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INDEX:
DEPARTMENTS PAGE
1 Dental 4
2 Medical 14
Cardiovascular infections 15
Central Nervous Infections 26
Infections In Immunocompromised Patients 31
Non-Surgical Chemoprophylaxis 48
Respiratory Infections 51
Sexually Transmitted Infections 57
Skin & Soft Tissue Infections 64
Tropical Infections 74
Tuberculosis Infections 81
Urinary Tract Infections 85
3 Neurosurgery 89
4 Obstetrics & Gynecology 94
5 Ophthalmology 99
6 Orthopedic 111
7 Otolaryngology 118
8 Paediatrics 127
Cardiovascular Infections 128
Central Nervous System Infections 131
Chemoprophylaxis 134

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Otorhinolaryngology Infections 141
Gastrointestinal Infections 143
Infections In Immunocompromised Patients 146
Neonatal Infections 147
Occular Infections 153
Respiratory Infections 154
Skin And Soft Tissue Infections 155
Surgical Infections 157
Tropical Infections 159
Urinary Tract Infections 161
Vascular Infections 162
9 Plastic Surgery 164
10 Surgical 167
11 Appendix 176
Colistin Dosing Guide 177
Vancomycin Dosing Guide 179

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DENTAL
DEPARTMENT

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Index:
ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS ANTIMICROBIAL USE FOR FUNGAL INFECTIONS
 Infections Of The Teeth And Supporting Structures  Oral Candidiasis
- Reversible/ Irreversible Pulpitis (Toothache) - Acute Pseudomembranous Candidiasis
- Localised Dentoalveolar Abscess - Chronic Erythematous Candidosis
- Dry Socket
- Localised Pericoronitis ORAL / DENTAL SURGERY PROPHYLAXIS
- Chronic Gingivitis - Clean Surgery (Class 1)
- Chronic Periodontitis - Minor Clean-contaminated surgery (Class 2)
- Aggressive Periodontitis - Major Clean-contaminated surgery (Class 3)
- Local missed Periodontal Abscess
 Infections of the Jaws
- Osteomyelitis of the jaws of dental origin
 Spreading Infections and Infections of Fascial Spaces
- Cellulitis±Abscess of dental origin
- Traumatic wound involving skin / Infection of skin origin
 Post Implant Infections (“Periimplantitis”)

ORAL / DENTAL INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
1. ANTIMICROBIAL USE FOR BACTERIAL INFECTIONS
A. Infections Of The Teeth And Supporting Structures
Reversible/ Irreversible Systemic antibiotic use not Systemic antibiotic use not Antibiotics and The Treatment of
Pulpitis (Toothache) recommended recommended Endodontic Infections.
Endodontics colleagues for Excellence 2006;
American Association of Endodontics

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Localised Dentoalveolar Systemic antibiotic use not Systemic antibiotic use not Incision and Drainage and Management
Abscess recommended recommended of Cause of Abscess and Symptomatic
Relief of Pain.
If patient medically Penicillin Allergy:
compromised, besides local Clindamycin 150-300mg PO JCan Dent Assoc 2003 Nov 69 (10):660
Clin.Microbiol.Rev.2013,26(2):255
treatment can consider: q6h
Amoxycillin 500mg PO q8h
Dry Socket Systemic antibiotic use not Systemic antibiotic use not Local treatment with saline irrigation
recommended recommended and antiseptic/ analgesic dressings and
symptomatic relief of pain.

Med Oral Patol Oral Cir Bucal 2005;


10:77-85
Localised Pericoronitis Systemic antibiotic use not Systemic antibiotic use not Local treatment with antiseptic irrigation
recommended in absence of recommended in absence of and mouthwash and symptomatic relief
regional or systemic signs and regional or systemic signs of pain.
symptoms and symptoms
JClinMicrobiol.2003;41(12):5794-7
Journal of the Irish Dental Association 2009; 55
(4): 190 – 192
Chronic Gingivitis Systemic antibiotic use not Systemic antibiotic use not 1st line treatment-Mechanical and
recommended recommended chemical plaque control.

*0.2% Aqueous Chlorhexidine


Gluconate not be used alone but as an
adjunct to mechanical debridement.

Clinical Periodontology-12thed.2014
2ndline treatment-Antimicrobial mouthrinse
Clinical Periodontology-9thed.2002
Chronic Periodontitis Systemic antibiotic use Systemic antibiotic use 1stline treatment-Mechanical plaque
generally not recommended. generally not recommended. control

Can be considered in cases of: Periodontology 2000, Vol. 62, 2013, 218-231

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
1. Unresponsive to conventional CPG Management of chronic periodontitis Nov
2. Episodes of acute infection 2012 MOH, Malaysia
3. Medically compromised
patientstherapy
Aggressive Periodontitis Amoxycillin 500mg PO q8h Azithromycin 500mg q24h Antibiotics are not used alone but are
A. actinomycetemcomitans, P. PLUS for 3 days used as an adjunct to scaling and root
gingivalis, Tannerella Metronidazole 400mg PO q8h debridement
forsythensis, P. intermedia,
Spirochaetes JClin Periodontol.2012;39:284-294
Clin Periodontol.2011;38:43-49
J Clin Periodontol 2008; 35: 696–704
J Periodont Res 2012; 47: 137–148
Local missed Periodontal Systemic antibiotic use not Systemic antibiotic use not Incision and Drainage and management
Abscess recommended recommended of cause of abscess and symptomatic
relief of pain.

Periodontology 2000. Jun2014, Vol. 65 Issue 1,


p149-177. 29p.
Malaysian Dental Journal (2008) 29(2) 154-157
CPG=Managementofperiodontal abscess-MOH,
Malaysia 2003
B. Infections of the Jaws
Osteomyelitis of the jaws of For acute cases,start with: **Clindamycin150-300mg Culture and sensitivity is necessary
dental origin Phenoxymethylpenicillin 250- PO q6h For chronic cases, start with surgical
Different organisms maybe 500mg PO q6h* OR treatment first.
involved OR **Clindamycin 150-450mg
**Benzylpenicillin 1-2MU IV IV q6h Antibiotics only when causative
q6h organisms are identified.

**Duration of antibiotic therapy can be


4-6 weeks depending on patient
response/ microbiological clearance of
the pathogen.

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
C. Spreading Infections and Infections of Fascial Spaces (with/without Systemic Signs)
Cellulitis±Abscess of dental Benzylpenicillin 2-4MU IV stat Penicilin Allergy: Empirical antibiotics are started.
origin then 1-2MU IV q4-6h Clindamycin150-450mg IV
Viridans Streptococci, PLUS/MINUS q6h Incision and drainange is advised and
Staphylococci, Prevotella, Metronidazole 500mg IV q8h antibiotics is changed in accordance with
Peptostreptococcus (or 1g q12h) Oral administration: result of culture and sensitivity.
Fusobacterium nucleatum Amoxycillin 250-750mg PO
Clostridium sp OR q8h
PLUS/MINUS
Surgical site infection & Amoxycillin/Clavulanate 1.2gm Metronidazole 400mg PO
Traumatic wound infection IV q6-8h (not more than1.2gm q8-12h
(Infection is usually by in a single dose- max 7.2gm
endogenous organisms rather daily) OR
than exogenous)
Viridans Streptococci OR Amoxycillin/Clavulanate
Staphylococci 625mg PO q8h.
Prevotella, Peptostreptococcus, Cefuroxime 750mg-1.5gm IV
Eubacterium,and q8h If severe, Amoxycillin/
Fusobacterium PLUS/MINUS Clavulanate 625mg PO q8h
Metronidazole 500mg IV OR
q8h(or 1gm q12h)* Cefuroxime 250-500mg PO
q12h
OR OR
Clindamycin 150-450mg PO
If not responding to above q6h
antibiotics,
Ceftriaxone 1-2gm IV q24h
(maybe given up to 4gm per
day)

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Traumatic wound involving Cloxacillin 500mg-1gm IV q6h
skin / Infection of skin origin (inskin involvement- if Staph.
expected)
OR
Clindamycin 150-450mg IV
q6h

Oral administration:
Amoxycillin 250-750mg PO
q8h
PLUS/MINUS
Metronidazole 400mg PO q8-
12h

OR

Clindamycin 150-450mg PO
q6h

D. Post Implant Infections (“Periimplantitis”)


Causative Organisms: Amoxycillin/ Clavulanic 625mg Penicillin Allergy: Bacteria associated with periimplantitis
Actinomyces sp. PO q8h Doxycycline100mg PO q12- are extremely resistant to antibiotics.
Eubacterium sp. 24h
Propionibacterium sp. OR OR Antibiotics are not used alone but are
Lactobacillus sp. Amoxycillin 500mg PO q8h Clindamycin 150-300mg PO used as an adjunct to local mechanical
Veillonella sp. PLUS q6h and chemical debridement.
P. gingivalis Metronidazole 400mg PO q8h
Prevotella intermedia Also irrigation with Chlorhexidine and
F. nucleatum optimal oral hygiene by patient.

Locally delivered antibiotics is preferred


compared to systemic administration
Currently there is no reliable study to

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
suggest most effective antibiotic therapy.

Eur J Oral Implantol 2012; 5 (Suppl): S21-S41


Clin Oral Impl Res 2012 (23): 205-210
Int.J Oral Maxillofac Implants 2014 (29): 325-
345
Maintenance system -CIST protocol
Clin Oral Impl Res 2000:11(suppl): 146-155
2. ANTIMICROBIAL USE FOR FUNGAL INFECTIONS
A. Oral Candidiasis
Acute Pseudomembranous Topical antifungal Am Fam Physician. 2008;78(&):845-852
Candidiasis Journal of Oral Microbiology 2011,3:5771-DOI:
10.3402/jom.v3i0.5771
Med Oral Patol Oral Cir Bucal. 2011 Mar
Hyperplastic Candidiasis Nystatin (oral suspension) 1:16(2):el 39-43
(Candidal Leukoplakia) 500,000-1,000,000U 6-8h /day Australia Dental Journal 2010; 55:(1 suppl):48
(to continue for 2 days after
perioral symptoms disappeared
or cultures show eradication of
candida sp.)

Systemic antifungal for severe


infections,immunocompromised
patients and for infections
resistant to topical antifungal:

Fluconazole 50-100mg PO/IV


q24h for 2 weeks
OR
Itraconazole 100mg PO q24h
for 2 weeks
Chronic Erythematous Local measures- denture Am Fam Physician. 2008;78(&):845-852
Candidosis cleansers, remove dentures at Journal of Oral Microbiology 2011,3:5771-DOI:
10.3402/jom.v3i0.5771
(candida-associated denture night Med Oral Patol Oral Cir Bucal. 2011 Mar

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
stomatitis with and without 1:16(2):el 39-43
angular chelitis) Soak dentures in Chlorhexidine Australia Dental Journal 2010; 55:(1 suppl):48-54
mouthwash 2%

Topical antifungals if local


measures fail -Nystatin (oral
suspension)
500,000-1,000,000U q6h-8h
(to continue for 2 days after
perioral symptoms disappeared
or cultures show eradication of
candida sp.)
3. ANTIMICROBIAL USE FOR VIRAL INFECTIONS
Common oral viral infections: Symptomatic treatment in Aust Dent J 2005;50 Suppl 2: S31-S35
Herpes simplex virus type 1 most cases.
(HSV-1)
- Primary herpetic Can also consider :
gingivostomatitis 1)Topical Acyclovir 5% cream
- Herpes labialis q4h for 5-10 days in prodromal
Herpes simplex virus type 2 phase for recurrent herpes
(HSV-2) labialis
Epstein-Barr virus 2) Systemic antiviral
Eg : Infectious Acyclovir 400-800mg PO 5
mononucleosis, oral hairy times daily for 7-14 days
leukoplakia
Varicella-zoster virus OR

Acyclovir 5mg/kg IV q8h for 5


Coxsackie virus days for severe infection or
- Herpangina immunocompromised patients
- Hand, foot and mouth disease
OR

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Acyclovir 10mg/kg IV q8h for
10-21 days for varicella zoster
in immunocompromised and
simplex encephalitis

ORAL / DENTAL SURGERY PROPHYLAXIS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Clean Surgery (Class 1) Not Indicated for most Prophylaxis is recommended for all
 Submandibular gland surgery surgeries patients with an increased risk of surgical
 TMJ surgery wound infection - i.e. in immune-
 Excision of benign tumours / May be indicated compromised patients
cysts i. if the duration of the
Minor Clean-contaminated surgery is expected to be
surgery (Class 2) very long
 Soft tissue surgery ii. for open reduction and
 Dentoalveolar surgery internal fixation of facial
 Periodontal surgery bone fractures
Minor Clean-contaminated Amoxycillin 1gm PO Amoxycillin/Clavulanate
surgery (Class 2) OR 1.2gm PO/IV
 Insertion of dental implants Clindamycin 600mg PO/IV OR
and use of graft material OR Cefuroxime 500mg PO/
 High degree of difficulty / Benzyl penicillin 2MU IV 1.5gm IV
long duration OR
Ampicillin/Sulbactam 1.5gm
IV
Major Clean-contaminated Benzyl penicillin 2MU IV Amoxycillin/Clavulanate For oral & maxillofacial fractures,
surgery (Class 3) OR 1.2gm IV antibiotics are recommended for the
 Orthognathic surgery Clindamycin 600mg IV OR immediate post trauma period and should
 Excision / enucleation of large Cefuroxime 1.5gm IV be discontinued once open reduction and
benign tumours / cysts OR internal fixation is completed.

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 All oral cancer surgery Ampicillin/Sulbactam 1.5gm
 Open reduction and internal IV
fixation of facial bone
fractures
Doses listed are adult doses - for paediatric patients adjust according to age/body weight.
References from KKM CPG: Antibiotic Prophylaxis against Wound Infections for Oral Surgical Procedures 2003 (Reviewed 2014).

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MEDICAL
DEPARTMENT

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Index:
- Streptococcus viridans - HACEK microorganisms
- Nutritionally variant streptococci - Candida
- Staphylococcus aureus and Coagulase-negative staphylococcus - Non-HACEK Gram- negative microorganisms
- Staphylococcal endocarditis in the presence of a prosthetic - Therapy for other microorganisms
valve or other prosthetic material
- Enterococcus species

CARDIOVASCULAR INFECTIONS

Streptococcus viridans

Endocarditis due to penicillin-susceptible viridans group streptococci (VGS) and S gallolyticus (bovis)
Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Penicillin-susceptible VGS and S. gallolyticus (bovis) (MIC ≤ 0.125 µg/ml) – native and prosthetic valve
Benzyl penicillin (Crystalline 3MU* every 4 to 6 hourly or 12-18 4 (native) * MU = mega unit; 600mg = 1MU
penicillin) MU/day as a continuous infusion 6 (prosthetic)
Ampicillin 2 g IV 4 hourly
Ceftriaxone 2 g IV once daily
Vancomycina,b 15-20 mg/kg/dose (actual body Vancomycin therapy is
weight) IV every 8-12 hourly; not to recommended only for patients
exceed 2 g/dose with immediate-type penicillin
hypersensitivity.
Relatively resistant to penicillin VGS and S. gallolyticus (bovis) (MIC > 0.125 to 2 µg/ml) – native valve endocarditis
Benzyl penicillin (Crystalline 4 MU 4 hourly or 24 MU/day as 4 (native) * MU = mega unit; 600mg = 1MU
penicillin) continuous infusion 6 (prosthetic)
OR Cephalosporins may be substituted
Ceftriaxone 2 g IV once daily for penicillin in patients whose
penicillin hypersensitivity is not of
PLUS the immediate type
See notes below on how to monitor
(Low dose) Gentamicinc 3 mg/kg/day IV once daily 2 (native) for gentamicin toxicity
6 (prosthetic)

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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Vancomycina,b 15-20 mg/kg/dose (actual body 4 (native) Vancomycin therapy is
weight) IV every 8-12 hourly; not to 6 (prosthetic) recommended only for patients
PLUS exceed 2 g/dose with immediate-type penicillin
hypersensitivity

(Low dose) Gentamicinc 3 mg/kg/day IV once daily 2 (native) See notes below on how to monitor
6 (prosthetic) for gentamicin toxicity
a. Vancomycin: aim for serum trough level of 10 – 15 mg/l.
b. Vancomycin dose should be adjusted in patients with renal impairment.
c. For patients on gentamicin:
 Monitor gentamicin level and renal function weekly. There should be a low threshold for stopping gentamicin in patients with deteriorating renal
function or other signs of toxicity.
 When given in a single daily dose give infusion over 30 minutes. Aim for pre-dose (trough) serum level of < 1 mg/l.
 Consider biweekly clinical screening for ototoxicity:
 Check baseline visual acuity using a Snellen pocket card.
 To screen for ototoxicity, have patient shake head and reread the card.
 Consider formal audiology test if patient loses 2 lines of visual acuity.

Nutritionally variant streptococci


 Abiotrophia defective and Granulicatella species (both formerly known as nutritionally variant streptococci; NVS)
Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Ampicillin 2 g IV 4 hourly 6 Follow susceptibility test results, if
OR available
Benzyl penicillin (Crystalline 4 MU IV 4 hourly or 24 MU/day as
penicillin) a continuous infusion). * MU = mega unit; 600mg = 1MU

PLUS

(Low dose) Gentamicinc 1 mg/kg IV 8 hourly 2 See notes below on how to monitor
for gentamicin toxicity

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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Ceftriaxone 2 g IV once daily 6 Ceftriaxone is preferred if
PLUS clinically not responding with
(Low dose) Gentamicinc 1 mg/kg IV 8 hourly 2 penicillin
Vancomycina,b 15-20 mg/kg/dose (actual body 6 Vancomycin therapy is
weight) IV every 8-12 hourly; not to recommended only for patients
exceed 2 g/dose with immediate-type penicillin
hypersensitivity
a. Vancomycin: aim for serum trough level of 10 – 15 mg/l.
b. Vancomycin dose should be adjusted in patients with renal impairment.
c. For patients on gentamicin:
 Monitor gentamicin level and renal function weekly. There should be a low threshold for stopping gentamicin in patients with deteriorating renal
function or other signs of toxicity.
 When given in a single daily dose give infusion over 30 minutes. Aim for pre-dose (trough) serum level of < 1 mg/l.
 Consider biweekly clinical screening for ototoxicity:
 Check baseline visual acuity using a Snellen pocket card.
 To screen for ototoxicity, have patient shake head and reread the card.
 Consider formal audiology test if patient loses 2 lines of visual acuity.

Staphylococcus aureus and Coagulase-negative staphylococcus


 Native valve endocarditis due to S. aureus
Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Methicillin-susceptible staphylococci (MSSA) – left-sided
Cloxacillin 12 g/day IV in 4-6 equally divided 4-6
doses
Methicillin-susceptible staphylococci (MSSA) – right-sided; tricuspid valve
Cloxacillin 12 g/day IV in 4-6 equally divided 2-4; see comments 2 weeks regime is sufficient
doses provided the patient fulfils all the
following criteria:
 MSSA
 Good response to treatment

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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
 Absence of metastatic sites of
infection or empyema
 Absence of cardiac and
extracardiac complications
 Absence of associated
prosthetic valve or left-sided
valve infection
 < 20 mm vegetation
 Absence of severe
immunosuppression (< 200
CD4 cells/ml) with or without
acquired immune deficiency
syndrome (AIDS)
Regimens for β-lactam allergic patients – both left-sided and right-sided
Cefazolin 2 g IV 8 hourly 4-6 Cephalosporins should be avoided
in patients with immediate-type
hypersensitivity to penicillin.
Cefazolin has inadequate blood-
brain barrier penetrability. In cases
of brain abscesses complicating
MSSA IE, watch out for treatment
failure.
Vancomycina,b 15-20 mg/kg/dose (actual body 4-6 Loading dose of 25-30 mg/kg
weight) IV every 8-12 hourly; not to (actual body weight) may be
exceed 2 g/dose considered for seriously ill
patients.

Vancomycin is inferior to
cloxacillin for treatment of MSSA.

Vancomycin therapy is
recommended only for patients

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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
with immediate-type penicillin
hypersensitivity
Methicillin-Resistant Staphylococci (MRSA) – left-sided and right-sided
Vancomycina,b 15-20 mg/kg/dose (actual body 4-6 Loading dose of 25-30 mg/kg
weight) IV every 8-12 hourly; not to (actual body weight) may be
exceed 2 g/dose considered for seriously ill patients
Daptomycin 10 mg/kg IV daily 4-6 Daptomycin is superior to
Vancomycin for MRSA
bacteraemia with vancomycin MIC
> 1 mg/l
a. Vancomycin: aim for serum trough level of 10 – 15 mg/l.
b. Vancomycin dose should be adjusted in patients with renal impairment.

Staphylococcal endocarditis in the presence of a prosthetic valve or other prosthetic material


Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Methicillin-susceptible staphylococci (MSSA)
Cloxacillin 2 g IV 4 hourly ≥6 Allergy to penicillin but not
immediate- type hypersensitivity
PLUS use cefazolin or vancomycin

Rifampicin 300-450 mg PO 12 hourly ** ≥6 Immediate-type hypersensitivity to


penicillin use vancomycin
PLUS
**Rifampicin has better
(Low dose) Gentamicinc 1 mg/kg IV 8 hourly 2 penetration. However to avoid the
development of resistance, it
should be started after 3–5 days of
effective initial cloxacillin therapy
and/or once the bacteraemia has
been cleared.

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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Methicillin-Resistant Staphylococci (MRSA)
Vancomycina,b 15-20 mg/kg/dose (actual body ≥6 For adults, loading dose of 25–30
weight) IV every 8-12 hourly; not to mg/kg (actual body weight) may be
PLUS exceed 2 g/dose considered for seriously ill
patients.
Rifampicin 300 – 450 mg PO 12 hourly ** ≥6
**Rifampicin has better
PLUS penetration. However to avoid the
development of resistance, it
(Low dose) Gentamicinc 1mg/kg IV 8 hourly 2 should be started after 3–5 days of
effective initial vancomycin
therapy and/or once the
bacteraemia has been cleared.
a. Vancomycin: aim for serum trough level of 10 – 15 mg/l.
b. Vancomycin dose should be adjusted in patients with renal impairment.
c. For patients on gentamicin:
 Monitor gentamicin level and renal function weekly. There should be a low threshold for stopping gentamicin in patients with deteriorating renal
function or other signs of toxicity.
 When given in a single daily dose give infusion over 30 minutes. Aim for pre-dose (trough) serum level of < 1 mg/l.
 Consider biweekly clinical screening for ototoxicity:
 Check baseline visual acuity using a Snellen pocket card.
 To screen for ototoxicity, have patient shake head and reread the card.
 Consider formal audiology test if patient loses 2 lines of visual acuity.

Enterococcus species
 Endocarditis due to enterococcus- native and prosthetic valve
Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Fully penicillin-susceptible strains (penicillin MIC ≤ 8 mg/l)
Ampicillin 2 g IV 4 hourly 4 or 6 depending on duration of Duration of symptoms < 3 months
symptoms and type of valve; see and native valve:

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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
PLUS comments Ampicillin duration - 4 weeks
Gentamicin duration - 2 weeks
(Low dose) Gentamicinc 1 mg/kg IV 8 hourly 2 or 6 depending on duration of
symptoms and type of valve; see Duration of symptoms > 3 months
comments or prosthetic valves:
Ampicillin duration - 6 weeks
Gentamicin duration - 6 weeks

See notes below on how to monitor


for gentamicin toxicity

For patients who develop renal


impairment or ototoxicity
secondary to gentamicin switch to
ampicillin/ceftriaxone regime
Ampicillin 2 g IV 4 hourly 6 Preferred in patients with renal
impairment (≤ 50 m/min) or
PLUS elderly

Ceftriaxone 2 g IV 12 hourly Ceftriaxone should not be used


alone for enterococcus infection, as
they are intrinsically resistant

This combination is not active


against E. faecium
Sensitive to penicillin and vancomycin but high level resistance to gentamicin (MIC > 500 mg/l)
Ampicillin 2 g IV 4 hourly 6 Ceftriaxone should not be used
alone for enterococcus infection, as
PLUS they are intrinsically resistant

Ceftriaxone 2 g IV 12 hourly This combination is not active


against E.faecium

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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Resistant to penicillin and susceptible to aminoglycosides and vancomycin
Vancomycina,b 15-20 mg/kg/dose (actual body 6
weight) IV every 8-12 hourly; not to
PLUS exceed 2 g/dose

(Low dose) Gentamicinc 1 mg/kg IV 8 hourly 6

a. Vancomycin: aim for serum trough level of 10 – 15 mg/l.


b. Vancomycin dose should be adjusted in patients with renal impairment.
c. For patients on gentamicin:
 Monitor gentamicin level and renal function weekly. There should be a low threshold for stopping gentamicin in patients with deteriorating renal
function or other signs of toxicity.
 When given in a single daily dose give infusion over 30 minutes. Aim for pre-dose (trough) serum level of < 1 mg/l.
 Consider biweekly clinical screening for ototoxicity:
 Check baseline visual acuity using a Snellen pocket card.
 To screen for ototoxicity, have patient shake head and reread the card.
 Consider formal audiology test if patient loses 2 lines of visual acuity.

HACEK microorganisms
 Therapy for endocarditis due to HACEK microorganisms (Haemophilus Parainfluenza, Aggregatibacter aphrophilus, Aggregatibacter
actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) both native and prosthetic valve
Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Penicillin-susceptible VGS and S. gallolyticus (bovis) (MIC ≤ 0.125 µg/ml) – native and prosthetic valve
Ceftriaxone 2 g IV once daily 4 (native) HACEK-group bacilli produce
6 (prosthetic) beta-lactamases; definitive
OR treatment should be adjusted based
on the cultures.

Ampicillin + Sulbactam 3 g IV 6 hourly 4 (native) May be an option if isolate is


6 (prosthetic) susceptible.

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Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
OR

Ciprofloxacin 400 mg IV 12 hourly or 4 (native) If unable to tolerate cephalosporin


500 mg PO 12 hourly 6 (prosthetic) and ampicillin therapy.
Fluoroquinolones generally not
recommended for patients < 18
years old.

Candida
 Therapy for Candida endocarditis (native and prosthetic valve)
Antimicrobial Dosage and Route Duration of therapy (Weeks) Comments
Penicillin-susceptible VGS and S. gallolyticus (bovis) (MIC ≤ 0.125 µg/ml) – native and prosthetic valve
Amphotericin B deoxycholate 0.6-1.0 mg/kg IV once daily At least 6 weeks after surgery Step down therapy – Fluconazole
400-800mg (6-12mg/kg) orally
OR daily for susceptible
microorganism in stable patients
Lipid formulation Amphotericin B 3-5 mg/kg IV once daily with negative blood cultures
(clearance of Candida from blood
With or without stream)

Flucytosine 25 mg/kg PO 6 hourly At least 6 weeks after surgery For synergistic effect.
Causes dose related marrow
toxicity.
Avoid using in patients with renal
failure.
Micafungin 150 mg IV daily At least 6 weeks after surgery Step down therapy – Fluconazole
400-800mg (6-12mg/kg) orally
Caspofungin 150 mg IV daily daily for susceptible micro-
organism in stable patients with
Anidulafungin 200 mg IV daily negative blood cultures (clearance
of Candida from blood stream)

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 Valve replacement is mandatory. Continue therapy for 6 weeks after replacement or longer in patient with perivalvular abscess.
 The duration of therapy will depend on patient response and surgical intervention.
 For patients who cannot undergo valve replacement, long-term suppression with fluconazole at a dosage of 400-800 mg (6-12 mg/kg) daily is
recommended.
 For PVE, the recommendations above apply, and suppressive therapy should be lifelong if valve replacement is not possible.

Non-HACEK Gram- negative microorganisms


 This includes microorganisms such as Pseudomonas aeruginosa, Escherichia coli and Salmonella. The choice of antimicrobials for these
microorganisms depends on antimicrobial susceptibility pattern. Commonly combination therapy with β-lactam (column A) and
aminoglycosides or fluoroquinolones (column B) are used (refer Table below). Medical therapy often needs to be combined with cardiac
surgery. The duration of therapy is 6 weeks.
Antimicrobial choices for pseudomonas endocarditis (6 weeks duration)
Column A Column B
Anti Pseudomonal β-lactams Aminoglycosides
Ceftazidime 2 g IV 8 hourly Gentamicin 5-7 mg/kg IV daily
Cefepime 2 g IV 8 hourly Amikacin 15 mg/kg IV daily
Piperacillin-tazobactam 4.5 g IV 6 hourly OR
Flouroquinolones*
Ciprofloxacin 400 mg IV 8 hourly
Levofloxacin 750 mg IV daily
*Flouroquinolones can be switched to appropriate oral dose if patient can tolerate oral medications.

Therapy for other microorganisms


Pathogen Antimicrobial Dosage and Route Duration of Therapy
Brucella spp. Doxycycline 100 mg PO 12 hourly 3-6 months
PLUS
Rifampicin 300 - 600 mg PO daily

ADD (For first 2-3 weeks only)


Streptomycin 1 g IM daily
OR
Gentamicin 5 mg/kg IV daily

24 | P a g e
Pathogen Antimicrobial Dosage and Route Duration of Therapy
C. burnetii Doxycycline 100 mg PO 12 hourly 18 – 24 months based on clinical
(agent of Q fever) PLUS and serological response
Hydroxychloroquine 600 mg PO daily or 200 mg PO 8
hourly
Bartonella spp. Doxycycline 100 mg PO 12 hourly 2 weeks
PLUS
Gentamicin 3 mg/kg IV daily

25 | P a g e
Index:
MENINGITIS (ACUTE) Viral encephalitis
- Empirical treatment MENINGITIS (CHRONIC)
- Haemophilus influenzae - Tuberculous meningitis
- Streptococcus pneumoniae - Cryptococcal meningitis
- Neisseria meningitidis - Neurosyphilis
- Enterobacteriaceae - HIV related CNS infection

CENTRAL NERVOUS INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
MENINGITIS (ACUTE)
Common organisms: Empirical treatment on If no clinical response after 3 Antibiotic treatment must be started
Streptococcus pneumoniae admission: days of antibiotics: immediately, regardless of any
Neisseria meningitidis Ceftriaxone 2gm IV q12h. Meropenem 2gm IV q8h. investigations undertaken. If no organism
Haemophilus influenzae OR isolated and patient is responding,
Cefotaxime 2-4gm IV q8h. continue antibiotics for 14 days. ·
Other organisms:
Gram negative rods Dexamethasone 10mg IV
Leptospirosis q6h is recommended to be
Scrub typhus administered 15 to 20
Melioidosis minutes before or at the time
Mycoplasma pneumoniae of first dose of antibiotics,
for up to 4 days or until there
is no evidence of
pneumococcal meningitis.
Causative organism isolated:
Haemophilus influenzae Ceftriaxone 2gm IV q12h Meropenem 0.5-2.0gm IV
(Gram-ve bacilli) OR q8h
Cefotaxime 2-4gm IV q8h OR
OR Cefepime 2gm IV q12h.
Ceftazidime 2gm IV q8h.
If organism is susceptible:

26 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Duration of treatment: 10-14 Chloramphenicol 1gm IV
days. (very ill patients may q6h for 14 days.
require treatment for 21
days.)
Streptococcus pneumoniae Penicillin-sensitive strains For penicillin resistant Tunkel, et al. Practice Guidelines for the
(Gram +ve cocci) Benzylpenicillin 4MU IV q4- strains Management of Bacterial Meningitis. Clin Inf Dis
2004; 39:1267-84.
6h for 10-14 days. Vancomycin 1gm IV q12h

Relatively-resistant strains PLUS


Ceftriaxone 2gm IV q12h
OR Ceftriaxone 2gm IV q12h
Cefotaxime 2-4gm IV q8h OR
for 10-14 days Cefotaxime 2-4gm IV q8h
OR (either)
Duration of treatment: 10-14 1. Meropenem 2gm IV q8h
days.(very ill patients may 2. Cefepime 2gm IV q12h.
require treatment for 21 3. Fluroquinolone PLUS
days.) Rifampicin
Neisseria meningitidis Ceftriaxone 2gm IV q12h Chloramphenicol 1gm IV Close contacts are defined as those
(Gram –ve cocci) OR q6h. individuals who have had contact with
Cefotaxime 2-4gm IV q8h oropharyngeal secretions either through
OR kissing or by sharing toys, beverages, or
Ceftazidime 2gm IV q8h. cigarettes.

Prophylaxis for household and Ciprofloxacin 500mg PO as Ceftriaxone 250mg IM as East Kent Hospitals University Foundation Trust
close contacts for single dose; single dose (especially in Antimicrobial Guidelines, 2012.
meningococcal meningitis OR pregnancy);
Rifampicin 600mg PO q12h OR
for 2 days (4 doses) [not Azithromycin 500mg PO as
recommended in pregnant single dose.
women].

27 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Gram-negative Ceftriaxone 2gm IV q12h. References
Enterobacteriaceae OR Woehrl B, Klein M,Grandgirard D,
Koedel U, Leib S. Bacterial meningitis: current
Cefotaxime 2-4gm IV q8h. therapy and possible future treatment options
Expert Rev Anti Infect Ther 2011; 9(11), 1053–
Duration of treatment: 10-14 1065.
days. (Very ill patients may Tunkel, et al. Practice Guidelines for the
Management of Bacterial Meningitis. Clin Inf Dis
require treatment for 21 2004; 39:1267-84.
days.)
Viral encephalitis IV Acyclovir 10mg/kg q8h Treat for 2-3 weeks if HSV encephalitis
proven by PCR:
 Early stages has polymorph
predominance
 5-10% normal CSF early stages

Stop early if:


 An alternative diagnosis has been
made, or
 HSV PCR in the CSF is negative on
two occasions 24-48 hours apart, and
MRI is not characteristic for HSV
encephalitis,
 HSV PCR in the CSF is negative once
> 72 hours after neurological symptom
onset, with unaltered consciousness,
normal MRI (performed >72 hours
after symptom onset), and a CSF
white cell count < 5 x 106/L
MENINGITIS (CHRONIC)
Tuberculous meningitis Intensive 2 months S/EHRZ Infection in HIV patients: Medium dose steroid cover for MRC
(Mycobacterium tuberculosis) and 10 months HR Recommendations for the stage 2 and 3 patients:
treatment of TB in HIV- Dexamethasone 12 - 16 mg daily in
Isoniazid (H) 5 (4-6) infected adults are identical divided doses for 6 weeks in tapering

28 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
mg/kg/24h PO to those for HIV-uninfected doses (intravenously initially, then switch
(max: 300 mg/day) adults when the disease is to oral when safe to do so). Alternatively,
PLUS caused by organisms that are oral prednisolone 30-40mg/24h in
Rifampicin (R) 10 (8-12) known or presumed to be tapering doses for 6 weeks.
mg/kg/24h PO susceptible to the first-line
(max: 600 mg/day) drugs. Reference:
PLUS CPG on management of Tuberculosis, 3rd
edition, 2012; 16, 22, 40-42, 56)
Pyrazinamide (Z) 25 (20-30) Daily dosing is WHO Treatment of Tuberculosis Guidelines, 4th ed.
mg/kg/24h PO (max: 2000 recommended rather than 2009
mg/day) intermittent dosing.
PLUS *Requires DG approvals
Streptomycin (S) 15 (12-18) Rifampicin is not
mg/kg/24h IM (max: 1000 recommended in
mg/day) combination with all protease
inhibitors (PIs) and rifabutin
Pyridoxine 10- 50mg PO should be used with PI-based
q24h needs to be prescribed HAART for HIV-TB co-
together with Isoniazid. infected adults.
MDR-TB:
(Streptomycin should replace Combination of one drug
Ethambutol in TB meningitis from each of the groups
as it crosses BBB better than below:-
Ethambutol.) Group 1 – Pyrazinamide,
Ethambutol, Rifabutin*
Treatment is continued for 12 Group 2 – Kanamycin*,
months. Amikacin, Capreomycin* (if
resistant to Kanamycin or
Amikacin)
Group 3 – Levofloxacin,
Moxifloxacin
Group 4 – Ethionamide*,
Cycloserine*, p-
Aminosalicylic Acid (PAS)*

29 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Group 5 – not routinely used
except in XDR-
TB:Clofazimine*, Linezolid,
Amoxicillin/Clavulanate,
Clarithromycin, Imipenem
Cryptococcal meningitis Induction Therapy: End point of treatment: till at least total of
Cryptococcus neoformans Amphotericin B 0.7-1 1.5-2.0gm of Amphotericin B given and
mg/kg/24h IV CSF shows clearance of fungus by 2
negative C&S one month apart, and CSF
PLUS Cryptococcal antigen titre becomes
negative or at least 1:2 or shows a
5-Flucytosine 100mg/kg/24h fourfold decrease.
PO q6h for 2-4 weeks. Liposomal Amphotericin may be used in
OR cases of severe toxicity to Amphotericin B
Fluconazole 400mg PO e.g. Abelcet 3-5mg/kg/day
q12h.
References:
Consolidation Therapy: Clin Infect Dis. Jul 1 2008; 47(1):123-30.
Clin Inf Dis 2010; 50: 291-322.
Fluconazole 400-800mg PO N Eng J Med 2013; 368: 1291-1302.
q24h for 8 weeks. Antimicrobial Agents And Chemotherapy
2007;51(3): 1038-1042
Neurosyphilis Refer to section (Sexually Treatment same for neurosyphillis in
Transmitted Infections) patients with HIV infection
Reference:
2010 CDC STD Treatment Guidelines; 32-33.
HIV related CNS infection Refer to section (Human
Immunodeficiency Virus)

30 | P a g e
Index:
A. HAEMATOLOGY  Cytomegalovirus (CMV) Disease
- Potential pathogens in immunocompromised patients - CMV retinitis
- Antifungal agent dosing - Extraocular CMV diseases
- Prophylaxis against bacterial, viral or fungal infections  Bacterial enteric infections
- Infections following haematopoietic stem cell transplant - Salmonellosis
- Shigellosis
B. HUMAN IMMUNODEFICIENCY VIRUS (HIV) - Campylobacteriosis
 Pneumocystis Pneumonia (PCP)  Herpes Simplex Virus (HSV) Infections
- Interstitial pneumonia - Genital or orolabial
- Prophylaxis (primary and secondary)  Varicella-Zoster Virus Diseases
 Mucocutaneous Candidiasis - Shingles, primary Varicella infection (Chickenpox), progressive
- Oropharyngeal (Oral thrush) outer retinal necrosis (PORN), acute retinal necrosis (ARN)
- Oesophageal  Histoplasmosis
- Vulvovaginal - Moderate- to-severe disseminated disease
 Cryptococcal Meningitis or Meningoencephalitis - Less severe disseminated disease
- Initial treatment - Chronic suppresive therapy (secondary prophylaxis)
- Maintenance therapy  Isospora belli Infection
 Toxoplasma Gondii Encephalitis  Nocardia Infection
- Acute infection  Penicilliosis
- Suppressive/Maintenance therapy - Acute infection
- Primary prophylaxis - Maintenance therapy/secondary prophylaxis
 Mycobacterium Avium Complex (MAC) disease  Progressive Multifocal Leukoencephalopathy (PML)
- Treatment  Cryptosporidiosis
- Mainternance/Secondary prophylaxis
C. SOLID TRANSPLANT

INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

31 | P a g e
A. HAEMATOLOGY

1. Any infection in the immunocompromised host is life-threatening and needs immediate attention. Febrile neutropenia is defined as a temperature of
>38.3oC on a single occasion or >38oC over one hour and ANC (Absolute Neutrophil Count) <500cells/uL or <1000cells/uL in those with anticipated
declining counts.

2. Cultures maybe positive in less than 40% of cases. Patients have impaired inflammatory responses and hence may have no localizing signs. The usual
sign is fever>38oC or hypothermia. The common portals of infection include the oral cavity, gastrointestinal tract, perianal region, lungs and IV lines.

3. Potential pathogens are dependent on the underlying defect, e.g.

Neutropaenia Gram –ve organisms Gram +ve organisms Fungi


Hypogammaglobulinaemia
Encapsulated organisms
Post splenectomy/ hyposplenic patients
Pneumocystis,Toxoplasma
Defective cellular immunity
Fungi, Viruses Mycobacteria

4. The choice of antibiotic is based on local organisms and sensitivity patterns. This should be based on sound clinical judgment, the clinical state of the
patient, prior infections with drug resistant bacteria, recent outbreaks e.g. MRSA or multi-drug resistant Enterobacteriaceae, as well as the availability and
cost of the antibiotics. Surveillance for CRE, Stenotrophomonas maltophilia and multi-resistant organisms should be carried out by the infection control
team of the respective hospitals. If this service is not available, the hospital should set up a local surveillance team to monitor these organisms. The
incidence of these organisms must be borne in mind when selecting agents for use in the first line setting

5. Risk assessment for complication of severe infection should be done during triage. Patient are deemed high risk if there is prolonged and profound
ANC< 0.1x109/L, hypotension, pneumonia, new onset abdominal pain or neurological signs, and should be admitted to hospital for IV antibiotics.

6. The administration of the first dose of empirical anti-pseudomonal antibiotic should be done as soon as possible following triage (within the first hour)
after taking blood cultures. The following regimens are suggested:

a. First lline therapy: Piperacillin/Tazobactam 4.5gm IV q6h OR Cefepime 2gm IV q8h. Aminoglycosides e.g Gentamicin or Amikacin may be added
in combination therapy prior knowing sesitivity results. Ceftazidime 2gm IV q8h can be used as an alternative. Duration: until neutrophils count
recovers to > 500 /u or longer if clinically indicated (> 1 x 109/L)

b. Second line therapy: Carbapenem; Imipenem 500mg IV q8h/q6h OR Meropenem 1gm q8h. Imipenem 1gm q8h is used in severe sepsis.

32 | P a g e
c. Monotherapy is likely just as efficacious and less toxic. Drugs that can be used as monotherapy are Piperacillin/Tazobactam, Cefepime, Imipenem or
Meropenem

d. Anaerobic infections account for <5% of all cases of bactaeraemia. Metronidazole 500mg IV q8h may be added to cefipime in the presence of severe
mucositis, intra abdominal infections, peri-anal abscesses or colitis. Piperacillin/Tazobactam and Carbapenems have good anaerobic coverage and
therefore do not need additon of metronidazole.

e. Glycopeptide therapy e.g. Vancomycin is not recommended as a standard part of the initial antibiotic regimen. Vancomycin 15mg/kg IV q12h OR
q8h may be added in suspected central device infections, known colonizers by MRSA, severe mucositis, sikin or soft tissue infection suspected
MRSA/MRSE infections and severe sepsis, septic shock or respiratory distress. Consider stopping after 48 hr if no microbiological evidence of
gram positive infection. Linezolid is an alternative in those patients with no clinical response to Vancomycin and in those with suspected or
confirmed VRE, VISA or VRSA.

f. Consider adding antifungal therapy if fever persisted or evidence of new infection after 5 to 7 days of broad spectrum antibiotic therapy or earlier
especially jn the presence of severe mucositis, oral thrush, painful swallowing, suspicious skin infiltrates or pulmonary infiltrates, fundal exudates or
prolonged steroid/antibiotic use more than 2 weeks). Amphotericin B remains the empirical therapy of choice for invasive fungal infections. For
patients who are intolerant, refractory or those with toxicity to conventional Amphotericin B, the lipid formulations of Amphotericin B, Voriconazole
and Echinocandins are alternatives empirical therapy based on local availability and costs. Voriconazole is an alternative to Amphotericin B for
preemptive and directed therapy for invasive aspergillosis. In candidiasis, echinocandins, azoles and ampho B are antifungals of choice.

Antifungal agent Daily dose


Liposomal ampho B 3 mg/kg
Caspofungin Load 70mg followed by 50 mg
ABCD 4 mg/kg
ABLC 5 mg/kg
Itraconazole 200 mg BD
Ampho B deoxycholate 0.5-1 mg/kg
Fluconazole 400 mg
Voriconazole 6 mg/kg BD followed by 4 mg/kg bd
Posaconazole 600 mg
ABCD: amphotericin B colloidal dispersion ABLC: amphotericin B lipid complex

g. The use of growth factors e.g.G-CSF may be considered as prophylactic use. The prophylactic use of growth factors significantly reduced the
relative risk for severe neutropenia, febrile neutropenia and infection. It should be considered in high-risk patients with ANC<100/uL multiple organ

33 | P a g e
dysfunction syndrome, pneumonia, invasive fungal infections or septic shock. However, there is no evidence that either G-CSF reduced the number
of patients requiring intravenous antibiotics or lowered infection related mortality.

h. The role of granulocytes remains controversial and should be discussed with haematologist. Granulocyte transfusions may be used in patients with
serious bacterial or fungal infections not responding to appropriate treatment and who will likely recover in the neutrophil count in the short term. The
risk of disease transmission e.g. CMV must be borne in mind.

i. The use of oral antibiotics with Ciprofloxacin and amoxicillin / Clavulanate, may be considered after careful assessment of risk factors and a
consult from the haematologist, in an outpatient setting for low risk patients (i.e no evidence of dehydration or hypotension, no evidence of
pneumonia/COAD) and it is important that patients must be able to access prompt medical attention if condition deteriorates.

j. Prophylaxis against bacterial, viral or fungal infections is advised after bone marrow or haematopoietic stem cell transplantation or in high-risk
patient after chemotherapy.

Disease / therapy Examples Antibacterial prophylaxis Duration


Antibacterial Autologous HSCT Ciprofloxain Start at time of conditioning.

Allogenic HSCT Penicillin V Until resolution of neutropenia or initiation


antibacterial therapy for febrile neutropenia
Post transplant until is continuation of
immunosuppresion
Antifungal AML Fluconazole During neutropenia until resolution and
achievement of complete remission.

CML in blast crisis

Autologous HSCT

Allogenic HSCT Until resolution of neutropenia


Antiviral Autologous HSCT Acyclovir During 30 days after HSCT.
OR
Allogenic HSCT Valacyclovir

Bortezomib (only in myeloma Until discontinuation of Bortezomib.


patients)

34 | P a g e
Purine Analog therapy At least 3 months after discontinuation of
(fludarabine / cladribine) purine analog.
Anti PCJ therapy Autologous HSCT Allogenic Co-trimoxazole Start when achieved engraftment, continue
HSCT until resolution of immunosuppression.

Purine Analog therapy At least 3 months after discontinuation of


purine analog.
(HSCT: haematopoietic stem cell transplant)

k. Infections following haematopoietic stem cell transplant are generally similar to that in the solid organ transplant setting. In addition to the usual
bacterial, fungal infections and viral infections especially CMV reactivation and parasitic infections e.g. Pneumocystis jiroveci (PCJ) and Toxoplasma
infection can occur. It is recommended that prophylactic use of Ganciclovir or pre-emptive monitoring for CMV reactivation should be carried out
during the first 100 days. Trimethoprim/ Sulphamethoxazole 480mg once daily or 960mg 3x/week is, also extremely effective in the prevention of
PCJ or toxoplasmosis. It is recommended that these measures be continued in patients with active graft-vs-host disease and in those remaining on
high dose immunosuppressive agents.

1st line Piperacillin/Tazobactam 4.5gm IV q6h Aminoglycosides e.g. Gentamicin or Amikacin may be added in combination
OR
Cefepime 2gm IV q8h
2nd line Imipenem 500mg IV q8h or q6h or Carbapenems are only indicated as first line therapy in seriously ill patient
1gm q8h (severe sepsis) either presenting as septic shock, or with known previous infections with
OR ESBL enterobacteriaceae or gram-negative organisms resistant to narrow
Meropenem 1gm q8h spectrum B-lactams.
Glycopeptides Vancomycin 15mg/kg IVq 12h or q8h Colonization with MRSA or MRSE or suspicion of serious catheter related
infections or skin and soft tissue infection.
Linezolide (dose): alternative and in those suspected or infected with
VRE/VISA/VRSA should be started on
Antifungal agents Conventional Amphotericin B Liposomal Maybe added as empirical therapy from D5-7.
Amphotericin B Echinocandins Voriconazole is the preferable preemptive and directed therapy for invasive
aspergillosis

35 | P a g e
7. Attention must be paid to:

a. Strict isolation measures.


b. Patient’s personal hygiene and diet.
c. Modification of antibiotic regimen if deterioration of clinical status or if there is no clinical improvement in 72-96h in a stable patient
d. The antibiotics are generally kept for a minimal duration of 5 to 7 days or stopped if afebrile for 3 days in patients with improving neutrophil counts
e. Regular culture and surveillance
f. HANDWASHING and strict aseptic technique
g. Venous cannula must be inspected daily for signs of phlebitis and changed every 72h or when necessary. Central devices are to be removed if there is
clinical deterioration in spite of appropriate antibiotics for 48-72h.

References:
1. NCCN Clinical Practice Guidelines in Oncology V.I2006. Fever and Neutropaenia
2. Hughes W T, Armstrong D, Bodey G P et al. 2002 Guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2002 ; 34 : 730-751
3. Herbrect R, Denning D W, Patterson T F et al. Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. NEJM 2002 ; 347: 408-415
4. WalshTJ, Teppler H, Donowitz G R et al .Caspofungin versus liposomal amphotericin B for empirical antifungal therapy in patients with persistent fever and neutropaenia. NEJM
2004;351(14):1391-1402
5. Dellinger RP, Levy MM, Carlet JM et al. Surviving sepsis campaign : international guidelines for management of severe sepsis and septic shock. Intensive Care Med 2008, 34 : 17-60
6. Bohlius J, Herbst C, Reiser M, Schwarzer G, Engert A. Granulopoiesis-stimulating factors to prevent adverse effects in the treatment of malignant lymphoma. Cochrane Database
of Systematic Reviews 2008, Issue 4.
7. Alison GF, Eirc JB, Kent A S et al. IDSA guideline : Clinical Practice guideline for the Use of Antimicrobial Agents in Neutropenic Patients with cancer :2010 update by the
Infectious Diseases Society of America . CID 2011; 52: 56-93.
8. Mica P, Sara B, Abigail F, Liat v and Leonard L. Empirical antibiotics against Gram-positive infections for febrile neutropenia : Systemic review and meta-analysis of randomized
controlled trials. J Antimicrob Chemother 2005; 55: 436-444.
9. Diana A, ChristinaO, Catherine C et al. European guidelines for empirical antibacterial therapy for febrile neutropenic patients in the era of growing resistance: summary of the
2011 4th European conference on the infections in Leukaemia. Haematologica 2013;98(12) :1826-1835
10. Paul M, Yahav D, Fraser A, et al. Empirical antibiotic monotherapy for febrile neutropenia: Systematic review and meta-analysis of randomized controlled trials. J Antimicrob
Chemother 2006;57:176-89.
11. Engelhard D. Akova M, Boeckh MJ et al. Bacterial infection prevention after hematopoietic cell transplantation. Bone marrow Transplant 2009; 44:467-470.
12. Cornely OA, Bohme A, Buchheidt D et al. Primary prophylaxis of invasive fungal infections in patients with hematologic malignancies. Recommendations of the Infectious Diseases
Working Party of the German Society for Haematology and oncology. Haematologica 2009; 94: 113-22.
13. Zaia J, Baden L, Boeckh MJ et al. viral disease protection after hematopoietic cell transplantation. Bone marrow Transplant 2009; 44:471-482.

B. Human Immunodeficiency Virus (HIV)

Important cut-offs for CD4 T cells, above which particular AIDS illnesses are improbable. These CD4 counts are only reference values; exceptions are always
possible.

36 | P a g e
No cut-off Kaposi’s sarcoma, pulmonary tuberculosis, HZV, bacterial pneumonia, lymphoma , HSV
< 250/μl PCP, esophageal candidiasis, PML, , HIV encephalopathy
< 100/μl Cerebral toxoplasmosis, , cryptococcosis, miliary tuberculosis
< 50/μl CMV end organ disease , cryptosporidiosis, atypical mycobacteriosis

The treatment regimes are based on drugs available in the Ministry of Health National Formulary and hence in some instances may vary from
internationally accepted treatments. Some regimes are chosen as preferred regimes due to cost considerations.

Reference:
Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents
Rrecommendations from the CDC, NIH and IDSA, 2013

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
PNEUMOCYSTIS PNEUMONIA (PCP)
Pneumocystic jiroveci (carinii) Trimethoprim For severe cases: Patients with severe disease should
Interstitial Pneumonia /Sulfamethoxazole 15- (PO2 < 70mmHg) receive steroids as soon as possible
20mg/kg / 75-100mg/kg/24h Pentamidine 4mg/kg/24h IV (within 72 hours of starting PCP
IV/PO (excellent (in 1 pint D5% or N/S run over treatment):
bioavailability) q6h-q8h for 1-2 hours) for 21 days
21 days Prednisolone 40mg PO q12h for 5 days
OR then 40mg PO q24h for 5 days then
20mg PO q24h for 11 days.
Primaquine 30 mg (base) PO
q24h Patients given Dapsone or primaquine
PLUS should be tested for G6PD deficiency.
Clindamycin 600 mg q6h IV/
900 mg IV q8h

For mild to moderate cases:


(PO2 70-80mmHg)
Clindamycin 600mg IV q8h/

37 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
300-450mg PO q6h-q8h
PLUS
Primaquine 30mg base PO
q24h for 21 days

OR

Dapsone 100mg PO q24h


PLUS
Trimethoprim 15mg/kg/24h
PO q8h
Prophylaxis Trimethoprim/Sulfamethoxaz Dapsone 100mg PO q24h Patients receiving pyrimethamine/
(primary and secondary) ole OR sulfadiazine for treatment or suppression
80/400mg-160/800mg PO Aerosolized Pentamidine of toxoplasmosis do not require
Indications: q24h 300mg monthly via additional prophylaxis for PCP.
 CD4 count <200 cells/mm3 Respiguard II nebulizer or
 Oropharyngeal candidiasis ultrasonic nebulizer Discontinuation:
 CD4% <14% +O2 agonist Consider in patients on HAART with
 Evidence of AIDS-defining CD4 > 200 for at least 3 months.
illness
 CD4 count 250-200 and if Restarting prophylaxis:
CD4 monitoring (e.g., every 3 CD4 count falls to <200 or
months) is not possible PCP recurred at a CD4 count >200
cells/mm3 (lifelong prophylaxis should
be considered).
MUCOCUTANEOUS CANDIDIASIS
Oropharyngeal Fluconazole 100mg PO q24h Nystatin suspension 500,000 Chronic suppressive therapy is usually
(oral thrush) for 7-14 days units PO q6h not recommended unless patients have
OR frequent or severe recurrences. If used, it
Itraconazole 200mg PO q24h is reasonable to discontinue therapy if
CD4 >200 cells/μL.

38 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Oesophageal Fluconazole 200-400mg Itraconazole 200mg PO q24h Candidiasis is the most common cause
PO/IV q24h for 14-21 days OR of esophagitis with HIV infection, but
Voriconazole 200mg PO/IV CMV, HSV and aphthous ulcerations
q12h can present with similar complaints.
OR
Amphotericin B 0.6mg/kg IV Endoscopy required with unusual
q24h presentations or lack of response to
azole within several days.
Vulvovaginal Azoles pessary Fluconazole 150mg PO stat Prolonged or refractory episodes is
(Clotrimazole) for 3-7 days OR observed in approximately 10% of
Itraconazole 200mg PO q24h patients and requires antimycotic
for 3 days therapy for >7 days.
CRYPTOCOCCAL MENINGITIS OR MENINGOENCEPHALITIS
Cryptococcus neoformans ƚ The lipid formulations (Amphotericin
B lipid complex 5mg/kg or liposomal 3-
Initial Treatment Amphotericin B Amphotericin B 4mg/kg IV q24h) may be used instead if
Induction therapy (for at least 2 deoxycholateƚ 0.7-1mg/kg IV deoxycholateƚ 0.7-1mg/kg IV available.
weeks) q24h q24h
PLUS PLUS If ICP >250mm or signs & symptoms of
Flucytosine 25mg/kg PO Fluconazole 800mg IV/PO cerebral oedema present, do daily LP to
q6h q24h reduce pressure until patient is
improved.

Consolidation therapy (for 8 Fluconazole 400mg PO q24h Itraconazole 200mg PO q12h If clinical signs of cerebral oedema do
weeks) not improve after about 2 weeks of daily
LPs, consider placement of a lumbar
drain or VP shunt.
Maintenance Therapy Fluconazole 200mg PO Itraconazole 200mg PO q24h Discontinuation:
(continued after consolidation) q24h for patients intolerant or failed  Completed initial (induction,
Fluconazole consolidation) therapy, and at least 1
year on maintenance therapy, and
 Remains asymptomatic from

39 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
cryptococcal infection, and
 CD4 count ≥100 cells/μL for ≥3
months and suppressed HIV RNA in
response to effective ART.
(http://aidsinfo.nih.gov/ contentfiles
/ lvguidelines/ adult_oi.pdf.)

Secondary prophylaxis Fluconazole 200mg PO Secondary prophylaxis:


q24h CD4 count decreases again to <100
cells/mm3
TOXOPLASMA GONDII ENCEPHALITIS
Acute Infection Pyrimethamine* 200mg PO Pyrimethamine* (dosing as per Adjunctive corticosteroids (e.g.
(up to 97% patients are loading dose followed by preferred regime) dexamethasone) should be administered
Toxo IgG +ve) Pyrimethamine 50mg (if PLUS when clinically indicated to treat a mass
BW≤60kg), 75mg (if Folinic acid 10-25mg PO q24h effect associated with focal lesions or
BW>60kg) PO q24h PLUS associated edema. Because of the
PLUS Sulfadiazine* 1-1.5gm PO q6h potential immunosuppressive effects of
Folinic acid 10-25mg PO for at least 6 weeks corticosteroids, they should be
q24h discontinued as soon as clinically
PLUS OR feasible.
Clindamycin 600mg IV/PO
q6h for at least 6 weeks Trimethoprim/Sulfamethoxazo *Requires DG approval
le (5mg/kg TMP/ 25mg/kg
OR SMX) IV/PO q12h for at least
6 weeks
Sulfadoxine/Pyrimethamine
500/25mg (Fansidar®) PO 1
tab q12h
PLUS
Folinic acid 10-25mg PO
q24h
PLUS

40 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Clindamycin 600mg IV/PO
q6h for at least 6 weeks
Suppressive/ Maintenance Pyrimethamine* 25-50mg Pyrimethamine* 25-50mg PO Discontinuation:
Therapy PO q24h q24h Consider when on HAART, CD4 >200
PLUS PLUS >3 months and viral load well
Clindamycin 600mg PO q8h Folinic acid 10-25mg q24h suppressed
PLUS PLUS
Folinic acid 10-25mg q24h Sulphadiazine* 0.5-1g PO q6h *Requires DG approval

OR

Trimethoprim/
Sulfamethoxazole 160/800mg
PO q12h
Primary Prophylaxis Trimethoprim/ Dapsone 50mg PO q24h All the recommended regimens for
Indications: Sulfamethoxazole PLUS preventing 1st episode of toxoplasmosis
ToxoIgG +ve with CD4<100 160/800mg PO q24h Pyrimethamine* 50mg PO q7d are also effective in preventing PCP
PLUS
Folinic acid 25mg PO q7d *Requires DG approval

OR

Dapsone 200mg PO q7d


PLUS
Pyrimethamine* 75mg P q7d
PLUS
Folinic Acid 25mg PO q7d
MYCOBACTERIUM AVIUM COMPLEX (MAC) DISEASE
Treatment Clarithromycin 500mg PO Azithromycin 500-1000mg PO ƚAddition of 3rd/4th drug should be
q12h q24h considered for patients with CD4 count
PLUS PLUS <50, high mycobacterial loads (>2 log
Ethambutol 15mg/kg PO Ethambutol 15mg/kg PO q24h CFU/mL of blood), or in the absence of
q24h

41 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
effective HAART.
PLUS/MINUSƚ
Discontinuation:
1
Amikacin 10-15mg/kg IV Consider if patient is on HAART and
q24h viral load well suppressed, CD4 > 100
OR ≥6 months, asymptomatic of MAC, and
Streptomycin 1gm IM q24h has completed > 12 months of therapy.
OR
Levofloxacin 500mg PO
q24h
OR
Moxifloxacin 400mg
PO q24h
Mainternance/ Same as the treatment Secondary prophylaxis restarted when
Secondary Prophylaxis regimen CD4<100.
CYTOMEGALOVIRUS (CMV) DISEASE
CMV Retinitis Immune recovery is essential for
successful treatment. Start HAART
Initial Therapy Intravitreal injections of Foscarnet* (2.4mg/injection) within 2 weeks if possible.
Immediate Sight-Threatening Ganciclovir (2mg/injection) for 1-4 doses over a period of
Lesions (Adjacent to the Optic 1-4 doses over 7-10 days 7-10 days Discontinuation:
Nerve or Fovea) PLUS PLUS Consider if patient is on HAART and
Ganciclovir 5mg/kg IV q12h Ganciclovir 5mg/kg IV q12h viral load well suppressed, CD4 > 100
for 14-21 days, then 5mg/kg for 14-21 days, then ≥3 months and after 3-6 months of CMV
IV q24h 5–7 times weekly Valganciclovir* 900mg PO treatment.
q24h
For Small Peripheral Lesions Gancyclovir 5mg/kg IV q12h *Requires DG approval
for 14 days
Extraocular CMV diseases Ganciclovir 5mg/kg IV q12h May consider switch to Maintenance therapy is generally not
(Oesephagitis, colitis, interstitial for 21-42 days or until signs Valganciclovir 900mg PO necessary; HAART offers best hope for
pneumonitis, neurological) and symptoms have been q12h once patient can absorb prevention of relapses.
resolved and tolerate orally (in CMV

42 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
oesophagitis and colitis only) *Requires DG approval

Secondary prophylaxis Ganciclovir 5mg/kg IV q24h Valganciclovir* 900mg PO


(CD4 + count <100 cells/mm3) 5–7 times weekly q24h
BACTERIAL ENTERIC INFECTIONS
Salmonellosis Ciprofloxacin 500-750mg Trimethoprim/Sulfamethoxazo Duration:
Salmonella non-typhi PO q12h le 160/800mg IV/PO q12h CD4≥200: 7-14 days.
OR OR If CD4 <200 and with bacteremia: 6
Ciprofloxacin 400mg IV Ceftriaxone 1gm IV q24h weeks. Longer course with debridement
q12h and drainage needed for persistent
bacteremia or metastatic disease.
Shigellosis Same regime as Duration:
Shigella sp. salmonellosis Gastroenteritis: 7-10 days
Bacteraemia: ≥14 days
Recurrent: 2-6 weeks
Campylobacteriosis Mild to Moderate Disease Duration:
Campylobacter sp. Same regime as Refer to shigellosis
salmonellosis

Bacteraemia
Ciprofloxacin 500-750mg
PO q12h OR 400mg IV
q12h
PLUS
Aminoglycoside IV
HERPES SIMPLEX VIRUS (HSV) INFECTIONS
Genital or orolabial Acyclovir 400mg PO q8h Duration:
Genital: 5-14 days
Moderate-to-severe Acyclovir 5mg/kg IV q8h Orolabial: 5-10 days
mucocutaneous infections After lesion begins to
regress, change to oral
regime as above and continue

43 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
until lesions have completely
healed

Suppressive therapy Acyclovir 400mg PO q12h Suppressive therapy indicated if


severe/frequent recurrences.
Duration: Continue indefinitely
VARICELLA-ZOSTER VIRUS DISEASES
Herpes Zoster (Shingles) Uncompliclated/Acute Consider treatment for severe infection
Primary Varicella Infection Localized Dermatomal whenever clinical diagnosis of zoster
(Chickenpox) including Acyclovir 800mg PO 5x/day likely with altered mental status or
progressive outer retinal for 7-10 days (shingles), 5-7 visual symptoms while definitive
necrosis (PORN) and acute days (chicnkenpox). Longer diagnosis pursued.
retinal necrosis (ARN) duration maybe needed for
slow to resolve lesions

Severe infection (CNS,


ocular, disseminated)
Acyclovir 10-15mg/kg IV
q8h, then switch to oral
regime as above when
improved for
10-14 days(shingles), 7-10
days(chickenpox)
HISTOPLASMOSIS
Histoplasma capsulatum Induction therapy All the triazole antifungals have the
Moderate- to-severe Amphotericin B† 0.6- potential to interact with certain ARV
disseminated disease 0.7mg/kg IV q24h for at least agents and other anti-infective agents.
2 weeks or clinical

improvement The lipid formulations of amphotericin
B may be used instead if available
Maintenance therapy
Itraconazole 200mg PO q8h

44 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
for 3 days, then q12h for at
least 12 months
Less severe disseminated Itraconazole 200mg PO q8h Fluconazole 800 mg PO q24h Itraconazole oral solution is preferred
disease for 3 days, then 200mg PO OR over capsule because of improved
q12h for at least 12 weeks Voriconazole 400mg PO q12h absorption, but is less well tolerated.
on day 1, then 200mg PO q12h However, this formulation may not be
necessary if itraconazole concentration
is increased by concomitant use of a
CYP3A4 inhibitor such as ritonavir-
boosted PIs
Chronic Suppresive therapy Itraconazole 200mg PO q24h Fluconazole 400mg PO q24h Discontinuation:
(Secondary prophylaxis)  Received azole for >1 year, and
Indication:  Negative fungal blood cultures, and
 severe disseminated or CNS  Serum Histoplasma antigen <2
infection after completion of ng/mL, and
at least 12 months of  CD4 count >150 for ≥6 months
treatment
 relapsed despite appropriate
initial therapy
 CD4<150
ISOSPORA BELLI INFECTION
Initial Therapy Trimethoprim/Sulfamethoxaz Pyrimethamine 50-75mg PO
ole 160/800mg PO/IV q6h q24h
for 10 days PLUS
Folinic acid 5-10mg PO q24h

OR

Ciprofloxacin 500mg PO q12h

45 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
NOCARDIA INFECTION
Initial Therapy Trimethoprim/ Imipenem/Cilastatin 500mg IV Use indefinite low dose oral suppression
Sulfamethoxazole q6h in patients with advanced HIV or
(TMP 15mg/kg /SMX PLUS significant immunosuppression to
75mg/kg/24h) IV/PO q6h Amikacin 7.5mg/kg IV q12h prevent relapse with TMP/SMX
for 2-4 weeks or clinical 160/800mg q12h.
May consider decreasing to improvement followed by oral
SMX/TMP (TMP regimen
10mg/kg/24h) after clinical
improvement OR

3rd gen. Cephalosporins,


e.g. Ceftriaxone 2gm IV q12-
24h
PLUS
Amikacin 7.5mg/kg IV q12h
for 2-4 weeks or clinical
improvement followed by oral
regimen
PENICILLIOSIS

Penicillium marneffei Severely-ill patients Voriconazole 6 mg/kg IV q12h The lipid formulations of amphotericin
Acute infection Amphotericin B† 0.6- on day 1, then 4 mg/kg IV B may be used instead if available.
0.7mg/kg IV for 2 weeks, q12h for at least 3 days,
followed by followed by voriconazole 200 Have to be followed by chronic
Itraconazole 200mg PO q12h mg PO q12h for a maximum maintenance therapy.
for 10 weeks of 12 weeks

Mild disease Voriconazole 400mg PO q12h


Itraconazole 200mg PO q12h on day 1, then 200mg PO q12h
for 8 weeks for a maximum of 12 weeks
Maintenance therapy/ Secondary Itraconazole 200mg PO q24h Discontinuation:
prophylaxis CD4 count >100 for ≥6 months

46 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
PROGRESSIVE MULTIFOCAL LEUKOENCEPHALOPATHY (PML)
Polyoma virus JC virus (JCV) No effective therapy exists With HAART, some patients improve
and others stabilise. Few may deteriorate
due to immune reconstitution
CRYPTOSPORIDIOSIS
Cryptosporidium sp. Symptomatic treatment of Effective HAART (to increase CD4+
diarrhoea >100) can result in complete, sustained
clinical, microbiological and histologic
resolution.

C. SOLID TRANSPLANT

For infections related to renal transplant – please refer to the MOH Renal Replacement Therapy Guidelines.

47 | P a g e
Index:
- Cardiac conditions requiring prophylaxis for dental procedures - Prophylactic regimens for dental, oral, respiratory tract, skin and
- Dental procedures for which prophylaxis is recommended musculoskeletal tissue
- Other procedures for which prophylaxis is recommended - Secondary prevention of rheumatic fever
- Rheumatic fever (type of infections & duration of treatment)

NON-SURGICAL CHEMOPROPHYLAXIS

Maintenance of optimal oral health and hygiene is essential to reduce the incidence of bacteraemia from daily activity. Infective endocarditis prophylaxis
for dental procedures is indicated for the following cardiac conditions:
 Prosthetic heart valves, including bio prosthetic and homograft valves
 Prosthetic material used for cardiac valve repair
 A prior history of IE
 Following congenital heart disease
 Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
 Completely repaired congenital heart defects with prosthetic material or device, whether placed by surgery or by catheter intervention, during the
6 months after the procedure
 Repaired congenital heart disease with residual defects at the site or adjacent to the site of the prosthetic device (which inhibit endothelisation)
 Cardiac "valvulopathy" in a transplanted heart. Valvulopathy is defined as documentation of substantial leaflet pathology and regurgitation

Dental Procedures for which Prophylaxis is recommended:

All dental procedures involve manipulation of gingival tissue or the periapical region of teeth or perforation of gingival mucosa:
 Dental Extraction
 Periodontal procedure including surgery, scaling and root planning, probing and recall maintenance
 Dental implant placement and re-implantation of avulsed teeth
 Endodontic (root canal) instrumentation or surgery only beyond the apex
 Sub gingival placement of antibiotic fibres or strips
 Prophylactic cleaning of teeth prior to implant where bleeding is anticipated

48 | P a g e
Other Procedures for which Prophylaxis is recommended:

Antibiotic prophylaxis may be given to high risk patients who undergo invasive procedure of the respiratory tract that involves incision or biopsy of
respiratory mucosa (level II A):
 Tonsillectomy and/or adenoidectomy
 Surgical operations that involve respiratory mucosa

For patients undergoing procedure to treat the infection e.g. drainage of empyema, antibiotic regime used to treat must be directed towards Streptococcus
viridans as well as Staphylococcus aureus.

The AHA guidelines 2008 no longer consider any gastrointestinal and genito-urinary procedures high risk and therefore do not recommend routine use of
IE prophylaxis even in patients with the highest risk cardiac conditions defined above.

For patients with established infections of the gastrointestinal and genito-urinary tract that have on-going enterococcal bacteraemia or who are undergoing
genito-urinary procedure, antibiotic prophylaxis is recommended (an agent active against enterococci).

For high risk cardiac patients who undergo surgical procedures that involve the infected skin, skin structure, and musculoskeletal tissue antibiotic
treatment against Streptococcus viridans and Staphylococcus is recommended.

Patients listed in who undergo an invasive respiratory tract procedure to treat an established infection, e.g. drainage of an abscess, should receive an
antibiotic regimen which contains an anti-staphylococcal penicillin or cephalosporin. Vancomycin should be given to patients unable to tolerate a β-
lactam. Vancomycin or another suitable agent should be administered if the infection is known or suspected to be caused by a methicillin-resistant strain
of S. aureus (MRSA).

In the case of an established infection or if antibiotic therapy is indicated to prevent wound infection or sepsis associated with a gastrointestinal or
genitourinary tract procedure in patients, it is reasonable that the antibiotic regimen includes an agent active against enterococci, e.g. ampicillin,
amoxicillin, or vancomycin. Vancomycin should only be administered to patients unable to tolerate β-lactams. If infection is caused by a known or
suspected strain of resistant enterococcus, consultation with an infectious diseases specialist is recommended.

For patients undergoing surgical procedures involving infected skin (including oral abscesses), skin structure, or musculoskeletal tissue, it is reasonable
that the therapeutic regimen contains an agent active against staphylococci and b-haemolytic streptococci, e.g. an anti-staphylococcal penicillin or
cephalosporin. Vancomycin or clindamycin may be used in patients unable to tolerate a β-lactam antibiotic. If the infection is known or suspected to be
caused by MRSA, vancomycin or another suitable agent should be administered.

(ESC guidelines on prevention of infective endocarditis 2009)

49 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
PROPHYLACTIC REGIMENS FOR DENTAL, ORAL, RESPIRATORY TRACT, SKIN AND MUSCULOSKELETAL
TISSUE
Prophylactic Regimes for Amoxycillin/Clavulanate Ampicillin 2gm IV single If patient is unable to tolerate PO
Dental, Oral, Respiratory Tract, 2gm PO single dose 1 hour dose 30 minutes before antibiotic.
Skin and Musculoskeletal before procedure procedure
Tissue OR
Cefazolin 1gm IV single dose If patient is unable to tolerate PO
30 minutes before procedure antibiotic or allergic to penicillin.
OR
Ceftriaxone 1gm IV single If patient is unable to tolerate PO
dose 30 minutes before antibiotic or allergic to penicillin.
procedure
OR
Clindamycin 600mg PO If patient has immediate-type penicillin
single dose 1 hour before hypersensitivity).
procedure OR 600mg IV
single dose 30 minutes before
procedure
SECONDARY PREVENTION OF RHEUMATIC FEVER
Secondary Prevention of Penicilin G Benzathine Penicillin V 250mg PO q12h
Rheumatic Fever (Benzathine OR
Penicillin)1.2MU IM every 3 Erythromycin Ethylsuccinate
weeks 800mg PO q12h

Type of Infection Duration of treatment


Rheumatic fever with carditis and residual heart disease 10 years or until 40 years of age, whichever is
(persistent valvular disease) longer; sometimes lifelong prophylaxis
Rheumatic fever with carditis but no residual heart 10 years or until 21 years of age, whichever is
disease (no valvular disease) longer
Rheumatic fever without carditis 5 years or until 21 years of age, whichever is
longer
The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2 nd edition)

50 | P a g e
Index:
 Community Acquired Pneumonia (CAP)  Acute Infective Exacerbation of Chronic Obstructive Pulmonary
- Mild pneumonia Disease (AECOPD)
- Moderate pneumonia - Fulfilled criteria for pneumonia
- Severe pneumonia - No increased purulent sputum
 Lung Abscess - Increased purulent sputum
 Empyema  Early onset HAP (including VAP) and low risk for infection with
multi-drug resistant (MDR) organisms
 Early onset HAP with MDR risk factors
 Late onset HAP

RESPIRATORY INFECTIONS
(Lower Respiratory Tract Infections)

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Community acquired pneumonia (CAP)
Mild pneumonia Outpatient
(CORB=0, SMART-COP≤2) Amoxicillin/Clavulanate Ampicillin/Sulbactam 375mg Consider admission if:
625mg PO q8h for 5 days PO q12h - Old age
Streptococcus pneumonia Inpatient - Poor co-morbidities
Haemophilus influenza Amoxicillin/Clavulanate Ampicillin/Sulbactam 1.5gm - Immune suppression
Klebsiella pneumoniae 1.2gm IV q8h for 5-7 days IV q8h - No caregiver available
Mycoplasma pneumoniae PLUS PLUS - Staying long distance from hospital or
Chlamydophila pneumonia Azithromycin 500mg PO Clarithromycin 500mg PO lack of transportations
q24h for 3-5 days q12h

* If penicillin allergy:
Moxifloxacin 400mg PO
q24h

51 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Moderate pneumonia Amoxicillin/Clavulanate Ampicillin/Sulbactam 1.5gm If patient had received antibiotics for
(CORB=1, SMART-COP 3-4) 1.2gm IV q8h for 7 days IV q8h current illness prior to admission, consider
PLUS PLUS adding gentamicin or use ceftriaxone as
Streptococcus pneumonia Azithromycin 500mg PO/IV Clarithromycin 500mg PO beta-lactam agent.
Haemophilus influenza q24h for 5 days q12h (see Severe pneumonia)
Klebsiella pneumoniae
Mycoplasma pneumoniae * If penicillin allergy: Criteria (>24 hours) for switching IV to
Chlamydophila pneumonia Moxifloxacin 400mg PO/IV oral antibiotics
Legionella pneumophila q24h - Absence of mental confusion
Staphylococcus aureus - Ability to take oral medication
Other gram negative bacilli - Temperature lower than 38.3°C
- Hemodynamic stability (heart rate
<100 beats/min and systolic blood
pressure >90 mm Hg)
- Respiratory rate lower than 25
breaths/min
- Sp02 > 90% while breathing in normal
room air or return to baseline oxygen
level for patients receiving long-term
oxygen therapy (LTOT)

(must fulfil all criteria)


Severe pneumonia Amoxicillin/Clavulanate Ceftriaxone 2gm IV q24h Risk of melioidosis
(CORB ≥2, SMART-COP ≥5) 1.2gm IV q8h for 7 days (If renal failure) - Occupation in farming, forestry,
PLUS OR fishing, army etc.
Klebsiella pneumoniae Azithromycin 500mg PO/IV Ceftazidime 2gm IV q8h - OR exposure to contaminated soil or
Streptococcus pneumonia q24h for 5 days (If risk of melioidosis) river water
Haemophilus influenza PLUS OR - AND underlying diabetes mellitus
Staphylococcus aureus Gentamicin 5mg/kg IV q24h Piperacilin/tazobactam - ± Presence of other foci of infections
Legionella pneumophila (Short course empirical 4.5gm IV q6h (e.g. intra-abdominal abscesses, septic
Mycoplasma pneumoniae coverage for gram negative (If risk of HCAP and MDR arthritis)
Chlamydophila pneumonia organisms until culture pathogens)
Burkholderia pseudomallei results available) Risk of HCAP

52 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Other gram negative bacilli - Hospitalization within the last 90 days
- Nursing home resident
- Chronic dialysis
- Home wound care
- Home infusion therapy

Risk of MDR pathogens


- Immune suppression
- Hospitalization within ≤ 90 days
- Poor functional status
- Antibiotic therapy within ≤ 6 months

* Use piperacilin/tazobactam if patient


has ≥1 risk of HCAP plus ≥1 risk of MDR
pathogens.
Lung Abscess
Anaerobes , Amoxycillin/Clavulanate Piperacillin/Tazobactam Weight adjusted dose for Ceftazidime is
Klebsiella pneumoniae 1.2gm IV q8h followed by 4.5gm IV q8hr for 4-6 weeks 120mg/kg/day in 3-4 divided doses
Streptococcus intermedius , 625mg PO q8h for 4-6 week Weight adjusted dose for Meropenem is
Streptococcus constellatus, 25mg/kg, max 1g IV q8h.
Streptococcus anginosus OR
Streptococcus viridans
Norcardia Ceftriaxone 2gm IV q24h
PLUS
Metronidazole 500mg IV
q8h followed by 400mg PO
q8h for 4-6 week

If suspect melioidosis Ceftazidime 2gm q8h for 4-6 Meropenem 1gm IV q8h
week (see section on
melioidodsis)

Staphylococcus aureus Cloxacillin 2gm IV q4-6hr Vancomycin 15mg/kg in q8-

53 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
(e.g. among IVDU/ elderly/ for 4-6 weeks 12h (if MRSA suspected or
pediatric) allergic to penicillin)
Vancomycin alternative
Empyema
Always investigate as per pleural effusion. Drainage via chest tube required. Tuberculosis must be excluded.
Streptococcus pneumonia Amoxycillin/Clavulanate Ceftriaxone 2gm IV q24h for
Streptococcus pyogenes 1.2gm IV q8h for 4-6 weeks 4-6 weeks
Staphylococcus aureus OR OR
Anaerobes Ampicillin/Sulbactam 1.5gm Cefotaxime 1gm IV q8h
Enterobactereriaceae IV q8h for 4-6 weeks
PLUS

Metronidazole 500mg IV
q8h followed by 400mg PO
q8h for 4-6 weeks
Acute infective exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD)
Fulfilled criteria for Refer to CAP treatment *Criteria for pneumonia
pneumonia * guidelines - Fever (≥38°C), cough, purulent
(If no clinical or radiological sputum, pleural pain, dyspnea
evidence of pneumonia, see - New focal chest signs (e.g.
below) crepitation) on examination
- New chest x-ray shadowing for which
there is no other explanation
No increased purulent sputum - No antibiotics
- Symptomatic treatment
- Optimize COPD
treatment
Increased purulent sputum Doxycycline 100mg PO Amoxycillin 500mg PO q8h *No risk factors
q12h for 3-5 days - Age < 65 years
Uncomplicated COPD - FEV1 >50% predicted
*No risk factors - <4 exacerbations/year
- No cardiac disease

54 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Increased purulent sputum Amoxycillin/clavulanate Ampicillin/sulbactam 1.5gm *≥ 1 risk factors
1.2gm IV q8h for 5-7 days IV q8h - Age > 65 years
Complicated COPD - FEV1 <50% predicted
*≥ 1 risk factors - ≥4 exacerbations/year
- Cardiac disease
Early onset HAP (including Amoxycillin/Clavulanate Ceftriaxone 2gm IV q24h S. aureus is more common in diabetes
VAP) and Low risk for 1.2gm IV q8h mellitus, head trauma.
infection with multi-drug OR
resistant (MDR) organisms - Cefuroxime 1.5gm IV q8h Monotherapy is recommended for early
< 5 days onset HAP/VAP/HCAP.
S. pneumoniae
H. influenzae
S. aureus
E. coli
K. pneumoniae

P.aeruginosa Piperacillin/ Tazobactam Highly dependent on local antibiogram/


4.5gm IV q6h prevalent organisms
OR
Cefepime 2gm IV q8h Consider in patients with chronic lung
disease.
Early onset with MDR risk
factors and Late onset HAP
(based on the predominant
causative organism in local
setting)

MDR Pseudomonas aeruginosa Piperacillin/Tazobactam Imipenem 500mg IV q6h Use combination therapy if MDR
4.5gm IV q6h OR pathogen is suspected.
OR Meropenem 1gm IV q8h
Cefepime 2gm IV q8h Aminoglycoside can be stopped after 3-5
PLUS days in patients on combination therapy
PLUS who are responding to treatment.

55 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Amikacin 15mg/kg/24h IV
Amikacin 15mg/kg/24h IV OR
OR Ciprofloxacin 400mg IV q8h
Ciprofloxacin 400mg IV q8h

Multi drug resistant Cefoperazone/Sulbactam Polymyxin E


Acinetobacter baumanii 4gm IV q6h ** Refer to appendix
OR (Colistin Dosing) for dosing
Ampicillin/Sulbactam 3gm guideline
IV q3h

ESBL producing Klebsiella Ertapenem IV 1gm q24h Imipenem 500mg IV q6h There is lack of adequate data on the
pneumoniae OR pharmacokinetics of once-daily
Meropenem 1gm IV q8h administration of ertapenem in critically
ill patients.

Methicillin-resistant PLUS
Staphylococcus aureus (if MRSA is suspected)
Vancomycin 1gm IV q12h Linezolid 600mg IV q12h

56 | P a g e
Index:
 Syphilis  Chlamydial/Non-specific urethritis (NSU)/Non-specific genital
- Primary, secondary & early latent syphilis infection in women (NSGI)
- Late latent, gummatous and cardiovascular syphilis  Chlamydial/Non-specific urethritis (NSU)/Non-Specific genital
- Neurosyphilis infection in pregnancy
 Gonorrhoea  Recurrent and persistent non-gonococcal urethritis
- Uncomplicated (urogenital, anorectal, pharyngeal  Chancroid
- Gonococcal conjunctivitis  Lymphogranuloma venereum
- Gonococcal epididymitis/Epididymo-orchitis  Granuloma inguinale
- Disseminated gonorrhoea (acral pustules, arthralgia,  Trichomoniasis
tenosynovitis, septic arthritis)  Bacterial vaginosis
- Gonococcal meningitis  Herpes genitalis (Herpes simplex virus 1 and 2)
- Gonococcal endocarditis
 Herpes genitalis in HIV
 Herpes genitalis in pregnancy

SEXUALLY TRANSMITTED INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Primary Syphilis Procaine Penicillin 600,000 Penicillin Allergy Contact tracing:
Treponema Pallidum units IM q24h for 10 days Doxycycline 100mg PO q12h Examine and investigate sex partner and
Secondary Syphilis OR for 14 days treat when indicated
Early Latent Syphilis Benzathine Penicillin OR
2.4MU IM STAT Tetracycline 500mg PO q6h for Reference:
14 days Malaysian Guideline in the Management of
Sexually Transmitted Infections 2014
Late Latent Syphilis Procaine Penicillin 600,000 Penicillin Allergy Contact tracing
Gummatous syphilis units IM q24h for 14 days Doxycycline 100mg PO q12h
Cardiovascular syphilis OR for 28 days Reference:
Benzathine Penicillin OR Centre of Disease Control, USA 2013.
2.4MU IM weekly for 3 Tetracycline 500mg PO q6h for
weeks 28 days

57 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Neurosyphilis Aqueous crystalline Ceftriaxone 2gm IM (with Repeat CSF examinations every 6
penicillin G, 18- Lidocaine as diluent) or IV months. Consider retreatment if cell
24MU/day, administered 3 (with water for injection as count is not decreased in 6 months or
- 4 MU q4h IV for 14 days diluent) for 10-14 days (if no CSF is not entirely normal in 2 years.
anaphylaxis to penicillin) (Ref: MMWR 1998; 47, RR-1)
OR
All patients with neurosyphilis should be
Procaine Penicillin 2.4MU considered for corticosteroid cover at the
IM q24h start of the therapy to prevent the
PLUS Jarisch-Herxheimer reaction
Probenecid 500mg PO q6h (Prednisolone 10-20mg PO q8h for
for 14 days 3 days commencing one day prior to
syphilis treatment).
Reference:
Centre of Disease Control, USA 2013.
Gonorrhoea Ceftriaxone 500mg IM as a Azithromycin 2gm PO stat Contact tracing
Neisseria Gonorrhoeae single dose (for severe cephalosporin
Uncomplicated PLUS allergy) Also treat for non-specific urethritis
(Urogenital, Azithromycin 1gm PO as a (NSU) in view of high incidence of
Anorectal, Pharyngeal) single dose coexisting NSU in patients with
gonorrhea.
OR
Patient to come back 1 week later for
Ceftriaxone 500mg IM as a test of cure if alternative treatment is
single dose used.
PLUS Reference:
Doxycycline 100mg q12h Centre of Disease Control, USA 2013
PO for 7 days
Gonococcal Conjunctivitis Ceftriaxone 500mg IM q24h Azithromycin 2gm PO STAT Reference:
for 3 days PLUS Centre of Disease Control, USA 2013
OR Doxycycline 100mg PO q12h
Ceftriaxone 1gm IM STAT for 7 days
PLUS

58 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Ciprofloxacin 250mg PO q24h
for 3 days
Gonococcal Epididymitis/ Ceftriaxone 500mg IM/IV Contact tracing
Epididymo-orchitis q24h for 7 days
References:
OR British Association of Sexual Health and HIV
Clinical Effectiveness Guidelines 2008.
Centre of Disease Control, CDC 2010 (updated
Ceftriaxone 250mg IM 2013)
STAT
PLUS
Doxycycline 100mg PO
q12h for 10 days
Disseminated Gonorrhoea Ceftriaxone 1gm IM/IV Cefotaxime 1gm IV q8h Admit patient
(Acral pustules, arthralgia, q24h for 7 days
tenosynovitis, septic arthritis) Contact tracing

Duration of treatment depends on


clinical response

Reference:
Centre of Disease Control, USA 2013.
Gonococcal Meningitis Ceftriaxone 1-2gm IV q12h Reference:
for 10 to 14 days Centre of Disease Control, USA 2013

Gonococcal Endocarditis Ceftriaxone 1-2gm IV q12h Reference:


for at least 4 weeks Centre of Disease Control, USA 2013

Chlamydial/Non-Specific Doxycycline 100mg PO Erythromycin Ethylsuccinate Contact tracing


Urethritis (NSU)/Non-Specific q12h for 7 days 800mg PO q6h for 7 days
Genital Infection in Women OR Doxycycline and Ofloxacin are
(NSGI) Azithromycin 1gm PO stat contraindicated in pregnancy.

Quinolone is contraindicated in
pregnancy and children less than 18
years old.

59 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Chlamydial/Non-Specific Azithromycin 1g PO STAT Erythromycin Ethylsuccinate Reference:
Urethritis (NSU)/Non-Specific OR 800mg PO q6h for 7 days Centre of Disease Control, USA 2013
Genital Infection in Amoxycillin 500mg PO q8h OR
Pregnancy for 7 days Erythromycin Ethylsuccinate
400mg q6h for 14 days
Recurrent and persistent Metronidazole 2gm PO Metronidazole 400mg q12h for Reference:
Non-gonococcal urethritis STAT 5 days Centre of Disease Control, USA 2013
PLUS
Erythromycin Ethylsuccinate
800mg PO q6h for 3 weeks

OR

Azithromycin 500mg STAT


then 250mg q24h for 4 days
PLUS
Metronidazole 400mg q12h
for 5 days
Chancroid Ceftriaxone 250mg IM stat Erythromycin Ethylsuccinate Contact tracing
Haemophilus ducreyi OR 800mg PO q12h for 7 days
Azithromycin 1gm PO stat Reference:
Centre of Disease Control, USA 2013
Lymphogranuloma Doxycycline 100mg PO Erythromycin Ethylsuccinate Contact tracing
Venereum q12h for 21 days 800 mg PO q6h for 21 days
Chlamydia trachomatis OR Final duration depends on clinical
Serovar L1, 2, 3 Azithromycin 1g PO weekly for response.
3 weeks
Reference:
Centre of Disease Control, USA 2013
Granuloma Inguinale Doxycycline 100mg PO Trimethoprim/Sulfamethoxazole Contact tracing
Klebsiella granulomatis q12h for 3 weeks and until 160/800mg PO q12h for 3
all lesions completely heal weeks and until all lesions Add Gentamicin 1.5mg/kg IM/IV q8h in
completely heal patients whose lesions do not respond in

60 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
OR the first few days to other agents.
Erythromycin Ethylsuccinate
800mg PO q6h for 3 weeks and Duration of treatment should be until
until all lesions completely heal lesions have healed. Healing times vary
OR greatly between patients. A minimum of
Azithromycin 1gm PO weekly 3 weeks treatment is recommended.
for 3 weeks or 500mg PO q24h
for 7 days and until all lesions References:
completely heal Centre of Disease Control, USA 2013.
British Association of Sexual Health and HIV
OR Clinical Effectiveness Guidelines 2008.
Ceftriaxone 1gm IV q24h for 3
weeks and until all lesions
completely heal
Trichomoniasis Refer to Obstetrics &
Trichomonas vaginalis Gynaecology Infections
Section
Bacterial vaginosis Refer to Obstetrics &
Gardnerella vaginalis, Gynaecology Infections
Anaerobes Section
Herpes Genitalis
Herpes Simplex Virus 1 and 2
Reference:
First episodic: Acyclovir 200mg PO 5 Centre of Disease Control, USA 2013
times a day for 5 days (max
10 days)

Recurrent episodic: Acyclovir 200 mg 5 times


/day PO for 5 days
OR
400mg q8h PO for 5 days
OR
800mg q12h PO for 5 days
OR
800mg q8h PO for 2 days

61 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
(short course)

Suppressive therapy: Acyclovir 400mg PO q12h


(may be indicated if > 6 or 200mg PO 4 times a day
recurrences per year) for up to 1 year, then
reassess
Herpes Genitalis in HIV
Primary: Acyclovir 400-800mg PO References:
q8-12h for 10 days Centre of Disease Control, USA 2013
British Association of Sexual Health and HIV
Clinical Effectiveness Guidelines 2008
Severe: Acyclovir 5 to 10mg/kg IV
q8h for 2 to 7 days and then
followed by Acyclovir PO
(min 10 days)

Recurrent: Acyclovir 400-800mg PO


q8-12h for 10 days

Suppressive: Acyclovir 400mg-800mg


PO q8-12h for up to 1 year,
then reassess
Herpes Genitalis in As in non-pregnant with As in non-pregnant with Herpes First and second trimester acquisition
pregnancy Herpes genitalis genitalis Acyclovir is not licensed for use in
pregnancy; however, there is substantial
clinical experience supporting its safety
i.e. the benefits of antiviral therapy
outweigh the risk of withholding
treatment (Pregnancy category B.
Vaginal delivery should be anticipated
(IV, C).

Third trimester acquisition: If a true


first episode is confirmed, CS should be

62 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
considered for all women, particularly
those developing symptoms after 34
weeks of gestation, as the risk of viral
shedding is very high. If vaginal
delivery is unavoidable, acyclovir
treatment of mother and baby may be
indicated.

References:
Centre of Disease Control, USA 2013
British Association of Sexual Health and HIV
Clinical Effectiveness Guidelines 2008

63 | P a g e
Index:
 Impetigo - Tinea unguium
 Ecthyma - Tinea versicolor
 Ecthyma gangrenosum - Candidiasis
 Boils/Carbuncles - Subcutaneous fungal infections
 Erysipelas - Sporotrichosis
 Cellulitis  VIRAL INFECTIONS
 Diabetic foot infections - Herpes simplex infections
 Gas gangrene/Myonecrosis/Necrotizing fasciitis - Chickenpox (Varicella zoster)
- Herpes zoster (Varicella zoster)
 MYCOBACTERIAL INFECTIONS
- Hansen’s disease (Leprosy)  PARASITIC INFESTATIONS
- Scabies
 FUNGAL INFECTIONS
- Head lice
- Tinea capitis
- Body lice/Pubic lice
- Tinea barbae
 Peripheral thrombophlebitis
- Tinea corporis/Tinea cruris/Tinea faciei
- Tinea manuum/Tinea pedis

SKIN & SOFT TISSUE INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Impetigo References:
S. aureus NHS Wiltshire CCG,BaNES CCG & Swindon
CCG Guidelines for Antibiotic Prescribing in the
S. pyogenes Community 2013-15
Generalised: Cloxacillin 500mg PO q6h for Cephalexin 500mg PO q6h
5-7 days for 5-7 days

Penicillin Allergy
Erythromycin Ethylsuccinate
800mg PO q12h for 5-7 days

Localised: Topical 2% Fusidic Acid q8- Topical 2% Mupirocin q8- Topical fusidic acid is not
12h for 7 days (Outpatient use 12h for 5 days recommended for inpatients

64 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
only) (Resistance to Mupirocin is
on the rise)
Ecthyma
S. pyogenes Topical mupirocin 2% q8-12h Reference:
Localised for 7 days Lippincott’s Guide to Infectious Disease 2011
Ecthyma gangrenosum Antipseudomonal penicillin e.g Use in combination initially before
Pseudomonas Piperacillin sensitivity results available.

PLUS References:
Aminoglycosides DermNet NZ Update Dec 2013.
Management of Ecthyma gangrenosum
OR MedscapeUpdated june 2013.
Fluoroquinolones

OR

Antipseudomonal
Cephalosporins
Boils/Carbuncles Cloxacillin 500mg PO q6h for Erythromycin Ethylsuccinate Surgical drainage is important in the
S. aureus 7-10 days 800mg PO q12h for 7-10 management
days
OR Reference:
Cefuroxime 500mg PO q12h National Healthcare System UK 2013
for 7-10 days
OR
Amoxycillin/Clavulanate
625mg PO q8h for 7-10 days
Erysipelas Penicillin PO 500mg q6h >2 Cefazolin 1gm IV q8h Reference:
Strep. pyogenes weeks OR Merck Manual 2013
OR Cephalexin 500mg PO q6h
Erythromycin Ethylsuccinate
800mg PO q12h for 10 days
OR

65 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Cloxacillin 500mg PO q6h for
10 days

If severe,
Penicillin G IV 1-3MU q6h

MRSA Vancomycin IV 1gm q12h


Cellulitis
Mild Amoxycillin 500mg PO q8h Cephalexin 500mg PO q6h Main organism: Strep. Pyogenes
(outpatient) (outpatient) Staph. Aureus
Grade 1 – no signs of systemic OR
toxicity, no uncontrolled co- Erythromycin Ethylsuccinate Duration: 7 to 10 days
morbidities 800mg PO q12h
Treat Tinea Pedis if present
Moderate Benzylpenicillin 1-2MU IV q6h Cefuroxime 750mg IV q8h Change to oral once condition improves
OR OR
Grade 2 – systemically ill or If Staph aureus is suspected Cefazolin 1gm IV q8h Total duration up to 10 days of therapy
systemically well but with a co- Cloxacillin 1gm IV q6h
morbidity which may (inpatient) Main organism:
complicate/delay resolution Strep. Pyogenes – causing erysipelas
(nonpurulent)
And Staph. Aureus – causing abscess and
bedside ultrasound may be helpful in
Grade 3 – significant systemic detection of deep abscess(es)
upset (acute confusion,
tachycardia, tachypnoea,
hypotension) or unstable co-
morbidities that may interfere
with response or have a limb
threatening infection due to
vascular compromise

66 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Severe Benzylpenicillin 2-4MU IV q4h Ampicillin-sulbactam 3gm Add Vancomycin 1gm IV q12h (if high
PLUS IV q6h risk of MRSA)
Grade 4 – sepsis syndrome or IV Clindamycin 600-900mg IV PLUS
severe life threatening infection q8h Clindamycin 600-900mg IV Early aggressive surgical intervention if
such as necrotising fasciitis q8h necrotising process suspected
OR
References:
Piperacillin-tazobactam 4.5g IV IDSA SSTI Practice Guidelines 2014
CREST Guidelines On The management of
q6h Cellulitis In Adults 2005
The Sandford Guide to Antimicrobial Therapy
2017
Johns Hopkins Abx POC-IT Guide 2016
Diabetic Foot Infections Refer to Bone & Joint Infections
Section (Orthopedic)
Gas Gangrene/ Myonecrosis/ Refer to Bone & Joint Infections
Necrotizing Fasciitis Section (Orthopedic)
Streptococci
Clostridium sp. Polymicrobial
MYCOBACTERIAL INFECTIONS
Hansen’s Disease (Leprosy) Paucibacillary Bacterial resistance or Remarks: Second line can only be
Mycobacterium Leprae Rifampicin 600mg PO monthly hypersensitivity to first line initiated by a dermatologist.
(supervised) Can be substituted with one
PLUS of the following:
Dapsone 100mg PO q24h Ofloxacin 400mg PO q24h References:
Duration: 6 months OR Malaysian Clinical practice Guideline on
Management of leprosy 2014
(Completion of 6 doses within 9 Clarithromycin 500mg PO World Health Organisation Health Guidelines
months) q24h
Surveillance: 5 years OR
Ethionamide 250mg PO
Multibacillary q24h
Rifampicin 600mg PO monthly
PLUS
Clofazimine 300mg PO monthly

67 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
PLUS
Dapsone 100mg PO q24h
PLUS
Clofazimine 50mg PO q24h

Duration:
1 year (if initial BI˂4) or 2 years
(if BI≥4)
Completion of 12 doses within
18 months (BI<4)
Completion of 24 doses within
36 months ( BI≥4)
Surveillance: 15 years
FUNGAL INFECTIONS
Tinea capitis Griseofulvin 20-25mg/kg/24h Terbinafine 250mg PO q24h 1) Kerion :Terbinafine 12-16 weeks
Trichophyton, Microsporum (microsized) Griseofulvin 10- OR 2) Contacts of patient may be treated
15mg/kg/day (ultramicrosized) Itraconazole 200mg PO with 2% ketoconazole shampoo 2
PO q24h – 3 times per week for 2 weeks
OR 3) Surgical excision is to be avoided
Griseofulvin 500mg q12h or Duration is based on
q24h for 6 to 12 weeks or longer mycological agent: Reference:
till fungal cultures are negative Trichophyton spp : 2-4 Primary Care Dermatology Society UK 2013.
weeks
PLUS Microsporum spp : 8-12
weeks
2.5% Selenium
sulphide shampoo
OR
2% ketoconazole shampoo ,
2 – 3 times per week for 2
weeks

68 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Tinea barbae Same as treatment of Tinea
capitis (above)
Tinea corporis / Tinea cruris
/ Tinea faciei
Trichophyton,Microsporum, Reference:
Epidermophyton RxFiles Newsletter : Antifungal newsletter (April
2010) Canadian: Bugs and Drugs

Mild infections: Topical imidazole cream:


Clotrimazole 1%
OR
Miconazole 2%
OR
Tioconazole 1% Duration: till
clinical clearance with
additional 2 weeks

Extensive infections: Griseofulvin 500mg PO q12h or Terbinafine 250mg POq24h


q24h for 4-6 weeks for 2 weeks
OR
Itraconazole 200mg PO
q24h for 2 weeks
Tinea manuum/ Tinea pedis Griseofulvin 500mg PO q12h Terbinafine 250mg PO q24h Patients with contraindications to
Trichophyton, Microsporum, for 6-12 weeks for 2-4 weeks systemic agents may consider topical
Epidermophyton OR antifungal agents.
Itraconazole 200mg PO q24h
for 2-4 weeks
Tinea unguium Terbinafine 250mg PO q24h For Amorolfine 5% Nail Amorolfine 5% Nail Lacquer is not
Trichophyton, Microsporum, 6 weeks (finger nails) For 12 Lacquer weekly application indicated for children less than 12 years
Epidermophyton weeks (toe nails) For 6 months (finger nails) old.
OR For 12 months (toe nails)
Pulse Itraconazole 200mg PO OR Patients with contraindications to
q12h for 1 week per month Griseofulvin 500mg PO systemic agents may consider topical
For 2 months (finger nails) For q12h For 6 months (finger antifungal agents.

69 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
3 months (toe nails) nails) For 12 months (toe
nails) Reference:
OR RxFiles Newsletter: Antifungal newsletter (April
2010) Canadian: Bugs and Drugs
Fluconazole 150mg PO once
weekly
6-12 months for toenail
≥3 months for fingernail
Tinea versicolor Selenium Sulphide 2% shampoo Itraconazole 200mg PO Reference:
Malassezia Furfur apply to affected areas 10 q24h for 1 week (recurrent Craig G Burkhart et al.Tinea Versicolor
Treatment & Management.medscape. updated
Pityrosporum Orbiculare minutes before bathing cases) Dec 2013.
OR
Dilute to 1:1 with water, apply
and leave overnight (treat for 1-
2 weeks)
For face:
Topical Imidazole for 4-6 weeks
e.g. Miconazole 2% cream,
Clotrimazole 1% cream,
Tioconazole 1% cream
Candidiasis
Candida albicans

Mild cutaneous candidiasis Topical Imidazole q12h till clear Fluconazole 100mg PO q24h Treatment of sexual partner is advisable
e.g. for 1 week (in severe and in case of recurrent infection.
Miconazole 2% cream, immunocompromised
Clotrimazole 1% cream, patients) Reference:
Tioconazole 1% cream RxFiles Newsletter: Antifungal newsletter (April
2010) Canadian: Bugs and Drugs

Extensive cutaneous Itraconazole 200mg PO q24h for


candidiasis 1 week

70 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Subcutaneous Fungal
Infections
a. Sporotrichosis
i. localized to skin only Itraconazole 200mg PO q24h Fluconazole 400-800mg In some immunocompromised
for 3-6 months for at least 2-4 q24h condition such as AIDS, longer
weeks after recovery. (max OR treatment may be necessary. Refer to
200mg q12h, if no response) Potassium Iodide (saturated Opportunistic Infections In HIV
OR solution 50mg/drop) 5 drops Patients.
Terbinafine 250mg q24h/q12h q8h may increase to 40-50
(max 500mg BD, if no response) drops q8h

ii.severe life threathening Amphotericin B, (lipid Reference


sporotrichosis formulation) 3–5mg/kg q24h, Clinical Practice Guidelines for the Management
of Sporotrichosis: 2007 Update by the Infectious
or Amphotericin B Diseases Society of America.
(deoxycholate),
0.7–1mg/kg q24h, *Online library.wiley.com: Tebinafine
250mg daily.
Step down therapy:
Itraconazole 6–10mg/kg Avoid azole in pregnancy
(maximum of 400mg)PO q24h

b. Sporotrichosis in pregnancy Localised hyperthermia


VIRAL INFECTIONS
Herpes Simplex Infections Primary: Severe cases: References:
Acyclovir 200-400mg PO 5 Acyclovir 5mg/kg IV q8h Centers for Disease Control and Prevention
(CDC) 2010.
times daily for 5 days for 5 days or until able to BASHH
Recurrent: take orally, then change
Regular normal saline to oral
dabs/gargle

Immunosuppressed patients.
Refer to chapter on HIV

71 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Genitalia:
(Refer to Sexually
Transmitted Infections-herpes
genitalis)

Eczema herpeticum:
Acyclovir 200mg PO 5 times
daily for 7-10 days
Chickenpox
Varicella zoster
Immunocompetent Acyclovir 800mg PO 5 times Advisable to start treatment early
daily for 7 days within 48 hours

Immunocompromised Acyclovir 10mg/kg IV q8h for 7 Reference:


days (change to oral once there Centers for Disease Control and Prevention
(CDC) 2010
is an improvement)
Herpes Zoster Acyclovir 800mg PO 5 times *Indicated in immunocompromised
Varicella zoster daily for 7days * patients, herpes zoster ophthalmicus,
Ramsay- Hunt syndrome and the
elderly.

Involving face/genitalia

Advisable to start treatment early within


48 hours
PARASITIC INFESTATIONS
Scabies Benzyl Benzoate emulsion 25% Gamma Benzene
Sarcoptes scabei (EBB) Hexachloride 1% (Lindane) Reference:
apply from neck down and apply and leave for 8 hours Centers for Disease Control and Prevention
(CDC) 2010 (updated 2013)
leave for 24 hours for 2 days (not to be repeated in less
than a week)
OR

72 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Permethrin 5% cream apply
and leave for 8 hours

In pregnancy Permethrin 5% lotion/cream


apply and leave for 8 hours
Head Lice Gamma Benzene Hexachloride 4% Dimeticone apply for Reference:
Pediculus humanus Capitis 0.1% (Lindane) apply and leave 8hrs day 1 and day 7 Centers for Disease Control and Prevention
(CDC) 2010
for 8 hours
OR
Malathion 1% shampoo
Body Lice/pubic Lice Malathion lotion 0.5% for 8-12 Reference:
Pediculus humanus hours and washed off Centers for Disease Control and Prevention
(CDC) 2010
OR
Permethrin 1% cream apply to
affected area for 10min and
washed off
Peripheral Thrombophlebitis Consider broad spectrum Superficial thrombophlebitis due to
Staph. aureus, antibiotics (e.g. Piperacillin/ peripheral catheters is generally a
Conagulase negative Tazobactam) in ill patients. benign, self-limiting condition that
Staphylococcus, Deescalate if blood cultures resolves with removal of the catheter
Gram negative rods taken prior to starting are without antibiotics.
negative.
However in situations where the patient
is septic (febrile) with redness,
tenderness and purulent discharge from
the catheter site, septic thrombophlebitis
must be considered.

Remove the intravenous canulla and


take blood cultures.

73 | P a g e
Index:
 Typhoid Fever  Malaria
 Cholera - Plasmodium falciparum (Uncomplicated, new infection)
 Scrub typhus - Plasmodium falciparum (Uncomplicated, treatment failure or
 Brucellosis relapse)
 Leptospirosis - Plasmodium falciparum (Complicated)
 Tetanus - Plasmodium vivax/ovale (New infection)
 Melioidosis - Plasmodium malariae/ knowlesi
- Mixed Infection
- Chemoprophylaxis

TROPICAL INFECTIONS
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
1. Typhoid Fever
Salmonella Typhi Ciprofloxacin 500mg PO Amoxycillin 75 – Fever clearance is faster with Quinolones
Stable Case q12h for 5-7 days 100mg/kg/day PO in 3-4
Fully sensitive divided doses for 14 days Reference:
OR WHO, 2003
Parry CM et al. Typhoid fever. N Engl J Med 2002;
Trimethoprim/ 347:1770.
Sulfamethoxazole
160/800mg PO q12h for 14
days
Quinolone resistance Ceftriaxone 60mg/kg/day for Azithromycin 500mg PO Reference:
10-14 days q24h for 7 days WHO, 2003
Unstable or complicated cases Ceftriaxone 60mg/kg/day Indication of dexamethasone:
for 10-14 days (discuss with physician)
OR i) Typhoid psychosis
Ciprofloxacin 400mg IV ii) Septic shock
q12h for 10-14 days Dose: 3mg/kg loading, then 1mg/kg q6h
for 2 days
Reference:
WHO, 2003
Paed. Inf. Dis J,1988

74 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
2. Cholera
Vibrio cholerae Principle of Treatment:
i) Rehydration ORS if tolerating orally
Non Tetracycline resistance Doxycycline 300mg PO stat Ciprofloxacin 1gm PO stat ii) Monitor urine output
(once patient can take orally) iii) Avoid antidiarrhoea agents -
Diphenoxylate HCL/Atropine
Tetracycline resistance Erythromycin Ethylsuccinate Ciprofloxacin 1gm PO stat Sulphate (Lomotil) or Loperamide
800mg PO q12h for 3 days HCL (Imodium)
OR
Azithromycin 1gm PO stat Reference:
WHO Global Task on Cholera Control 2004
Saha D et al. Single-dose azithromycin for the
treatment of cholera in adults. N Engl J Med 2006;
354:2452.
3. Scrub Typhus
Orientia tsutsugamushi Doxycycline 100mg PO Azithromycin 500mg PO ƚ Recommended alternative for pregnant
(rickettsia tsutsugamushi) q12h for 3-7 days statƚ woman
Tetracycline sensitive
Reference:
CID 2004 Nov 1; 39(9):1329-35
4. Brucellosis
B. melitensis, Streptomycin 1gm (15mg/kg) Doxycycline 100mg PO Longer duration (up to 12 weeks) may be
B. abortus, B. suis and B. canis IM q24h for 2 - 3 weeks q12h for 6 weeks required in spodylitis, neurobrusellosis,
PLUS PLUS IE, localized suppurated lesions
Doxycycline PO 100mg Gentamicin 5mg/kg/24h IV
q12h for 6 weeks for 7 days

OR OR

Doxycycline 100mg PO Rifampicin 600-900mg ƚRecommended alternative for pregnant


q12h for 6 weeks (15mg/kg) PO q24h for 6 woman
PLUS weeks ƚ
Rifampicin 600-900mg Reference:

75 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
(15mg/kg) PO q24h for 6 PLUS CPG Brucellosis, MOH 2012
weeks Trimethoprim/ Ariza J et al. Perspectives for the treatment of
brucellosis in the 21st century: the Ioannina
Sulfamethoxazole recommendations. PLoS Med 2007; 4:e317.
160/800mg PO q12h for 6 Mandell, Douglas & Bennett’s Principles &
Practice of Infectioius Diseases. 8th Edition
weeks ƚ
5. Leptospirosis
Mild disease Doxycycline 100mg PO
(No or mild organ dysfunction) q12h 5-7 days
Severe disease C-Penicillin 1.5-2 megaunits Ceftriaxone 2gm IV q24h
(moderate to severe organ IV q6h for 7-14 days (If evidence of pneumonia or
dysfunction) (If no evidence of pneumonia suspected gram negative
or gram negative sepsis) sepsis)
6. Tetanus
Clostridium tetani Metronidazole 500mg IV Benzylpenicillin 2MU IV
q6h-q8h for 7-10 days q6h for 7-10 days
Human Tetanus All patients with tetanus should undergo
Immunoglobulin wound debridement to eradicate spores
3000- 6000 units IM stat and necrotic tissue.e

At a different site initiate age


appropriate active
immunization
7. Melioidosis
Burkholderia pseudomallei
Intensive/Induction Therapy Ceftazidime 100- Meropenem 25mg/kg/24h IV Consider to add on Trimethoprim/
200mg/kg/24h IV q8h (usual q8h (usual dose: 1gm q8h; if Sulfamethoxazole in neurologic, prostatic,
dose : 2gm q8h) CNS infection 2gm q8h) bone, joint, cutaneous, and soft tissue
PLUS/MINUS OR melioidosis.
Trimethoprim/ Imipenem 50-
Sulfamethoxazole 60mg/kg/24h IV q6h (usual To consider G-CSF for severe cases
8/40mg/kg/24h IV/PO in dose: 1gm q6h)

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
divided doses within 72 hours of admission.
PLUS/MINUS
Duration: Look for source of infection.
2 - 3 weeks Trimethoprim/
4 - 8 weeks if severe/ deep Sulfamethoxazole Folic Acid 5mg PO q24h to be given for
focal infection 8/40mg/kg/24h IV/PO in patient on Trimethoprim/
divided doses Sulfamethoxazole.
Duration:
2 - 3 weeks Reference:
4 - 8 weeks if severe/ deep CPG Melioidosis Pahang 2011
focal infection Inglis TJJ. The treatment of melioidosis.
Pharmaceuticals 2010;3:1296-1303
Bart Currie, Nicholas Anstey, Treatment &
Eradication/Maintenance Trimethoprim/ Amoxycillin/Clavulanate
Prognosis of Melioidosis, Wolters Kluwer Health.
Therapy Sulfamethoxazole 1250mg (2 tabs of 625mg)
< 40 kg: 160/800mg q12h; PO q8h
40-60kg:240/1200mg q12h; OR
>60kg:320/1600mg q12h Doxycycline 100mg PO
q12h or 200mg PO q24h
Duration: minimum 3
months Duration: minimum 3
months
In patients with neurological
or osteomyelitis up to 6
months treatment is
recommended.
8. Malaria
WHO recommends the use of Artemisinin Combination Therapy (ACT) as the standard treatment for malaria and discourages the prescription
of monotherapy or sub-standard ACT as this will promote resistant.

Features of severe/complicated Malaria includes at least one of the following clinical or laboratory features:
Clinical manifestation:
Impaired consciousness or unrousable coma

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Prostration (generalized weakness so that the patient is unable to walk or sit up without assistance)
Failure to feed/ not tolerating orally
Convulsion
Deep breathing, respiratory distress (acidotic breathing)
Circulatory collapse or shock
Clinical jaundice and evidence of other vital organ dysfunction
Haemoglobinuria
Abnormal spontaneous bleeding
Pulmonary oedema (radiological)

Laboratory test:
Hypoglycaemia, metabolic acidosis, severe normocytic anaemia, haemoglobinuria, hyperparasitaemia, hyperlactataemia or renal impairment.

Reference:
CPG Malaria, MOH 2013, WHO Guideline on Treatment of Malaria 2010 and WHO A Practical Handbook: Management of Severe Malaria 2012

Plasmodium falciparum Riamet® Artesunate /Mefloquine Artesunate /Mefloquine available as FDC


a) Uncomplicated (1 tablet: Artemether/ 5 - 8kg : 25/55mg PO q24h tablet:
i) New Infection lumefantrine 20/120mg) 9 - 17kg : 50/110mg 25/55mg and 100/220mg
PO q24h
The patient should receive an 18 - 29kg: 100/220mg PO Primaquine 0.75mg/kg (max: 45mg) to be
initial dose, followed by 2nd q24h given on Day 1 as a single dose except in
dose 8 hours later, then 1 ≥30kg : 200/440mg PO pregnant/lactating woman (check G6PD
dose q12h for the following 2 q24h status before use).
days for 3 days
ƚ Pregnancy: Limited data on safety of
<15kg : 1 tab per dose OR artemisinin given during 1st trimester.
15 - <25kg: 2 tab per dose Exposure of artemisinin derivatives
25 - <35kg: 3 tab per dose Quinine 10mg/kg PO q8h during 2nd and 3rd trimester has shown no
≥35kg : 4 tab per dose PLUS adverse effects on the mother or
Doxycycline 100mg PO foetus. Thus, quinine and clindamycin is
Should always be taken with q12h for 7 days recommended.
a fatty diet (e.g. milk)

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
OR

Quinine 10mg/kg PO q8h


PLUS
ƚ Clindamycin 600mg PO

q12h for 7 days


Plasmodium falciparum An alternative ACT regimen Quinine 10mg/kg PO q8h Mefloquine should not be repeated within
a) Uncomplicated to be used. PLUS 60 days of first treatment due to increased
ii) Treatment failure or relapse (e.g.: If Riamet® is used as ƚ Doxycycline 100mg PO risk of neuropsychiatric side effects.
the first line regimen, so the q12h for 7 days
choice will be Artesunate
/Mefloquine and vice versa)
Refer above for dosing
Plasmodium falciparum Artesunate 2.4mg/kg IV at 0 Loading dose Quinine *Parenteral artesunate should be given for
b) Complicated hour, 12 hour, 24 hour and 20mg/kg IV over 4 hours in a minimum of 24 hours (3 doses) or until
(see definition above) q24h till day 7* D5% on day 1, then patient can tolerate orally then it can be
PLUS/MINUS Quinine 10mg/kg IV/PO q8h switched to a complete course of oral
Doxycycline 100mg PO PLUS ACT regime, eg: Riamet® or
q12h for 7 days Doxycycline 100mg PO Artesunate/Mefloquine.
q12h for 7 days
Monitor patient’s blood glucose and ECG
OR while on IV quinine.

Quinine 7mg/kg IV over 1 Pregnancy: Artesunate IV as for normal


hour, followed by 10mg/kg adults.
in
D5% over 4 hours on day 1,
then
Quinine 10mg/kg IV/PO q8h
PLUS
Doxycycline 100mg PO
q12h for 7 days

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Plasmodium vivax/ovale Riamet® Chloroquine 10mg/kg (max G6PD deficiency: Primaquine 0.75mg/kg
New infection (dosing as per Plasmodium 600mg) PO stat, then 5mg/kg PO q7d for 8 weeks. If significant
falciparum treatment) (max 300mg) 6 hours later, haemolysis occurs, should be stopped.
PLUS followed by q24h for 2 days.
Primaquine 0.5mg/kg (max PLUS Pregnancy: Full course chloroquine to be
30mg) PO q24h for 14 days. Primaquine 0.5mg/kg (max given, followed by 300mg q7d till
30mg) PO q24h for 14 days. delivery. Full course of primaquine only
to be given post-delivery.
Plasmodium malariae/ Riamet® Artesunate /Mefloquine If severe P.malariae/knowlesi, treatment
knowlesi (dosing as per Plasmodium (dosing as per Plasmodium is as complicated P.Falciparum.
falciparum falciparum treatment)
OR
Chloroquine 10mg/kg (max
600mg) PO stat, then 5mg/kg
(max 300mg) 6 hours later,
followed by q24h for 2 days
Mixed Infection Treat as Plasmodium
falciparum
Chemoprophylaxis Doxcycline 100mg PO q24h Mefloquine 250mg PO q7d Pregnancy: Only melfoquine can be used
Start: 1-2 days before Start: 2 weeks before
departure departure Refer to the drug resistance pattern and
Stop: 4 weeks after travel Stop: 4 weeks after travel recommended prophylaxis in the
Max duration: 2 years Max duration: 1 year travelling destination.
OR
Atovaquone/proguanil *Requires DG approval
(Malarone®)* 100/250mg
q24h
Start: 1-2 days before
departure
Stop: 7 days after travel

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Index:
 Drugs  Management of Tuberculosis in Special Situations
- First-line antiTB drugs - Tuberculosis during pregnancy and lactation
- Fixed-dose combination (FDC) dosing - Tuberculosis and use of oral contraceptive pill
- Second-line antiTB drugs - Tuberculosis in patients with liver impairment
 Treatment Regimens - Tuberculosis in patients with renal impairment
- New case of pulmonary tuberculosis (PTB) - Tuberculosis-HIV co-Infection
- Treatment of previously treated cases
- Extra-pulmonary tuberculosis
- Multi-drug resistant tuberculosis (MDR-TB)

TUBERCULOSIS INFECTIONS
(Adapted from the Clinical Practice Guidelines For The Management of Tuberculosis, Ministry of Health Malaysia,3 rd edition 2012)
1. Drugs
1.1 First-line AntiTB Drugs
Recommended Dose
Drug Daily 3 times/week
Dose (range) in mg/kg Max/day in mg Dose (range) in mg/kg Max/day in mg
Isoniazid (H)* 5 (4 - 6) 300 10 (8 - 12) 900
Rifampicin (R) 10 (8 - 12) 600 10 (8 - 12) 600
Pyrazinamide (Z) 25 (20 - 30) 2000 35 (30 - 40)** 3000**
Ethambutol (E) 15 (15 - 20) 1600 30 (25 - 35)** 2400**
Streptomycin (S) 15 (12 -18) 1000 15 (12 - 18)** 1500**
*Pyridoxine 10 – 50mg/day needs to be added.
**Daily treatment is the preferred regimen.

1.2 Fixed-Dose Combination (FDC) Dosing

The two FDCs available in MoH Drug Formulary for adults are:-
(i) 4-Drug FDC : Isoniazid 75mg, Rifampicin 15 mg, Pyrazinamide 400mg and Ethambutol 275mg tablet
(ii) 3-Drug FDC: Isoniazid 75mg, Rifampicin 150mg and Pyrazinamide 400mg tablet

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The recommended dosages for the two FDCs are:
Body weight (kg) Recommended dose
30 - 37 2 tabs daily
38 - 54 3 tabs daily
55 - 70 4 tabs daily
>70 5 tabs daily
*Pyridoxine 10 – 50mg/day needs to be added.

1.3 Second-line AntiTB Drugs


Recommended Dose
Drug Route
Dose (range) in mg/kg Max/day in mg Frequency
Kanamycin IV 15 - 20 1000 OD
Amikacin IV 15 - 20 1000 OD
Ethionamide PO 15 - 20 1000 OD
p-aminosalicylic acid (PAS)* PO 150 12 000 2 -3 equally divided doses
Capreomycin* IV 15 - 20 1000 OD
Cycloserine** PO 15 - 20 1000 BD
Clofazimine PO 100 – 300mg/day 300 OD
Ofloxacin PO 15 - 20 1000 BD (commonly given as 400mg BD)
Levofloxacin PO 7.5 - 10 1000 OD (commonly given as 750mg OD)
Moxifloxacin IV/PO 7.5 - 10 400 OD
* Requires DG approval
**Pyridoxine 50mg needs to be added for every 250mg of cycloserine.

2. Treatment regimens

Treatment regimens are divided into:


(i) Initial or intensive phase.
(ii) Continuation or maintenance phase.

2.1 New Case of Pulmonary Tuberculosis (PTB)

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 New patients with pulmonary tuberculosis should receive daily 2EHRZ* (2 months of intensive phase), followed by daily 4HR* (4 months of
maintenance phase).
 Regimen should contain six months of rifampicin.
 Rifampicin should be rounded to higher recommended dose if tolerated.
 If ethambutol is contraindicated, streptomycin can be substituted

*The number preceding the treatment regimen refers to the treatment duration in months.

2.2 Treatment of Previously Treated Cases


 Previously treated TB patients include those patients treated as new cases who have taken treatment for more than one month and are
currently smear or culture positive again (i.e. failure, relapse or return after default).
 Drug sensitivity test (DST) must be done for the patients. When the results become available, the drug regimen should be adjusted
appropriately.
 Physician with experience in TB management should be consulted for all patients requiring retreatment of TB.

2.3 Extra-pulmonary Tuberculosis


 The regimen of treatment is similar as for pulmonary tuberculosis but the duration may be extended and it varies from 6 months to 12 months
or longer.
 All extrapulmonary tuberculosis should be treated with antiTB for a minimum of 6 months except for bone (including spine) and joint
tuberculosis for 6 - 9 months and tuberculous meningitis for 9 - 12 months.
 Streptomycin should be used instead of ethambutol in adult TB meningitis.
 Steroids should be given in tuberculous meningitis or pericarditis.

2.4 Multi-Drug Resistant Tuberculosis (MDR-TB)


 MDR-TB is defined as Mycobacterium tuberculosis infection resistant to both isoniazid and rifampicin with or without resistance to other
drugs.
 Extensively drug-resistant tuberculosis (XDR-TB) is when the Mycobacterium tuberculosis is resistance to isoniazid and rifampicin plus
resistance to quinolones and at least one second-line aminoglycosides.
 Newly MDR-TB (i.e. not previously treated for MDR-TB), total treatment duration is 20 months for most patients.
 Treatment usually consist of
o Fluoroquinolone
o Ethionamide
o A parenteral agent
o Pyrazinamide
o Cycloserine or PAS (if cycloserine cannot be used)

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3. Management of Tuberculosis in Special Situations
3.1 Tuberculosis during pregnancy and lactation
 First-line antiTB drugs except streptomycin are safe for pregnancy and lactation.
 Standard treatment using Isoniazid, Rifampicin, Pyrazinamide and Ethambutol is used.
 Streptomycin should be avoided in pregnancy due to foetal ototoxicity.
 Pyridoxine (25mg daily) should be given to all pregnant/lactating women on isoniazid to prevent foetal neurotoxicity.
 Once active TB in the baby is ruled out, the baby should be given six months isoniazid prophylaxis, followed by BCG vaccination.

3.2 Tuberculosis and use of oral contraceptive pill


 Rifamycin drugs such as rifampicin and rifabutin reduce the contraceptive efficacy of both combined oral contraceptives and progesterone-
only pills.
 Alternative contraception methods are recommended during rifampicin therapy and also up-to one month stopping the therapy even if it has
been administered for less than a week.

3.3 Tuberculosis in patients with liver impairment


 If baseline ALT is more than three times upper limit of normal before the initiation of treatment, one of the following antiTB regimens should
be considered.
o Two hepatotoxic drugs: 9HRE or 2SHRE/6HR
o One hepatotoxic drug: 2SHE/10HE
o No hepatotoxic drug: 18 - 24 months of streptomycin, ethambutol and fluoroquinolones.
 The more unstable or severe the liver disease, the fewer hepatotoxic drugs should be used.
 Regular monitoring of liver enzymes should be performed in patients with pre-existing liver disease or at risk of drug-induced hepatitis.

3.4 Tuberculosis in patients with renal impairment


 Frequency of pyrazinamide and ethambutol should be adjusted.
 Streptomycin should be avoided if possible.
 The usual regime is 2E3HRZ3/4HR. (The subscript indicates number of doses per week)

3.5 Tuberculosis-HIV Co-Infection


 AntiTB regimen offered to HIV-positive adults should be the same as for HIV-negative adults.
 Daily treatment should be offered in the maintenance phase.
 Minimum duration of antiTB in HIV-infected adults is 6 months in PTB and 6 -12 months in extrapulmonary TB.
 The timing of initiation of HAART in TB patients depends on the type of TB and CD4 counts.

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Index:
 Acute uncomplicated cystitis  Acute pyelonephritis in pregnancy
 Acute cystitis in pregnancy  Asymptomatic bacteriuria
 Recurrent urinary tract infections prophylaxis  Asymptomatic bacteriuria in pregnancy
 Acute uncomplicated pyelonephritis  Catheter related bacteriuria
 Acute complicated pyelonephritis  CAPD peritonitis

URINARY TRACT INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Acute Uncomplicated Cystitis Nitrofurantoin 50mg PO q6h Amoxycillin/Clavulanate The choice of agents should be based
E.coli for 3 days 625mg PO q8h for 3 days on local culture and susceptibility
Enterobacteriaceae: Klebsiella OR results.
Proteus Cefuroxime 250mg PO q12h
Enterobacter species for 3 days Nitrofurantoin should be used with
Staphylococcus-saprophyticus caution in elderly and is
Enterococcus contraindicated if GFR < 40 ml/min.

Duration of treatment should be up to 7


days in male.
Acute Cystitis in Pregnancy Nitrofurantoin 50mg PO q6h Cephalexin 500mg PO q12h The choice of agents should be based
for 7 days for 7 days on local culture and susceptibility
OR OR results.
Cefuroxime 250mg PO q12hr Amoxycillin/Clavulanate
for 7 days 625mg PO q8h for 7 days Avoid trimethoprim in pregnancy.
Recurrent Urinary Tract Nitrofurantoin 50mg PO nocte Trimethoprim/Sulphamethoxaz
Infections Prophylaxis: for 3-12months ole 80/400mg PO nocte for 3-
OR 12months
>3 episodes/year Trimethoprim 100mg PO nocte OR
for 3-12months Cephalexin250mgPO ON for
3-12months

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Acute Uncomplicated The choice of agents should be based
Pyelonephritis on local culture and susceptibility
E.coli, Enterobacter, Proteus results.
Pseudomonas
May step down to oral antibiotic
For patients not requiring Ciprofloxacin 500mg PO Amoxycillin/Clavulanate following clinical improvement
hospitalization q12hrs for 7 days with/ without 625mg PO q8h for 14 days (afebrile for 48 hours).
an initial Ciprofloxacin 400mg
stat IV
Ciprofloxacin 400mg IV q12h
For patients requiring Ceftriaxone 1-2gm q24h IV for for 7 days
hospitalization 14 days with/without
aminoglycoside.
OR
Amoxycillin/Clavulanate
1.2gm IV q8h for 14 days
Acute Complicated Refer to Surgical Infections
Pyelonephritis Section
Acute Pyelonephritis in Cefuroxime 750mg IV q8h for Amoxycillin/Clavulanate Avoid trimethoprim and
Pregnancy 14 days 1.2gm IV q8h for 14 days fluoroquinolones in pregnancy.
OR
Ceftriaxone 1-2gm IV q24h for
14 days
Asymptomatic Bacteriuria Trimethoprim 100mg PO Cefuroxime 250mg PO q12h The choice of agents should be based
q12hr for 7 days or for 7days on local culture and susceptibility
Recommendation for treatment 300mg PO q24h for 7 days results.
is only for the following OR
conditions:- Nitrofurantoin 50mg PO q6h Avoid trimethoprim in pregnancy.
a) Pregnant women if test for 7 days
results are positive (refer to
Asymptomatic Bacteriuria
in Pregnancy)
b) Patients who undergo

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
traumatic urologic
interventions with mucosal
bleeding,and such patients
should be treated prior to
such interventions
c) Before transurethral
resection of the prostate
d) Before renal transplant or
early post-operative period
Asymptomatic Bacteriuria in Nitrofurantoin 50mg PO q6h Cephalexin 500mg PO q12h Avoid trimethoprim and
Pregnancy for 7 days for 7 days fluoroquinolones in pregnancy.
OR OR
Cefuroxime 250mg PO q12hr Amoxycillin/Clavulanate
for 7 days 625mg PO q8h for 7 days
Catheter Related Bacteriuria Antibiotics not recommended Remove or change catheter if possible.
for asymptomatic bacteriuria Only consider antimicrobial treatment
with indwelling urethral if bacteriuria persists 48hrs after
catheter catheter removal.
CAPD Peritonitis Intra peritoneal Cefazolin 15 If patient has been colonized Consider adding the same intravenous
Staph aureus mg/kg per bag once daily with MRSA or is in clinical antibiotics on top of intraperitoneal
CoNS PLUS sepsis or has hypersensitivity to antibiotics in severely ill patients.
Pseudomonas aeruginosa Intra peritoneal Ceftazidime 1- cephalosporins, Vancomycin
Enteric gram negatives 1.5gm per bag once daily can replace Cefazolin at 15-30 If possible, centrifuge removed dialysis
mg/kg every 5-7 days fluid – gram stain and culture directly
into blood culture bottle. .
For hypersensitivity to
Cephalosporins, Ceftazidime If multiple enteric gram negatives are
can be replaced with grown, consider bowel perforation and
Gentamycin 0.6 mg/kg per bag removing catheter.
once daily .
Also consider catheter removal in
relapsing or refractory peritonitis;
refractory exit or tunnel infection and

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
for fungal peritonitis.

References:
1. The Sanford Guide To Antimicrobial Therapy 2011
2. Guidelines on Urological Infections, European Association of Urology 2014
3. IDSA Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in Adults 2005
4. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the IDSA and European Society for
Microbiology and Infectious Diseases 2011.
5. Sanford, Australian therapeutic guidelines on antibiotics

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NEUROSURGICAL
DEPARTMENT

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Index:
 Classification of Types of Neurosurgical Procedures According to  Neurosurgery
the Risk of Infection Recurrent urinary tract infections - Cranial trauma
prophylaxis - Skull base fracture without CSF fistula
 Chemoprophylaxis for Neurological Surgery - Skull base fracture with CSF fistula
- Clean - Skull fracture with pneumocranium
- Clean + implant - Brain abscess
- Clean contaminated
- Contaminated
- Dirty

NEUROSURGERY

Chemoprophylaxis for Neurological Surgery

Classification of Types of Neurosurgical Procedures According to the Risk of Infection


Category Definition Examples
Clean No identifiable risk factors present; diagnoses by Ideal operation conditions, closed suction below
exclusion of all other categories drainage not exceeding 24 hours
Clean with implants Either a temporary or permanent implants Shunt surgery, intracranial pressure monitors,
ventricular drains, acrylic cranioplasties
Clean contaminated Risk of contamination of operative site during surgery Entry into paranasal air sinuses, transphenoidal or
transoral procedures, prolonged surgery, breaches in
surgical technique
Contaminated Contamination is known to have occurred Compound skull fractures, open scalp lacerations,
cerebrospinal fluid fistulae, subsequent operations
(early)
Dirty Established sepsis at the time of surgery Brain abscess, subdural or parafalcine empyema,
osteitis, ventriculitis, meningitis, purulent skin
infection

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Infection / Condition & Suggested treatment
Comments
likely organism Preferred Alternative
Clean
(Craniotomy, burrhole for clean
pathology)

< 4 hours Cefuroxime 1.5gm IV single Ceftriaxone 2gm IV single


dose one hour prior to skin dose one hour prior to skin
incision incision

> 4 hours Cefuroxime 1.5gm IV one Ceftriaxone 2gm IV one hour


hour prior to skin incision, prior to skin incision,
followed by repeat dose followed by repeat dose 1g
750mg IV q8h till IV q12h till completion of
completion of surgery surgery

β-Lactam Allergy:
Clindamycin 900mg IV

MRSA colonisation:
Vancomycin 15mg/kg IV
Clean + Implant (CSF Cefuroxime 1.5gm IV single Ceftriaxone 2gm IV single
diversion procedures e.g. Shunt, dose one hour prior to skin dose one hour prior to skin
EVD, omaya, DBS, incision incision
Titanium/acrylic cranioplasty,
artificial dura used) β-Lactam Allergy:
Clindamycin 900mg IV

MRSA colonisation:
Vancomycin 15mg/kg IV

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Infection / Condition & Suggested treatment
Comments
likely organism Preferred Alternative
Clean Contaminated Cefuroxime 1.5gm IV single Ceftriaxone 2gm IV single
(Transphenoidal, Acoustic dose one hour prior to skin dose one hour prior to skin
neuroma, involving air sinuses) incision, followed by three incision followed by three
repeated doses of 750mg IV repeated doses of 1gm IV
q8h q12h

β-Lactam Allergy:
Clindamycin 900mg IV

MRSA colonisation:
Vancomycin 15mg/kg IV
Contaminated Cefuroxime 1.5gm IV q8h Ceftriaxone 2gm IV q12h
(Skull fracture, previous PLUS/MINUS PLUS/MINUS
surgery, lacerated scalp) Metronidazole 500mg IV Metronidazole 500mg IV
q8h for 72hours q8h for 72hours

β-Lactam Allergy:
Clindamycin 900mg IV

MRSA colonisation:
Vancomycin 15mg/kg IV
Dirty Ceftriaxone 2gm IV q12h Meropenem 2gm IV q8h
(Brain abscess, subdural PLUS/MINUS PLUS/MINUS
empyema, ventriculitis Metronidazole 500mg IV Metronidazole 500mg IV
q8h for 6-8 weeks depending q8h
on response
MRSA colonisation:
Vancomycin 20mg/kg IV

Pseudomonas infection:
Cefepime 2gm IV q8h
OR
Ceftazidime 2g IV q8h

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Reference:
1. Am J Health-Syst Pharm Vol 70 Feb 1, 2013
2. Scottish Intercollegiate Guidelines Network. Antibiotic prophylaxis in surgery. www.sign.ac.uk/pdf/sign104.pdf (accessed Nov 2014)
3. Nottingham Antibiotic Guidelines Committee, January 2014
4. National Institute for Health and Clinical Excellence. Surgical site infection (clinical guideline 74) 2008. www.nice.org.uk/CG74 (accessed Nov 2014)
5. Tunkel, et al. Practice Guidelines for the Management of Bacterial Meningitis. Clin Inf Dis 2004; 39: 1267-84
6. IDSA 2014

Neurosurgery

Infection / Condition & Suggested treatment


Comments
likely organism Preferred Alternative
Cranial Trauma

Open fracture As per Neurosurgical


Penetration injuries Procedure for Contaminated
Condition
(Chemoprophylaxis)

Closed fracture Antibiotic not required Antibiotic not required


Skull base fracture without Antibiotic not required Antibiotic not required
CSF fistula
Skull base fracture with CSF As per Penetrating injuries Duration: 5 - 10 days. Refer neurosurgery
fistula if fistula persist for more than 1 week
Skull fracture with As per Penetrating injuries
pneumocranium
Brain abscess As per Neurosurgical To screen for immunocompromised
Procedure for Dirty conditions
Condition
(Chemoprophylaxis)

Reference:
1. Am J Health-Syst Pharm Vol 70 Feb 1, 2013
2. Scottish Intercollegiate Guidelines Network. Antibiotic prophylaxis in surgery. www.sign.ac.uk/pdf/sign104.pdf (accessed Nov 2014)
3. Nottingham Antibiotic Guidelines Committee, January 2014
4. National Institute for Health and Clinical Excellence. Surgical site infection (clinical guideline 74) 2008. www.nice.org.uk/CG74 (accessed Nov 2014)
5. Tunkel, et al. Practice Guidelines for the Management of Bacterial Meningitis. Clin Inf Dis 2004; 39: 1267-84

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OBSTETRICS
&
GYNEACOLOGIC
AL DEPARTMENT
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Index:
 Septic abortion  Vaginitis, bacterial vaginosis
 Intrapartum prophylaxis for group B strep., positive mothers  Candidiasis - uncomplicated infection
 Pre-op prophylaxis (emergency caesarean)  Candidiasis - complicated infection
 Preterm premature rupture of membranes (PPROM)  Trichomoniasis (Trichomonas vaginalis)
 Chorioamnionitis  Acute uncomplicated cystitis (UTI)
 Pelvic inflammatory disease IV therapy (moderate to severe  Recurrent urinary tract infection
disease)
 Pelvic inflammatory disease outpatient therapy (mild disease)

OBSTETRICS & GYNEACOLOGICAL INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Septic Abortion Ampicillin/Sulbactam 3gm IV Cefuroxime 750mg IV q8h Intravenous antibiotics are
q6h PLUS administered until the patient has
Metronidazole 500mg IV q8h improved and been afebrile for 48
hours, then are typically followed by
oral antibiotics to complete a 10-to
14-day course
Intrapartum Prophylaxis Ampicillin 2g IV stat, Penicillin G 5MU IV initial Prophylaxis is begun at hospital
for Group B Strep., positive then 1g q4h until delivery dose, then 2.5–3MU IV q4h admission for labour or rupture of
mothers until delivery. membranes and continued every four
Penicillin Allergy: hours until the infant is delivered
Clindamycin 900mg IV q8h
until delivery
Pre-op Prophylaxis Cefazolin 2g IV 30-60mins Ampicillin/Sulbactam 1.5 gm
(Emergency Caesarean) before skin incision. stat 30-60 mins before skin
incision.
If blood loss is more than 1.5L,
additional dose of Cefazolin IV
2g is required

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Preterm Premature Rupture Erythromycin Ethylsuccinate RCOG 2010
of Membranes (PPROM) 400-800mg PO q12h until
delivery
Chorioamnionitis Ampicillin/Sulbactam Cefuroxime 750mg IV q8h
3gm IV q6h PLUS
Metronidazole 500mg IV q8h
Pelvic Inflammatory Disease Ceftriaxone 2g IV stat and OD Clindamycin IV 900mg q8h BASH 2011
IV Therapy (for moderate to PLUS PLUS
severe disease): Doxycycline 100mg IV/PO Gentamicin IV 2mg / kg
q12h loading dose, then IV 1.5
mg.kg q8h
Followed by:
Doxycycline PO 100mg q12h Followed by:
PLUS Clindamycin PO 450 mg q6h
Metronidazole PO 400mg q12h
For total 14days OR

BASH 2011 Doxycycline PO 100 mg q24h


PLUS
Metronidazole PO 400 mg
q24h
For a total 14 days
Pelvic Inflammatory Disease Ceftriaxone 500mg IM in a Ceftriaxone 500mg IM in a BASH 2011
Outpatient therapy (for mild single dose, then single dose,then
Disease) Doxycycline 100 mg PO q12h Azithromycin 1g PO per week
PLUS for 2 weeks
Metronidazole PO 400 mg
q24h
for 14 days

96 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Vaginitis Metronidazole 400mg PO q8h Clindamycin 300mg PO q12h Meta-analysis has not found any
Bacterial vaginosis for 7 days for 7 days relationship between metronidazole
exposure during the first trimester of
pregnancy and birth defects and the
CDC no longer discourage the use of
metronidazole in the first trimester.
Candidiasis Clotrimazole 500mg as a single
Uncomplicated infection vaginal pessary (Stat dose)
Candida albicans OR
Clotrimazole 200mg as vaginal
pessary for 3 nights
Candidiasis
Complicated infection
1.Severe vaginitis symptoms Fluconazole 150mg PO q72h
for 2 or 3 doses

2.Recurrent vulvovaginal Fluconazole 150mg PO q72h Clotrimazole 500mg vaginal


candidiasis for 3 doses then weekly for 6 suppository once weekly for 6
months months
Trichomoniasis Metronidazole 2gm PO as In Pregnancy: Patients should be advised to not
Trichomonas vaginalis single dose Metronidazole 400mg PO q8h consume alcohol for 24 hours after
OR for 7 days metronidazole treatment because of
Metronidazole 400mg PO q8h the possibility of a disulfiram-like
for 7 days (Antabuse effect) reaction.

The CDC no longer discourages the


use of metronidazole in the first
trimester.
Acute Uncomplicated Cystitis Cephalexin 500mg PO q12hr Cefuroxime 250mg PO q12hr Avoid trimethoprim in pregnancy.
(UTI) for 7 days for 7 days

97 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Recurrent Urinary Tract Cephalexin 125 -250mg ON Post coital prophylaxis SOJC 2011
Infection For 3- 12 months ( will need to Ciprofloxacin 125 mg single
>3 episodes/year evaluate after 6 months ) dose
( Continous prophylaxis)
During pregnancy
Cephalexin 250 mg PO single
dose

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OPHTHALMOLOGY
DEPARTMENT

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Index:
 Blepharitis  Herpes zoster ophthalmicus
 Internal hordeolum with secondary infection  Ocular toxoplasmosis
 External hordeolum (Stye)  Acute retinal necrosis
 Bacterial conjunctivitis  CMV retinitis
 Gonococcal conjunctivitis  Ocular syphilis
 Chlamydial conjunctivitis  Ocular tuberculosis
 Gonococcal kerato conjunctivitis  Post-operative bacterial endophthalmitis
 Bacterial keratitis  Post-operative fungal endophthalmitis
 Contact lens related bacterial keratitis  Endogenous endophthalmitis
 Acanthamoeba keratitis  Dacryocystitis
 Gonococcal kerato conjunctivitis  Preseptal cellulitis
 Fungal keratitis  Orbital cellulitis/abscess
 Herpes simplex keratitis

OCULAR INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Blepharitis Eyelid hygiene/scrubs is the Oxytetracycline with In resistant cases, Doxycycline 100mg PO
Staph. aureus mainstay of therapy Polymyxin B eye ointment q24h or Tetracycline 250mg PO q6h for
Staph. epidermidis applied q12h to the lid 2-6 weeks or as necessary.
Topical antibiotics are margin
not indicated as an initial OR Tetracyclines are contraindicated in
therapy Fusidic Acid 1% eye children <8 years. The option would
ointment applied q12h to the be Erythromycin Ethylsuccinate 30-
lid margin 50mg/kg/day PO q6h.
Internal Hordeolum with Warm compresses Systemic antibiotics are indicated in the
Secondary Infection presence of superficial cellulitis or
Staph. aureus abscess.

In the presence of superficial Cloxacillin 500mg PO q6h Amoxycillin 500mg PO q8h No topical antibiotics are indicated.
cellulitis or abscess for 5 days for 5 days

100 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
External Hordeolum (Stye) Epilation of affected eye lash Systemic antibiotics are indicated in the
Staph. aureus and warm compresses presence of superficial cellulitis or
abscess.
No antibiotic recommended
as condition is self-limiting

In the presence of superficial Cloxacillin 500mg PO q6h


cellulitis or abscess for 5 days
OR
Amoxycillin 500mg PO q8h
for 5 days
Bacterial Conjunctivitis
Staph aureus, Strep pneumonia,
H. influenzae

Non severe conjunctivitis Chloramphenicol 0.5% eye


drop q2-4h for 1 week

Severe conjunctivitis Moxifloxacin 0.5% eye drop


q2-4h for 1 week
OR
Ciprofloxacin 0.3% eye drop
q2-4h for 1 week
Gonococcal Conjunctivitis Requires systemic therapy. Copious irrigation with topical saline
(including neonates) Refer to Sexually drops or artificial tears every 30-60
Neisseria Gonorrhoea Transmitted Infections & minutes
Neonatal Infection Sections
Ciprofloxacin 0.3% eye drop q2h may
supplement but cannot replace systemic
therapy

101 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Chlamydial Conjunctivitis Requires systemic therapy. Topical antibiotics are not indicated
(including neonates) Chlamydial Refer to Sexually
Trachomatis Transmitted Infections &
Neonatal Infection Sections
Gonococcal Kerato Requires systemic therapy. *Ceftazidime 5% Commence a loading dose of one drop
conjunctivitis Refer to Sexually eyedrop q1-2h every 15minutes for 3 hours followed by
Neisseria Gonorrhoea Transmitted Infections & OR hourly drops around the clock. Taper
Neonatal Infection Sections *Gentamicin 0.9% or 1.4% based on clinical response
PLUS eye drop q1-2h
Ciprofloxacin 0.3% eye drop OR *Prepared ready to use extemporaneous
q1-2h Moxifloxacin 0.5% eye drop by using injectable forms
q1-2h
Bacterial Keratitis Commence a loading dose of one drop
No Growth/ Mixed Growth every 15 minutes for 3 hours followed by
hourly drops around the clock. Taper
Non severe keratitis (small Ciprofloxacin 0.3% eye drop based on clinical response. .
peripheral keratitis) may q1-2h
consider monotherapy OR *Prepared ready to use extemporaneous
Moxifloxacin 0 .5% eye drop by using injectable forms
q1-2h

Severe bacterial keratitis dual *Cefuroxime 5% eye drop


therapy is advocated q1-2h
PLUS
*Gentamicin 0.9% or 1.4%
eye drop q1-2h
Bacterial Keratitis Commence a loading dose of one drop
Gram-Positive Cocci *Cefuroxime 5% eye drop Moxifloxacin 0 .5% eye drop every 15minutes for 3 hours followed by
q1-2h q1-2h hourly drops around the clock. Taper
based on clinical response. .
Gram-Negative Rods *Gentamicin 0.9% or 1.4% *Ceftazidime 5% eye drop
eye drop q1-2h q1-2h Vancomycin 5% eye drop may be
OR indicated for MRSA. .

102 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Ciprofloxacin 0.3% eye drop
q1-2h *Prepared ready to use extemporaneous
by using injectable forms. .
Gram-Negative Cocci *Gentamicin 0.9% or 1.4% *Ceftazidime 5% eye drop
eye drop q1-2h q1-2h
OR
Ciprofloxacin 0.3% eye drop
q1-2h
OR
Moxifloxacin 0 .5% eye drop
q1-2h
Contact Lens Related Commence a loading dose of one drop
Bacterial Keratitis every 15 minutes for 3 hours followed by
No Growth hourly drops around the clock. Taper
Non severe keratitis (small Ciprofloxacin 0.3% eye drop based on clinical response. .
peripheral keratitis) may q1-2h
consider monotherapy *Prepared ready to use extemporaneous
by using injectable forms.
Severe bacterial keratitis dual *Gentamicin 0.9% or 1.4%
therapy is advocated eye drop q1-2h
PLUS
*Ceftazidime 5% eye
drop q1-2h
Acanthamoeba Keratitis *Chlorhexidine 0.02% eye Topical therapy tapered with response
Acanthamoeba sp. drop q1-2h over a duration of 6-12 month. .
PLUS
**Propamidine isethionate *Prepared ready to use extemporaneous
0.1% q1-2h by using injectable forms. .

**Requires DG approval

103 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Gonococcal Kerato Requires systemic therapy. *Ceftazidime 5% Commence a loading dose of one drop
conjunctivitis Refer to Sexually eyedrop q1-2h every 15minutes for 3 hours followed by
Neisseria Gonorrhoea Transmitted Infections & OR hourly drops around the clock. Taper
Neonatal Infection Sections *Gentamicin 0.9% or 1.4% based on clinical response. .
PLUS eye drop q1-2h
Ciprofloxacin 0.3% eye drop OR *Prepared ready to use extemporaneous
q1-2h Moxifloxacin 0.5% eye drop by using injectable forms.
q1-2h
Fungal Keratitis *Amphotericin B 0.15%- **Natamycin 5% eye Topical therapy tapered with response
Filamentous Fungi/Yeast 0.2% eye drop q1-2h drop q1-2h
PLUS OR *Prepare ready to use extemporaneous
*Fluconozole 0.2% eye **Voriconazole 1% eye
dropq 1-2h drop q1-2h **Requires DG approval
PLUS
Fluconozole 200mg PO q24h PLUS References:
Sun CQ, Lalitha P, Prajna NV, Karpagam R,
Geetha M, O'Brien KS, Oldenburg CE, Ray KJ,
Ketoconazole 200mg PO McLeod SD, Acharya NR, Lietman TM; Mycotic
q24h Ulcer Treatment Trial Group
Association between In Vitro Susceptibility to
Natamycin and Voriconazole and Clinical
Outcomes in Fungal Keratitis. Ophthalmology
2014 Apr 15. pii:S0161-6420(14)00202-4. doi:
0.1016/j. ophtha. 2014.03. 004.
LohAR, Hong K, Lee S, Mannis M, Acharya NR.
Practice patterns in the management
offungalcorneal ul cers. Cornea. 2009;28(8) :856-
859.
Herpes Simplex Keratitis
Herpes Simplex Type 1 & 2
Epithelial Keratitis Acyclovir 3% eye ointment 5 Acyclovir 3% eye ointment 5 times/day is
times/day used as a prophylactic against epithelial
keratitis.
Non-necrotizing In addition to topical
Stromal Keratitis corticosteroids

104 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Acyclovir 3% eye ointment 5
times/day

Necrotizing Stromal Keratitis Superadded bacterial or


fungal infection must be
excluded
PLUS
Acyclovir 400mg PO 5
times/day

Recurrent Herpes Simplex Prophylaxis:


Stromal Kerititis Acyclovir 400mg PO q12h
for 12 months
Herpes Zoster Ophthalmicus Needs systemic therapy
Herpes Zoster Virus Refer to Skin & Soft Tissue
Infections Section
Ocular Toxoplasmosis TMP /SMX 960mg PO q12h Pyrimethamine 25-50mg PO Pregnancy: May consider Intravitreal
Toxoplasma gondii q24H Clindamycin 1.0mg /0.1mls. .
PLUS
Folinic acid 10-25mg PO Systemic steroids are usually indicated in
q24H immunocompetent patients. .

PLUS *Prophylaxis for recurrent lesions: T.


Bactrim 480mg q12H PO three times a
Sulfadiazine 1gm PO q6H week.
OR
Azitromycin 500mg PO q24h Reference:
OR Sobrin L, Kump L, Foster CS. Intravitreal
clindamycin for toxoplasmic retinochoroiditis
Clindamycin 300mg PO q6H Retina 2007. Sep;27(7): 952-7.
x 3-4 weeks, then 150mg
q6H PO x 3-4 weeks

105 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Acute Retinal Necrosis Acyclovir 10mg/kg/dose * Valacyclovir 1gm PO q8H * Requires DG approval. .
Herpes Simplex IV q8h for 12 weeks (not
more than 800mg) Systemic steroid is indicated depending
on location or severity of the infection.
FOLLOWED BY
Acyclovir 800mg PO 5 References:
times/day for 6 weeks Patrick MKT, Claire Y H, Susan L. Antiviral
selection in the management of acute retinal
necrosis. Clinical Ophthalmology 2010:4 11–20
Peter R, Jost H, Livia G, et al. Virus Diagnostics
and Antiviral Therapy in Acute Retinal Necrosis
(ARN). Antiviral Drugs – Aspects of Clinical Use
and Recent Advances. Intechopen.
MN Muthiah, M Michaelides, CS Child, et al. Acute
retinal necrosis: a national population-based study
to assess the incidence, methods of diagnosis,
treatment strategies and outcomes in the UK. Br J
Ophthalmol 2007;91:1452–1455
Simon RJT, Robin H, Claire YH, Sue Lightman.
Valacyclovir in the treatment of acute retinal
necrosis. BMC Ophthalmology 2012, 12:48.
Robert WW, Emmett TC et al. Diagnosing and
Managing Acute Retinal Necrosis. Retinal
Physician.
CMV Retinitis Ganciclovir 5mg/kg IV * Valganciclovir: 900mg PO Systemic therapy is indicated in all cases.
Cytomegalovirus q12h for 2-3 weeks q12h for 3 weeks (induction) Intravitreal therapy is indicated in zone 1
followed by 900mg PO q24h and 2 lesions. .
for 1 week
Intravitreal to be tapered according:
Intravitreal Ganciclovir Intravitreal *Foscarnet - To clinical response
2mg/0.1ml biweekly 2.4mg/0.1ml - May need to continue until CD4 count
(1-2weekly) is >150cell/mm3 .
Ganciclovir implant: 4.5gm an option to
intravitreal Ganciclovir. .
*Requires DG approval

106 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Ocular Syphilis Ocular Syphilis (syphilitic Referral to Physician/ID Physician
Treponemap Pallidum uveitis) should be treated as
Neurosyphilis
Refer to Sexually Transmitted
Infections Section
Ocular Tuberculosis Needs systemic therapy Ocular TB: presents as a unilateral/
Mycobacterium Tuberculosis Refer to Tuberculosis bilateral infective uveitis characterized by
Infections Section multifocal choroiditis/ granuloma and
there may be supportive FFA findings of
Ethambutol may cause optic occlusive vasculitis. The diagnosis maybe
neuropathy and should clinical as vitreous sampling for AFB or
avoided depending on the TB PCR may not be very sensitive due to
case small sample size and sensitivity of the
tests. Clinical response to anti-TB is often
diagnostic.
Uveitis secondary to TB Hypersen-
sitivity is an immune response to acid fast
bacilli in the eye and manifests
predominantly as an inflammatory uveitis.
Treatment includes anti-TB in
combination with an immunosuppressive
dose of systemic steroids for at least 6-9
months.
Systemic steroid maybe indicated but is
only for:
- non-active systemic TB
- severe ocular inflammation and vision
threatening condition .
References
Helm CJ, Holland GN. Ocular tuberculosis.Surv
Ophthalmol. 1993 Nov-Dec;38(3):229-56
Bodaghi B1, LeHoang P. Ocular tuberculosis. Curr
Opin Ophthalmol. 2000 Dec;11(6):443-8

107 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Post-Operative Bacterial Intravitreal antibiotic Intravitreal antibiotic Systemic antibiotics are indicated in
Endophthalmitis injections injections: severe, virulent endophthalmitis
Staphylococcus epidermidis Vancomycin 1-2mg in 0.1ml Vancomycin 1-2mg in 0.1ml Repeat intravitreal antibiotics after 48 to
Staphylococcus aureus PLUS PLUS 72 hours if indicated. .
Pseudomonas aeruginosa, Ceftazidime 2mg in 0.1ml Amikacin 0.4mg in 0.1ml
Bacteroids Species Endogenous Endophthalmitis:
Streptococcus pneumoniae, If suspicious of fungal Treatment is based on primary infection
Alpha- Haemolytic streptococci endophthalmitis: (bacterial/fungal etc) and culture and
ADD sensitivity results.
Intravitreal Amphotericin B .
0.005mg in 0.1ml All cases require systemic therapy.
Intravitreal injection is indicated in cases
Topical treatment-options Ceftazidime 5% eye drop, with vitreous involvement and sight
Vancomycin 5% eye drop, threatening lesions. .
Gentamycin 1.2% eye drop Do not use systemic steroids.
Moxifloxacin 0.5% eye drop
(monotherapy or
combination)

Ciprofloxacin 750mg PO * Moxifloxacin 400mg PO


Systemic treatment
q12h for 10 days q24h for 10 days (caution in
children)
For culture negative cases OR
ADD Vancomycin
Clarithromycin 250-500mg and Ceftazidime IV
PO q12h for 7-14 days
Post-Operative Fungal Intravitreal Amphotericin B *Intravitreal Miconazole Intravitreal and Systemic therapy are
Endophthalmitis 0.005mg in 0.1ml (0.01mg in 0.1ml) indicated in all cases. .
OR
Fluconazole 200mg PO q24h *Intravitreal Voriconazole *Requires DG approval. .
for 6 weeks (minimum) 50ug-100ug/0.1mls
CPG for Management of Post- Operative
* Voriconazole 200mg PO Endophthalmitis, Ministry of Health
q12h Malaysia, August 2006.

108 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Endogenous Endophthalmitis Treatment is based on primary infection
Systemic treatment Ciprofloxacin 750mg PO *Moxifloxacin 400mg PO (bacterial/fungal etc) and culture and
q12h for 10days q24h for 10 days (caution in sensitivity results. .
children)
For culture negative cases OR All cases require systemic therapy.
add: Vancomycin Intravitreal injection is indicated in cases
Clarithromycin 250-500mg and Ceftazidime IV with vitreous involvement and sight
PO q12h for 7-14 days threatening chroidal lesions. .

Topical treatment-options: Ceftazidime 5% eye drop, Topical therapy may supplement therapy.
Vancomycin 5% eye drop, Not to use systemic steroids in these
Gentamycin 1.2% eye drop cases.
Moxifloxacin 0.5% eye drop
(monotherapy or
combination)

Intravitreal antibiotic injections: Vancomycin 1-2mg in 0.1ml Vancomycin 1-2mg in 0.1ml Review antibiotic regimen after
PLUS PLUS microbiology results.Repeat intravitreal
Ceftazidime 2mg in 0.1ml Amikacin 0.4mg in 0.1ml antibiotics after 48 to 72 hours if indicated

If suspicious of fungal
endophthalmitis, ADD
Intravitreal Amphotericin B
0.005mg in 0.1ml
Dacryocystitis Cefuroxime 250mg PO q12h Amoxycillin/ Clavulanic Consider intravenous antibiotics in severe
Strep pneumonia, Staph aureus, for 7 days Acid 625mg PO q8h for 7 infections.
Gram-ve Anaerobes days
Preseptal Cellulitis Cloxacillin 500mg -1gm PO Amoxycillin/Clavulanic Acid Consider intravenous antibiotics in severe
Strep pneumoniae,Staph aureus, q6h for 5 days 625mg PO q8h for 7 days infections.
Strepcoccus sp. OR
Ceftriaxone 1-2gm IV q24h

109 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Orbital Cellulitis/abcess Amoxycillin/ Clavulanic Ceftriaxone 1-2gm q24h IV Periorbital and orbital cellulitis : A 10 year review
Strep pneumoniae, Staph 1.2gm q8h IV for 7-10 days for 7-10 days of Hospitalized children. Eur J Ophthalmol
2010;20(6): 1066-1072.
aureus, Strepcoccus sp. Microbiology and Antibiotic Management of
Gram-ve Anaerobes If Anaerobes suspected: Orbital Cellulitis Pediatrics 2011;127;e56.6
ADD
Metronidazole 500mg IV
q8h for 7-10 days

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ORTHOPAEDIC
DEPARTMENT

111 | P a g e
Index:
 ADULT: SURGICAL CHEMOPROPHYLAXIS - Prosthetic joint infections
- Internal fixation of all closed fracture, total joint - Osteomyelitis
replacement/spine surgery & arthroscopy - Diabetic foot infections
- Amputations for diabetic wounds and ischaemic limbs - Necrotizing fasciitis
 ADULT: SURGICAL INFECTION, BONE AND JOINT - Soft tissue infection secondary to gas producing organism
INFECTIONS - Suppurative wound infections, surgical or traumatic
- Compound fractures - Muscular, skeletal and soft tissue trauma, crush injuries and
- Vertebral osteomyelitis (OM), epidural abscess stab wounds
- Septic arthritis

ORTHOPAEDIC

Adult: Surgical Chemoprophylaxis


Infection/Condition & Suggested treatment
Preferred Alternative Comments
Likely Organism
Internal fixation of all closed Cefuroxime 1.5gm IV, Cloxacillin 1gm IV 30-45 minutes before skin incision and
fracture continue 750mg IV q8h (3 OR before tourniquet inflation.
Total Joint Replacement/ doses) post-operation Cefazolin 1-2gm IV
Spine surgery &
Arthroscopy
AMPUTATIONS FOR DIABETIC WOUNDS AND ISCHAEMIC LIMBS
Polymicrobial Infection Ampicillin/Sulbactam 1.5- Ceftriaxone 1 gm IV Complete amputation of all dead and
Likely organism: 3gm IV PLUS/MINUS necrotic tissue.
Staphylococcus aureus, Metronidazole 500 mg IV
Streptococcus spp. Moderate or severe infection:
Enterobacteriaceae - Erythema more than 2cm involving
deeper tissues, e.g. abcess,
osteomyelitis, septic arthritis, fasciitis

WITH/WITHOUT:
- Temperature >38ºC or <36ºC
- Heart rate >90BPM/

112 | P a g e
Infection/Condition & Suggested treatment
Preferred Alternative Comments
Likely Organism
- Resp rate>20/min
- PaCO2 <32mmHg
- White cell count >12000 or
<4000cells/uL

Initial parental then switch to oral.

Adult: Surgical Infection, Bone and Joint Infections


Infection/Condition & Suggested treatment
Preferred Alternative Comments
Likely Organism
Compound fractures Cefuroxime 1.5gm IV as a Cloxacillin 2gm IV q6h In all cases, a patient's tetanus
loading dose followed by OR immunization status should be assessed.
750mg IV q8h Cefazolin 1-2gm IV q8h
Mostly nosocomial and gram positive.
If wound soiling or tissue If wound soiling or tissue Need MRSA empirical cover if local
damage is severe and/or damage is severe and/or prevalence is high.
devitalized tissue is present: devitalized tissue is present:
PLUS PLUS Duration:
Gentamicin 5mg/kg q24h Gentamicin 5mg/kg q24h 24 hrs after wound closure or up to 5- 10
PLUS PLUS days
Metronidazole 500mg IV Metronidazole 500mg IV
q8h q8h
Vertebral Osteomyelitis (OM) Cloxacillin 2gm IV q4h Penicillin Allergy: In the absence of bacteraemia, clinical
Epidural Abscess OR Vancomycin 25mg/ kg IV stability or signs and symptoms of spinal
>50 % of the cases are due to: Ceftriaxone 2gm IV q24h loading dose, then 15mg/ kg cord compression.
Staph aureus, IV q12h
Enteric Gram negatives, PLUS/MINUS All antibiotic should be withheld till gram
Group B strep (especially in Ciprofloxacin 400mg IV q8h stain and culture results are available.
DM) Duration: Empiric gram negative should be covered
6-8 weeks; guided by if patient had recent spinal hardware
inflammatory parameters inserted/ surgery, DM or recurrent UTI.

113 | P a g e
Infection/Condition & Suggested treatment
Preferred Alternative Comments
Likely Organism
Surgical therapy is necessary in
progression of disease despite adequate
antibiotic, spinal cord compression/spinal
instability and/or presence of epidural
abscess.
Septic Arthritis Drainage, debridement and washout of
i. Acute monoarticular Cloxacillin2gm IV q6h Penicillin Allergy: infected joint are important to limit further
 no STD risk (Staph/Strep) (immediate hypersensitive damage.
type)
Clindamycin 600mg IV q6- Empirical therapy wherever possible
8h, should be directed by the result of the
followed by oral therapy Gram stain of the joint aspirate.
(same dose)
OR If initial gram stain is gram positive
Vancomycin 15-20mg/kg IV cocciuse Cloxacillin.
q12h
If initial gram stain is gram negative
Cefotaxime 1gm IV q8h bacilli use Ceftriaxone 2gm IV q24h.

 STD risk (gonorrhea, Ceftriaxone 2gm IV q24h Duration:


Strep/ Staph/ gram – PLUS/MINUS - Non STD GNB: 2-4
vebacili (GNB)) Azithromycin 1gm stat weeks
- STD septic arthritis: 1-2
OR weeks

Doxycycline 100mg PO
q12h for 7 days

ii. Polyarticular Ceftriaxone 2gm IV q24h


Gonorrhoae,
burkholderiaburgdorferi, viral
(Hep b) acute rheumatic fever

114 | P a g e
Infection/Condition & Suggested treatment
Preferred Alternative Comments
Likely Organism

Consider MRSA in previously


damaged joints/known MRSA
infection/recent admission
Prosthetic Joint Infections: Empiric therapy is NOT recommended.
MSSA Cloxacillin 2gm IV q4-6h To treat based on C&S.
Intensive phase OR
Cefazolin 2gm IV q8h Rifampicin should never be used alone or
in bacteraemia.
PLUS
(The choice of de-escalation will depend
Rifampicin 300-450mg PO on the sensitivity of the Staph aureus).
q12h (usually 2-6 weeks)
Need to confirm sensitivity of
Vancomycin 15-20mg/kg IV antimicrobial agent prior to usage.
q12h Duration: 3 months for hip /6 months for
PLUS knee
MRSA Rifampicin 300-450mg PO
Intensive therapy q12h (usually 2-6 weeks)
OSTEOMYELITIS
Acute Osteomyelitis No open wound: Penicillin Allergy: Duration: Initial IV therapy for 2-4 weeks
Cloxacillin 2gm IV q4-6h (immediate hypersensitive followed by oral therapy. Minimum 6
S. aureus(80%), type) weeks. Modify according to clinical
Group A Strep pyogenes, If gram negative bacilli on response.
Rarely gram negative bacilli gram stain: Clindamycin 600mg IV q8h
Ceftriaxone 2gm IV q24h followed by oral therapy
(same dose)
Chronic Osteomyelitis Empirical treatment is not Minimum length 6 weeks but usually > 3
(after 3 months of appropriate indicated. months.
antibiotic therapy or presence of
dead bone on X-ray) Thorough Surgical Treat until inflammatory parameters are
debridement required normal.

115 | P a g e
Infection/Condition & Suggested treatment
Preferred Alternative Comments
Likely Organism
Commonest organism: (Removal of deadbone/
S. aureus orthopaedic hardware).

Choice of antibiotic depends


on C&S result from
tissue/bone.
DIABETIC FOOT INFECTIONS
Antibiotics should not be used unless there are local or systemic symptoms of infection. Local treatment including surgical debridement is
important. Antibiotic selection should be based on the most recent culture and sensitivity report.
Mild & Moderate Infections: Ampicillin/Sulbactam 1.5- Ceftriaxone 1-2gm q24h Duration: usually 1-2 weeks. Modify
3gm IV q6-8h PLUS/MINUS according to clinical response.
Metronidazole 500mg IV
q8h If proven osteomyelitis: at least 4-6
weeks. However, a shorter duration (3 to
If pseudomonas is suspected Piperacillin/Tazobactam 5 days) is sufficient if the entire infected
4.5mg IV q6-8h bone is removed. If antibiotic-resistant
organisms are likely, treat as severe
infection.
Severe Infections: Piperacillin/Tazobactam Cefepime 1-2gm IV q8h Add Vancomycin 1gm IV q12h, if high
2 or more SIRS 4.5gm IV q8h PLUS risk for MRSA
Metronidazole 500mg IV
q8h Duration of treatment:
2-4 weeks
NECROTIZING FASCIITIS
Polymicrobial infection Piperacillin/Tazobactam Cefepime 1-2gm IV q8h Add Vancomycin 1gm IV q12h, if high
Primarily occurs in patients who 4.5gm IV q6-8h PLUS risk for MRSA
are immunocompromised or Metronidazole 500mg IV
have certain chronic diseases q8h Early aggressive surgical debridement
such as diabetes essential.

With septicaemia/ severe sepsis, refer ICU


guideline

116 | P a g e
Infection/Condition & Suggested treatment
Preferred Alternative Comments
Likely Organism
SOFT TISSUE INFECTION SECONDARY TO GAS PRODUCING ORGANISM
Clostridium spp, Benzylpenicillin 2-4MU IV Ceftriaxone 1-2gm q24h *For Clostridium sp.: Benzylpenicillin
Gram –ve organism q4h PLUS 4MU IV q4-6h is preferred
PLUS Clindamycin 600-900mg IV
Clindamycin 600-900mg IV q6h Early aggressive surgical debridement is
q6h PLUS/MINUS essential.
PLUS/MINUS Gentamicin 5mg/kg IV q24h
Gentamicin 5mg/kg IV q24h Duration: 10 – 28 days
SUPPURATIVE WOUND INFECTIONS, SURGICAL OR TRAUMATIC
Suppurative wound infections, Cefuroxime 1.5gm IV as a Change antibiotics accordingly after C&S
surgical or traumatic loading dose followed by result are available.
750mg IV q8h
Topical antibiotics are not recommended
for treatment of wound infections as it
may result in the emergence of resistant
organisms.

Patient tetanus immunization status


should be assessed in all cases.
MUSCULAR, SKELETAL AND SOFT TISSUE TRAUMA, CRUSH INJURIES AND STAB WOUNDS
Muscular, skeletal and soft Cefuroxime 1.5gm IV as a Cloxacillin 2gm IV q6h Thorough surgical debridement, soft
tissue trauma, crush injuries and loading dose followed by OR tissue and fracture stabilisation.
stab wounds 750mg IV q8h Cefazolin 1-2gm IV q8h
If wound soiling or tissue For severe penetrating injuries, especially
If wound soiling or tissue damage is severe and/or those involving joints and/or tendons,
damage is severe and/or devitalized tissue is present: antibiotics must be given for at least 5
devitalized tissue is present: PLUS days.
PLUS Gentamicin 5mg/kg q24h
Gentamicin 5mg/kg q24h PLUS
PLUS Metronidazole 500mg IV
Metronidazole 500mg IV q8h
q8h

117 | P a g e
OTOLARYNGOLOGY
DEPARTMENT

118 | P a g e
Index:
 Chemoprophylaxis  Rhinology
- Head and neck surgery - Acute bacterial rhinosinusitis (ABRS)
 General Sore Throat  Otology
 Throat and Upper Respiratory - Acute otitis media
- Tonsillitis/Pharyngitis - Malignant otitis externa/Necrotizing otitis externa
- Acute peritonsillar abscess - Acute diffuse otitis externa
- Diphteria - Chronic suppurative otitis media
- Acute epiglottitis - Otomycosis
- Deep neck space abscess - Perichondritis
- Acute mastoiditis

OTORHINOLARYNGOLOGY INFECTIONS

Chemoprophylaxis

It is the use of antibiotics to prevent infections at the surgical site. It should be considered when there is significant risk of post-operative
infection or where post-operative infection would have severe consequences. Ideally, the prophylaxis when given intravenously should be
given as soon as the patient is stabilized after induction. Usually a single dose is sufficient. A second dose may be required in the following
situations:

a. delay in start of surgery


b. in prolonged operations when the time is more than half of the usual dosing interval of the antibiotic

Pre-operative dose timing: The optimal time for administration of preoperative doses is within 60 minutes before surgical incision. Some
agents, such as Clindamycin, Fluoroquinolones, Gentamicin, Metronidazole and Vancomycin, require administration over one to two hours;
therefore, the administration of these agents should begin within 120 minutes before surgical incision.

(Reference: Am J Health-Syst Pharm Vol 70: 195-283, 2013@IDSA.)

Giving more than 1 or 2 doses postoperatively is generally not advised. The practice of continuing prophylactic antibiotics until
surgical drains have been removed is NOT RECOMMENDED.

119 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
HEAD AND NECK
Clean Antibiotic not required Antibiotic not required
Clean with placement of Ceftriaxone 2g stat IV β -lactam Allergy:
prosthesis Clindamycin 900 mg IV
(excludes tympanostomy tubes)
Clean-contaminated cancer Cefuroxime 1.5gm IV β -lactam Allergy: Redosing:
surgery PLUS Clindamycin 900 mg IV Procedure longer than 4 hours for
Metronidazole 500mg IV Cefuroxime, and 2 hours for
Other clean-contaminated Ampicillin/Sulbactam.
procedures with the exception of OR
tonsillectomy and functional
endoscopic sinus procedures Ampicillin/Sulbactam 3gm
IV
For procedures in which pathogens other than staphylococci and streptococci are likely, an additional agent with activity against those
pathogens could be considered. For example, if there are surveillance data showing that gram-negative organisms are a cause of surgical-site
infections (SSIs) for the procedure, practitioners may consider combining Clindamycin or Vancomycin with another agent (Cefazolin if the
patient is not β -lactam allergic; gentamicin, or single-dose fluoroquinolone if the patient is β -lactam allergic).

References:
1. Am J Health-Syst Pharm. 2013; 70:195-283, 2013@IDSA
2. Weber RS, Callender DL. Antibiotic prophylaxis in clean-contaminated head and neck oncologic surgery. Ann Otol Rhinol Laryngol. 1992; 101:16- 20
3. Johnson JT, Wagner RL. Infection following uncontaminated head and neck surgery. Arch Otolaryngol Head Neck Surg. 1987; 113:368-9.
4. Saginur R, Odell PF, Poliquin JF. Antibiotic prophylaxis in head and neck cancer surgery. J Otolaryngol. 1988; 17:78-80.
5. Simo R, French G. The use of prophylactic antibiotics in head and neck oncological surgery. Curr Opin OtolaryngolHead Neck Surg. 2006; 14:55-61
6. Strauss M, Saccogna PW, Allphin AL. Cephazolin and metronidazole prophylaxis in head and neck surgery. J Laryngol Otol. 1997; 111:631-4.
7. Skitarelić N, Morović M, Manestar D. Antibiotic prophylaxis in clean contaminated head and neck oncological surgery. J Craniomaxillofac Surg.2007; 35:15-20.
8. National Institute for Health and Clinical Excellence. Surgical site infection (clinical guideline 74) 2008. www.nice.org.uk/CG74 (accessed 2012 Dec 9).
9. Fennessy BG, Harney M, O’Sullivan MJ et al. Antimicrobial prophylaxis in otorhinolaryngology/head and neck surgery. Clin Otolaryngol. 2007; 32:204-7.
10. Seven H, Sayin I, Turgut S. Antibiotic prophylaxis in clean neck dissections. J Laryngol Otol. 2004; 118:213-6
11. Slattery WH III, Stringer SP, Cassisi NJ. Prophylactic antibiotic use in clean, uncontaminated neck dissection. Laryngoscope. 1995; 105:244-6.

120 | P a g e
GENERAL SORE THROAT
The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or
empiric antibiotic therapy.
The cumulative score determines the likelihood of streptococcal pharyngitis and the need for antibiotics

Criteria Score Age Score


Absence of cough 1 3 to 14 years 1

Swollen and tender anterior cervical lymph nodes 1 15 to 44 years 0

Temperature > 100.4° F (38° C) 1 45 years and older -1

Tonsillar exudates or swelling 1

Cumulative score

Total score Risk Comment


0 or 1 Low risk Do not require testing or antibiotic therapy
2 or 3 Testing recommended. Positive results warrants antibiotics. If test not available, antibiotics may be considered
4 or more High risk Empiric therapy may be considered

References :
A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CAN MED ASSOC J • JAN. 13, 1998

121 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
THROAT AND UPPER RESPIRATORY
Tonsillitis/Pharyngitis Phenoxymethylpenicillin Amoxicillin 500mg PO q8- Antibiotics should be prescribed in
Group A Streptococcus 500mg PO q12h for 10 days 12h for 10 days suspected/proven bacterial infections
OR only, as sore throats are common viral in
Benzathine Penicillin Penicillin Allergy: origin.
1. 2MU IM, for single dose Azithromycin 500mg
PO q24h for 5 days
OR
Clindamycin 300-450mg PO,
q8h for 10 days
Acute Peritonsillar Abscess Ampicillin/Sulbactam 3 g IV Amoxicillin/Clavulanate 625 Abscess to be drained
Group A Streptococcus q6h mg PO q8h
Staphylococcus aureus
Haemophilus influenza OR OR
Fusobacterium necrophorum
Amoxycillin/Clavulanate Phenoxymethylpenicillin
1.2gm IV q8h 500mg PO q6h
PLUS
OR Metronidazole 500mg PO
q6h
Benzylpenicillin (Penicillin
G) 2 MU IV q6h OR
PLUS
Metronidazole 500mg IV Clindamycin 300-450mg PO
q8h for 10-14 days q6h

Penicillin Allergy:
Clindamycin 600mg IV q8h

122 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Diphteria Antitoxin
Corynebacterium diphtheriae
PLUS

Erythromycin Lactobionate
500mg IV q6h followed by
Erythromycin Ethylsuccinate
800mg PO q12h for total of
14 days
OR
Benzylpenicillin 50,000
units/kg to a maximum of 1.2
MU IV q12h
followed by
Phenoxymethylpenicillin
250mg PO q6h total of 14
days
Acute Epiglottitis Ceftriaxone 2gm IV q24h Penicillin Allergy: Urgent hospitalisation. May present with
Haemophilus influenzae Type b, OR Clindamycin 600-900mg IV life threatening upper airway obstruction,
Streptococcus pneumoniae Ampicillin/Sulbactam 3gm q8h especially in paediatrics.
IV q6h PLUS
Ciprofloxacin 400mg IV
Oral step down q12h
Amoxicillin/Clavulanate
625mg PO q8h for 7 – 14
days

123 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Deep Neck Space Abscess Ampicillin/Sulbactam 3gm
Streptococcus pyogenes IV q6h 10-14 days
Staphylococcus aureus
Fusobacterium necrophorum OR

Ceftriaxone 2gm IV q24h


PLUS
Metronidazole 500mg IV
q6h
RHINOLOGY
Acute Bacterial Rhinosinusitis Amoxicillin 500mg PO q8h Β-lactam allergy: Pregnant patients with Penicillin Allergy
(ABRS) OR Doxycycline 100mg PO would need to be treated with
Streptococcus pneumoniae, Amoxicillin/Clavulanic Acid q12h Azithromycin 500mg PO q24hr. .
Haemophilus influenzae, 625mg PO q8h for 5-7 days
Moraxella catarrhalis

Severe infection requiring Ampicillin/Sulbactam 1.5–


hospitalization: 3gm IV q6h
OR
Amoxicillin/Clavulanic
1.2gm IV q8h
OR
Cefuroxime 1.5g IV stat,
then 750mg q8h
OR
Ceftriaxone 1–2gm IV q12–
24h

124 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
OTOLOGY
Acute Otitis Media For severe disease or Penicillin Allergy: Antibiotics should not be routinely
Streptococcus pneumoniae, when risk of complications: Clarithromycin 500mg PO prescribed for uncomplicated AOM.
Haemophilus influenzae Amoxicillin 500mg PO q8h q12h
M.catarrhalis OR
If not responding 48-72hrs; Azithromycin 500mg PO on
Amoxicillin/Clavulanate day 1,
625mg PO q8h for 5 days followed by 250mg PO OD
OR on day 2 through day 5
Cefuroxime 500mg PO q12h
Malignant Otitis Externa/ Ciprofloxacin 400mg IV q8h
Necrotizing Otitis Externa OR
Ceftazidime 2gm IV q8h
Pseudomonas aeruginosa followed by
Ciprofloxacin 750mg PO
q12h for 6 weeks
Acute Diffuse Otitis Externa Ofloxacin 0.3% otic solution Aural toileting required in discharging
P. aeruginosa Instill 10 drops into affected ears
Staph aureus ear(s) once daily for 7 days
OR
Sofradex (Framycetin
sulphate, Gramicidin &
Dexamethasone) ear drop
3 drops q8h for 7 days
Chronic Suppurative Otitis Ofloxacin 0.3% otic solution Aural toileting required in discharging
Media Instill 10 drops into affected ears
P. aeruginosa ear(s) twice daily for 10-14
Staph aureus days
OR
Sofradex (Framycetin
sulphate, Gramicidin &
Dexamethasone) ear drop

125 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
3 drops q8h for 7 days
Otomycosis Clotrimazole 1% ear Aural toileting required.
Aspergillus sp. solution, applied twice daily
for 10 to 14 days
Perichondritis Ciprofloxacin 400mg PO
q12h
Acute Mastoiditis Amoxicillin/Clavulanate 1.2g
IV q8h
OR
Ceftriaxone 1-2g IV q12-24h

126 | P a g e
PAEDIATRICS
DEPARTMENT

127 | P a g e
Index:
 Acute Myocarditis - Streptococcus viridans
 Acute Pericarditis - Enterococcus
 Infective Endocarditis - Staphylococcus
- Empirical Therapy - Culture-negative endocarditis

PAEDIATRICS CARDIOVASCULAR INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
ACUTE MYOCARDITIS
Commonly caused by viruses Treatment mainly supportive

ACUTE PERICARDITIS
Viral (commonest cause) Treatment mainly supportive Consider surgical drainage if pericardial
empyema detected
Bacterial: Cloxacillin 200 mg/kg/24h Penicillin Allergic:
Staphylococcus aureus IV q4-6h for 6 weeks Cefazolin 100 mg/kg/24h IV
PLUS/MINUS q8h
Gentamicin 1 mg/kg IV/IM OR
q8h for 3 -5 days Vancomycin 40 mg/kg/24h
IV in 2-4 divided doses
INFECTIVE ENDOCARDITIS
Empirical Therapy for Benzylpenicillin 200,000 Vancomycin 15 mg/kg q12h
Infective Endocarditis units/kg/24h IV q4-6h for 4 IV for 4-6 weeks
weeks PLUS
PLUS Gentamicin 1 mg/kg IV/IM
Gentamicin 1 mg/kg IV/IM q8h for 2 weeks
q8h for 2 weeks

128 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Infective Endocarditis Benzylpenicillin 200,000 Ceftriaxone 100mg/kg IV/IM Dosages suggested are for patients with
Streptococcus viridans units/kg/24h IV q4-6h for 4 q24h for 4 weeks normal renal and hepatic function.
Strains fully susceptible to weeks PLUS
penicillin (MIC < 0.125 mg/l) PLUS Gentamicin 1mg/kg IV/IM Maximum dosages per 24 hours:
Gentamicin 1mg/kg IV/IM q8h for 2 weeks Penicillin 18 MU; Ampicillin 12gm;
q8h for 2 weeks Ceftriaxone 4gm, Gentamicin 240 mg.
Penicillin/Ceftriaxone Vancomycin dose adjusted for trough
Allergic: concentration of 15-20
Vancomycin 40mg/kg/24h mg/ml
IV q8-12h for 4 weeks
Infective Endocarditis Benzylpenicillin 300,000 Penicillin allergic:
Enterococcus units/kg/24h IV q4-6h Vancomycin 40 mg/kg/day
OR IV q8-12h
Ampicillin 300 mg/kg/24h PLUS
IV q4-6h for 4-6weeks Gentamicin 1mg/kg IV/IM
q8h for 2 weeks for 4-6
PLUS weeks

Gentamicin 1mg/kg IV/IM


q8h for 4-6 weeks
Infective Endocarditis Cloxacillin 200 mg/kg/24h Penicillin allergic: Clinical benefit of Aminoglycosides has
Staphylococcus IV q4-6h for 6 weeks Cefazolin 100 mg/kg/24h IV not been established.
a) Methicillin sensitive PLUS q8h for 6 weeks
Gentamicin 1mg/kg IV/IM OR Cefazolin or other first-generation
q8h for3-5 days Vancomycin 40 mg/kg/24h cephalosporin in equivalent dosages may
IV q2-4h for 6 weeks be used in patients who do not have a
history of immediate type hypersensitivity
(urticaria, angioedema, anaphylaxis) to
b) Methicillin Resistant Vancomycin 60 mg/kg/24h penicillin or ampicillin.
IV q6h for 6 weeks
Target trough concentration between 15-
20 μg/ml

129 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Culture-Negative Endocarditis Ampicillin/Sulbactam 300 Patients with culture-negative
mg/kg/24h IV q4-6h for 4-6 endocarditis should be treated in
weeks consultation with an ID specialist
PLUS
Gentamicin 1mg/kg IV/IM
q8h for 4-6 weeks

130 | P a g e
Index:
 Meningitis (empirical treatment)  Cryptococcal meningitis
 Meningitis (Haemophilus influenza, Streptococcus pneumoniae)  Herpes Simplex Encephalitis
 Neisseria meningitidis  Brain Abscess

PAEDIATRICS CENTRAL NERVOUS SYSTEM INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Meningitis empirical Cefotaxime 50mg/kg IV q4- If suspected penicillin- Prophylaxis for all household contacts if
treatment 6h resistant Strep pneumonia: there are unimmunised or partially
OR Cefotaxime 50mg/kg IV q4- immunised children < 4 years old.
Ceftriaxone 50-75mg/kg IV 6h
q12-24h for 10-14 days. OR
Ceftriaxone for 50-75mg/kg
If < 3 month-old, IV q12-24h for 10-14 days
ADD:
Benzylpenicillin 50mg/kg PLUS
IVq4-6h
OR Vancomycin 15mg/kg IV
Ampicillin 50mg/kg IV q4- q6h
6h

Haemophilus influenza Cefotaxime 50mg/kg Chloramphenicol 40mg/kg


Strepcoccus pneumoniae IV q4-6h IV stat then 25mg/kg q6h for
OR 10-14 days;
Ceftriaxone 50-75mg/kg IV OR
q12-24h for 10-14 days. Cefepime 50mg/kg IV q8h
for 10-14 days.

131 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Neisseria meningitidis Benzylpenicillin 50mg/kg IV Cefotaxime 50mg/kg IV q4- Prophylaxis for all household contacts and
q4-6h for 7 days 6h Health Care Workers involved in
OR intubation and suctioning of airway
Ceftriaxone 50-75mg/kg IV
q12-24h for 7 days.
OR
Chloramphenicol 40mg/kg
stat then 25mg/kg IVq6h
Cryptococcal meningitis Induction Therapy:
Cryptococcus neoformans Amphotericin B
1.0mg/kg/24h IV
PLUS/ MINUS
5-Flucytosine 400-
1200mg/m2 (max 2gm) PO
in q6h for 2-4 weeks.

Consolidation Therapy:
Fluconazole 10-12mg/kg/24h
PO in q12h for 8 weeks.
Herpes Simplex Encephalitis Acyclovir: Duration: for 14-21 days.
<12 weeks old: 20mg/kg IV
q8h

12 weeks-12 years old:


500mg/m2 IV q8h

If >12 years olds: 10mg/kg


IV q8h

132 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Brain Abscess Cefotaxime 50mg/kg IV q4- If secondary to trauma: Surgical drainage may be indicated if
6h ADD appropriate.
OR Cloxacillin 25-50mg/kg IV
Ceftriaxone 50-75mg/kg IV q4-6h. Duration 6-8 weeks, depending on
q12-24h response as seen from neuroimaging.

PLUS

Metronidazole 15mg/kg IV
stat then 7.5mg/kg IV q8h.

133 | P a g e
Index:
 Rheumatic fever  Meningococcal exposure
 Infective Endocarditis (IE)  Neonatal Group B Strep Infection
 Postsplenectomy  Malaria prophylaxis
- At risk for pneumococcus, meningococcus, haemophilus  Pertussis
- Haemophilus influenza b Close contacts  Chicken pox

PAEDIATRICS CHEMOPROPHYLAXIS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Rheumatic fever Benzathine Penicillin IM Penicillin V 250mg PO q12h
(Secondary prevention) 1.2 MU (>25kg) ;
0.6 MU (<25 kg) every 3-4 Penicillin Allergy :
weeks Erythromycin Stearate
250mg PO q12h
Duration:
With carditis:
10 years or until 25 years of
age
Without carditis:
5 years or until 18 years of
age
Infective Endocarditis (IE) Amoxycillin 50mg/kg PO 1 Penicillin Allergy : IE prophylaxis recommended for patients
hour before procedure Clindamycin 20mg/kg IV/PO with the highest risk cardiac conditions
OR 1 hour before procedure undergoing procedures likely to result in
Ampicillin IV 50mg/kg bacteremia with a microorganism that has
the potential ability to cause bacterial
Include coverage for endocarditis
staphyloccus for surgical
procedures on infected skin, For highest risk procedures:
skin structure, or  Dental procedures that involve
musculoskeletal tissue manipulation of either gingival tissue
or the periapical region of teeth or

134 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Genitourinary or perforation of the oral mucosa; this
gastrointestinal does not include routine dental
procedures: cleaning.
IE prophylaxis only if  Procedures of the respiratory tract that
ongoing GI or GU tract involve incision or biopsy of the
infection Require activity respiratory mucosa.
against enterococci  Procedures in patients with ongoing
(amoxicillin or ampicillin) or gastrointestinal (GI) or genitourinary
vancomycin for penicillin (GU) tract infection.
allergic  Procedures on infected skin, skin
structure, or musculoskeletal tissue.
 Surgery to place prosthetic heart
valves or prosthetic intravascular or
intracardiac materials.

Maintenance of optimal oral hygiene may


reduce the incidence of bacteremia from
daily activities and is more important than
prophylactic antibiotics for a dental
procedure to reduce the risk of IE.
Postsplenectomy Penicillin V PO Amoxicillin (20mg/kg/day) Risk of sepsis is lifelong, but especially
At risk for Pneumococcus, 125mg q12h for ≤3 years old the first 2 years after splenectomy.
Meningococcus, Haemophilus 250mg q12h for >3years old Penicillin Allergy :
Erythromycin Ethylsuccinate Important adjunct:
Duration: 200mg PO daily < 2 years Immunization against pneumococcus,
 Children up to the age of old Haemophilus, meningococcus at least 14
16 years 400mg daily > 2 years old days prior to splenectomy. (If not possible
 Post splenectomy for at then 14 days postoperative day).
least 2-3 years
 Indefinitely for patients Yearly influenza vaccine also
with an underlying recommended.
immunodeficiency or (Please refer relevant immunization
guidelines for schedule)

135 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
immunocompromised
state and asplenia. To seek immediate medical attention
when febrile or to instruct on immediate
(Require ongoing self-directed empiric antibiotics
surveillance for resistant (Amoxicillin/Clavulanate or Cefuroxime
pneumococci) Axetil) before promptly seeking medical
care.

Haemophilus influenza b Close Rifampicin PO Close (household) contact is defined as a


contacts Children: person who resides with the index patient
20mg/kg/day q24h for 4 days or who spent ≥4 hours with the index
Infants: patient for at least five of the seven days
10mg/kg/day q24h for 4 days before the day of hospital admission of
the index case.

Indications
Household contacts
 Household with at least one contact
<4 years who has not received an age-
appropriate number of doses of Hib
conjugate vaccine.
 Household with a contact who is an
immunocompromised child (<18
years), regardless of that child's Hib
immunization status.

Nursery Contact
For child-care and preschool contacts
(regardless of age or vaccine status) when
unimmunized or incompletely immunized
children attend the facility and two or
more cases of Hib invasive disease have
occurred among attendees within 60 days,

136 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative

Give chemoprophylaxis to index case if


treated with regimens other than
cefotaxime or ceftriaxone.

For Contacts < 2 years not immunized:


complete immunization.
Meningococcal exposure Rifampicin PO Ceftriaxone IM CLOSE contact defined as individuals
Children: <15 years old : 125mg stat who have had prolonged (>8 hours)
<1 month: 5mg/kg/dose q12h >15 years old : 250mg stat contact while in close proximity (<3 ft) to
for 2 days the patient or who have been directly
>1 month: 10mg/kg/dose Ciprofloxacin PO exposed to the patient's oral secretions
(max 600mg) q12h for 2 >18 years old: 500mg single during the seven days before the onset of
days dose the patient's symptoms and until 24 hours
after initiation of appropriate antibiotic
therapy:
All household, child care and nursery,
school contacts.

Others
 Close contact for at least 4 hours
during the week before illness onset.
 Exposure to index’s nasopharyngeal
secretions (eg kissing, sharing of
toothbrushes, eating utensils).
 Airline flights lasting >8 hours:
directly next to case.

Healthcare staff
Routine prophylaxis not recommended,
unless exposure to secretions such as
unprotected mouth to mouth resuscitation,
intubation or suctioning.

137 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Neonatal Group B Strep Intrapartum maternal Ampicillin 2gm IV load then
Infection prophylaxis till delivery 1gm q6h
Treat during labour if previously Penicillin G IV
delivered infant with invasive (5MU load then 2.5MU q6h Penicillin allergy
GBS, GBS bacteriuria or till delivery) Clindamycin 900mg IV q8h
antenatal screening swabs (according to susceptibility)
positive OR
OR if GBS status not known Vancomycin (weight based
AND any of the following: dosing 20mg/kg, max 2gm
 Preterm <37 weeks q12h)
 PROM >18 hours
 Intrapartum temp >38ºC
Malaria prophylaxis Please refer to National
Guidelines on Malaria
Pertussis <1 month : Antimicrobial prophylaxis for close
(Postexposure prophylaxis) Azithromycin 10mg/kg q24h contacts of the index case and for exposed
for 5 days individuals at high risk for severe or
>1 month : complicated pertussis.
Erythromycin Ethylsuccinate
40-50mg/kg/day q6h for 14 Close contact definition:
days  Face-to-face exposure within three
feet of a symptomatic patient.
 Direct contact with respiratory, oral,
or nasal secretions from a
symptomatic patient.
 Sharing the same confined space in
close proximity with a symptomatic
patient for ≥1 hour.

At risk:
 Infants younger than one year,
especially <4 months of age.

138 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
 Persons with immunodeficiency.
 Persons with underlying medical
conditions (chronic lung disease,
respiratory insufficiency, cystic
fibrosis).
 Because of the risk of severe disease
in infants younger than one year of
age, especially those younger than
four months of age, women in the
third trimester of pregnancy should be
given postexposure prophylaxis.

Complete immunization for close contact


≤7 years of age.

Routine vaccination of children,


adolescents, and adults (including
pregnant women) is the most important
preventive strategy.

Chicken pox For passive PEP:


(Postexposure prophylaxis) Susceptible hosts include
 Immunocompromised children and
Active Varicella vaccine: adults who lack evidence of immunity
Within 3-5 days of exposure to VZV.
for the susceptible healthy  Newborns of mothers with varicella
adult/child shortly before or after delivery (ie, 5
days before to 2 days after delivery).
Passive For patients who are at high  Premature infants born at ≥28 weeks
risk for severe infection and of gestation who are exposed during
complications, and who are their hospitalization and whose
not candidates for the VZV mothers do not have evidence of
vaccine

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
immunity.
Varicella zoster immune  Premature infants born at <28 weeks
globulin (dose as per product of gestation or who weigh ≤1000 g at
information – weight based) birth and were exposed during their
hospitalization, regardless of their
OR mothers' evidence of immunity to
varicella.
IVIG (400mg/kg)

As soon as possible after


exposure up to10 days after

Patients receiving monthly


high dose (≥400mg/kg) IVIG
are likely to be protected and
probably do not require
VariZIG if the most recent
dose of IVIG was
administered ≤3 weeks
before exposure

140 | P a g e
Index:
 Tonsillitis/Pharyngitis  Acute Otitis Media
 Rhinosinusitis  Acute Diffuse Otitis Externa

PAEDIATRICS OTORHINOLARYNGOLOGY INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Tonsillitis/Pharyngitis Phenoxymethylpenicillin Penicillin Allergy:
Group A streptococcal <27kg: 250mg PO q8-12h for Azithromycin 12 mg/kg PO
10 days; q24h for 5 days
≥27kg: 500mg PO q8-12h for OR
10 days Clarithromycin
OR 7.5mg/kg/dose q12h for 10
Amoxicillin 25 mg/kg PO days
q12h (max 500mg) for 10
days
Rhinosinusitis Amoxicillin/Clavulanate Risk for antibiotic Antibiotic therapy for acute bacterial
Streptococcus pneumonia 22.5mg/kg PO q12h for 10- resistance or failed initial sinusitis in children with severe onset or
Haemophilus influenza 14 days therapy: worsening course, of high grade fever,
Moraxella catarrhalis Amoxicillin/Clavulanate purulent nasal discharge.
Severe infection: 45mg/kg PO q12h
Ampicillin/Sulbactam 200–
400 mg/kg/day IV q6h
OR
Ceftriaxone 50 mg/kg/day IV
q12h
OR
Cefotaxime 100–
200mg/kg/day IV q6h
Acute Otitis Media Amoxycillin 40-45 mg/kg Amoxicillin/Clavulanate 45
Streptococcus pneumonia PO q12h for 5 days mg/kg PO q12h
Haemophilus influenza OR
Moraxella catarrhalis Cefuroxime 15 mg/kg PO

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
q12h
OR
Ceftriaxone 50 mg/kg IM/IV
for 1 dose

Penicillin Allergy:
Clarithromycin 7.5mg /kg
PO q12h
OR
Azithromycin 10mg/kg PO
on day 1, followed by
5mg/kg PO q24h on day 2 to
day 5
Acute Diffuse Otitis Externa Ofloxacin 0.3% otic solution Aural toileting required in discharging
P. aeruginosa and Staph. aureus Instill 5 drops into affected ears
ear(s) once daily for 7 days 1-12 years.
> 12 years refer to adult dose

142 | P a g e
Index:
 Acute gastroenteritis  Cholera
 Dysentery  Liver abscess
 Giardiasis  Acute cholangitis
 Typhoid fever  Peritonitis

PAEDIATRICS GASTROINTESTINAL INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Acute Gastroenteritis Antibiotics not recommended Oral rehydration is the cornerstone of
Usually viruses eg: rotavirus treatment

Antibiotic therapy may prolong


carriage state of salmonellosis
Dysentery Most mild infections resolved
Shigella, E. coli, spontaneously without
Campylobacter antibiotics

Mild or uncomplicated Trimethoprim/Sulphamethoxazo Ampicillin 100mg/kg/24h PO in


le (TMP: 5-8mg/kg/24h) PO in 4 divided doses for 5-7 days
2 divided doses for 5-7 days

Cefotaxime 25-50mg/kg IV q6-


Severe 8h for 7 days
Dysentery Metronidazole 30-50mg/kg/24h
Amoebiasis PO in 3 divided doses for 5 days
(10 days for severe infection)
Giardiasis Metronidazole 30mg/kg/24h PO
once daily for 3 days

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Typhoid fever
Salmonella Typhi
S. paratyphi
Mild or uncomplicated Ciprofloxacin 15-20mg/kg/d PO Chloramphenicol 50- *Fluoroquinolones need to be used
in 2 divided doses for 5-7 days 100mg/kg/d PO in q6h for with caution in children due to
minimum 14 days possible arthropathy and rapid
development of resistance. However,
Severe infection or suspected Ceftriaxone 60-80mg/kg IV *Ciprofloxacin IV 10-15mg/kg there is now increasing data on safety
resistant organism q24h for 7-14 days IV q12h for 7-14 days and efficacy of quinolones in children.

Chronic carrier state (> 1 Ampicillin/Amoxycillin *Ciprofloxacin 20-30mg/kg/24h


year) 100mg/kg/24h PO in q6-8h for PO in q12h for 4 weeks
6 weeks
OR
Trimethoprim/Sulphamethoxazo
le 8 mg (TMP)/kg/24h PO in 2
divided doses for 6 weeks
Cholera Trimethoprim/ Erythromycin 50mg/kg/24h PO Oral or IV rehydration is the
Sulphamethoxazole in q6h for 3 days (for strains cornerstone of treatment. Antibiotics
8-10mg (TMP)/kg/24h PO in 2 resistant to tetracyclines) therapy reduces the volume and
divided for 3 days duration of diarrhea.
OR Single dose Azithromycin or
Tetracycline 50mg/kg/24h PO Ciprofloxacin may be Monitor antimicrobial sensitivity
q6h for considered in special pattern at beginning of & during the
3 days (children > 8 years) circumstances (e.g. during outbreak as it can change.
OR major outbreaks)
Doxycycline 6mg/kg (max. Avoid using Tetracycline or
300mg) PO q24h (children > 8 Doxycycline for young children as
years) they can cause staining of the teeth.

(2mg/kg 12hly -severe)

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Liver abscess (amoebic) Metronidazole 7.5mg/kg IV q8h Amoebic abscess tend to be solitary
Entamoeba histolytica for 10-14 days lesion. Consider surgical drainage if
needed
Liver abscess (pyogenic) Cloxacillin 25-50mg/kg IV q4- Cefotaxime 25-50mg/kg IV q6- Surgical drainage is needed in most
S. aureus, Gram negative, 6h 8h cases
Anaerobes PLUS PLUS
Gentamicin 5mg/kg IV q24h Metronidazole 7.5mg/kg IV q8h
PLUS
Metronidazole 7.5mg/kg IV q8h
for 4-6 weeks
Acute cholangitis Ampicillin 25-50mg/kg IV q6h Cefoperazone 25-50mg/kg IV
Gram negative, anaerobes, PLUS q6-8h
gram positive Gentamicin 5mg/kg IV q24h PLUS
PLUS Metronidazole 7.5mg/kg IV q8h
Metronidazole 7.5mg/kg IV q8h
for 7-14 days
Peritonitis Ampicillin 25-50mg/kg IV q6h Cefotaxime 25-50mg/kg IV q6- May omit metronidazole in primary
Gram negative, anaerobes, PLUS 8h peritonitis
gram positive Gentamicin 5mg/kg IV q24h PLUS
PLUS Metronidazole 7.5mg/kg IV q8h
Metronidazole 7.5mg/kg IV q8h for 7-14 days
for 7-14 days

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INFECTIONS IN IMMUNOCOMPROMISED PAEDIATRICS PATIENTS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
First Line Cefepime 50mg/kg IV q8h Piperacillin/Tazobactam Meta analysis has shown that there is no
Febrile neutropenia <9 months : 80 mg/kg IV q8h clinical advantage with β lactam-
Fever >38°C 9month-<40kg : 100 mg/kg aminoglycoside combination therapy.
Neutrophil<500mm³ IVq8h
>40 kg : 3gm IV q6h
Klebsiella sp (non ESBL),
E.coli, Pseudomonas
Second Line Imipenem 25mg/kg IV q6h Meropenem 20mg/kg IV q8h Consider adding Vancomycin in
Persistent fever > 72 hours PLUS/MINUS PLUS/MINUS suspected catheter related infections,
Vancomycin 15mg/kg IV Vancomycin 15mg/kg IV positive blood culture for gram +ve cocci,
MRSA , ESBL Klebsiella, q6h q6h hypotension patients and patients who are
coagulase -ve staph known to be colonised with MRSA.
Third Line Imipenem 25mg/kg IV q6h Meropenem 20mg/kg IV q8h 1/3 of febrile neutropenia patients with
Fever > 4-7 days with no PLUS PLUS persistent fever >1 week have systemic
identified source of fever Amphotericin B 0.5mg/kg IV Amphotericin B 0.5mg/kg IV fungal infections.
and gradually escalate by and gradually escalate by
Candida sp. Aspergillus sp. 0.25mg/kg to 1mg/kg q24h 0.25mg/kg to 1mg/kg q24h
(max. 1.5 mg/kg/d) (max. 1.5 g/kg/d)

146 | P a g e
Index:
 Congenital & Perinatal Infections - Early onset sepsis (<48 hrs)
- Congenital syphilis - GBS infection
- Congenital toxoplasmosis  Postnatal Infections
- Herpes simplex - Community acquired infections
- Tetanus neonatorum - Hospital acquired infection
- Gonococcal ophthalmitis - Necrotising enterocolitis (NEC)
- Chlamydia trachomatis conjunctivitis

NEONATAL INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
CONGENITAL & PERINATAL INFECTIONS
Congenital Syphilis Aqueous crystalline Procaine Penicillin G, 50,000 Only severe cases are clinically apparent
T. pallidum penicillin G: 50,000 units/kg units/kg IM daily in a single at birth.
IV q12h during the first 7 dose for 10 days  Isolate till non-infectious (at least 24
days of life and q8h hours of treatment)
thereafter) for 10 days  Screen for other STDs and HIV
 If more than one day of penicillin
If diagnosed with therapy is missed, the entire course
congenital syphilis after should be restarted
one month of age:  Investigate and treat parents
Aqueous Penicillin G 50,000  Evaluation of the siblings of an index
units/kg IV q4-6h for 10 case of congenital syphilis may be
days. warranted if such an evaluation did
not occur previously
If findings compatible with
CNS involvement, some Follow-up:
experts suggest that 10 days Nontreponemal serologic tests at 3, 6, 12
course of aqueous penicillin and 24 months. (Should become neg by 6
be followed with a single months).
dose of benzathine penicillin
50,000 units/kg IM For those with abnormal CSF –

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
recommended to repeat CSF FEME and
VDRL at 6 month intervals. Persistent
+VDRL of CSF requires reevaluation and
possible re-treatment.
Congenital Toxoplasmosis Pyrimethamine (initial Fansidar Drug regimen not definitively established.
T. gondii loading dose of 2 mg/kg PO Pyrimethamine (1.25 mg/kg Clinical trials ongoing.
once/day for 2 days followed every 15 days)
by 1 mg/kg PO once/day, PLUS Prednisolone (0.5 mg twice per day) can
max 25 mg) for 6 months, Sulfadoxine (25 mg/kg every be added if cerebrospinal fluid (CSF)
then 3 times a week for 15 d) for 24 months protein is >1 gm/dL or when active
subsequent 6 months PLUS chorioretinitis threatens vision and
PLUS Folinic Acid, 5 mg/week by continued until resolution of elevated CSF
Sulfadiazine (50 mg/kg/dose mouth protein or active chorioretinitis that
PO q12h, maximum 4 gm) threatens vision.
for 1 year
PLUS Clindamycin may be substituted for
Leucovorin (10 mg PO 3 sulfadiazine in children with G6PD
times a week) for 1 year (and deficiency or who develop allergy to
for one week after sulphadiazine.
Pyrimethamine therapy)
Regular FBC recommended: Main
(IV formulation of adverse effect of Pyrimethamine is
Leucovorin may be neutropenia. The folinic acid dose should
considered for oral use) be increased if the ANC falls below 1,000
cells/microL. Pyrimethamine should be
temporarily withheld if the ANC is below
500 cells/microL. Persistent neutropenia
despite withholding of Pyrimethamine
may be caused by Sulfadiazine
Herpes Simplex Acyclovir 60mg/kg/day IV Isolate Ocular involvement requires
Neonatal q8h topical antiviral.
 Localized skin, eye, and Screen for other STDs.
mouth (SEM) Duration: For CNS disease.

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
 Central nervous system Skin, eyes, mouth: 14 days Repeat LP at end therapy for HSV PCR
(CNS) with or without SEM CNS/ Disseminated: 21 days and treat till negative.
 Disseminated disease Investigate and treat parents.
involving multiple organs Recurrence of HSV can occur and may be
a lifelong problem.
Tetanus neonatorum Metronidazole IV/PO for 10 Penicillin G IV Debridement
days (100, 000U/kg q12h for 1st Human Tetanus IG IM
Neonates (Neofax dosing): week of life and q6h after 1st
 Loading dose: 15mg/ week) for 10 days Optimum dose for IM human TIG yet to
kg/dose IV/PO x 1 be established. Traditional
 Maintenance dose: recommendations: single dose of 3,000-
7.5mg/ kg/dose IV/PO 6,000U. Limited data suggests doses as
low as 500U as effective.
Metronidazole Dosing
Interval Chart Penicillin-GABA antagonist and
Post- Post- Dosing associated with seizures. Metronidazole
menstrual natal interval recommended as choice.
age age (hours)
(weeks) (days)
≤29 weeks 0-28 d q48h Check maternal immunization.
>28 d q24h
30-36 0-14 d q24h
weeks >14 d q12h
37-44 0-7 d q24h
weeks >7 d q12h
≥45 weeks AL q8h
Gonococcal Ophthalmitis Immediate and frequent Evaluate for signs of disseminated
saline eye irrigation infection (e.g. sepsis, arthritis, and
meningitis).
Non-disseminated disease
Ceftriaxone 50mg/kg IV Screen mother and baby for chlamydial
once (max 125mg) infection.

Disseminated disease Screen for other STDs.

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Ceftriaxone IV (50mg/kg
daily 1st week of life, 12H Investigate and treat parents.
>1week of life) for 7 days

Duration 10-14 days if


meningitis documented

(Cefotaxime for neonates


with hyperbilirubinemia:
25 mg/kg IV/IM q12h for 7
days, with a duration of 10-
14 days, if meningitis is
documented)
Chlamydia trachomatis Erythromycin base or Azithromycin 20 mg/kg/day Initial treatment for chlamydial
conjunctivitis Ethylsuccinate 50mg/kg/day PO, 1 dose daily for 3 days conjunctivitis should be based upon a
PO q6h for 14 days positive diagnostic test.
Diagnosis by tissue culture, antigen
(Topical therapy not detection (IFA, EIA) or NAAT.
necessary if systemic Eye swab from conjunctiva of everted
treatment given) eyelid with Dacron tipped swab or swab
from test kit.
Test also for gonococcus.
Treat mother & sexual partner.

Efficacy of treatment 80%, follow-up


necessary. Second course of treatment
may be required.

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Early onset sepsis (<48 hrs) Penicillin G IV Imipenem IV Suspect in maternal chorioamnionitis,
Sepsis / pneumonia / meningitis) OR sepsis, PROM (>18 hours).
GBS, GNB Ampicillin IV
Do full septic workup, CXR.
PLUS
In babies given antibiotics because of risk
Amikacin IV factors for infection or clinical indicators
of possible infection, review need for
(Till C&S results) continued antibiotics at 48 hours with
- Sepsis 7-10 days culture results.
- G+ meningitis: 2 weeks
- G- meningitis: 3 weeks No evidence from randomised trials to
suggest that any antibiotic regimen may
be better than any other in the treatment of
presumed early neonatal sepsis.

For meningitis Meropenem IV Cephalosporin not used in HSgB due to


Pathogen unknown ESBL
Meropenem IV
Gram negative Tailor according to culture results
Meropenem IV
Gram positive (Drug Dosages – Refer Drug Database in
NICU)
GBS Infection Penicillin G IV Duration:
Streptococcus agalactiae OR Sepsis: 10 days
Ampicillin IV Meningitis: 14 days
Osteomyelitis: 4 weeks
PLUS

Amikacin IV

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
POSTNATAL INFECTIONS
Community Acquired Ampicillin Imipenem IV Inadequate evidence from randomised
Infections OR trials in favour of any particular antibiotic
(Late onset sepsis >48 hrs) Penicillin regimen for the treatment of suspected
Pneumonia, Sepsis late onset neonatal sepsis.
Group B Strep, E. coli, PLUS
Klebsiella, Enterobacter, S Discontinue antibiotics after 48 hours if
aureus Amikacin culture negative or course does not
Possible Listeria support diagnosis.
Hospital Acquired Infection Imipenem IV Cefepime IV
(Pneumonia, sepsis, meningitis) OR
Based on predominant flora and Meropenem IV
susceptibility OR
Coagulase-negative Vancomycin IV if MRSA
staphylococci, Staphylococcus strongly suspected
aureus, E.
coli, Klebsiella, Pseudomonas,
Enterobacter, Candida, GBS,
Serratia, Acinetobacter
Necrotising Enterocolitis Ampicillin IV Amoxicillin/Clavulanate There is insufficient evidence regarding
(NEC) PLUS PLUS choice of antibiotic regimens or duration
Klebsiella, E. coli, Clostridia, Amikacin IV Amikacin of antibiotic treatment of NEC.
coagulase negative PLUS
Staphylococcus, Enterococci, Metronidazole IV Decisions regarding antibiotic choice and
Bacteroides duration might best be guided by culture
Duration results as well as flora & antibiotic
10-14 days resistance patterns present within
nurseries.
(Vancomycin if CoNS
MRSA or VRE suspected) Empiric regimens can be modified based
upon the results of cultures of blood,
peritoneal fluid, or surgical specimens.

152 | P a g e
PAEDIATRICS OCCULAR INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Preseptal cellulitis Failure to respond within 24-48 hours
Strep pneumoniae, Staphaureus, Amoxicillin/Cavulanate Cloxacillin 12.5-25mg/kg may indicate orbital cellulitis or
Strepcoccu ssp. 22.5mg/kg PO q12h for 5-7 (max 1gm) PO q6h underlying sinus disease.
days OR
Cephalexin 25mg/kg (max
1gm) PO q8h

Systemically unwell Cloxacillin 25-50mg/kg (max


2gm) IV q6h

PLUS

Cefotaxime 50mg/kg (max


2gm) IV q8h
OR
Ceftriaxone 50mg/kg IV
(max 2gm) q12h
Orbital Cellulitis/ Abscess Ceftriaxone 50mg/kg(max Penicillin Allergic : This condition is considered surgical
Strep pyogens, Strep pneumonia, 2gm) IV q12h may consider emergency and require immediate
Staph aurea PLUS Clindamycin consultation with ENT surgeon and
H. influenza (unvaccinated child Cloxacillin 50mg/kg (max PLUS ophthalmologist. Urgent CT scan needed
or untypeable strains) 2gm) IV q6h for 7-14 days Ciprofloxacin to exclude associated abscess and
intracranial extension.
OR
Urgent surgical drainage of the ethmoid
Vancomycin sinuses or of an orbital, subperiosteal or
intracranial abscess may be needed.

153 | P a g e
PAEDIATRICS RESPIRATORY INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
LOWER RESPIRATORY TRACT INFECTIONS
1. Community acquired pneumonia
Pneumonia outpatient Amoxycillin 45- Amoxycillin/Clavulanate Macrolide antibiotics should be used if
75mg/kg/24h PO q8h for 5-7 Cefaclor either mycoplasma or chlamydia
days Erythromycin pneumonia is suspected. It may be added
Azithromycin at any age if there is no response to first-
Clarithromycin line empirical therapy.
Pneumonia inpatient Benzylpenicillin 30-60mg/kg Macrolide antibiotics should be used if
IV q6h for 7 days either mycoplasma or chlamydia
pneumonia is suspected
2. Severe Community Acquired Pneumonia
Severe community acquired Cefotaxime 50mg/kg q4-6h Add IV Cloxacillin if considering
OR Staphylococcus aureu.
Ceftriaxone 50mg/kg q12h
OR
Cefuroxime 50mg/kg IV q8h

PLUS

Erythromycin 15-25mg/kg
IV q6h for 7 days
OR
Azithromycin 15mg/kg IV
loading dose then 7.5 mg/kg
q24h if considering atypical
organisms

154 | P a g e
Index:
 Abscess  Necrotizing fasciitis
 Animal bites  Scalded skin syndrome
 Cellulitis  Scabies
 Impetigo
PAEDIATRICS SKIN AND SOFT TISSUE INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Abscess Cloxacillin 100-200mg/ Incision & drainage if indicated. Pus for
Staphyloccus aureus kg/24h PO/IV q6h for 7-10 culture. Parenteral route for severe
days infections. Consider CA-MRSA if poorly
resolving , based on local epidemiology.
Animal bites Ampicillin/Sulbactam 50 Piperacillin/Tazobactam 125 Consider rabies prophylaxis according to
Pasteurella multocida, Staphy. mg/kg (ampicillin mg/kg IV (piperacillin local epidemiology.
spp, Streptococcus spp , component) IV q6h for 7 component) q8h
Capnocytophaga, anerobes days
Cellulitis Cloxacillin 100-200mg/ Amoxicillin 25-30mg/kg/24h Parenteral route for extensive lesions.
Staphyloccus aureus kg/24h PO/IV q6h for 7-10 PO q8h for 7 days
Streptococcus pyogenes days OR
Cephalexin 50-75mg/kg/24h
PO q6-8h for 7 days
Impetigo
Staphylococcus aureus,
Streptococcus pyogenes
Localised Topical 2% fusidic acid q8-
12h for 7 days (outpatient)
Generalised Cloxacillin 50-100 Amoxycillin /Clavulanate
mg/kg/24h PO q6h for 7 days 25-30mg/kg/24h PO q12h for
7 days
OR
Cephalexin 50-75 mg/kg/24h
PO q6-8h for 7 days

155 | P a g e
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Necrotizing fasciitis Benzylpenicillin 50,000 Aggressive surgical debridement;
Group A Streptococcus units/kg IV consider adding IVIG to bind toxin for
Polymicrobial: Gram +ve cocci, q4h streptococcal infection with toxic shock.
Anerobes , Gram-ve rods PLUS Tissues should be gram stained and
Clindamycin 25-40 mg/kg/d cultured.
IV q6-8h
Refer IDSA 2014 guidelines
OR

Piperacillin/Tazobactam 60-
75 mg/kg/dose IV q6h
PLUS
Vancomycin 10-13
mg/kg/dose IV q8h
Scalded skin syndrome Cloxacillin 150 mg/kg/24h
Staphylococcus aureus IV in q6h then, step down
to 50mg/kg/24h PO q6h for 7
days
OR
Cephalexin 50-75mg/kg/24h
PO q8h for 7 days
Scabies Permethrin 5% cream apply For children > 2 years and
Sarcoptes scabeii and leave for 8 hours (not for <12: Benzyl Benzoate
babies less than 2 months) Emulsion (EBB) 12.5%
- two or more applications , apply from neck down and
each a week apart leave for 24 hours for 2 days

Babies less than 2 month : Gamma Benzene


Sulphur 6% in calamine Hexachloride 0.5%
lotion q12h (Lindane) apply and leave for
OR 8 hours (not to be repeated in
Crotamiton (Eurax) cream less than a week)
q12h for 2-3 weeks

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PAEDIATRICS SURGICAL INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Empyema thoracis (Lung Cefuroxime 50mg/kg/dose Staph aureus (methicillin Based on C&S of pleural fluid/tissue or
empyema): IV q8h sensitive): blood culture.
Staph aureus PLUS Cloxacillin 50mg/kg/dose IV
Streptococcus pneumonia Cloxacillin 50mg/kg/dose IV q6h All children with empyema need to
q6h receive high dose antibiotic therapy via
Empiric treatment: Streptococcus pneumonia intravenous route to ensure pleural
Need to cover organisms (penicillin sensitive): penetration.
mentioned above. Benzylpenicillin 200,000-
400,000 MU/kg/day IV q4- Pneumatocoele on CXR indicate Staph
Other bacteria implicated: 6h aureus BUT they can also been seen in
Strep pyogenes, Haemophilus pneumococcal disease.
influenza, other gram negative Streptococcus pneumonia
organisms in (penicillin resistant-use There is NO need to routinely use a
immunocompromised result of C&S): macrolide antibiotic but its use should be
individuals Cefuroxime 50mg/kg/dose considered in children whom Mycoplasma
IV q8h pneumonia is thought to be the cause
In patients not responding to OR (Mycoplasma usually cause effusion, not
treatment need to rule out TB Amoxycillin/Clavulanate: empyema).
30mg/kg/dose IV q8h (up to
50mg/kg of ampicilin) There is NO CONSENSUS on how long
antibiotic need to be given. Most
recommend 4-6 weeks of total antibiotics.

For other adjunct therapy-refer consensus


guideline 2013-MOH.
Septic Arthritis(SA) & Empiric antibiotics should be started
Osteomyelitis (OM): based on clinical diagnosis of SA or OM
Surgical debridement often not required in
0-2 months: OM.
Staph. aureus. Cloxacillin 50mg/kg dose IV Amoxycillin/Clavulanate 30-
Streptococcus agalactiae q6h 50mg/kg/dose IV q8h (based Urgent wash out & drainage is needed in

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Gram negative enteric organism PLUS on amoxycilin dose) SA in hip and other joints to reduce
Cefotaxime 50mg/kg/dose pressure on growth plate.
q6-8h Optimize antimicrobial
treatment based on C&S *IV antibiotics can be switch to oral if no
concurrent bacterimia when:
Less than 5 yrs: Child afebrile and pain free for at least 24
Staph. aureus. Cefuroxime 50mg/kg/dose Cefazolin 25mg/kg/dose IV hrs and CRP <20mg/L or CRP decreased
Streptococcus pyogens IV q8h (monotherapy) q8h by≥2/3 of highest value
Streptococcus pneumoniae
Non- type able Haemophilus Can be use in children with Duration of antibiotics:
spp. suspected Staph aureus or SA: total of 3-4 weeks
K.Kingae Strep pyogenes; OM: 4-6 weeks
Less hypersensitivity
reaction compared to In complex disease (multifocal,
Cloxacillin and dosing significant bone destruction, immuno -
convenience compromised host and resistant /unusual
pathogens-need prolonged intravenous
*Kingenella kingae- antibiotics and duration might exceed 6
uncommon organism causing weeks
infection in
<5yrs old ;sensitive to β-
lactam antibiotics e.g.
Cefuroxime or
Ampicilin/Clavulanate

Older than 5 yrs:


Staph. aureus. Cloxacillin 50mg/kg/dose IV
Streptococcus pyogens q6h

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Index:
 Scrub thyphus  Leptospirosis
 Brucellosis  Melioidosis

PAEDIATRICS TROPICAL INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Scrub Thyphus For children > 8 yr: Chloramphenicol 50- Avoid using Tetracycline or Doxycycline
Ricketsia tsutsugamushi Doxycycline 2-4mg/kg/24h 75mg/kg/24h PO q6h for 5-7 for young children as they can cause
q12-24h for 5-7 days days staining of the teeth.
OR
Azithromycin 10mg /kg PO
q24h for 3 days
Brucellosis For children < 8 yr: Trimethoprim/ For children > 8 yr:
B. melitensis, Trimethoprim/ sulfamethoxazole Refer adult regime
B. abortus, B. suis and B. canis Sulfamethoxazole 8/40mg/kg/24h PO q12h for
8/40mg/kg/24h PO q12h for 6 weeks
6 weeks PLUS
PLUS Rifampicin (15mg/kg) PO
Streptomycin 30 mg/kg (max q24h for 6 weeks
1gm) IM q24h for 3 weeks
OR

Rifampicin (15 mg/kg) PO


q24h for 6 weeks
PLUS
Gentamicin 5mg/kg IV q24h
for 7 -10 days

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Leptospirosis L.
icterohaemorrhagiae, L.
canicola
Moderate to severe disease Benzylpenicillin 100,000 Ceftriaxone 80-100mg/kg IV
units/kg IV q6h for 7 days q24h for 7 days
OR
Cefotaxime 150-
200mg/kg/24h IV in 4
divided doses for 7 days

Mild disease Amoxicillin 20-50mg/kg PO For children > 8 yr:


q6h-q8h for 7 days Doxycycline 4mg/kg PO
q12h for 7 days
Melioidosis Parenteral treatment should be used for at
Burkholderia pseudomallei least 10-14 days or until clear
Intensive/Induction therapy: Ceftazidime 200mg/kg/24h For children > 8 yr: improvement is noted.
IV q6h for 10-14 days Imipenem 75-100mg/kg/24h
IV q6-8h Folic Acid 5mg PO q24h to be given for
OR patient on Trimethoprim/
Meropenem 75mg/kg/24h IV Sulfamethoxazole.
q8h

Maintenance therapy: Amoxycillin (60/mg/kg/24h)/


Clavulanate PO q8h
OR
Trimethoprim/
Sulfamethoxazole
8mg/kg PO q12h

Duration: 12-20 weeks

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PAEDIATRICS URINARY TRACT INFECTIONS

Infection/Condition & Suggested treatment


Comments
Likely Organism Preferred Alternative
Acute cystitis Cefuroxime 25 mg/kg IV q8h Nitrofurantoin 6mg/kg PO Amoxycillin/Clavulanate and
E. coli for 5-7 days q6h (max 100mg) for 5- Trimethoprim are alternative for acute
Proteus spp PLUS/MINUS 7days cystitis.
IV Gentamicin (to cover
Klebsiella sp) Note: single dose of antibiotic therapy not
recommended. Empirical antibiotic
choices guided by local organism resistant
pattern.
Acute pyelonephritis Cefotaxime 50 mg/kg IV q8h Cefuroxime 50 mg/kg IV q8h Culture should be repeated within
E. coli OR OR 48hours. Antibiotic may need to be
Proteus spp Ceftriaxone 50-75 mg/kg Gentamicin 5mg/kg IV q24h changed according to sensitivity.
q24h
Suggest to continue intravenous antibiotic
PLUS/MINUS until child is afebrile for 3-4 days and then
switch to appropriate oral therapy after
IV Gentamicin (to cover culture results e.g. Cefuroxime, for total
Klebsiella sp) of 10-14 days if susceptible.
Prophylaxis for UTI Trimethoprim 1-2mg/kg PO Nitrofurantoin 1-2mg/kg PO Antibiotic prophylaxis should not be
For infants and children with nocte nocte routinely recommended in children with
recurrent UTI first-time UTI.

Prophylactic antibiotics should be given


for 3 days with MCUG (Micturating
Cystourethogram) taking place on the
second day.

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Index:
 Catheter Related Blood Stream Infection  Suppurative Thrombophlebitis
- S. epidermidis (CoNS), S. aureus, MSSA - S. aureus
- Candida albicans or other Candida species
- Gram -ve bacilli
PAEDIATRICS VASCULAR INFECTIONS
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
CATHETER RELATED BLOOD STREAM INFECTION
For infant and children: Indication of catheter removal is
S. epidermidis(CoNS) Vancomycin 10-15 mg/kg/day similar to adult but benefit of catheter
S. aureus IV q6h removal must be weight against the
difficulties of obtaining alternate
MSSA Cloxacillin IV 100-200 venous access.
mg/kg/day q6h Treatment without catheter removal
Candida albicans or Fluconazole 6-12 mg/kg IV For children 3 months-17 years: should be closely monitored clinically
Other Candida species q24h Caspofungin loading dose 70 with additional blood culture;
mg/m³/day IV on day 1 removed catheter if there is persistent
followed by 50 mg/ m³/day or recurrent infection.
thereafter (max 70mg)
Gram –ve bacilli Antibiotic lock therapy should be used
(E.coli, Enterobacter, for catheter salvage in combination
Klebsiella, Pseudomonas, with conventional antibiotic therapy
Acinetobacter) for 10-14 days. S.aures may required
longer course up to 4-6 weeks.
ESBL –ve Cetriaxone/Cefotaxime/
Ceftazidime Exact optimal duration of therapy has
PLUS/MINUS not established in children with or
Aminoglycoside without catheter removal. 10-14 days
after first negative blood culture is
ESBL +ve Imipenem 60-100mg/kg/day IV usually recommended.
q6h Fungaemia: treatment without catheter
OR removal associated with low success
Meropenem 20mg/kg IV q8h rate and higher mortality.

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
SUPPURATIVE THROMBOPHLEBITIS
S. aureus Diagnosis requires positive blood
MSSA Cloxacillin 100-200mg/kg/day culture plus radiographic
IV q6h demonstration of thrombus.

MRSA Vancomycin 10-15 mg/kg/day Removed catheter and minimum of 3-


IV q6h 4 weeks of antibiotics. Surgical
resection of involved vein if failed
conservative therapy.

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PLASTIC
SURGERY
DEPARTMENT

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Index:
 Plastic Surgery
 Burns

PLASTIC & RECONSTRUCTIVE SURGERY

Suggested treatment
Wound classification Comments
Preferred Alternative
PLASTIC SURGERY
Clean wounds
e.g.:
Excision of skin lesions Not required Not required

Clean wounds with implants


e.g.:
Integras IV Amoxicillin + IV Cefuroxime - given 1 hour prior to operation as
Tissue expanders Clavulanate Acid 750mg (adults) prophylaxis
Autologous & allografts 1.2g (adults) 50mg/kg (paediatrics)
30mg/kg (paediatrics)
Clean contaminated wounds
e.g.:
Lip repair IV Amoxicillin + IV Cefuroxime
Palatoplasty Clavulanate Acid 750mg (adults)
Alveolar bone grafting 1.2g (adults) 50mg/kg/dose (paediatrics)
Intraoral & intranasal lesions 30mg/kg/dose (paediatrics)
Facial traumas
Contaminated wounds
e.g.:
Abscess, infected wounds IV Cloxacillin IV Cefuroxime
1g (adults) 750mg (adults)
25-50mg/kg/dose 50mg/kg/dose (paediatrics)
(paediatrics)

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Suggested treatment
Wound classification Comments
Preferred Alternative
Dirty wounds
e.g.:
Post traumatic wounds with IV Cloxacillin
devitalized tissue 1g (adults)
Avulsion, degloving wounds 25-50mg/kg/dose
with foreign body contamination (paediatrics)
For diabetic & immuno-compromised patients – to cover with IV Ampicillin + Sulbactam 1.5g

Suggested treatment
Wound classification Comments
Preferred Alternative
BURNS
Clean burn wounds Not recommended Not recommended Prophylactic antibiotic are not routinely
given to burn patients as they do not
reduce the risk of infection
Infected burn wounds IV Cloxacillin Penicillin allergies:
1g (adults) IV Cefuroxime
25-50mg/kg/dose (paediatrics) 750mg (adults)
OR 25-50mg/kg/dose
IV Ampicillin + Sulbactam 3g (paediatrics)
Wound debridement IV Amoxicillin + Clavulanate IV Cefuroxime
Skin grafting Acid 750mg (adults)
1.2g (adults) 25-50mg/kg/dose
30mg/kg/dose (paediatrics) (paediatrics)
For diabetic & immuno-compromised patients – to cover with IV Ampicillin + Sulbactam 1.5g

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SURGICAL
DEPARTMENT

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Index:
CHEMOPROPHYLAXIS  Bites (penetrating injuries)
- General surgery
- Vascular surgery UROLOGY
 Pyonephrosis/Perinephric abscess
GENERAL SURGERY  Renal abscess
 Appendicitis  Acute prostatitis
 Perforated appendix, appendicular mass  Chronic bacterial prostatitis (CPPS NIH Type II)
 Perforated viscus, peritonitis  Prostatic abscess
 Abdominal trauma  Non gonoccocal urethritis
 Suspected bowel or solid organ injury  Epididymo-orchitis
 Breast abscess  Testicular abscess
 Vascular  Fournier’s gangrene
- Mycotic pseudoaneurysm in IVDU  Urosepsis (Septicaemia post urological instrumentation or
- Prosthetic graft infection urological infections)
- Ischaemic ulcers

SURGERY

Chemoprophylaxis
It is the use of antibiotics to prevent infections at the surgical site. It should be considered when there is significant risk of post-operative
infection or where post-operative infection would have severe consequences. Ideally, the prophylaxis when given intravenously should be
given as soon as the patient is stabilized after induction. Usually a single dose is sufficient. A second dose may be required in the following
situations:
c. delay in start of surgery
d. in prolonged operations when the time is more than half of the usual dosing interval of the antibiotic
Pre-operative dose timing: The optimal time for administration of preoperative doses is within 60 minutes before surgical incision. Some
agents, such as Clindamycin, Fluoroquinolones, Gentamicin, Metronidazole and Vancomycin, require administration over one to two hours;
therefore, the administration of these agents should begin within 120 minutes before surgical incision.
(Reference: Am J Health-Syst Pharm Vol 70: 195-283, 2013@IDSA.)

Giving more than 1 or 2 doses postoperatively is generally not advised. The practice of continuing prophylactic antibiotics until
surgical drains have been removed is NOT RECOMMENDED.

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
GENERAL SURGERY
Upper GIT oesophagus, stomach Amoxycillin/Clavulanic acid Cefotaxime 1gm IV
& upper small bowel 1.2gm IV OR
Cefoperazone 1gm IV
Distal small bowel colorectal Cefuroxime 1.5gm IV Cefoperazone 1gm IV
PLUS PLUS
Metronidazole 500mg IV Metronidazole 500mg IV

OR

Amoxycillin/Clavulanic acid
1.2gm IV

OR

Ampicillin/Sulbactam 1.5gm
IV
Hernia repair with mesh Cloxacillin 1gm IV Amoxycillin/Clavulanic acid Includes laparoscopic repair
1.2gm IV
OR
Ampicillin/Sulbactam 1.5gm
IV
Breast Cloxacillin 1gm IV Amoxycillin/Clavulanic acid Not recommended for minor excisions
Mastectomy with axillary 1.2gm IV
clearance with/without OR
reconstruction Ampicillin/Sulbactam 1.5gm
IV
VASCULAR SURGERY
Vascular graft implants
a. AVF graft Vancomycin 1gm IV Linezolid 600mg IV
MRSA infection prophylaxis

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
b. Aortic graft / TEVAR / Amoxycillin/Clavulanic acid Ampicillin/Sulbactam 1.5gm
EVAR 1.2gm IV IV
Suspected organism:
Staph. spp. & anaerobic
organism
Ischemic limb Ampicillin/Sulbactam 1.5- Amoxycillin/Clavulanic acid
Suspected organism: 3gm IV 1.2gm IV
Staph. spp. & anaerobic
organism

General Surgery
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Appendicitis 1st gen. Cephalosporins, e.g; -lactam/-lactamase inhibitors, Start upon diagnosis, discontinue after
Enterobacteriaceae Cefazolin 1g IV q8h eg; surgery.
enterococci, Bacteroides PLUS Amoxycillin/Clavulanate 1.2gm
Metronidazole 500mg IV IV q8h
q8h
Perforated appendix, 1st gen. Cephalosporins, e.g; -lactam/-lactamase inhibitors, Duration 7 days.
Appendicular mass Cefazolin 1g IV q8h eg;
PLUS Amoxycillin/Clavulanate 1.2gm
Metronidazole 500mg IV IV q8h
q8h
Perforated Viscus 1st gen. Cephalosporins, e.g; -lactam/-lactamase inhibitors, Duration 7 days.
Peritonitis Cefazolin 1g IV q8h eg;
PLUS Amoxycillin/Clavulanate 1.2gm
Metronidazole 500mg IV IV q8h
q8h
Abdominal trauma 3rd Cephalosporins, e.g. Cefoperazone/Sulbactam 1g IV Duration 7 days.
Suspected bowel or solid Cefotaxime 1g IV q8h q12h
organ injury PLUS PLUS
Gram negative enteric aerobes Metronidazole 500mg IV Metronidazole 500mg IV q8h

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
and anaerobes q8h
OR

-lactam/-lactamase inhibitors,
eg;
Ampicillin/Sulbactam 1.5g IV
q8h
OR
Amoxycillin/Clavulanate 1.2gm
IV q8h
Breast abscess Cloxacillin 1g IV q6h Cefuroxime 1.5g IV q8h Drainage may be required.
Staph aureus Duration 7 days.
VASCULAR
Mycotic Pseudoaneurysm in Cloxacillin 2g IV q6h Based on C&S Initial therapy is high dose IV followed
IVDU by oral therapy once debridement and
ligation done. The duration will depend
on clinical response.
Prosthetic Graft Infection

Non-MRSA 1st gen. Cephalosporins, e.g; Based on C&S Duration may need to be prolonged if
Cefazolin 1g IV q8h Graft salvage considered.
OR Duration 7 days or more.
3rd gen. Cephalosporins, e.g;
Cefoperazone 2-4g/day IV in
divided dose q12h

MRSA Vancomycin1 1g IV q12h Linezolid 600mg IV q12h Vancomycin levels need to be


monitored. Graft may need to be
explanted.

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Ischaemic Ulcers -lactam/-lactamase Based on C&S Given IV if diabetes present
inhibitors, eg; Duration 7 days
Amoxycillin/Clavulanate
625mg PO q12h
OR
Ampicillin/Sulbactam
375mg PO q12h
BITES (penetrating injuries)
Animal bite Amoxycillin/Clavulanate If severe or allergic to penicillins, Duration 7 days.
Staph aureus, Strep., 1.2g IV TDS Cefuroxime 750mg IV q8h If infected (secondary infection): 10
Gram –ve bacilli, Anaerobes PLUS days
Metronidazole 500mg IV q8h
Human bite Amoxycillin/Clavulanate If allergic to Penicillin, Duration 7 days
Staph aureus, anaerobes, 1.2g IV TDS Clindamycin 300mg PO q6h Delay or do not suture
Eikenella sp
PLUS

Ciprofloxacin 500-750mg PO q12h


OR
Trimethoprim/Sulphamethoxazole
160/800mg PO q12h
1
Refer Page 105 (Clinical Pharmacokinetic Guidelines: Aminoglycosides & Vancomycin)

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Urology
Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Pyonephrosis / Perinephric nd
2 gen. Cephalosporins, e.g Ciprofloxacin 200mg –400mg PLUS Drainage followed by
abscess Cefuroxime 750mg-1.5g IV q8h IV q12h definitive surgery.
E coli, Klebsiella, OR
Proteus,Enterococcus, -lactam/-lactamase
Pseudomonas inhibitors, eg;
Ampicillin/Sulbactam 1.5-3g IV
q8h
Renal abscess 2nd gen. Cephalosporins, e.g 3rd gen. Cephalosporins, e.g; Drainage may be required.
E coli, Klebsiella, Cefuroxime 750mg-1.5g IV q8h Ceftriaxone 1-2g IV q24h
Proteus,Enterococcus, OR Commence oral after temperature
Pseudomonas, Staph aureus -lactam/-lactamase settled.
inhibitors, eg;
Ampicillin/Sulbactam 1.5-3g IV
q8h

PLUS/MINUS

Gentamicin1 5mg/kg IV q24h


Acute Prostatitis If ill and hospitalized/severe: 3rd gen. Cephalosporins, e.g; Duration 2-4 weeks.
E.Coli Ciprofloxacin 200mg IV q12h e.g Cefoperazone 1g IV q12h
Staph saprophyticus PLUS/MINUS PLUS
Enterococus Gentamicin1 5mg/kg IV q24h Gentamicin 5mg/kg IV q24h
Enterobacteriacie
Proteus Less Severe or mild infection:
Trimethoprim/Sulfamethoxazole
160/800mg PO q12h

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Chronic Bacterial Prostatitis Ciprofloxacin 500mg PO q12h Trimethoprim/Sulfamethoxazole Pending positive culture on prostatic
(CPPS NIH Type II) for 2 weeks 160/800mg PO q24h for 2 secretion.
Mostly culture negative weeks
Then reassess, if beneficial, to
continue for 4-6 weeks Then reassess, if beneficial, to
continue for 4-6 weeks
Prostatic abscess Ciprofloxacin 200mg – 400mg 3rd gen. Cephalosporins, e.g; Drainage mandatory.
IV q12h Cefoperazone 1g IV q12h
E coli, Klebsiella, Proteus,
Enterococcus, Pseudomonas Followed by, Followed by,
Ciprofloxacin 500mg PO q12h Cefuroxime 500mg PO q12h
minimum of 2 -4 weeks minimum of 2-4 weeks
Non Gonoccocal Urethritis Refer to page (Sexually Transmitted
Infections).
Epididymo-orchitis -lactam/-lactamase Ciprofloxacin 500mg PO q12h
E coli, Klebsiella, Proteus, inhibitors, eg; minimum of 2 weeks
Enterococcus, Pseudomonas Amoxycillin/Clavulanate 1.2g
IV q8h
OR
Ampicillin/Sulbactam 1.5g IV
q8h

Sexually transmitted Doxycycline 100mg PO q12h Refer to Sexually Transmitted


organisms minimum of 2 weeks Infections.
Chlamydia trachomatis,
ureaplasma sp

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Infection/Condition & Suggested treatment
Comments
Likely Organism Preferred Alternative
Testicular abscess -lactam/-lactamase 3rd gen. Cephalosporins, e.g; PLUS drainage
inhibitors, eg; Cefoperazone 1g IV q12h
E coli, Klebsiella, Amoxycillin/Clavulanate 1.2g
Proteus,Enterococcus, IV q8h
Pseudomonas OR
Ampicillin/Sulbactam 1.5g IV
q8h
Fournier’s gangrene Ampicillin/Sulbactam 1.5-3g IV PLUS debridement
E coli, Klebsiella, q8h
Proteus,Enterococcus,
Pseudomonas, Anaerobes OR

3rd gen. Cephalosporins, e.g,


Cefoperazone 1g IV q12h
PLUS
Metronidazole 500mg IV q8h

PLUS/MINUS

Gentamicin 5mg/kg IV q24h


Urosepsis Cefuroxime 1.5g IV q8h; Cefoperazone/Sulbactam 1g IV Choice of antibiotics should be
(Septicaemia post urological OR q12h adapted based upon culture results.
instrumentation or If severe infection OR
urological infections) Imipenem/Cilastatin 500mg IV Cefepime 1g IV q12h Duration 7 days or more.
E coli, Klebsiella, q8h
Proteus,Enterococcus,
Pseudomonas, MRSA
1
Refer Page 105 (Clinical Pharmacokinetic Guidelines: Aminoglycosides & Vancomycin)

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APPENDIX

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COLISTIN DOSING GUIDE

1. Use ideal bodyweight for calculation


IBW female (kg) = (2.3 x inches over 5') + 45
IBW male (kg) = (2.3 x inches over 5') + 50

2. Loading dose is standard for all creatinine clearance and is based on IBW
Maximum 9MU
Loading dose = 2.0 x 2.0 x IBW x 30000

3. Maintenance dose
Dosing Comments
Se CrCl > 50 4.5 MU q12h
CrCl calculated using
Cockcroft Gault
Se CrCL 20 - 50 4.5 MU q24h
formula adjusted to
1.73m2
Se CrCL <20 4.5 MU q48h

In patients with persistent infection/ slow to respond/ deterioration despite above dosing regime, can consider higher dosing regime:

Higher dosing regime for patients with persistent infection/ deterioration/ slow to repond:
Creatinine clearance Maintenance dosing per day
10-19 4 MU
20-29 5 MU
30-39 6 MU
41-49 7 MU

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4. Dosing in patients undergoing various renal replacement therapy
Renal replacement therapy Dosing Comments
2 MU q12h, on non HD day To give the additional
2 MU pre HD/ 3.5 MU post supplemental dosing of 10%/hr
Patients on intermittent HD
HD of baseline dose per day after
Assuming a 4 hr HD session the HD session is over (at the
next regular dosing interval)
Patients on SLED Supplement additional 10%/hr
4 MU q12h
(10 hr session) of baseline dose/day.
Advisable to do SLED at night
6 MU q12h Supranormal doses are required
Patients on CRRT (if unable to achieve to achieve the required PK/PD
clearance, can go up to 8 MU effect.
q12h) Supplement additional 10%/hr
of baseline dose/day.
Patients on Peritoneal dialysis Normal loading dose
(2l exchanges-dwell time 6hrs/ 3 MU q12h To give maintenance dosing
4x/day) 24 hrs later

References:
- Garonzik SM. AAC 2011;55:3284-94,
- Garonzik et al. CID. 2016
- Kift E. S Afr Med J 2014;104(3):183-186
- Dalfino L. et al. CID 2012: 54

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VANCOMYCIN DOSING

1. Use actual body weight for vancomycin dosing calculation

2. Loading dose is necessary to achieve faster therapeutic level

3. Trough level targets:


Target Levels
Infections
mmol/L mg/L
Bacteraemia
Endocarditis
Osteomyelitis 10-14 15-20
HAP
Deep seated infections
CNS infections 20-25
Skin and soft tissue infections 7-10 10-15
* To convert from mg/L to μmol/L, multiply by the conversion factor of 0.69

Loading dose recommendation

25-30 mg/kg, especially in critically ill patients (irrespective of CrCL)


Doses ≥ 1gm should be infused over 1.5-2 hrs (max of 2 gm)
* Dosing in obesity (BMI ≥ 40 kg/m2) 30 mg/kg/day divided 8 to 12 hrly
** Do not give any individual dose >2gm.

Vancomycin dosing in patients undergoing intermittent hemodialysis

General principles:

1. Trough levels should be done pre-HD on the morning of the hemodialysis or if not done can be taken after at least 6 hrs Post HD

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2. Vancomycin administration should be given preferably post hemodialysis unless dialysis is expected to be delayed

3. Residual kidney function will influence the dose (patients may need higher doses if there is residual renal function)
.
First dose: (depends on the timing of the next dialysis session)
Timing of dialysis Dosing Comment
± top up 5 mg /kg if the first
Same day dialysis 15-20 mg/kg
dose was pre HD

Next day dialysis Vancomycin 25 mg/kg stat Check Trough pre HD to


determine the next dose post
Dialysis in 2 days* Vancomycin 25 mg/kg stat HD

* In cases where there is residual renal function/critically ill patients, it is recommended to


check random vancomycin levels during the interval period to guide if additional dosing is
required.

Subsequent dosing
Trough level Subsequent dosing post first dose
<10 mg/L Consider redosing as above
1000 mg of IV Vancomycin post HD (40- 75 kg); 1250 mg (75-90 kg);
10-15 mg/L
1500 mg (>90 kg)

15-20 mg/L 500 mg (if HD in 2 days) or 750 mg (if HD in 3 days)


>25 mg/L Withhold vancomycin and check next day random levels/next pre HD level
Further dosing will depend on the trough levels taken pre HD

* Continuous infusion protocol


- Loading: 15 mg/kg/day
- Then start on 30 mg/kg/day for 24 hrs infusion
o Keep spot vancomycin levels at 20-25 mg/L

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Vancomycin levels Recommendations
<15 mg/L Increase the 12 hourly dose by 250mg

If the patient is responding, maintain the present dosage regimen.


15-25 mg/L If the patient is seriously ill, consider increasing the dose amount to
achieve a steady state concentration of 20-25 mg/L.

26-30 mg/L Decrease the 12 hourly dose by 250 mg


> 30 mg/L STOP infusion for 6 hours, decrease the 12 hourly dose by 250mg

References:
- Heintz. (Pharmacotherapy 2009;29(5):562–577)
- John Hopkins antibiotic guidelines
- Standford antibiotic guidelines
- CID 2011. 15:53(2):124-9

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