2014 antimicrobial new

8/12/2019 2014 Antimicrobial New

1/33

Editors:

Dr. B N HarishDr. Sujatha Sistla

Dr. Jharna MandalDr. Kadhiravan TDr. Vishnu BhatDr. Sriram KrishnamurthyDr. Narayanan PDr. Biswajit Dubashi

Dr. Krishnan BalasubramaniamDr. Srinivas RajagopalanDr. DG ShewadeDr. Dinoop KP

Acknowledgements:

Dr. S.C.Parija

Department of MicrobiologyJIPMER - Pondicherry

2014

Third edition June 2014

Handbook of

Antimicrobial Useat JIPMER

Front Cover inside


2/33

Contents PageGI and intra Abdominal Infecons. ............................ 5-8

CVS Infecons .......................................................... 9-10

Skin and so ssue Infecons .................................... 11

Bone and joint Infecons. .......................................... 12Respiratory Infecons ............................................ 14-16

Genitourinary Infecons............................................. 17

CNS Infecons ....................................................... 18-19

Ocular Infecons ................................................... 20-21

Dental Infecons ........................................................ 22

Empiric anbioc therapy for ICU .............................. 23

Treatment of Paents with

Fever and Neutropenia ............................................... 28

For management in NICU ........................................... 31

Changes made in the handbook- an entire section which deals with empiric antibi-otic therapy in febrile neutropenia and one section dedicated to empiric therapy

in the ICU,NICU. Certain new class of antibiotics have been included so that the

pressure on certain groups of antibiotics are minimized like the carbapenems.


3/33

OBJECTIVES OF

THE HANDBOOK

The appropriate use of antimicrobials is an essential part of patientsafety and deserves careful attention and guidance. Antimicrobial

resistance is an evolutionary phenomenon and the selection of re-

sistant pathogens is signicantly associated with antimicrobial use.

Antimicrobial resistance results in increased morbidity, mortality,

and costs of health care. Prevention of the emergence of resistance

and the dissemination of resistant microorganisms will reduce these

adverse effects and their attendant costs. We therefore urge everyone

to restrict our use of antimicrobial agents. In this revised edition, we

have added a few sections on the empiric treatment of febrile neu-

tropenia and in the intensive care units. We hope that this second

edition of the Handbook of Antimicrobial Use at JIPMERwould

address some of the pending issues of the last edition. We are very

grateful to all our colleagues who gave their valuable suggestions in

making of this edition of the handbook. There are bound to be errors

and we would welcome all feedback so that future editions can be

corrected. We hope that this handbook would act as a basic refer-

ence to the clinicians in prescribing antibiotics and help streamline

the management of common infections encountered in the hospital.


4/335

GIandintra-ab

dominalinfections

Disease

Etiologicalagents

Antibioticsinadults

Antibioticsinc

hildren

Remarks/Alternative

antibiotics

Acute

gastroenter

itis

Viral

Enterotoxigenicand

EnteropathogenicE.c

oli,

nontyphoidalsalmone

lla

Noantibioticsusually

required.

Promptrehydrationessential.

Ifdiarrheapersists

beyond2daysorin

immunosuppressed

patients:Ciprooxacin

500mgbdX5days

Nil

Whenbloo

dormucus

appearins

tool,orifthere

isevidence

ofcholera

orinvasive

diarrhea;

antibioticsareindicatedin

children

Cholera

V.cholerae

CapDoxycycline300

mg,singledose(6mg

/

kg,maximum300mg

OrTabCiprooxacin1gm

single

dose

Ciprooxacinsingledose

30mg/kgmaxim

um1g

Above8years,doxycycline5

mg/kgtobepreferred

Promptreh

ydration

essential,antibiotic

therapyisonlyadjunctto

rehydration

Bacillary

dysentery

Shigella

TabCexime400mgodX5

days(8mg/kg/day)Or

TabCiprooxacin500

mgbd

X5days

TabCexime

(10mg/kg/day)x7days.

Continue

feedingandadd

zinc

Supplementation

Ifnoresponsethenswitch

tocefopera

zonesulbactam

i.v(150mg/kg/day)

Amoebic

dysentery

Entamaoeba

histolytica

Metronidazole400mg

tdsfor10days

Metronidazole3

0-35mg/kg/

dayinthreedivideddosesfor

10days


5/336

Disease

Etiologicalagents

Antibioticsinadults

Antibioticsinc

hildren

Remarks/Alternative

antibiotics

Giardiasis

Giardialamblia

Metronidazole250mgPO

tidfor5-7daysOrTin

idazole

2gm1dose

Metronidazole3

0-35mg/kg/

dayinthreedivideddosesfor

10days

Typhoidfev

er

S.TyphiorParatyphi

A

Outpatients-

Azithromycin

Ifnoclinicalresponse

then

switchtoInjCeftriaxone2gm

I.V.BDfor14days

Oral-Tab.Cexime(20mg/

kg/day)max.400

mg/dayfor

10-14days

Parenteral-I.V.Ceftriaxone

100mg/kg/dayintwodivided

dosesfor10-14

days

Alternatively,Inj

Chloramphenico

l

500mgqidfor14days

Cholangitis

Enterobacteriacae,

Anaerobes

Cefoperazone-sulbactam

2gmIVBDplus

Metronidazole500mgI.V.tds

x5-7days

Cefoperazone-s

ulbactam

150mg/kg/dayinthree

divideddosesi.vplus

Metronidazole3

0-35mg/kg/

dayinthreedivideddoses

x7days

Piperacillin

-Tazobacta

m4.5gm

i.v.tdsplus

Metronidazole

500mg

I.V.tdsx5-7days

Acute

Community

-

acquired

cholecystitis

Acutecholecystitis

ofmildtomoderate

severity-

Enterobacteriaceae

Ceftriaxone1-2gmevery

12hourlyx7days

Ceftriaxonei.v1

00mg/kg/day

intwodivideddoses

Oftenanin

ammatorybut

non-infectiousdisease:If

infection

suspected,antibioticsto

cover

Enterobacteriaceae

GIandintra-ab

dominalinfections


6/337

Community-acquired

acutecholecystitisof

severephysiologic

disturbance,

advancedage,or

immunocompromised

state-

Enterobacteriaceaea

nd

anaerobes

Ciprooxacin400mg

x

5-7days12thhourlyp

lus

Cefoperazone-sulbactam2gm

IVevery12hourly(max8g/

day)incombinationw

ith

Metronidazole500mg

8th-12thhourlyx5-7

days

Cefepime

2gmevery

8-12hours

in

combinatio

nwith

Metronidaz

ole500mg

8th-12thhourlyx5-7

Acutecholangitis

followingbilio-enteric

anastamosisofany

severity-

Enterobacteriaceae

Cefoperazone-sulbact

amw

ith

Metronidazolex5-7d

ays

Cefepimein

combinatio

nMetronidazole

x5-7days

Healthcare-

associatedbiliary

infectionofany

Severity-Enterobacte

ri

aeceae,Enterococccu

s

andanaerobes

Cefoperazone-sulbact

am/

Piperacillin-Tazobacta

mplus

Ciprooxacin/

Levooxacinin

combination

withMetronidazole

Cefepimeplus

Ciprooxac

in/

Levooxac

inin

combinatio

n

withMetronidaz

ole,

Vancomycin

addedtoe

achregimenx

5-7days

Note:Ifan

abscessor

perforation

ofthegall

bladderisn

otedthenthe

sameantib

ioticsneedtobe

givenfor10-14days


7/338

Disease

Etiologicalagents

Antibioticsinadults

Antibioticsinc

hildren

Remarks/Alternative

antibiotics

Spontaneous

bacterial

peritonitis

Enterobacteriaceae

(mostoftenE.coli)

CeftriaxoneIV2gm12hourly

x14days

Ceftriaxone100

mg/kg/dayin

twodivideddosesx14days

Cefoperazone-sulbactam

orPiperacillin

-Tazobactam

Secondary

peritonitis

(bowel

perforation),

Intra

abdominal

abscess

Enterobacteriaceae

B.fragilis

Enterococcussp.

CeftriaxoneIV2gm12hourly

x14days

withMetronidazole

andAmpicillinx14da

ys

CeftriaxoneIV1

00mg/kg/day

intwodivideddoses;

Metronidazole3

0-35mg/

kg/day

andAmpicillin100mg/kg/day

x14days

Drainageofabscess.

Cefoperazone-sulbactam/

Piperacillin

Tazobactam

plusmetronidazoleand

ampicillin

H.pylori

associated

disease,

gastricMAL

T1

lymphomas

Omeprazole40mgbd

+

Clarithromycin500mg

p.o

bd+Amoxicillin1gmb

dp.ox

14days

Omeprazole+C

larithromycin+

+Amoxicillinx14days

Amoebicliv

er

abscess

Entamoebahistolytica

Metronidazole

I.V.500mgtid/800mg

p.otidfor10days

followedbyDiloxanide

furoate500mgp.o.fo

r

10days

Metronidazole3

0-35mg/kg/

dayinthreedivideddoses

followedbydiloxanide20mg/

kg/dayfor10da

ys

Ultrasound

guided

drainagein

caseof

largeabscesses,

imminentrupture

ornoresponseto

medicaltre

atment

Pleasesendappropriatesampleforcultureandsensitivity

andde-escalatewhereve

rpossibleasperthesensitivityreport

GIandintra-ab

dominalinfections


8/339

CVSinfections

Disease

Etiologicala

gents

Antibioticsinadu

lts

Antibioticsin

children

Remarks/Alternative

antibioti

cs

Infectiveen

docarditis

Empiricalpen

ding

cultures

Inj.Crystallinepen

icillin

20millionunitsperdayin

6divideddoses(q4h)+

Cloxacillin2gi.v.q4h+

gentamicin1mg/kgq8h

Revisefo

llowingculture

results

Infective

endocarditis(native

valve)

Penicillin-

Susceptible

Streptococcu

s

viridans

InjCrystallinePenicllin(CP)

12-18millionunits

perdayin

6divideddoses(q4h)+Inj

Gentamicin1mg/k

gi.v.q8h

for2weeksor

CPalonefor4weeks

OrInjCeftriaxone2gm

I.Vodfor

4weeks

Inj.Crystalline

penicillin2lac

units/kgbody

weighti.vevery

4hourlyorInj.Ceftriaxone

100mg/kg/dayi.v.

Alternate:

Inj.Crystalline

penicillin2lac

unitsi.vevery

4hourlyplus

Inj.Gentamicin7.5mg/kg/day

inthreedivide

ddoses

Treatmentdurationis4-6

weeksforallr

egimes

Patientsallergicto

Penicillin

shouldreceive

Vancomy

cinx14days

Enterococcus

sp.

S.viridans

resistantto

penicillin

Vancomycin15mg

/kgq12h

+Gentamicin1mg

/kgq8h

for4-6weeks

Inj.Vancomyc

in60mg/kg/day

in4divideddosesi.v.

For4-6weeks


9/3310

Disease

Etiologicala

gents

Antibioticsinadu

lts

Antibioticsin

children

Remarks/Alternative

antibioti

cs

Culturenegative

Inj.Crystallinepen

icillin

20millionunitsperdayin

6divideddoses(q4h)+

gentamicin1mg/kgq8h

Inj.Ceftriaxon

e100mg/kg/

dayintwodivideddosesplus

Inj.Gentamicin7.5mg/kg/day

inthreedivide

ddosesFor

4-6weeks

Infectiveen

docarditis

(prostheticvalves)

Empiricalpen

ding

cultures

Inj.Vancomycin15

mg/

kgI.V.Q12h+

Rifampicin600mgODP.O.+

Gentamicin1mg/kgI.V.Q8h

Revisefo

llowingculture

results

Infective

endocarditis

(prostheticvalve)

MSSA

Inj.Cloxacillin2gm

IV.Q4h+

Gentamicin1mg/kg

I.V.for6weeks

Inj.Cloxacillin

100mg/kg/

dayi.v.in4divideddoses

plusgentamic

in7.5mg/kg/

dayi.vin3div

ideddosesfor

4-6weeks

MRSA

Inj.Vancomycin15

mg/kgI.V.

Q12h+Rifampicin

300mg

P.O.+Gentamicin1mg/kg

I.V.Q8hfor6weeks

Inj.Vancomyc

in60mg/kg/

dayi.v.in4divideddosesfor

4-6weeks




CVSinfections


10/3311

Skinandsofttissueinfections

Disease

Etiologicala

gents

Antibioticsinad

ults

Antibioticsinchildren

Remarks/

Alternative

ant

ibiotics

Cellulitis

Streptococcus

pyogenes

Staphylococc

us

aureus

Cloxacillin500-10

00mgP.O.6th

hourlyfor7-10da

ys

ORCephalexin500m

g

P.OQ6hfor7-10days

Inj.Cloxacillin100mg/kg/day

i.v.plusgentamicin7.5mg/

kg/dayi.v.for2-3weeks

Furunculosis

Diabeticfoo

t-mild

(localizedc

ellulitis,no

systemicsy

mptoms)

S.aureus

TopicalMupirocin,Fusidicacidor

Framycetin

Cloxacillin500mg

P.OQ

6hfor

7-10days

ORCephalexin500m

gP.OQ6hfor

7-10days

Cloxacillin100mg/kg/day

for10da

ys(diabeticfootnot

applicab

le)

Clo

xacillin500mg

P.O

Q6Hfor

7-1

0days

Diabeticfoo

t-oderate

tosevere(limb

threatening

-severe

cellulitis/gangrene/

SIRS)

Necrotizing

fasciitis

Polymicrobial-

S.aureus,

S.pyogenes,

Gramnegativ

e

bacilli,anaerobes

S.pyogenes

CP20lakhunitsI.V.

Q4h+Clindamycin

600mgI.V.Q6hx

14days+

Gentamicin5mg/kgI.V.Q24h

Cloxacillin100mg/kg/day

for10da

ys(diabeticfootnot

applicab

le)

ins

uspected

ren

alinvolvement

sub

stitute

Gentamicin

Wit

hCiprooxacin

400

mgi.v.Q12H





11/3312

Boneandjointinfections

Disease

Etiological

agents

Antibioticsinadults


Remarks/Alterna

tiveantibiotics

Acute

osteomyelitis

(non-diabetic)

S.aureus

Cloxacillin1gmI.VQ4h

Inchildren,


QIDi.v.plusInj.Ceftriaxone

100mg/kg/dayBDplus

Inj.

Amikacin15mg/kg/day

BD

(Ceftriaxoneforcoverin

g

gramnegativeosteomy

elitis

inyounginfantsaswellas

salmonellaosteomyelitisin

sicklecellanemia)

Foroptimaltreatm

ent

microorganismsshouldbe

identiedbyblood

cultureor

aspirationorbone

biopsy

Duration-6weeks.Canswitch

tooraltherapyonceclinical

improvementoccu

rs

Acute

osteomyelitisin

diabetics

Polymicrobial

Notapplicable

Surgicaldebridem

entwillenhance

curerate

Denitivetreatmentguidedby

bonebiopsy/deep

curettings

(NOTsupercial

swabs)cultureand

susceptibility

studies

Durationoftherap

y

-minimum6weeksaftersurgical

debridement

Chronic

Osteomyelitis

M.tuberculosis

Brucella

Noempirictherapy

Workupfortubercular

etiologyorguidedbyculture

sensitivity

Denitivetherapy

guidedbybone

biopsycultureand

susceptibilityresults


12/3313

Septicarthritis

S.aureus

Cloxacillin1gmI.V.Q4h

ORCefazolin1gmI.VQ8h

Duration-2-4weeks

Inchildren,


QIDi.v.plusInj.Ceftriaxone

100mg/kg/dayBDplus

Inj.

Amikacin15mg/kg/day

BD

Prostheticjoint

infections

Noemprictherapy

unlessacutelyill

Inseverelyillpatients,

Vancomycin15mg/kgI.V

Q12h+Gentamicin1mg/kg

I.V.Q8h+

Rifampicin300mg

P.O.Q8h

Notapplicable

Obtaincultureofp

eri

prosthetictissue/synovialuid.

Avoidculturingsupercialwound/

sinustracts.Treat

for10dayswith

replacementofprostheses





13/3314

Respiratory

tractinfections

Disease

Etiologicalagents

Antibioticsinadul

ts

Antibioticsin

children

Rema

rks/Alternative

antibiotics

Acutepharyngitis

Viral

GroupAbeta

hemolytic

streptococci(GABHS)

BenzathinePenicillin12L

unitsI.M.1dose

ORPenicillinVK500mg

P.O.Q8hfor10day

s

Amoxicillin500mg

P.O.Q8hfor10day

s

InPenicillinallergic

patients,

Erythromycin500m

g

P.O.Q6hfor10days

Mostchildren

withsymptomsof

acutepharyng

itishaveaselflimited

illnessforwhichsymptomatic

therapywiths

alinegarglesand

analgesicswillsufceLimit

antibioticusageonlyforpatients

likelytohave

GABHSinfection

(fever,tonsilla

rexudates,nocough,

tendercervica

llymphnodesand

positivethroatswabcultures

NOTrecommended

forroutineevaluation

ofpharyngitis

Acuteepiglottitis

Ludwigsan

gina,

Vincentsangina

H.infuenzae

Polymicrobial(ora

l

anaerobes)

Viral

S.pneumoniae

H.infuenzae

M.catarrhalis

Ceftriaxone2gmI.V

.

BDfor7-10days

Clindamycin600mg

I.V.Q8h

Alternative

Amoxicillin-

Clavulanate1000mg

P.Obdx10days

Notrequired

Amoxicillin500mg

P.Otdsfor10-14Days

Inj.Ceftriaxon

eorcefotaxime

100mg/kg/da

y;metronidazole

30mg/kg/day

i.vfor14days


14/3315

Acutebacte

rial

exacerbatio

n

ofCOPD

(inpatients)

S.pneumoniae

H.infuenzae

M.catarrhalis,aerobic

GNBs

Azithromycin500mg

P.O.odfor5-7

daysor

Co-amoxyclav625

mgbdfor5-7days

Notapplicable

InjCo

-Amoxyclav

1.2gmQ8hfor

5-7daysSwitchto

oralw

henclinically

appro

priate

Community

acquired

pneumonia

S.pneumoniae

H.infuenzae

Atypicalpathogen

s

Azithromycin500mg

P.O.odfor5daysor

Doxycycline100mg

P.O.bdfor7days

Childrenaged3years-Inj.Ampicillin

100mg/kg/da

yx14days

OrTab.Amoxycillin50mg/kg/day

Ifatanyage,

rapidlyworsening

pneumoniaoc

cursor

pneumatocele

sarefoundonchest

x-ray,addcloxacillin100mg/kg/

dayorvancom

ycin60mg/kg/dayto

coveragainst

S.aureus

TabC

o-Amoxyclav

1gmBD

+Azithromycin500mg

odfor7days


15/3316

Disease

Etiologicalagents

Antibioticsinadul

ts

Antibioticsin

children

Rema

rks/Alternative

antibiotics

Community

acquired

pneumonia

(hospitalize

dbut

notinICU,

NOT

CRITICALL

YILL)

S.pneumoniae

H.infuenzae

Atypicalpathogen

s

InjCo-Amoxyclav

1.2gmQ8hfor5-7

days+

InjAzithromycin500

mgodfor5-7days

Switchtooralwhen

clinicallyappropriate

Childrenage

d3y

ears-Inj.Ampicillin

100mg/kg/da

yx14days

OrTab.Amoxycillin50mg/kg/day

Ifatanyage,

rapidlyworsening

pneumoniaoc

cursor

pneumatocele

sarefoundonchest

x-ray,addcloxacillin100mg/kg/

dayorvancom

ycin60mg/kg/dayto

coveragainst

S.aureus

InjCe

fotaxime1gm

Q8ho

rInjCeftriaxone

2gmod+inj

Azithromycin500mg

odfor5-7days

Lungabsce

ss

oraspiration

pneumonia

Anaerobes

S.pneumoniae

H.infuenzae

InjCeftriaxone2gm

BDplusinj

Clindamycin600mg

Q8h

switchtooralwhen

clinically

stabletreatfor4-6w

eeks

Inj.Ceftriaxon

e100mg/kg/day

plusmetronidazole35mg/kg/day

for4-6weeks.

InjCe

ftriaxone2gmBD

PLUS

injMetronidazole

500m

gQ8h

OrInjCrystalline

Penic

illin2millionunits

Q4h




Respiratory

tractinfections


16/3317

Genitourinaryinfections

Disease

Etiologicalagents

Antibioticsinadults


Remarks/A

lternative

antibiotics

Acute

uncomplica

ted

cystitisin

Non

pregnant

women

Escherichiacoli

Nitrofurantoin100mgP.O.

BD

for7days

Or

Ciprooxacin500mgBD

P.Ofor5days

Notapplicable

Acute

pyelonephritis

(nounderly

ing

GUdisease

)

Escherichiacoli

Amikacin15mg/kgI.VQ24H

for7days(mildillness)or

14

days(severeillness)

Inj.Ceftriaxoneo

rcefotaxime

100mg/kg/dayB

Dfor10-

14days

Ertapenem

1gmI.VQ24H

Complicate

d

UTI

(underlying

GU

disease)

E.coli,

Proteus

Pseudomonas

Acinetobacter

Cefoperazonesulbactam

Or

Piperacillin-tazobactamx

10-14

days

Inj.Ceftriaxoneo

rcefotaxime

100mg/kg/dayIVBDfor

10-14days

Catheter

associated

UTI

Gramnegative

bacilli

Treatonlywhenpatient

hassystemicsymptoms

Inj.Meropenem60mg/kg/

dayBDi.v

OrInj.Ceftazidime150mg/kg/

dayTDSi.v.plus

amikacin15

mg/kg/dayBDi.v

Urinesamp

lefor

culturetobe

obtained

throughcatheterport

andNOTfromurine

bag.CathetertipisNOT

acceptable

forculture

Note:Asymptomaticbacteriuriashouldbe

treatedonlyinpregnancyor

inpatientswithurinarytracta

bnormalities





17/3318

CNSinfections

Disease

Etiologicalagents

Antibioticsinadults

Antibioticsin

children

Remarks/A

lternative

antibiotics

Acute

bacterial

meningitis

S.pneumoniae(CPsen

sitive)

H.infuenzae

S.pneumoniae(CPresistant)

InjCeftriaxone2gmQ12h

I.V.

for10-14

days+InjVancomycin

500mgI.VQ6h

for

10-14days

Childrenaged3y

ears-Inj.

cefotaxime100mg/kg/dayi.v.

x14days

Gramnegativeorganisms

(otherthanPseudomonas)

InjCeftriaxone2gm

Q12hI.V.for21

days

OrInjCeftazidime

2gm

I.VQ8hfor21days

Asabove

Listeria

InjAmpicillin2g

mI.V

Q4hfor10days+Inj

Gentamicin7.5mg/kgI.V

Q8hfor21days

Inj.Ampicillin100mg/kg/

dayi.v6hourlyplusInj.

Gentamicin7.5mg/kg/day

for21days


18/3319

Brain

abscess

Mixtureofaerobes

andanaerobes

InjCeftriaxone2gmI.V.

Q12h

+InjAmikacin5

00mgIV

Q8h+InjMetro

nidazole

I.V500mgI.VQ

8hx14

days

Inj.Ceftriaxone100mg/kg/

dayIVplusInj.vancomycin

60mg/kg/day

plusInj.

metronidazole

35mg/kg/

dayx4weeks

i.v

Ventriculitis

Pseudomonas,

Acinetobacter,MRSA

Inj.Ceftriaxone100mg/kg/

dayplusInj.vancomycin

60mg/kg/day

x4weeks

I,v.





19/3320

Ocularinfections

Disease

Etiologicalagents

Antibioticsinadults

Antibioticsinch

ildren

Remarks/Alternative

antibiotics

Acute

dacrocystitis

Streptococcus

pneumoniae

Staphylococcus

aureus

OralantibioticsCloxacillin250-

500mgpoqid

Topicalantibiotics-Tobram

ycin

0.3%

Ophthalmicsolution1drop

qid

(or)Ciprooxacin0.3%1d

ropbd

ivCiprooxacin2

00mgBD

Orbitalcellu

litis

Streptococcus

speciesS.aureus

Haemophilus

infuenzaetypeb

Polymicrobial

infectionswith

involvementof

anaerobesmore

commoninpatients

aged16andabove

Inj.Ceftriaxone1-2givq12hrly

+Inj.Vancomycin1givq1

2hrly;

toaddmetronidazole15mg/kg

ivloadingthen7.5mg/kgiv

6hrly

forchronicorbitalcellulitis

when

anaerobicinfectionsuspec

ted.

Inj.Ceftriaxone1

00mg/kg/

dayBDplusInj.V

ancomycin

60mg/kg/dayQIDplus

metronidazole30

-35mg/kg/

dayTDSi.v.for3

-4weeks


20/3321

Conjunctivitis

Neonates

Chlamydia

trachomatis

S.aureus

H.infuenzae

S.pneumoniae

Children

H.

infuenzae

S.pneumoniae

S.aureus

Adults

S.aureus

Coagulase-negative

Staphylococcus

H.

infuenzae

S.pneumoniae

Simplebacterialconjunctiv

itis:

0.3%Ciprooxacineyedrops

8-10timesadayand0.3%

ciprooxacineyeointment

at

night.

Adultchlamydialconjunctivitis:

Azithromycin1gsingledosedaily.

Tobramycin0.3%

Forprophylaxis

Againstsecondary

Bacterialinfectionsin

caseofviralconjunctivitis

0.3%ciproo

xacineyedrops

5timesada

y





21/33


22/3323

Empiric antibiotic therapy for ICU

Patient risk stratication

Patient type I

Community acquired

infection (CAI)

Patient type II

Healthcare associated

infection/Nosocomial

infection

Patient type III

Healthcare associated

infection/Nosocomial

infection

Patient coming to the ICU

with CAI

No contact with healthcare

system

No prior antibiotic treatment

No procedures done

Patient young (65 years) with

few co-morbidities

Long hospitalization and/ or

invasive procedures within

last 90 days

Recent & multiple antibiotic

therapies- with in last 90

days

Patient old (>65 years) within

multiple co-morbidities

Major invasive procedures

done Structural lung disease,

AIDS, Neutropenia other

severe immunodeciency

Please send appropriate sample for culture and sensitivity and de-escalate

wherever possible as per the sensitivity report.


23/3324

Blood

Stream

Infections

Patient type I Patient type II Patient type III

Before

Culture

reports are

available

Inj. Amoxycillin-

clavulanate

plus

Inj. Amikacin

OrCeftriaxone

plus

Inj. Amikacin

Inj. Amoxycillin-

clavulanate plus

Inj. Amikacin

Or

Cefoperazone-Sulbactam plus

amikacin

Cefoperazone-

Sulbactam plus

amikacin

Or

Piperacillin-Tazobactam plus

amikacin

After

culture

reports are

available

If non-ESBL/

MSSA then

treat as per the

susceptibility

report

ESBL positive:

Continue the same

as above MRSA:

Vancomycin

(Linezolid

only whenvancomycin is

contraindicated)

Isolation of

Candida:

Fluconazole

ESBL positive:

Continue the same

as above MRSA:

Vancomycin

(Linezolid only

when vancomycinis contraindicated)

Isolation of Candida:

Fluconazole

Escalation If ESBL positive

or MRSA

positive then

treat as type II

If patient does not

respond then treat

as in type III

Only when all others

are found resistant-

Cefepime- tazobactam

OrCarbapenem

(Imipenem- cilastatin,

Meropenem) If a

carbapenemase

producer :

Colistin Antifungal-

(Voriconazole/

Amphotericin B)

De-escalation

If non-ESBL/MSSA then

treat per the

susceptibility

report

If non-ESBL/MSSA then

treat as type I

or treat per the

susceptibility

report

If non-ESBL/MSSA /non-

carbapenemase

producer then treat as

type I or treat as per

the susceptibility

report


24/3325

Pneumonia Patient Type I Patient type II Patient type III

Before

culture

reports are

available

Inj Amoxycillin-

clavulanate

plus inj

Azithromycin

OrInj ceftriaxone

plus Inj

Azithromycin

Cefoperazone-

sulbactam (add

Inj.metronidazole

if aspiration

suspected)plusinj azithromycin

Cefoperazone-

sulbactam

Or

Piperacillin

tazobactam (addInj.metronidazole

if aspiration

suspected)

Consider adding

vancomycin only

if strong clinical

indication of MRSA

After culture

reportsavailable

If non-ESBL/

MSSAthen treat per

the

susceptibility

report

ESBL positive:

Continuethe same as

above MRSA:

Vancomycin

(Linezolid

only when

vancomycin is

contraindicated)

Isolation of

Candida:

Fluconazole

ESBL positive:

Continue the sameas above MRSA:

Vancomycin

(Linezolid only

when vancomycin

is contraindicated)


Fluconazole

Escalation If ESBL positive

or MRSA

positive

then treat as

type II

If patient does

not

respond then

treat

as in type III

Only when all

others are found

resistant: Cefepime-

tazobactam

Or

Carbapenem

(Imipenem-cilastatin

,Meropenem) If a

carbapenemase

producer :


(Voriconazole/

Amphotericin B)

De-escalation If non-ESBL/

MSSA then

treat per the

susceptibility

report

If non-ESBL/

MSSA then

treat as type I

or treat per the

susceptibility

report

If non-ESBL/MSSA/

non-carbapenemase

producer then treat

as type I or treat as

per the susceptibility

report


25/3326

UTI Patient type I Patient type II Patient type III

Before culture

reports available

Amikacin

Or

Ceftriaxone

Amikacin

Or

Cefoperazone-

sulbactam

Amikacin

Or

Cefoperazone-

sulbactam

After culture

reports

available

Non-ESBL /

MSSA:

continue the same

as above

ESBL positive:

Continue

the same as

above MRSA:

Vancomycin

(Linezolid

only when

vancomycin is

contraindicated)

Isolation ofCandida:

Fluconazole

ESBL positive:

Continue the same

as above MRSA:

Vancomycin

(Linezolid only

when vancomycin

is contraindicated)

Isolation of

Candida:

Fluconazole

Escalate If ESBL positive or

MRSA positive

then treat as

type II

If patient does not

respond then treat

as in type III

Only when

all others are

found resistant-

Cefepime-

tazobactam

Or

Carbapenem(Imipenem-cilastatin

,Meropenem) If a

carbapenemase

producer :


(Voriconazole/

Amphotericin B)

De-escalate If non-ESBL/

MSSA thentreat per the

susceptibility

report

If non-ESBL/

MSSA thentreat as type I

or treat per the

susceptibility

report

If non-ESBL /

MSSA / non-carbapenemase

producer then

treat as type I or

treat as per the

susceptibility report

Please send appropriate sample for culture and sensitivity and de-escalate wher-

ever possible as per the sensitivity report.


26/3327

Complicated

Intra-

abdominal

infections

Patient type I Patient type II Patient type III

Before

Culture

reports

available

Inj. Amoxycillin-

clavulanate

plus Inj.

Amikacin plus

metronidazoleOr

Ceftriaxone

plus Inj.

Amikacin plus

metronidazole

Inj. Amoxycillin-

clavulanate plus

Inj. Amikacin plus

metronidazole

OrCefoperazone-

sulbactam plus

metronidazole/

Cefoperazone-

sulbactam plus

metronidazole

Or

Piperacillin-tazobactam plus

metronidazole

After

culture

reports are

available

If non-ESBL/

MSSA then

treat per the

susceptibilityreport

ESBL positive:

Continue

the same as

above MRSA:Vancomycin

(Linezolid

only when

vancomycin is

contraindicated)

Isolation of

Candida:

Fluconazole

ESBL positive:

Continue the same

as above MRSA:

Vancomycin(Linezolid only

when vancomycin

is contraindicated)


Fluconazole

Escalation If ESBLpositive or

MRSA positive

then treat as

type II

If patient doesnot respond then

treat as in type III

Only when all othersare found resistant-

Cefepime-tazobactam

Or

Carbapenem

(Imipenem-cilastatin,

Meropenem): If a

carbapenemase

producer :


(Voriconazole/

Amphotericin B)

De-escalation If non-ESBL/

MSSA then

treat per the

susceptibility

report

If non-ESBL/

MSSA then

treat as type I

or treat per the

susceptibility

report

If non-ESBL/MSSA/

non-carbapenemase

producer then treat

as type I or treat as

per the susceptibility

report

NOTE: It may be noted that the following antibiotics can be prescribed only by the HOD or Professor or Additional professor:

Cefepime Cefepime-tazobactam Vancomycin

Piperacillin-tazobactam Meropenem Linezolid


27/3328

Treatment of Patients with

Fever And Neutropenia

Principles

Empirical anbioc therapy should be administered promptly to all neutropenic paents at the onset of fever

or any other new signs and symptoms of infeconAnbiocs chosen should:

Provide adequate coverage of Pseudomonas aeruginosa

Be based on local antimicrobial susceptibility patterns of frequently identied bacterialPathogens

Low risk High risk

Solid organ malignancy with no organ All haematological malignancies, solid organ

dysfunction malignancies with organ dysfunction

Age60 years

No comorbid illness Presence of comorbid illness

Initial empirical antibiotic therapy :

Low-risk patients should receive initial oral antibiotics: Levooxacin plus amoxicillin-clavulanate incombination is recommended.

High-risk patients require hospitalization for IV empirical antibiotic therapy; monotherapy with an

antipseudomonal -lactam agent, such as cefepime, a carbapenem (meropenem or imipenem-

cilastatin), or piperacillin-tazobactam, is recommended. Other antimicrobials (aminoglycosides,

uoroquinolones, and/or vancomycin) may be added to the initial regimen for management of

complications (eg, hypotension and pneumonia) or if antimicrobial resistance is suspected or

proven.

First line: Ceftazidime +amikacin Or cefepime+ amikacinSecond line : Piperacillin-tazobactam + amikacin Or Cefepime-tazobactam + amikacinOr Meropenem.

Vancomycin (or other agents active against aerobic gram positive cocci) is not recommendedas

a standard part of the initial antibiotic regimen for fever and neutropenia . These agents should be

considered for specic clinical indications, including suspected catheter-related infection, skin or

soft-tissue infection, pneumonia, or hemodynamic instability.

Vancomycin plus 1 or 2 anbiocs, if criteria for use of Vancomycin is met: As above + Vancomycin.


28/3329

Modications of initial antibiotic therapy:

Modications to initial empirical therapy may be considered for patients at risk for infection with

the following antibiotic-resistant organisms, particularly - if the patients condition is unstable or

if the patient has positive blood culture [methicillin-resistant Staphylococcus aureus(MRSA),

vancomycin-resistant enterococcus (VRE), extended-spectrum b-lactamase (ESBL)producing

gram-negative bacteria, and carbapenemase-producing organisms, including Klebsiella

pneumoniae carbapenemase (KPC)].

Modications to the initial antibiotic regimen should be guided by clinical and microbiologic data and

should be treated with antibiotics appropriate for the site and for the susceptibilities of any isolated

organisms.

Escalation: Patients who remain hemodynamically unstable after initial doses with standard agents

forneutropenic fever should have their antimicrobial regimen.

De-escalaton: Low-risk patients who have initiated oral antibiotics in the hospital may have their

treatment approach simplied if they are clinically stable.

Empirical antifungal coverage should be considered in high-risk patients who have persistent fever

after 47 days of a broad-spectrum antibacterial regimen and no identied fever source.

First line: amphotericin B for Candidaspp, voriconazole forAspergillussppSecond line: Caspofungin for Candidaspp

Please send appropriate sample for culture and sensitivity and de-escalate wher-

ever possible as per the sensitivity report.


29/3330

Therapy Duration

A. Patient becomes afebrile in 3 days 1. Patient afebrile by day 3.

Eologic agent idened - adjust therapy to most

appropriate drugs.

No eologic agent idened :

Paent at low risk inially, and on oral anbiocs

with no subsequent complicaons - connue use

of the same drugs

Paent at low risk inially and therapy with

i.v.drugs begun with no subsequent complicaons

change to oral ciprooxacin + amoxicillin

clavulanate aer 48 hours.

Paent at high risk inially with no subsequent

complicaon connue use of same i.v.drugs

ANC 500cells /mm 3 for 2 consecuve days,

no denite site of infecon, and no posive

cultures - stop anbioc therapy when the

paent is afebrile for 48 h.

ANC < 500 cells /mm 3

Paent inially at low risk , and no

subsequent complicaons -stop therapy

when paent is afebrile for 5-7 days

Paent inially at risk and no subsequent

complicaons - connue same anbiocs

B. Persistent fever throughout the rst 3 days 2. Persistent fever on day 3.

Reassess therapy on day 3

If no clinical worsening , connue use ot the same

anbiocs.

Stop Vancomycin ( if part of inial regimen) if

cultures negave

If there progressive disease, change anbiocs

( Imipenem 0.5gm i.v.Q6H / Meropenem

1gmi.v.Q8H).

If paent febrile aer 72-96 hours, consider

adding Amphotericin B, with and without a change

in anbioc regimen.

Addional indicaons for Amphotericin B /

Voriconazole: Pleural rub, pulmonary inltrates

suggesve of invasive aspergillosis, paranasal

sinusis.

ANC 500cells /mm 3 - stop anbiocs 4-5

days aer ANC 2 500cells /mm3.-

ANC < 500 cells /mm 3- reassess and connue

anbiocs for 2 more weeks; reassess and

consider stopping therapy if no disease site

found

Others

Hand hygiene, maximal sterile barrier precautions, and cutaneous antisepsis with chlorhexidine

during CVC insertion are recommended for all CVC insertions.

Please send appropriate sample for culture and sensitivity and de-escalate

wherever possible as per the sensitivity report.


30/3331

For Management in the NICU

S.no. Clinical situation Antibiotics and dose

1 Babies born to mothers with PROM of > 18

hrs, or foul smelling liquor or evidence of

chorioamnionitis

Cefotaxime 100mg/kg/day BD and

gentamicin 5mg/kg/day OD

2 Babies who re admitted in the nursery

from birth with suspected sepsis/persistent

respiratory distress >6 hrs with initial septic

screen positive

Cefotaxime 100mg/kg/day BD and


3 Babies who are shifted fro the mothers

side with suspicion of late onset sepsis and

meningitis

Cefotaxime200mg/kg/day BD and


4 Babies with clinical suspicion of necrotizing

enterocolitis

Cefaperazone+sulbactam 150mg/

day BD ,gentamicin 5mg/kg/day

OD and metronidazole 7.5 mg/kg/

dose Q8H

5 Preterm babies born through meconium

stained liquor with respiratory distress and

clinical suspicion of Listeria infection

Ampicillin 100mg/kg/day- 150mg/

kg/ day BD and gentamicin 5mg/k/

day OD

Duration of Therapy

1.

Started for risk factors,sepsis screen

negative,baby well

48-72 hours, till blood culture

reported sterile

2.

Sepsis screen positive, baby improves with

rst line antibiotics, blood culture sterile 7 days

3. Blood culture positive

10-14 days, based on organism and

sensitivity

4.

Strong clinical suspicion of meningitis,CSF

biochemical values suggestive, CSF and

blood culture sterile 10-14 days based on clinical course

Second line antibiotic used empirically if clinical situation not improving/worsening and/or if repeat

septic screen is positive after at least 48 hours of the rst line antibioticcefaperazone+sulbactam

150mg/kg/day BD and amikacin 15mg/kg/day OD


31/3332Back Cover inside

Notes


32/3333

Rub palms together.

nterlock fingers and rub the back

f fingers of both hands

Rub thumb in a rotating manner

followed by the area between index

finger and thumb for both hands.

ub both wrists in a rotating

anner. Rinse and dry

horoughly

Rub the back of both hands.

Rub fingertips on palm for both

hands.

Seven steps of handwashing

Interlace fingers and rub hands

together.

Back Cover

Published by

Department of Microbiology,

JIPMER


33/33

Handbook of

Antimicrobial Useat JIPMER

POCKET GUIDE

Front Cover

2014 antimicrobial new

Documents