for use:
• Infection with documented C/S data resistant to other first line agents and sensitive to Carbapenems
• Empirical use for serious life threatening gram negative sepsis where 3rd generation Cephalosporins & Quinolones are ineffective (not more than for 72 hours)
• Empirical use in Febrile Neutropenia

• Appropriate cultures obtained prior to begin therapy
• Dose adjustment as per renal status
• Monitor WBC at least once a week, temperature 4 times a day and serum creatinine twice a week
• Duration of therapy must be individualized;
Not more than 72 hours Empiric therapy, if it has to be continued for any valid reason, ID consult should be involved
14-28 days C/S documented bacteremia or CNS infection
4-8 weeks Bone/Joint infections
10-14 days UTI
10-14 days Pneumonia
Drug Usage Criteria for Polymyxin B

Justification for use:
• Infection with documented C/S data resistant to other first line agents and sensitive to Polymyxin B. E.g. Acinetobacter resistant to all first line antibiotics.
• Appropriate cultures obtained prior to begin therapy

• Pretreatment serum creatinine and CBC done
• Monitor WBC at least once a week, temperature 4 times a day, electrolytes and serum creatinine twice a week
• Duration of therapy must be individualized;
Not more than 72 hours Empiric therapy, if it has to be continued for any valid reason, ID consult should be involved
14-28 days C/S documented bacteremia or CNS infection
45
Drug Usage Criteria for Piperacillin/Tazobactam
Justification of Use:
1. Infections with documented C/S data resistant to all first line agents and sensitive to Tazocin only.
2. Consider empiric use for selected patients with Diabetic foot ulcer, Nosocomial Sinusitis, VAP and high risk Febrile Neutropenia.
3. ID specialist consult is recommended if the treatment is to be continued beyond 72 hours
4. Duration of therapy: As suggested by ID specialist (usually 10-14 days)
Critical Indicators:
• Appropriate cultures obtained prior to the therapy

• Monitor WBC at least once a week, temperature 4 times a day and serum creatinine twice weekly.
• Individualized duration of therapy
Drug Usage Criteria for Linezolid

Introduction:
A number of studies have shown Vancomycin and Linezolid to have equivalent efficacy for a variety of infections due to gram positive organisms (1-5). Recent data
regarding emergence of resistance to Linezolid in both Enterococcus spp. and Staphylococcus aureus create a significant concern over the durability of this agent with
widespread use (7,8). Also, recent reports of toxicity including bone marrow suppression, neurotoxicity, serotonin-syndrome, uveitis and peripheral neuropathy create
concerns over long term use (9-12). Toxicities may increase when the drug is given for longer than 2 weeks.
Justification of use:
1. Culture-directed therapy of serious Vancomycin-resistant Enterococcus (VRE) infections
2. Patients with serious culture-documented MRSA infections failing Vancomycin who have clearly documented Vancomycin troughs of 15-20 mcg/ml after 3
to 5 days of therapy.
3. Severe MDR TB
4. Patients in which glycopeptides are not possible (e.g. owing to poor or no IV access)
5. Treatment of serious culture-documented MRSA infections in patients with severe adverse reactions to Vancomycin, such as defined below:
a. Stevens-Johnson syndrome
b. Anaphylaxis or accelerated allergic reactions
c. Interstitial nephritis
The above statement does NOT include: Red-Man’s syndrome, renal insufficiency, mild rash during previous therapy.
6. Outpatient therapy of culture documented severe MRSA skin and soft tissue infections or pneumonia where the alternative therapy would be intravenous
Vancomycin. Duration of therapy should not exceed 2 weeks due to toxicity concerns.
7. Infections for which outpatient therapy of Gram-positive resistant infections is required, e.g. for complicated skin soft tissue infections (cSSTIs)
8. A change from IV to oral glycopeptide where Rifampicin, trimethoprim is deemed less desirable
Note: For patients in whom the attending physician feels that Linezolid is indicated but do not meet the above criteria, written approval from the Infectious
Diseases consult service is required.
Restrictions on Linezolid use:

1. Empiric therapy is not allowed
2. Vancomycin-resistant Enterococcus (VRE) infections (NOT stool colonization or uncomplicated urinary tract infections susceptible to an alternative agent
such as Chloramphenicol, Doxycycline, Nitrofuratoin etc)
3. Serious culture-documented MRSA infections in which Vancomycin is used but Vancomycin dosing was inappropriate as evident from troughs levels i.e.
below therapeutic range (< 15-20 mcg/ml) after 3 to 5 days of therapy.
4. In cases of mild to moderate skin and soft tissue infections (SSTI) due to culture proven MRSA, susceptibility-directed therapy with Clindamycin,
Trimethoprim-Sulfamethoxazole, Doxycycline, or Minocycline should be utilized when appropriate.
46
Summary of recommendations for appropriate use of Linezolid
Duration of
Indication Infecting pathogen Restrictions Dose
therapy
Allergy or resistance to other first-line agents for which culture and
sensitivity is reported by the institution’s microbiology and laboratory
Methicillin-susceptible
(beta-lactams, cephalosporins, Clindamycin, Cotrimoxazole,
Staphylococcus aureus <30 kg adult
Skin and soft tissue Fluoroquinolones, Macrolides, Tetracyclines), including allergy or
300 mg every 12 h
infections intolerance to Vancomycin
>30 kg adult ≤28 days
(complicated Allergy or resistance to other first-line agents for which culture and
600 mg every 12 h
uncomplicated) sensitivity is reported by the institution’s microbiology laboratory
Methicillin-resistant S
(fusidic acid combination therapy, Rifampin combination therapy
aureus
[unless there is Rifampin drug interaction], Cotrimoxazole,
Clindamycin), including allergy or intolerance to Vancomycin
Pneumonia sensitivity is reported by the institution’s microbiology laboratory
(PSSP, PRSP (beta-lactams, cephalosporins, Cotrimoxazole, fluoroquinolones,
multiresistant species) Macrolides, Tetracyclines), including allergy or intolerance to
Vancomycin
sensitivity is reported by the institution’s microbiology laboratory <30 kg Adult
Methicillin-susceptible S
(beta-lactams, cephalosporins, Clindamycin, Cotrimoxazole, 300 mg every 12 h
Pneumonia aureus ≤28 days
Fluoroquinolones, Macrolides, Tetracyclines), including allergy or >30 kg adult
intolerance to Vancomycin 600 mg every 12 h
sensitivity is reported by the institution’s microbiology laboratory
Methicillin-resistant S (fusidic acid combination therapy, Rifampin combination therapy
aureus [unless there is Rifampin drug interaction], Cotrimoxazole,
Clindamycin),
including allergy or intolerance to Vancomycin
600 mg bid, Decrease to
300 mg bid if
MDR TB M Bovis, M. tuberculosis Resistant to all 1st line ATT and other 2nd line ATT 6-40 weeks*
hematological side effects
appear
Infection
<30 kg Adult
(including
Vancomycin-resistant 300 mg every 12 h
osteomyelitis and Infectious diseases specialist consultation required ≤28 days
enterococci >30 kg adult
prosthetic joint
600 mg every 12 h
infection)
Allergy or resistance to other first-line agents for which culture and or
Methicillin-resistant S <30 kg Adult
Osteomyelitis and sensitivity is reported by the institution’s microbiology laboratory
aureus or coagulase- 300 mg every 12 h
prosthetic joint (fusidic acid combination therapy, Rifampin combination therapy ≤28 days
negative methicillin- >30 kg adult
infection [unless Rifampin drug interaction], Cotrimoxazole, Clindamycin),
resistant staphylococci 600 mg every 12 h
including allergy or intolerance to Vancomycin
Reference: Infectious Disease Pharmacy Specialty Network (Canadian Pharmacist Association)
*optimum duration still not established
• Obtain appropriate cultures prior to use

• Pretreatment complete blood count
Monitoring:
1. For treatment duration less than or equal to 2 weeks: Monitor WBC at least once a week and temperature 4 times a day
2. For treatment duration > 2 weeks:
a. Monitor CBC at least twice a week and temperature 4 times a day
b. Monitor especially for development of severe leukopenia, pancytopenia, thrombocytopenia, and anemia
c. Monitor for signs of peripheral neuropathy
d. Monitor for signs and symptoms of lactic acidosis
3. Monitor for visual changes in patients receiving therapy > 3 months and in whom reporting any new visual change
4. Duration of therapy must be individualized;
≤ 28 days C/S documented infection as per table 1
> 28 days MDR TB
Complications:
47
1. Myelosuppression with prolonged use (> 2weeks), anemia requiring transfusion
2. Irreversible or partially reversible neuropathy
3. Seizures in patients with history or risk factors for; increased risk of convulsions
4. optic nerve disorder
Outcome Measures:
• Fever reduction within 3 days of initiation of therapy (decrease of at least 1 oC from peak temperature
• Signs of clinical improvement
• Sterile TB cultures (AFBS)
48
Annexures
IV to PO Switch Guidelines
Introduction
IV to oral switch is the prompt conversion of IV antibiotic therapy to oral. Patients may be considered candidates for switching from IV to oral therapy once the patient
has shown clinical improvement and is medically stable.
Rationale
The majority of patients with a severe infection who are adequately absorbing oral medication and initially require IV therapy can be safely switched to oral therapy
within 48 hours. There are a number of advantages to support the prompt switch from IV to oral therapy these are as follows1,2,3:
• Reduction in the likelihood of hospital acquired bacteraemia and infected/phlebitic IV lines.
• Saves both medical and nursing time
• Reduces discomfort for patients and enables improved mobility and the possibility of earlier hospital discharge.
• Potential to significantly reduce treatment costs.
• Patient is more likely to receive antibiotics at the correct time.
• Potential reduction in the risk of adverse effects; errors in preparation are significantly higher with parenteral drugs, compared to oral formulation.
Considerations for the early switch to oral therapy COMS (review at 24-48 hours)
C Clinical improvement observed
O Oral route is not compromised (vomiting, malabsorptive disorder, swallowing problems, unconscious, severe diarrhea)
NB: if NG/PEG feeding then please consult your pharmacist
M Markers showing a trend towards normal: Patient should be apyrexial for the last 24 hours (Temp>360C and <380C) and NOT have more than one of the following,
heart rate>90/min, resp rate>20/min, BP unstable, WCC<4 or>12 White cell count should show a trend towards normal; absence of such should not impede the switch
if all other criteria are met and not neutropenic.
S Specific indication/deep-seated infection (Prior to switch refer to table 1)
High risk/deep-seated infections

Certain infections may appear to respond promptly to intravenous therapy, but warrant prolonged IV therapy. This is to ensure that adequate drug levels are attained at
the site of infection and to optimize the response and prevent relapse.
Discuss with Microbiology before switching patients with a high risk/deep seated infection to oral therapy.
Deep seated infections that may High risk infections requiring

require an initial 2 weeks of IV therapy prolonged IV therapy
• Liver abscess • Staphylococcus aureus bacteraemia
• Osteomyelitis,Septic arthritis • Severe necrotizing soft tissue infections
(N.B. high-dose oral Clindamycin may be • Severe infections during chemotherapy related neutropenia
appropriate once patient is stable) • Infected implants/prosthesis
• Empyema • Meningitis/encephalitis
• Cavitating pneumonia • Intracranial abscesses
• Mediastinitis
• Endocarditis
• Exacerbation of cystic fibrosis/bronchiectasis
• Inadequately drained abscesses or empyema
References
1. Sevinc F et al. Early switch from intravenous to oral antibiotics: guidelines and
implementation in a large teaching hospital. Journal of Antimicrobial Chemotherapy 1993 43:601-606
2. Guidance for intravenous antibiotic ‘switch’ therapy. 2004. North West Antibiotic
Pharmacists Network Advisory Group.
3. www.bsac.org/pyxis
4. McLaughlin C et al. Pharmacy-implemented guidelines on switching from
intravenous to oral antibiotics: an intervention study. Q J Med 2005;98:745:752
49
Carbapenem Interchange Policy
The Antibiotic subcommittee had approved Carbapenem Interchange Policy which has been in vogue for a long period. Hospital Pharmacy and Therapeutic Committee
(P & TC), an oversight committee of the Antibiotics Subcommittee also approved this policy. Primary reasons have been the cost per gram of the Meropenem
(estimated savings of Rs.1500-2000 per day depending on dose), identical and similarity of spectrum and usage in approved indication.
The policy contains the following salient features:
• All eligible patients can be switched to Imipenem automatically by pharmacy

• Normal dose of Imipenem is to be given (i.e. 500 mg Q6h) in case of normal renal function (exception meningitis and sepsis requiring higher doses)
• In case of renal impairment it should be adjusted as per CrCl and severity of infection (see formulary)
Exclusion criteria (Meropenem indication):

• Pediatric age group
• Known case of epilepsy or having seizures
• CNS infections
• Head trauma/injury (conditions in which seizure threshold may decrease)
Standardized Volume of Antibiotics in Pediatrics
Volume
Weight in
Penicillin Ampicillin Cloxacillin Cefazolin Cefotaxime Ceftriaxone Ceftazidime Piperacillin/Tazobactam used
Kg
(ml)
3-5 - - - - - - - - 2
5-7 3lac 200 200 150 250 400 250 500 10
8-10 4 lac 300 300 200 350 650 350 1000 15
11-15 6lac 400 400 300 500 850 500 1500 20
16-20 10lac 500 500 500 1000 1000 750 2000 25
21-25 10lac 800 800 500 1000 1500 1000 2500 30
26-30 20lac 1000 1000 750 1000 2000 1000 3000 35
25000-
Dose 12.5-50 6.25-25 17-33 15-50 50-75 30-50 50-100
100,000
range mg/Kg mg/Kg mg/Kg mg/Kg mg/Kg mg/Kg mg/Kg
units/kg
Max
10 lac 70 40
Conc. For 30 mg/ml 50 mg/ml 130 mg/ml 120 mg/ml 200 mg/ml
units/ml mg/ml mg/ml
infusion
Vancomycin
Weight in Kg Meropenem
Dose (mg) Max Vol Min Vol.
3-5 40 10 5
Non-Meningitic Dose
Meningitic Dose
5-7 65 15 7
20 mg/kg/dose
40 mg/kg/dose
8-10 100 20 10
11-15 150 30 15
16-20 200 40 20
21-25 250 50 25
26-30 300 60 30
Dose range mg/Kg Dose range 10-15 mg/kg
Max Conc. For 10 mg/ml

50 mg/ml Conc. For infusion 5 mg/ml
infusion Fluid restriction
Drugs Normal concentration Max Conc. (fluid restricted)

Acyclovir < or equal to 7mg/ml 10 mg/ml
Amphotericin B 0.1 mg/ml 0.5 mg/ml (but via central line)
Polymyxin B 1000 units/ml 1700 units/ml
Ceftriaxone 10-30 mg/ml 40 mg/ml
50
Antimicrobial Ophthalmic Agents
Antibiotics
S# Trade Name Generic Indication Dose
2. Ciloxan e/d Ciprofloxacin 0.3% Bacterial eye infection 1-2 drops QID
Conjunctivitis, Trachoma, Blepharitis,
3. Econochlor e/d Chloramphenicol 0.5 % 2-3 drops QID
Keratitis
Conjunctivitis, Trachoma, Blepharitis,
Neo-Phenicol oint Chloramphenicol 1 % Up to q3 hrly & PRN
Keratitis
1-2 drops q 2-4 hrly x 2 days
4. Exocin e/d Ofloxacin 0.3% Bacterial eye infection
then qid x total 10 days
Optoflox ointment Ofloxacin 0.3% Bacterial eye infection 2-3 times a day
Bacterial eye infection, Prophylaxis in
5. Fucithalmic e/d Fusidic acid 1% (SR) 1 drop Q12 hrly
connection with removal of foreign bodies
6. Genticyn e/d Gentamicin 0.3% Conjunctivitis, Blepharitis, corneal ulcer 1-3 drops Q 3-4 hrly
9. Polyfax ointment Polymyxin B+ Bacitracin Bacterial Conjunctivitis 2 or more times a day
10. Tobrex e/d & oint. Tobramycin 0.3% Bacterial eye infection q1-4 hrly
11. Cycloz ointment Acyclovir 3% Herpes simplex Keratitis 1 cm ribbon 5 times a day, 4 hours apart
Steroid + Antibiotic
Betamethasone 0.1% Inflammatory conditions where infection is 1-2 drops 1-2 hrly
1. Betnesol N e/d, oint.
Neomycin 0.5% suspected Oint.; 2-3 times a day
Post surgery infection, chronic anterior
Dexamethasone 0.1% + One drop q2 hrly x 24-48 hours then 1-2 drop
2. Dexoflox e/d uveitis, corneal injury from chemical,
Ofloxacin 0.3% 4-6 times a day
radiation or thermal burns
Dexamethasone 0.2%
3. Fluorobioptal e/d Infected ocular inflammation 1-2 drops q4-6 hrly
Chloramphenicol 0.5 %
Neomycin + Polymyxin
4. Maxitrol e/d, oint. Infected ocular inflammation 1-2 drops q 4-6 hrly
+ Dexamethasone
Spersadex Compound Dexamethasone 0.1%
5. Infected ocular inflammation 1-2 drops q 4-6 hrly
e/d Chloramphenicol 0.5%
Tobramycin 0.3%
6. Tobradex e/d, oint. Infected ocular inflammation 1-2 drops q 4-6 hrly
Dexamthasone 0.1%
Steroid +/- Antibiotic +/- Adrenergic agonist
Prednisolone 0.2%
1. Blephapred e/d, oint. Sulphacetamide 10% Blepharitis, bacterial conjunctivitis 1-2 drops q 3-4 hrly
Phenylepherine 0.12%
AKUH Compounded Ophthalmic agents

S# Drug E/D Strength Indication Expiry
1. Amikacin 33 mg/ml & 66 mg/ml Corneal ulcers caused by Ps.aeroginosa 7 days
2. Amphotericin 0.5% ,0.3%, 0.2%,1% Ocular fungal infection 7 days
3. Benzyl penicillin 30 mg Bacterial endophthalmitis 4 days
4. Cefazolin 33 mg/ml & 50 mg/ml Bacterial endophthalmitis 4 weeks
5. Chlorhexidine 0.02% Acanthamoeba Keratitis 30 days
6. Fluconazole 2% Fungal endophthalmitis 30 days
7. Gentamicin 13.6mg/ml, 15mg/ml Bacterial endophthalmitis 3 months
8. Ketoconazole 2% Keratomycosis 14 days
9. Vancomycin 50mg/ml Bacterial endophthalmitis 7 days
51
Topicals Available at AKUH
Antibiotics / Antiseptic
Dalacin-T
1. Clindamycin Moderate to severe acne vulgaris Apply 2-3 times a day
L
Fucidin
2. Fusidic acid Bacterial skin infection Apply 2-3 times a day
C, O
Apply in layer 3-5mm thick, change dressing
Wounds, burns, leg ulcer (infected),
3. Quench (C) Silver sulfadiazine 1% every alternate day for ulcers and daily for
pressure sores
burns
4. Polyfax (O) Polymyxin B, Bacitracin Skin infections Apply 2 or more times a day
Neomycin 0.5%, Bacitracin 250U,
Prophylaxis in burns, cuts, ulcers,
5. Cicatrin powder Cysteine 0.2%, Glycine 1%, Threonine Apply 3 times a day
scratches
0.1%
Genticyn
6. Gentamicin Aminoglycoside antibacterial Apply 2-3 times a day
C
Antimicrobials +/- Steroids
Betnovate-N Eczema, infantile, vulval pruritis, otitis
7. Betamethasone 0.1 %,neomycin 0.5% Apply sparingly 2 or 3 times a daily
C externa
Fusicort Inflammatory dermatoses where
8. Fusidic acid 20 mg, Betamethasone 1mg Apply 3-4 times daily.
C bacterial infection is present
Nerisone - C
9. Difluocortilone0.1%,chlorquinaldol1 5 Anti-inflammatory + antibacterial Apply 2-3 times daily
C
Fucidin - H Fusidic acid 20 gm, hydrocortisone10
Inflammatory dermatoses where
10. C mg Apply2-3 times daily
bacterial infection is suspected
Canestan (C)
11. Clotrimazole 1% Candida infection Apply 2-3 times daily
Clotrim (L)
Clobetasol propionate 0.5%, neomycin
Dermovate NN Psoriasis, intractable eczema, Apply once or twice weekly, max 40 gms
12. sulphate 0.1%, nystatin 100,000
C inflammatory dermatoses /week, max duration 4 weeks
units/1gm
Antiseptic, topical: apply to abrasions, minor
Candidiasis, mucosal
Gentian Violet cuts, and surface injuries of the skin
13. Gentian Violet Antiseptic, topical, Surgical skin
L Candidiasis, mucosal: apply to mucosal surface
marker
2 to 3 times daily for several days
Nizoral Tinea infections, cutaneous candidiosis,
14. Ketoconazole Apply once or twice daily
C seborrhea
Lamisil
15. Terbinafine athlete's foot, jock itch, and ringworm Apply once or twice daily
C
Daktarin
16. Miconazole vaginal and mucocutaneous candidiasis Apply once or twice daily
C
Kenacomb Triamcinolone, Gramicidin, Neomycin, Bacterial/fungal infection with
17. Apply 2-3 times a day
O Nystatin inflammation
Travacort
18. Isoconazole, difluocortolone Dermatomycosis Apply 2 times a day
C
Antivirals
Zovirax
19. Acyclovir 5% Herpes zoster and simplex infection Apply 4-6 times a day
C
Pediculocide/Scabicide
Lotrix
20. Permethrin Scabies Apply once, repeat after 14 days
C
Adult: Apply for 24 hours & wash
Use diluted solution in children
21. S.P. Lotion Benzyl Benzoate Scabies, Pediculosis
Infants: (1:3 in water)
Others : (1:1 in water)
* C ; cream
O: ointment
G: gel
L: lotion
V/C: Vaginal cream
52
AKUH Compounded Dermatological/Topical Agents
S# Compounding Indications Expiry
Antibiotic/Antifungals/Antiseptics
1. Whitfield ointment Fungal infections 1 year
2. Bismuth Iodoform paste (sterile) used for packing cavities after oral and otorhinological surgery 6 months
3. Eusol ½ strength solution Skin disinfectant, for wound dressing 14 days
4. Acetic acid solution 1%, 3%, 5% Bactericidal for wound care 1 year
5. Metronidazole gel 0.75% Acne Rosacea 28 days
6. Potassium permanganate sol 1:5000 Disinfectant, deodorants, in bromhidrous 7 days
7. Silver nitrate sticks Burns, wounds & treatment of warts 3 months
Routine Childhood Immunization Schedule
Age Vaccine Dose Comments

BCG 0.05 ml (0-3 months) Intradermally one dose in upper part of right deltoid muscle
At birth 0.1 ml (>3months)
OPV 2 drops Administer orally
DPT-Hep B- Hb 0.5 ml Administer IM lateral side of right thigh
6th week OPV 2 drops Administer orally
PCV* 0.5 ml Administer IM
10th week
Rotavirus* 1 ml Administer orally
14th week
Rotavirus* 1 ml Administer orally
9th month Measles 0.5 ml SC in middle of deltoid muscle
Hepatitis A* 0.5 ml Administer IM
12th month
Chicken Pox* 0.5 ml Administer SC
MMR** 0.5 ml SC in middle of deltoid muscle
15th month
DTaP*Hib ** 0.5 ml Administer IM lateral side of right thigh
18th month OPV 2 drops Administer orally
Hepatitis A* 0.5 ml Administer IM
>2 yrs Typhoid* 0.5ml Administer IM
DTaP* 0.5 ml Administer IM
4-5 years Chicken Pox* 0.5 ml Administer SC
5-7 years MMR* 0.5 ml Administer IM
TT 0.5 ml Administer IM in middle of deltoid muscle
10-15 years
MMR** 0.5 ml Administer SC
* These vaccines are not supported by EPI, however they are strongly recommended
** These vaccines are not included in National EPI but are very strongly recommended
*** To be administered only if no evidence of second MMR administration at age 5-7 years
53
Catch-Up Immunization Schedule for Children aged 4 months through 18 years who start late or who are more
than 1 month behind
The table below provides catch-up schedules and minimum intervals between doses for children whose vaccination has been delayed. A vaccine
series does not need to be restarted, regardless of the time that has elapsed between doses. Use section appropriate for the child’s age:
A: Catch-up schedule for children aged 4 months through 6 years

Minimum interval between doses
Vaccine Min. age for
Dose 1-2 Dose 2-3 Dose 3-4 Dose 4-5
dose 1
Hepatitis B Birth 4 weeks 4 weeks
DPT 6 weeks 4 weeks 4weeks 6 months 6 months
6 weeks 4weeks 4 weeks 8 weeks (as final
If 1st dose administered at If current age is younger dose)
younger than 12 months of than 12 months This dose only
age 8 weeks (as final dose) necessary for children
8 weeks (as final dose) If current age is 12 aged 12-59 months
If first dose administered at month or older and 2nd who received 3 doses
age 12-14 months dose administered at before age 12 months
Hib
No further doses needed younger than 15 months
If 1st dose administered at of age
age 15 months or older No further doses
needed
If previous dose
administered at age of
15 months or older
6 weeks 4weeks 4 weeks 8 weeks (as final
If 1st dose administered at If current age is younger dose)
younger than 12 months of than 12 months This dose only
age 8 weeks (as final dose necessary for children
8 weeks (as final dose for for healthy children) aged 12-59 months
healthy children) If current age is 12 who received 3 doses
If first dose administered at month or older before age 12 months
Pneumococcal age 12 or older or current No further doses or for high risk
age 24-59 months needed children who received
No further doses needed for healthy children If 3 doses at any age
For healthy children If 1st previous dose
dose administered at age 24 administered at age of
months or older 15 months or older
9 months 4 weeks 4 weeks

2nd dose should be given 3rd dose to be given only
when the child is 12 months if the child received 1st
MMR
or older dose of measles at
younger than 12 months
age
Polio Birth 4 weeks 4 weeks 4 weeks 4 weeks
Varicella 12 months 3 months
Hepatitis A 12 months 6 months
B: Catch-up schedule for children aged 7 through 18 years
7 years 4 weeks 4 weeks 6 months 6 months

If 1st dose administered If 1st dose administered
at younger than 12 at younger than 12
months of age months of age
Td or TdaP
6 months
st
If 1 dose administered
at age 12 months or
older
Hepatitis A 12 months 6 months
Birth 4 weeks 4 weeks
Hepatitis B And at first 16 weeks
after 1st dose
MMR 12 month 4 weeks
Polio Birth 4 weeks 4 weeks 4 weeks 4 weeks
12 months 4 months
If the person is
younger than 13
Varicella years of age
4 weeks
if the person is of 13
years or older
54

Antibiotic Guidelines

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Antibiotic Guidelines

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4th Edition,

Dr S. Faisal Mahmood, Chair Antibiotic Subcommittee

Please send us your feedback trough email at: drug.information@aku.edu

Chapter 1: Empiric Antibiotic Regimens

1. Skin, soft tissue, bone/joint infections

Chapter 3: Treatment Guidelines and Protocols

Chapter 4: Treatment of Miscellaneous Infections

Chapter 5: Antimicrobial Coverage & Sensitivity

Chapter 6: Drug Dosing, Pharmacokinetic and Safety

1. Normal adult doses and cost of therapy

Skin and Soft Tissue/ Bone/ Joints Infections

Infected wound post-operative - (Not involving GI or female GU tract)

Upper Respiratory Tract Infections

Timing of Antimicrobial Prophylaxis:

Non-Antimicrobial methods of preventing infection:

Gynaecological and Obstetrics Surgery

Head and Neck Surgery

Empirical Antifungal Therapy

Modification of the Antibiotic Regimen

Colony-Stimulating Factors (CSF)

Outpatient Management of low-risk Febrile Neutropenic Patients

MP: Trophozoites of P.vivax

Assess for the presence of any of the following

-Severe anemia -Severe thrombocytopenia -Acute renal failure

Chloroquine phosphate Treat as severe malaria

Consider MP daily for 72 hours

In 48 hours, MP -ve for trophozoites Consult ID

Complete course of Chloroquine

MP: Trophozoites of P. falciparum

Assess for the presence of any of the following

-Prostration -Impaired consciousness/coma -Respiratory distress -Multiple convulsions

Co-Artemether 40/240mg* Treat as severe malaria

Consider MP daily for 72 hours

-Development of signs of severe malaria in the presence

*complete dose guide Co-Artemether - Treatment of uncomplicated falciparum malaria:

MP: Trophozoites of P. falciparum or P.vivax

Severe Malaria is defined by the presence of any of the following

-Prostration -Impaired consciousness/coma -Respiratory distress -Multiple convulsions

-Support airway, breathing, circulation

IV Quinine (20mg/kg over 4 hrs, followed by 10mg/kg q8hrs)

Development of signs of severe malaria in the presence of

Continue IV for 48 hours then switch to oral therapy;

1st line Treatment Options – Adults

Treatment Options – Paediatric

Duration of antibiotic therapy

1) Non severe pneumonia (microbiologically undefined) 7 - 10 days

Consider ‘CURB 65’ clinical adverse prognostic features:

Consider “pre-existing” Consider “additional”

PO Amox/Clav (2 gm bid) or IV B-lactam (Ceftriaxone 2g QD) Without risk of Pseudomonas

Risk factors for P.aeruginosa: With risk of P. aeruginosa

Pulmonary tuberculosis (PTB)

Smear-positive PTB case

Extrapulmonary tuberculosis (EPTB)

Patient Registration Groups

2 months of RHEZ followed by 4 months of RH

Defaulted or relapsed patient

Send sputum/bronchial wash for AFB C/S and start ATT

Drug Adults/children Daily dose Available as

Pyrazinamide and Ethambutol doses for adults weighing 40–90 kilograms

40-55 kg 56-75 kg 76-90 kg

Fixed Dose Combinations (FDCS)

Initial Phase Continuation Phase

Managing Side effects

Side-effects Drug(s) probably responsible Management