CENTRAL NERVOUS SYSTEM
CNS INFECTIONS | ORGANISMS | INITIAL TREATMENT | ALTERNATIVES | COMMENTS |
---|---|---|---|---|
ACUTE MENINGITIS | ||||
Neonate (preterm to <1 month) | Group B Streptococci, E.coli, Listeria monocytogenes | Ampicillin 50–100 mg/kg/d IV q4h (max 12 gm/d) + Gentamicin 3–5 mg/kg/d IV/IM q8h × 10–14d (max 300 mg/d) | Cefotaxime 0–1 week:100 mg/kg/d 1–4 week: 150 mg/kg/d | See pediatric dosing. |
Child (< 5 years) | H. influenzae S. pneumoniae N. meningitidis Mumps virus (aseptic, if not immunized) | Penicillin G 25–40,000 units/kg/d IV q4h | Ceftriaxone 100 mg/kg/d IV q12h (max 4 gm/d) or Cefotaxime 200–300 mg/kg/d IV q6h × 10–14d | See pediatric dosing. In Penicillin allergy use Chloramphenicol or Vancomycin as per organism. Steroids reduce mortality and neurologic sequelae. |
MU = 1 million units = 10 lakh units | ||||
ACUTE MENINGITIS | ||||
Adult immunocompetent Bacterial Community-acquired (Spinal fluid with >90% polymorphs and low glucose) | S. pneumoniae H. influenzae (uncommon) N. meningitidis (rare) | Penicillin G 40 lac units IV q4h × 10–14d | Cefotaxime 2 gm IV q4h or q6h or Ceftriaxone 2 gm IV q12h × 10–14d Likely etiological agents in the following conditions: | Hyposplenism: S. pneumoniae, N. meningitidis, H. influenzae (uncommon); CSF rhinorrhea: S. pneumoniae; Alcoholism: S. pneumoniae, L. monocytogenes; Cluster/epidemic: N. meningitidis, H. influenzae type B. Use Dexamethasone 0.4 mg/kg/d IV divided q6h × 4d. Administer before or with antibiotic. Penicillin non-susceptible S. pneumoniae strains causing invasive diseases such as meningitis not reported from India. Prophylaxis for N. meningitidis with Rifampicin 600 mg PO twice daily (for 2d for close family members and health care workers who come in contact with infected patients for activities such as intubation, endotracheal suctioning, etc.). |
Hospital acquired | Acinetobacter spp. | Imipenem can be used but high rate of seizure activity. Meropenem IV is preferred | ||
* Acinetobacter meningitis (Aerobic gram-negative bacilli) Imipenem can be used (but high rate of seizure activity); meropenem IV is preferred if susceptible. | ||||
ACUTE MENINGITIS | ||||
Viral (aseptic) Community-acquired (spinal fluid mostly lymphocytes, normal glucose) | HSV-1, HSV-2, Enterovirus, LCM Virus, HIV Mycoplasma | If HSV suspected give Acyclovir 10 mg/kg IV q8h; supportive treatment (IV Mannitol and steroids to lower intracranial tension). For Mycoplasma, Doxycycline 200 mg PO BD × 3 days followed by 100 mg PO BD × 2–4 wks | HSV-2 meningitis occurs with primary genital herpes. (Leptospirosis may present as aseptic meningitis, use Ampicillin 1–2 gm IV q 6h or Crystalline Penicillin 20 lac units IV q6h). Consider rabies if history of exposure (rabid dog bite); usually causes a meningeal encephalitis. Consider partially treated bacterial meningitis if patient has received antimicrobials. | |
Hospital-acquired | ||||
Post-neurosurgical or post-head trauma | S. aureus and coagulase negative Staphylococci Gm negative organisms: (E.coli, Klebsiella spp., Enterobacter spp.) | Vancomycin 1 gm IV q12h + Cefotaxime 2 gm IV q4h × 10–14d or Teicoplanin 400 mg IV/IM OD + Cefotaxime 2 gm IV/IM q4h | Vancomycin 1 gm IV q12h + Meropenem 1 gm q8h × 10–14d or Teicoplanin 400 mg IV/IM OD + Meropenem 1 gm q8h × 10–14d | Meropenem if ESBL-producing gram-negative organisms are found. Seizures can occur with Imipenem-Cilastatin. |
P. aeruginosa | Ceftazidime 2 gm IV q8h | |||
Shunt or prosthetic Infection | S. aureus, S. epidermidis coagulase negative staphylococci in ventriculo-atrial shunt; Gm negative organism in VP × shunts E. coli, K. pneumoniae, Enterobacter, S. morcescens | Cloxacillin 1–2 gm IV q4h × 1–2 wks after removal of shunt Cefotaxime 2 gm IV q6h × 2 wks after shunt removal | Vancomycin 1 gm IV q12h × 1–2 wks or Teicoplanin 400 mg IV/IM OD 1–2 wks after removal of shunt Ceftriaxone 2 gm IV q12h after removal of shunt × 2 wks. | For ventriculo atrial or VP shunt infections, Gram positive cocci more likely. Remove shunt. Use Vancomycin or Teicoplanin. If Methicillin resistance among staphylococci (MRSA or MRSE) is found Linezolid 600 mg PO BD × 1–2 wks may be used. Linezolid should not be used for longer than two weeks. |
Adult immunocompromised. Must concurrently suspect for usual bacterial organisms along with the organisms cited below. | ||||
HIV/AIDS | Cryptococcus neoformans | Amphotericin B 0.7 mg/kg/d until afebrile or for 2 weeks, then Fluconazole 400 mg PO for 10 weeks and 200 mg OD, as prophylaxis for indefinite period | Fluconazole 400 mg IV or PO q24h if oral cannot be tolerated. Switch to oral for 10 weeks and then 200 mg PO OD as prophylaxis indefinitely | Liposomal or lipid complex of Ampho B is expensive but associated with lowered renal toxicity. IV Mannitol and Dexamethasone to reduce CSF pressure. If CSF opening pressure >250 mmH2O, then repeat LP and CSF drainage to reduce pressure. |
Listeria monocytogenes | Ampicillin 2 gm IV q4h × 10–14d | Diptheroids isolated from CSF should be speciated to rule out Listeria spp. | ||
Lipid Amphotericin B 5 mg/kg IV q24h usually given to patients with renal impairment (Serum Creatinine > 2.5 mg or estimated Cr Cl (creatinine clearance) < 40 ml/min or increase of Serum Cr to twice baseline levels while receiving conventional Ampho B). LP = Lumbar Puncture | ||||
HIV/AIDS Continued… | Treponema pallidum | Penicillin G 20–40 lac units IV q4h × 10d | ||
Non-HIV (on steroids and immunosuppressive agents or solid organ transplant recipients) | M. tuberculosis (acute disseminated) | See TB section | ||
Nocardia spp. | TMP/SMX 1 DS PO BD | Treat for 3 months for immunocompetent hosts and 6 months for immunocompromised hosts. | ||
Listeria spp. | Ampicillin 2 gm IV q4h × 14d | Inj Crystalline Penicillin 20 L IV q6 hrly × 14d | Seen among elderly and in patients with malignancy. | |
Cryptococcus neoformans | Amphotericin B (as above) | Fluconazole 400 mg IV or PO q24h | ||
ACUTE ENCEPHALOPATHY | ||||
Specific causes | Plasmodium spp (Malaria), S. typhi and other Salmonella spp., M. tbc, Fungal, Rabies | Treat according to etiology | See table on Malaria and TB section. | |
HSV-1, HSV-2 | Acyclovir 10 mg/kg IV q8h × 14–21d | Must treat early if HSV suspected to reduce morbidity and mortality. | ||
CHRONIC MENINGITIS | ||||
Most common cause | M. tuberculosis | INH, Rifampicin, PZA, and (SM or Ethambutol) × 2 months continued INH, Rifampicin, PZA for 10 more months Daily regimen preferred | Add steroids for the first month, if protein > 500 mg, cranial nerve involved, signs of raised ICP, vasculitis, confusion or altered sensorium present or comatose. | |
HIV associated | Cryptococcus neoformans | As above in section on Cryptococcus | ||
Sexual exposure | Treponema pallidum | Penicillin G 20–40 lac units IV q4h × 10d or Procaine Penicillin 24 lac units IM q24h with Probenecid 0.5 gm PO QID × 14d | Ceftriaxone 2 gm IV q24h × 14d | Penicillin allergy: Desensitize check protocol. Usually serum or CSF VDRL is positive with CSF analysis showing an abnormality. |
Animal exposure | Brucella abortus (rare) | Doxycycline 100 mg po BD + Streptomycin 1 gm IM OD × 6 wks | Doxycycline 100 mg PO BD + Rifampicin 600 mg PO OD × 6 wks | If there is a brain abscess, continue treatment for 3 months. |
BRAIN ABSCESS. Treat for at least 4 wks with neuroimaging to document clearing of abscess | ||||
Direct extension from a focus (dental, otitic mastoid, sinus) | Aerobic and anaerobic Streptococci Bacillus fragilis, B. melaninogenicus, Fusobacterium spp., Enterobacteriaceae group, Haemophilus spp. | Penicillin G 40 lac units IV q4h × 4 wks or Ampicillin 2 gm IV q4h × 4 wks + Metronidazole 500 mg IV q8h × 4 wks | Cefotaxime 2 gm IV q4h + Metronidazole 500 mg IV q8h × 4 wks or Ceftriaxone 2 gm IV q12h + Metronidazole 500 mg IV q8h × 4 wks | Extends from sinusitis, otitis media, dental abscesses. Usually in the temporal or frontal lobe. Aspirates (obtained by CT guidance) for gram stain, culture and sensitivity are useful. Chloramphenicol as a single agent is less preferred. |
Absidia (fungus) | Amphotericin B | Correction of metabolic derangements + surgical debridement | ||
Hematogenous spread from distant focus or cryptogenic (cardiac or pulmonary source) | Aerobic and anaerobic Streptococci, B. fragilis, Fusobacterium spp., Haemophilus spp., S. aureus | Penicillin G 40 lac units IV q4h or Ampicillin 2 gm IV q4h + Metronidazole 500 mg IV q8h × 4 wks | Cefotaxime 2 gm IV q4h + Metronidazole 500 mg IV q8h × 4 wks or Ceftriaxone 2 gm IV q12h + Metronidazole 500 mg IV q8h × 4 wks | Usually from sources such as empyema, lung abscess bronchiectasis, endocarditis and pelvic infection. Abscess may often be multiple in the parietal lobe or may be located in other lobes and brain-stem. For S. aureus Cloxacillin 2 gm IV q4h × 4 wks. |
Scedosporium apiospermum (fungus) | IV Voriconazole | |||
Spinal epidural abscess | S. aureus, Streptococcus spp, Anaerobes, gram negative organisms | Cefazolin 2 gm IV q8h + Metronidazole 500 mg PO q8h × 4–6 wks | Clindamycin 600–900 mg IV q8h + Ciprofloxacin 400 mg PO q12h × 4–6 wks | Surgical drainage must be considered. |
Subdural empyema | Oral anaerobes, H. influenzae | Cefotaxime 2 gm IV q4–6h + Metronidazole 500 mg IV q8h × 4–6 wks | Cefpirome 2 gm IV q12h + Metronidazole 500 mg IV q8h × 4–6 wks | Cefepime 2 gm IV q12h can be used instead of cefpirome |
Cavernous or sagittal sinus thrombosis, Intracranial suppuration, thrombophlebitis | S. aureus, Group A Streptococci H. influenzae | Cloxacillin 2 gm IV q4h × 2–4 wks | Vancomycin 1 gm IV q12h or Teicoplanin 400 mg IV OD × 2–4 wks | Add anticoagulants heparin or fractionated heparin. For diabetes, consider fungal etiology. Cefpirome or Cefepime if methicillin-susceptible staphylococci is suspected. |
HIV/AIDS Treat empirically, usually responds in 7–10 days. If no response, plan stereotactic brain biopsy | Toxoplasma gondii Prevalence: India 7–10% | Pyrimethamine 200 mg PO × 1 dose, then 50–75 mg PO daily + Sulfadiazine 1.5 gm q6h PO + | Pyrimethamine and Folinic acid + Any one of the following for 6–8 wks may be substituted for sulfa allergy | Suppressive Rx: Pyrimethamine 50 mg PO daily with folinic acid 10 mg daily and Sulfadiazine 0.5–1 gm PO BD or Clindamycin 300 mg PO QID. TMP/SMX DS tabs given twice daily may be adequate |
(Encephalopathy or mass lesion in brain on neuroimages) | Folinic Acid 10 mg PO daily × 6 wks or TMP/SMX (Trimethoprim content) 10 mg/kg PO q12h | Clindamycin 600 mg IV PO q6h or Azithromycin 1.2–1.5 gm PO OD or Dapsone 100 mg PO OD | ||
Non-HIV: Those receiving steroids immunosuppresive agents | Nocardia asteroides | TMP/SMX DS 2 tablets PO BD × 3–6 months; may halve the dose after 1 month | Sulfa Allergy: Ceftriaxone 2 gm IV q12h and Amikacin 400 mg IV q12h × 3 months | 3 months for immunocompetent 6 months for immunosuppressed. |
Parasites | Cysticercosis (Taenia solium) | Praziquantel 50 mg/kg/d PO TID × 30d or Albendazole 400 mg PO OD × 30d | Consider with history of eating undercooked pork, meat, or raw underwashed vegetables | |
Amoeba fresh water exposure | Entamoeba histolytica abscess | Metronidazole 500 mg IV TID × 30d | Amebic meningoencephalitis caused by Acanthamoeba usually fatal despite early treatment | |
Naeglaria fowleri (meningitis) | TMP/SMX DS 2 tab PO BD × 6 wks | |||
CMV Encephalitis or polyradiculitis | Ganciclovir 5 mg/kg IV q12h until symptomatic | Cidofovir 5 mg/kg/IV every other week for 2 wks and then every | ||
improvement maintenance therapy for life | two weeks for 24 wks. Give probenecid 2 gm PO 3 hrs before and 1 gm PO 2 and 8 hrs after cidofovir. For severe cases Foscarnet 60 mg/kg/IV q 8h × 3 wks + Ganciclovir 5 mg/kg × q12h + 3 wks. Consider HAART (Highly Active Antiretroviral Therapy) if HIV +ve. | |||
If recurrent meningitis, then check for communication with the CSF, such as basal skull fracture or presence of pilonidal sinus. Must consider M. tuberculosis (M.tbc) in the differential diagnosis in every presentation of acute meningitis, especially in those with partially treated bacterial meningitis. If intracranial tension is increased, hyperventilate to reduce PCO2 to 25–30 mmHg; Administer Mannitol 0.25 to 1 gm/kg IV in 30 min bolus every 4 hours. In acute meningitis symptoms occur within 7 days, usually within 48–72 hours, chronic usually > 7 days to 1 month. TMP-SMX (Trimethoprim-Sulfamethoxazole) not available as an IV preparation in India. |
OPHTHALMIC INFECTIONS
OCULAR INFECTIONS | ORGANISMS | INITIAL TREATMENT | ALTERNATIVES | COMMENTS |
---|---|---|---|---|
EYELID INFECTION | ||||
Blepharitis | S. aureus | Topical ointment-Bacitracin BD | ||
Hordeolum (Stye) Stye internal | S. aureus | Warm compresses | Treatment with anti-Staph antibiotic is optional. Some advise oral therapy with antibiotics since it may include territory of dangerous area of face (retrograde flow to cerebral venous sinus). | |
Stye external | S. aureus | Cloxacillin 500 mg PO QID or Dicloxacillin 250 mg QID Warm compresses | Cephalexin 250–500 mg PO QID × 5–7 days | |
LACRIMAL SAC | ||||
Dacryocystitis or Dacryoadenitis | S. pneumoniae S. aureus, H. influenzae | Cephalexin 250–500 mg PO QID | May drain spontaneously. Obtain ophthalmological consult. | |
CONJUNCTIVITIS | ||||
Infant Bacterial | N. gonorrhoeae Chlamydia trachomatis | Cefotaxime 25 mg/kg/iv/IM q12h × 7d + Topical-Gentamicin/Tetracycline/Penicillin | Check if N. gonorrhoeae strain is susceptible to Penicillin. | |
Adult Purulent | N. gonorrhoeae N. meningitidis | Procaine Penicillin 8 lac units BD for 3–5d or Ceftriaxone 1 gm IM once or Cefixime 400 mg PO × 1 dose | Systemic treatment for gonorrhoea | Usually in sexually active adults and spread by autoinoculation from infected genitalia. If septicemia/corneal ulcer is present, then Ceftriaxone 1 gm IM/iv q12h × 3d + topical saline irrigation + Ciprofloxacin/Ofloxacin drops every 5 min × 30 min, then every 15 min × 1 hr, then every hr × 5–7d. |
Adult Muco-purulent | S. pneumoniae H. influenzae S. aureus | 0.5% Chloramphenicol 1 drop every 5 mins × 30 mins followed by every 2 hrs × 5–7d or | Norfloxacin 0.3% drops q2h × 7d or ointments of Erythromycin | Mostly outbreaks are due to viral causes and may not need any antiviral or antibacterial agents. Wash eyes frequently |
Ciprofloxacin drops 0.4% or Ofloxacin 0.3% for 5–7d every 2 hours | Bacitracin, or Neomycin or Polymyxin B QID × 7d | |||
Chronic bacterial conjunctivitis | S. aureus, Mycoplasma lacunata | Nightly application of Bacitracin or Erythromycin or Polymyxin ointment + lid hygiene. Wash eyelids BD with non-irritating soap solution.(eg. Johnson's baby shampoo) | Often with associated blepharitis. Lasts 3–4 wks or longer. | |
Trachoma | Chlamydia trachomatis | Doxycycline 100 mg PO BD × 21d + Erythromycin-Tetracycline ointment BD × 5 days/month × 6 months | Erythromycin 250 mg PO QID × 21d | Treat any concurrent genital infection. For children less than 8 years, use Tetracycline or Erythromycin ointment. |
Viral | Adenovirus, Enterovirus, Coxsackie virus | Supportive | Can occur in epidemics. Usually self-limited over 2–3 wks. Avoid rubbing eyes and wash hands before contact. | |
KERATITIS (CORNEA) | ||||
Viral | Herpes simplex virus type 1 | Acyclovir eye ointment or drops 5 times/d × 2 wks | Trifluridine 1% eyedrops one drop onto cornea every 2 hours not to | Oral Acyclovir of no value. Need ophthalmology consult. Need to differentiate keratitis/iritis |
exceed 9 drops/d for 21 days or Vidarabine ointment 5 times/d × 14d | from conjunctivitis. Keratitis/iritis reduces vision, causes true pain (not gritty irritation), no exudate, photophobia or lacrimation and small pupillary diameter. | |||
Varicella-zoster | Acyclovir 800 mg PO 5 times/d × 10d | Famciclovir 500 mg PO TDS × 10d | No consensus regarding the use of topical steroids, tear supplements, eye patching or tarsorrhaphy. Analgesics for pain. | |
Bacterial | S. aureus, Streptococci, Enterobacteriaceae | Ciprofloxacin 0.4% or Ofloxacin 0.3% drops q2h × 5–7d or Fusidic acid1% gel q12h × 7d or Cefazolin eye drops + Gentamicin eye drops every 1 hour-taper as pt. improves | Systemic therapy not required as topicals achieve high levels. | |
Protozoal | Pseudomonas spp. | Topical Tobramycin eyedrops or Gentamicin eyedrops every 1 hour taper as patient improves | Risk factor: Soft contact lens user | |
Fungal | Candida spp. | Amphotericin B 0.1–0.15% eye drops q2h × several wks | Flucytosine1% eye drops q2h × several wks | If part of a disseminated infection, a suppressive dose of fluconazole 200 mg/day can be used. |
Keratitis | ||||
Fungal | Aspergillus spp. Fusarium spp. | |||
Protozoan | Acanthamoeba spp. | Propamide (0.1%), neomycin, polymyxin B eye drop every hourly for 1–2 wks | Chlorhexidine (0.02%) eye drop hourly for 1–2 wks | Risk factor: Soft contact lens user |
IRITIS | ||||
M. leprae, Syphilis, HIV | Treatment of primary condition along with steroids | Refer specific treatment for each pathogen/parasite. | ||
Herpes (zoster and simplex) | Acyclovir 800 mg po 5 times/d × 10d | Acyclovir eye drops every 4 hrs × two wks | ||
RETINITIS | ||||
HIV + usually CD4 <100 | Cytomegalovirus, Toxoplasma | Ganciclovir Induction: 5 mg/kg IV q12h for 21d Maintenance: 5 mg/kg IV q24h | Local intravitreal injection of Ganciclovir for CMV may be useful. See toxoplasma therapy for meningo encephalitis. Consider HAART therapy for Toxoplasma and CMV. | |
Non-HIV Acute retinal necrosis syndrome | Varicella-zoster virus Herpes simplex virus | Acyclovir 500 mg IV q8h × 7–10d, then acyclovir 800 mg PO 5 times/d × 6–12 wks. Consider local/systemic steroids + NSAID | Ganciclovir 5 mg/kg/d IV q12h × 14–21d | |
UVEITIS | ||||
Leptospira spp. | Doxycycline 100 mg BD × 7d | |||
ENDOPHTHALMITIS | Presents with decreased vision, ocular pain, and headache. On eye exam, vitreous haziness is diagnostic. Ophthalmological consult urgent. Consider intravitreal antibiotics with possible vitrectomy as first line treatment then systemic and topical treatment. | |||
ACUTE ENDOPHTHALMITIS | Aspergillus spp Fusarium spp | |||
Post-Operative Acute 2–5 days post-op | S. aureus or Gram negatives | 0.5% Chloramphenicol 2 drops every 5 mins × 30 mins and then every 2 hrs × 5–7 days | Ciprofloxacin drops 0.4% × 4 times 20 mins apart, within 1 hr of surgery | If MRSA Vancomycin 3.3% × 3 to 6 hrs apart, and 1–2 hrs before surgery. |
NSAID: Non-Steroidal Anti-inflammatory Drugs | ||||
Low grade | Propionibacterium acnes, Coagulase negative Staphylococcus | 0.5% Chloramphenicol 2 drops every 5 mins × 30 mins and every 2 hrs × 5–7d | Vancomycin 3.3% drops × 3–6 hrs apart or Ciprofloxacin 0.4% drops × 4d, 20 mins apart, within 1 hr of surgery | Usually spreads directly as contaminants from the eyelids and conjunctiva. A 5% solution of Povidone-iodine should be applied to eyelids and ocular surface prior to surgery. |
Fungal | Candida spp. | Oral Fluconazole 400 mg PO/IV OD × 12 weeks. Voriconazole 400 mgm IV or PO q12h for 2d then 200 mgm q12h till improvement occurs | Amphotericin B 0.1–0.15% eye drops q2h × several wks | IV Amphotericin B does not penetrate the vitreous. Aspergillus needs surgical care. |
Exogenous | Streptococci Staphylococci Haemophilus spp. Pseudomonas spp. | 0.5% Chloramphenicol 2 drops every 5 mins × 30 mins and every 2 hrs × 5–7d or Fusidic acid drops 1% q12h × 5–7d | Vancomycin 3.3% drops × 3 applications, 6 hrs apart; + Ciprofloxacin 0.4% drops × 4 applications, 20 mins apart | Intravitreal/subconjunctival/ systemic therapy to be considered. Steroids to be considered (Vitrectomy). |
ORBITAL CELLULITIS | ||||
Streptococci spp. H. influenzae, M. catarrhalis, S. aureus | Ampicillin 2 gm IV q4h or Cefazolin 2 gm IV q8h × 14d | Amox/Clav 500 mg PO/IV q8h × 14d | In cavernous sinus thrombosis or subperiosteal abscess Cefotaxime 1 gm IV q8h or Cloxacillin 1 gm IV every 4–6 hrs. | |
Subperiosteal abscess | S. aureus Streptococcus spp. H. influenzae | Cefotaxime | Immediate surgical drainage of abscess and involved sinus; IV antibiotics should include cefotaxime | |
CATARACT SURGERY WITH INTRAOCULAR LENS INFECTIONS | ||||
S. aureus, Propionibacterium acnes, Pseudomonas aeruginosa | Intravitreal Vancomycin 100 mg + Topical antibiotics Cefazolin + Gentamicin can be instilled 3–4/doses into the conjunctival sac or intravitreally | Intravenous high dose systemic antibiotic treatment for 5–14d. Surgical removal is technically difficult and hazardous. Inj. (for Pseudomonas) Piperacillin/Tazobactam 3.375 gm IV q6h along with Inj. Amikacin 7.5 mg/kg/d IV once daily (Vitrectomy). | ||
Mucormycosis: Absidia, Mucor, Rhizopus, Rhizomucor. Treatment with Amphotericin B; Surgical debridement |
EAR, NOSE AND THROAT INFECTIONS
ENT INFECTIONS | ORGANISMS | INITIAL TREATMENT | ALTERNATIVES | COMMENTS |
---|---|---|---|---|
OTITIS MEDIA | ||||
Acute | S. pneumoniae, H. influenzae, M. catarrhalis, S. pyogenes, S. aureus 35% are sterile | Amoxicillin 500 mg PO TDS in adults (40 mg/kg/day divided in 3 doses × 10d in children) | Erythromycin 50 mg/kg/d PO QID or Cefuroxime 30 mg/kg/d PO BD × 10d | Tympanocentesis to be considered for persistent ear ache and/or bulging tympanic membrane and for treatment failure of antibiotic in 48–72 hours. Nasal decongestants and antihistamines helpful. Change treatment if not responding within 3 days. |
Failed acute initial treatment | Drug resistant strains of above organisms | Amoxicillin/Clavulanate 625 mg PO TDS (or Amoxicillin content 40–90 mg/kg/d divided in 3 doses) × 10d | Ceftriaxone 50–100 mg/kg IV q24h or 2 gm IV q 24h × 10d | If persistent effusion for 3 months, consider myringotomy, adenoidectomy, and/or tympanostomy. Keep ear dry and clean. Tympanoplasty later (when there is no discharge) if hole in eardrum persists. |
Recurrent | S. pneumoniae H. influenzae M. catarrhalis | Amoxicillin 20 mg/kg PO OD × 6 months | If 3 or more separate episodes in 6 months. Consider recurrence. | |
OTITIS EXTERNA | ||||
Acute “swimmer's ear” | S. aureus P. aeruginosa, E. coli. Proteus spp | Eardrops: Neomycin/Polymyxin/Hydrocortisone QID or Ofloxacin 200 mg PO BD + Ear wick or Cloxacillin 500 mg q6h × 7d PO | Ciprofloxacin for Pseudomonas sp | Occurs due to swimming. Selenium sulfide drops in ear canal plus steroid solution are helpful. Acute infections may be caused by S. auerus |
Malignant (with diabetes) | P. aeruginosa | Amikacin 7.5 mg/kg q12h + Ceftazidime 2 gm IV q8h × 10d or Ciprofloxacin 400 mg IV q12h change to oral Ciprofloxacin 750 mg PO BD (if osteomyelitis) for six weeks | Ciprofloxacin 400 mg IV q12h + Amikacin 7.5 mg/kg q12h × 10d | Occurs in diabetics. Can substitute Cefpirome or Cefoperazone/Sulbactam or Ceftazidime mono-therapy if susceptible. Needs prolonged treatment and debridement in case of skull base involvement, i.e. osteomyelitis. |
MASTOIDITIS | ||||
Acute mastoiditis | S. pneumoniae, H. influenzae Proteus spp. P. aeruginosa | Amoxicillin 500 mg PO TDS or Cefuroxime 500 mg PO BD or TMP/SMX 1DS PO BD or Amoxicillin/Clavulanate 625 mg PO TDS × 14–21d | Cefotaxime 1 gm IV q8h or Ceftriaxone 1 gm IV q24h × 14–21d or Any parenteral first generation Cephalosporin | If there is an abscess in the mastoid bone, consider mastoidectomy. Anaerobes usually in chronic mastoiditis. Consider adding Metronidazole Beware of intracranial complications. |
SINUSITIS | ||||
Acute (symptoms <4 weeks) | H. influenzae, S. pneumoniae, M. catarrhalis | Amoxicillin 500 mg PO TDS × 10d or Doxycycline 100 mg PO BD × 10d | Azithromycin 500 mg PO once then 250 mg × 5d | Sinus lavage for refractory cases, topical and systemic decongestants, mucolytic agents, humidifiers, topical steroids, anti-histaminics for allergic patients. |
Viruses: Rhino, Influenza, Parainfluenza, Adenovirus | No treatment required | |||
Acute (Failed initial treatment) | Drug-resistant strains of above organisms | Cefuroxime 500 mg PO BD × 10d or Amoxicillin/Clavulanate 1 gm PO BD × 10d | Levofloxacin 500 mg PO OD × 10d | Can substitute newer Fluroquinolones, Moxifloxacin 500 mg OD, Gatifloxacin 400 mg OD × 7–10d. |
Chronic (symptoms >1 months) | Polymicrobial; include Anaerobe cover | Amoxicillin/Clavulanate 625 mg TDS × 14–21d | Amoxicillin 500 mg PO TDS + Metronidazole 500 mg PO TDS × 14–21d | ENT consult. Nasal decongestants as necessary. |
Nosocomial Non-ICU | Enterobacteriaceae E. coli Streptococcus spp. Anaerobes Pseudomonas spp. Fungus | Ceftriaxone 2 gm IV q24h + Metronidazole 500 mg TDS ×14d | Cloxacillin 1 gm IV q6h + Metronidazole 500 mg PO TDS + Ciprofloxacin 750 mg PO BD × 14d | Common symptoms include significant nasal secretions. Consider CT of sinuses & surgical therapy; usually occurs with intubated patients. Drainage if air-fluid levels present. Change NG tube to OG tube. If fungus present, treat appropriately |
NG: Nasogastric; OG: Orogastric | ||||
ICU associated | P. aeruginosa, S. aureus | Cloxacillin 1 gm IV q4h + Metronidazole 500 mg IV q8h + Amikacin 7.5 mg/kg IV q12h (Can substitute Ciprofloxacin for Amikacin depending on local susceptibility) | Vancomycin 1gm IV q12h (for MRSA) + Amikacin 7.5 mg/kg IV q24h or Ceftazidime 2 gm IV q8h × 14d | Other options include: Ticarcillin/Clavulanate, Piperacillin/Tazobactam, Cefoperazone/Sulbactam, Cefpirome. Imipenem or Meropenem. Add Vancomycin if MRSA suspected. |
PHARYNGITIS | ||||
Pharyngitis (exudative diffuse erythema) | Streptococcus group A | Benzathine Penicillin 12 lac units IM 1 dose or Penicillin V 250–500 mg PO TDS × 10d | Amoxicillin 500 mg PO TDS or Azithromycin 750 mg once and then 250–500 mg OD × 7–10d or Cephalexin 500 mg PO QID × 10d | Other macrolides, Azithromycin can be used in cases of Penicillin allergy. Consider N. gonorrhoeae if sexually active with oral sex practices. |
Pertussis | Bordetella pertussis | Vaccine as part of DPT, Refer vaccines | ||
Diphtheria (membranous) | C. diphtheriae | Penicillin G 10–20 lac units IV q4h × 14d + Diphtheria antitoxin 20–40,000 units IV once | Erythromycin 50 mg/kg/d PO QID × 14d + Diphtheria antitoxin 20–40,000 IV once | Diphtheria antitoxin should be used if the diagnosis is made. For extensive disease can use diphtheria antitoxin doses of 80,000–120,000 units IV once. Immunization prevents disease. Refer to Immunization chart. |
Virus (ulcerative and vesicular) | Rhinovirus, Adenovirus, EBV, Cytomegalovirus RSV, Myxovirus, HSV | No specific treatment | If HSV, Acyclovir 400 mg PO TDS × 10d | Penicillin group contraindicated in EBV infection, because it can cause a rash |
EBV: Epstein Barr Virus; RSV: Respiratory Syncytial Virus; HSV: Herpes Simplex Virus; 10 lakh units = 1.0 million units Hantavirus causes Hantavirus pulmonary syndrome | ||||
Fungus HIV+ | Candida species | Nystatin or Clotrimazole suspension for topical application, QID × 5–7d or Fluconazole 100–200 mg/d PO OD × 7d | Itraconazole 100–200 mg PO BD × 3–5d | Oral therapy if immunocompromised and unresponsive to topical applications. Clotrimazole lozenges can be used. Check blood sugar status, recent antibiotic therapy and oral hygiene, if HIV negative. |
TONSILLITIS | ||||
Acute | Streptococcus group A | Penicillin G 12 lac units IM 1 dose or Penicillin V 250–500 mg PO TDS × 10d | Amoxicillin 500 mg PO TDS or Erythromycin 250–500 mg PO QID ×10d or other | Macrolides Other drugs (macrolides) used in cases of Penicillin allergy. |
Peritonsillar abscess | Streptococcus group A | Penicillin G 10–20 lac units IV q4h or Amoxicillin/Clavulanate 1.5–3.0 gm IV q8h | Clindamycin 600–900 mg IV q8h or 450 mg PO QID | Surgical drainage if needed. Two weeks therapy may be required. |
Retropharyngeal abscess | Anaerobes Streptococcus group A | Penicillin G 20–40 lac units IV q4h + Metronidazole 500 mg IV q8h or Amoxicillin/Clavulanate 1.5–3.0 gm IV q8h | Clindamycin 600–900 mg IV q8h or 450 mg PO QID when ease in swallowing is possible | Surgical drainage needed. Consider TB in adults. Two weeks therapy may be required. |
LARYNGITIS | ||||
Acute | Rhinovirus, Parainfluenza, RSV | No specific treatment. Voice rest. Steam inhalations | GERD to be considered. | |
Chronic | M. tuberculosis | INH, Rifampicin, PZA, and (SM or Ethamb.) × 2 months then INH, Rifampicin for 4 more months Refer to TB section—DOTS | ||
Parapharyngeal infection | Anaerobes | Penicillin G 10–20 lac units IV q4h + | Clindamycin 600–900 mg IV q8h or 450 mg PO QID or | Includes spaces: sublingual, submandibular, submaxillary, lateral pharyngeal, retropharyngeal, pretracheal. |
GERD: Gastro-Esophageal Reflux Disease; DOTS: Directly Observed Treatment Short Course | ||||
Parapharyngeal infection Continued… | Metronidazole 500 mg PO TDS × 7–10d or Amoxicillin/Clavulanate 1.5–3.0 gm IVq8h | Amoxicillin 500 mg PO TDS + Metronidazole 500 mg PO TDS × 7–10d | ||
Epiglottitis | H. influenzae, Streptococcus group A | Cefotaxime 1–2 gm IV q8h or Ceftriaxone 1–2 gm IV q24h × 5d | Chloramphenicol 50–100 mg/kg IV q6h × 5d | Intubation if required. H. influenzae common in children, while group A Strep. common in adults. Beta lactamase negative ampicillin-resistant (BLNAR) strains of H. influenzae have not been detected in India. |
SALIVARY GLAND INFECTIONS | ||||
Acute parotitis Unilateral | S. aureus | Cloxacillin 1 gm IV q4h or 500 mg PO QID × 10d or Dicloxacillin 250–500 mg PO QID × 10d | Cefazolin 1 gm IV q8h or Cefalexin 500 mg PO QID × 7–10d | Oral hygiene important. Analgesics for pain |
Bilateral | Paramyxovirus (mumps) | Analgesics | ||
ORAL, DENTAL AND PERIMANDIBULAR INFECTIONS | ||||
Thrush | Candida species | Fluconazole 100–200 mg PO OD × 7d | Ketoconazole 200 mg PO OD or Clotrimazole troche 5 doses/day or Nystatin suspension 1.5 million units in 5 ml swish and swallow q3h for 5 days until oral lesions clear | Avoid concomitant administration of antacids, H2 blockers with Ketoconazole. Check for previous antibiotic therapy and screen HIV status. |
Herpetiform ulcers | Herpes simplex virus | Acyclovir 200 mg PO 5 times per day × 14d | Oral hygiene important Screen for HIV status | |
Gum abscess, peripheral abscess infection around empty wisdom tooth | Anaerobes Streptococcus spp. | Amoxicillin 500 mg PO TID or Amoxicillin/Clavulanic acid 1 gm PO BD × 7d | Cephalexin 500 mg PO QID + Clindamycin 300 mg PO QID × 5–7d or Cefuroxime axetil 250 mg PO BD + Metronidazole 500 mg PO TDS | Surgical intervention/ extraction to be considered. Long acting twice daily oral cephalexin can be used. |
* Candidiasis caused by Candida spp. | ||||
Fascial space infections (buccal space, submasseteric, submandibular and Ludwig's angina) | Anaerobes Streptococcus spp. | Penicillin G 10–20 lac units IV × 7d + Metronidazole 500 mg q8h × 7d | Surgical management involves drainage and extraction of involved teeth. Ludwig's angina may need tracheostomy to maintain airway if obstructed. | |
Necrotizing gingivitis “Vincent's angina or trench mouth” | Anaerobes | Penicillin G 10–20 lac units IV q4h or Amoxicillin 500 mg PO TID + Metronidazole 500 mg PO TID or Amoxicillin/Clavulanate 1 gm PO BD | Clindamycin 300–450 mg PO QID or Cefuroxime 500 mg PO BD + Metronidazole 500 mg TDS or Cefalexin 500 mg PO QID + Metronidazole 500 mg PO TID | Treat for 7–10 days. Consider IV therapy initially if there is difficulty in swallowing. |
DENTAL AND ORAL INFECTIONS | ||||
Sub-acute “Lumpy Jaw” | Actinomyces spp | Penicillin G 10–20 lac units IV q4h × 4–6 weeks then Penicillin V 500 mg PO QID × 6 months | Amoxicillin 500 mg PO TID or Doxycycline 100 mg PO BD or Erythromycin 500 mg PO QID Treat for six months | Surgical drainage to be considered. |
Osteomyelitis of the jaws | Streptococcus spp | Amoxicillin/Clavulanic acid 1 gm PO BD × 1 month | To rule out tuberculous osteomyelitis. |
CARDIOVASCULAR INFECTIONS
HEART | ORGANISMS | INITIAL TREATMENT | ALTERNATIVES | COMMENTS |
---|---|---|---|---|
ENDOCARDITIS | ||||
Native valve | ||||
Empiric | No organisms identified | “Culture negative” Ampicillin 2 gm IV q4h + Gentamicin 1 mg/kg q8h × 4–6 wks or Ceftriaxone 2 gm IV q24h × 4–6 wks | Vancomycin 1 gm IV q12h + Gentamicin 1 mg/kg q8h × 4–6 wks | Must obtain blood culture prior to starting antibiotics. If blood culture is negative due to prior use of antibiotics or is unavailable due to lack of testing facility, give empiric therapy. Adjust Vancomycin and Gentamicin doses for weight and renal function. |
Acute Usually <1month | S. aureus | Cloxacillin 2 gm IV q4h × 4–6 wks + (optional) Gentamicin 1 mg/kg IV q8h for 3–5d | Cefazolin 2 gm IV q8h × 4–6 wks | If MRSA, use Vancomycin 15 mg/kg IV q12h × 4–6 wks or Linezolid 600 mg IV/PO q12h × 4–6 wks. Use of Linezolid for greater than 2 wks is not recommended due to blood dyscrasias. Monitor use |
Subacute Most common in community setting, | S. viridans MIC < 0.1 μg/mL | Penicillin G 20–40 lac units IV q4h × 4 wks | ||
especially postdental extraction with or without underlying heart valvular disease | S. viridans MIC 0.1–0.5 μg/mL | Penicillin G 20–40 lac units IV q4h × 4–6 wks + Gentamicin 1 mg/kg q8h × 2 wks | Ceftriaxone 2 gm IV q24h × 4 wks or Vancomycin 15 mg/kg IV q12h × 4 wks | Diagnosis needs high degree of suspicion. Patient with PUO, cardiac murmurs, congestive cardiac failure, conduction defects, myocarditis, pericarditis, splenomegaly, cutaneous manifestations of splinter hemorrhages and petechiae. If symptoms > 3 months, treat for 6 wks. If MIC is known to be low, oral Amoxycillin can be used. Treatment may be stopped after 2 wks; otherwise treat with parenteral Ampicillin for 4 wks. |
S. viridans MIC > 0.5 μg/mL | Penicillin G 20–40 lac units IV q4h + Gentamicin 1 mg/kg q8h × 4–6 wks | |||
Enterococcus spp. | Ampicillin 2 gm IV q4h + Gentamicin 1 mg/kg IV q8h × 4–6 wks | For Penicillin allergy, Vancomycin 15 mg/kg IV q12h + Gentamicin 1 mg/kg IV q8h × 4–6 wks | Usually subacute occurs with symptoms for 3–4 months. Often post GU/GYN procedure. If Streptococcus bovis identified, work up for colon cancer. Adjust Vancomycin and Gentamicin for weight and renal function. | |
GU = genitourinary; GYN = gynecological | ||||
Intravenous drug users [Native Tricuspid valve] | S. aureus, Enterococcus spp, Streptococci, gram-negative bacilli, fungi | Cloxacillin 2 gm IV q4h + Gentamicin 1 mg/kg IV q8h × 2 wks | Vancomycin 15 mg/kg IV q12h × 6 wks + Gentamicin 1 mg/kg q8h × 2 wks | Adjust Vancomycin and Gentamicin for weight and renal function. Can substitute Teicoplanin IV or Linezolid IV/PO for Vancomycin Metastatic infections (Mycotic aneurysm, abscesses, etc.) 6 wks therapy advised. Monitor WBC while on Linezolid. |
Prosthetic Valve | ||||
Empiric | While awaiting culture results or when no organisms identified | Vancomycin 1 gm IV q12h + Gentamicin 1 mg/kg IV q8h × 6 wks | Cloxacillin 1–2 gm IV q4h + Ampicillin 2 gm IV q4h + Gentamicin 1 mg/kg IV q8h × 6 wks | Check renal functions every 48 hrs. Piperacillin + Tazobactam 3.375 gm q6h + Vancomycin 1 gm q12h may be used. If Extended Spectrum β Lactamase (ESBL) producers are considered use Meropenem. |
Early (< 2 months after surgery) | S. epidermidis S. aureus | Cloxacillin 2 gm IV q4h + Gentamicin 1 mg/kg IV q8h + Rifampicin 300 mg PO q8h × 6 wks | Vancomycin 1 gm IV q12h + Gentamicin 1 mg/kg IV q8h + Rifampicin 300 mg q8h × 6 wks | Urgent surgery if rapid decline, congestive failure, multiple emboli, fungal (candidal) vegetation and other indication. Adjust Vancomycin and Gentamicin for weight and renal function. Can substitute Vancomycin with Teicoplanin or |
Early (< 2 months after surgery) | Gram-negative bacilli, diphtheroids HACEK group | Cloxacillin 2 gm IV q4h + Gentamicin 1 mg/kg IV q8h + Rifampicin 600 mg OD × 6 wks | Vancomycin 1 gm IV q12h + Gentamicin 1 mg/kg IV q8h (concern for renal toxicity, measure drug levels) × 6 wks | Linezolid IV/PO. Use of Linezolid not proven by sufficient clinical trials. |
Late (> 2 months) | S. viridans, S. epidermidis, Enterococcus spp. S. aureus, Diphtheroids, Fungi, Gram-negative bacilli | Penicillin G 20 lac units IV q4h × 6 wks + Gentamicin 1 mg/kg IV q8h × first 2 wks or Cloxacillin 1–2 gm IV q4h × 6 wks + Gentamicin 1 mg/kg IV q8h first 2 wks | Vancomycin 1 gm IV q12h × 6 wks + Gentamicin 1 mg/kg q8h IV × initial 2 wks | For gram-negative organisms, use Ceftazidime + Amikacin (or Tobramycin). This usually involves tricuspid valve with a hospital pathogen. For MRSA, use Vancomycin or Teicoplanin. Adjust Vancomycin and Gentamicin for weight and renal function. |
Candida spp. | Amphotericin B 1 mg/kg/d IV or Fluconazole 400 mg IV or PO q24h | Caspofungin 70 mg × loading dose followed by 50 mg IV q24h | Along with adjunctive surgical replacement of infected valve; Indication for surgery after therapy has commenced. Continue until dose of 2–3 gm of Ampho B has been given. Fluconazole, Voriconazole | |
HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella and Kingella spp. | ||||
or newer agents like Caspofungin (Echinocandins) have not been proven to be effective by clinical trials. Fungus is likely, if persistent fever on broad spectrum antibiotic for more than 96 hours or no obvious cause of fever or evidence of Candida colonization in two sets of blood culture. | ||||
MYOCARDITIS | ||||
Viral | Coxsackie, Echovirus, Adenovirus, Influenza, VZV, HSV, CMV, HIV | Supportive care | Unexplained heart failure in a young person. Supportive with oxygen, CCF control measures, pacing | |
Bacterial | C. diphtheriae | Treatment for the specific organism | Diphtheria antitoxin should be used in proven cases, 20,000–40,000 units IV | |
PERICARDITIS | ||||
Tuberculosis: Constitutional symptoms with chest pain (acute or chronic) | M. tuberculosis | INH, Rifampicin, PZA, and (SM or Ethambutol) × 2 months then INH, Rifampicin, for 4 more months See TB DOTS section | Consider adding corticosteroids: Prednisone 60 mg PO OD × 4 wks, then 30 mg PO OD × 4 wks, followed by 15 mg PO OD × 2 wks, followed by 5 mg PO OD × 1 wk and stop. | |
CCF: Congestive cardiac failure | ||||
Viral: Chest pain with flu-like illness | Coxsackie, Echovirus, Adenovirus, influenza, VZV, HSV, CMV, HIV, EBV, hepatitis, polio, mumps, rubella | <14d: No corticosteroids, avoid alcohol, beta blockers, anticoagulants, or NSAID Give digitalis, diuretics, and antiarrhythmic agents | Pericardiocentesis/pericardiectomy, if effusion >14d: Bedrest until stable. | |
Bacterial: Purulent Acutely ill | S. aureus, S. pneumoniae | Cloxacillin 2 gm IV q4h + Gentamicin 1 mg/kg IV q8h 2–4 wks | Ampicillin/Sulbactam 1.5–3 gm IV q6h or Ceftriaxone 2 gm IV q24h × 2–4 wks | Drainage essential with pigtail catheter. Cefazolin or Dicloxacillin can be used. |
ACUTE RHEUMATIC FEVER | ||||
Rheumatic fever without carditis | Streptococcus group A | Benzathine Penicillin 24 lac units IM + Adjuvant therapy with salicylates 70 mg/kg/d QID × 2 wks | A Cochrane review has suggested that single dose Benzathine Penicillin may not be adequate for treatment of Streptococcus infection. Antibiotic Penicillin spread over 7–10 days is more effective. | |
Rheumatic fever with carditis | Streptococcus group A -post-infectious sequelae | Benzathine Penicillin 24 lac units IM + Corticosteroids (Prednisolone 2 mg/kg/d PO OD × 2 wks for associated myocarditis, valvulitis, or pericarditis) + Diuretics and salicylates | Penicillin V 250 mg tds or Erythromycin 500 mg QID × 10d | 30% chance of recurrence of carditis if reinfection occurs. Prophylaxis with Benzathine Penicillin 12 lac units IM once in 21 days or Penicillin V 250 mg PO BD or Erythromycin 250 mg PO BD or Sulfadiazine 500 mg PO BD for 5 years after initial presentation. Other clinical signs seen with rheumatic fever are: polyarthritis, chorea, subcutaneous nodules, and erythema marginatum. |
STERNAL WOUND | ||||
Surgical site infection following Open heart surgery | S.aureus Gram-negative organism | Cloxacillin 1–2 gm IV q4h or Cefazolin 1–2 gm IV q8h + 14d | Piperacillin/Tazobactam 4.5 gm IV q6h + Vancomycin 1 gm IV q12h or Linezolid 600 mg IV/PO BD × 14d | If P. aeruginosa—Ceftazidime 2 gm IV q8h + Amikacin (if Gram negative organisms are ESBL producers consider Imipenem or Meropenem 0.5–1 gm IV q8h) |
MEDIASTINITIS | ||||
Due to oesophageal rupture | Anaerobes, aerobic gram-positive cocci or gram-negative bacilli | Ticarcillin/Clavulanate 3.1 gm IV/ q6h or Piperacillin/Tazobactam 3.375 gm IV q6h | Clindamycin 600 mg IV q8h + Ceftriaxone 1 gm q24h | Treat for 4 wks |
Post-thoracotomy surgical site infections | S. aureus, Coagulase negative staphylococci | Cefazolin 1–2 gm IV q8h | If MRSA Vancomycin 1 gm IV q12h or Linezolid 600 gm IV/POBD or Teicoplanin 400 gm IV/IM OD | Seen in diabetes mellitus, multiple surgical procedures, hematomas Early: Occurs 2–4 wks symptoms local and Late: (> 4 wks) symptoms may be seen systemically. |
RESPIRATORY INFECTIONS
RESPIRATORY TRACT INFECTION | ORGANISMS | INITIAL TREATMENT | ALTERNATIVES | COMMENTS |
---|---|---|---|---|
TRACHEOBRONCHITIS | ||||
Acute laryngo-tracheobronchitis | Viral or bacterial | No antibiotics necessary | Usually self-limiting in a non-compromised host. If secondary bacterial infection, antibiotics are required. If persistent barking cough for > 3 wks, then consider pertussis even in adults. Treat with Erythromycin or newer Macrolides. Check sputum for M. tbc | |
Acute Bacterial Exacerbation of Chronic Bronchitis (ABECB) | H. influenzae, S pneumoniae, Moraxella catarrhalis, Mycoplasma spp. | Amoxicillin 250–500 mg PO TDS×10d or Doxycycline 100 mg PO BD × 10d or Cefadroxil 500 mg PO BD × 10d | Cefuroxime 250 mg PO BD × 10d or Amoxicillin/Clavulanate 1 gm PO BD or Azithromycin 500 mg once; then 250–500 mg PO OD × 7/5d | In smokers: H. influenzae, S. pneumoniae and M. catarrhalis generally need treatment for 10 days. If beta lactamase- producing organisms present, treat with AM/CL or macrolide, or newer Quinolones such as Levofloxacin 500 mg PO OD or Moxifloxacin 500 mg |
Chlamydia spp Chlamydia psittaci | Doxycycline 100 mg bd × 14–21d | PO OD × 10d | ||
Bronchiolitis | Viruses:RSV, Parainfluenza, Influenza, Adenovirus | No antiviral required | If RSV, give Ribavirin. If infiltrates present in chest X-ray, treat as RSV pneumonia. See viral section | |
BRONCHIECTASIS | ||||
Acute exacerbation, Anaerobes and gram-negative organisms | Doxycycline 100 mg PO BD or Ciprofloxacin 500–750 mg PO BD + Metronidazole 500 mg PO TDS | Cefuroxime 0.75–1.5 gm IV q8h or Cefuroxime axetil 250 mg PO BD + Metronidazole 500 mg PO TDS or Amoxicllin/Clavulanate 1 gm PO BD | Duration of treatment to be individualized. Usually 2–3 wks of postural (dependent) drainage of lungs. To prevent recurrent attacks postural drainage is to be continued. Patient may be advised to initiate self therapy with Doxycycline 100 mg BD whenever fever occurs with increased sputum production, or change in color of sputum. | |
ACUTE PNEUMONIA: Must consider TB in all patients, especially in those with fever and/or cough for greater than 3 wks or not responding to initial antibiotic treatment | ||||
Community-acquired acute non-viral | S. pneumoniae (most common) M. catarrhalis H. influenzae Other Gram negative organism such as, Klebsiella spp; Staphylococcus spp, M. pneumoniae C. pneumoniae Legionella spp M. tuberculosis | Outpatient Treatment Amoxicillin 1 gm PO q8h or Azithromycin 500 mg PO then 250–500 mg OD × 7d | Outpatient Treatment Amoxicillin Clavulanate 1 gm PO BD × 10d or Cefuroxime axetil 250–500 mg PO BD × 10d or Cefpodoxime 200 mg PO BD × 10d or Cefprozil 500 mg PO BD × 10d or Cefixime 400 mg PO OD × 10d or Gatifloxacin 400 mg PO OD × 10d or | Treat for 10–14 days. If critically ill-must add atypical intracellular pathogen coverage with either Doxycycline or Azithromycin (for example, Cefuroxime axetil 500 mg PO q12h + Azithromycin 500 mg PO and then 250 mg OD) After 48 hours may change Penicillin G to Procaine Penicillin 0.8 mill units IM q12h. Newer respiratory Fluoroquinolone, Levofloxacin, Moxifloxacin may be added to OP regime if comorbid conditions are present and patient not willing for hospitalization. Has a better coverage against intracellular pathogens. Expected response is clinical (subjective) improvement in 2–3 days, afebrile in 3–5 days and X-ray |
Note: Radiography is critical for establishing diagnosis of pneumonia. Indications for in-patient treatment include a clinical judgement of patients overall health and suitability for OP care. Suggest hospitalization for those with age > 60 years, frail, comorbid illness, altered mental status, abnormal range vital signs BP < 90/60 mm Hg, Respiratory rate > 30/mt, Pulse rate > 100/mt, Temperature > 38°C and hypoxemia by O2 satn. < 90%. | ||||
* Legionnaire's disease causative org. Legionella spp. (Mainly Legionella pneumophilia Legionella micdadei) | ||||
Moxifloxicin 400 mg PO OD × 10d or Levofloxacin 500 mg PO OD × 10d | clearing within 3–12 wks. Consider TB if not responding Certain radiological signs will help determine etiology. One lobe likely to be S. pneumoniae. Multiple lobe consolidation, likely to be atypical organisms H. influenzae or S. aureus. | |||
Inpatient Treatment (non-ICU) Penicillin G 10 lac U IV q4h × 10d or Ampicillin 2 gm IV q6h or Ceftriaxone 1–2 gm IV q24h + Azithromycin 500 mg PO then 250–500 mg OD × 7–10d | Interstitial likely to be PCP. Pneumatocele likely to be S. aureus. Pleural effusion is rare in Pneumocystis carinii and with atypical pathogens. If rapidly progressive or multiple abscesses single lobe pneumonia, consider gram negative such as Klebsiella or drug resistant organism. | |||
In Patient (ICU) | Gram negative including Pseudomonas aeruginosa, | β-lactam IV (Ceftriaxone 2 gm IV q24h or Cefotaxime 1–2 gm IV q8h) | If Legionella is strongly considered, then add an advanced | |
Klebsiella spp and S aureus, E coli, Enterococcus spp. | + Advanced Macrolide (Azithromycin or Clarithromycin 500 mg) Switch to Cefuroxime axetil 250–500 mg PO BD or Levofloxacin 500 mg or Moxifloxacin 500 mg IV q24h (Switch to PO when Temp < 38°C, RR < 24, HR < 100 for 24h) | Macrolide + Rifampicin 600 mg OD. For Pseudomonas spp add Ceftazidime | ||
HIV (PCP) | Pneumocystis jiroveci | Cotrimoxazole (Bactrim DS) 2 tablets TDS + Steroids | See HIV Section | |
SARS Severe Acute Respiratory Syndrome | SARS Corona virus | Supportive therapy | Isolation for airborne transmission prevention | In SARS—protective precautions for aerosol-borne respiratory secretions. Isolation and quarantine needed for health care workers with significant exposure. Aggressive progression may need |
Influenza viruses | Influenza virus A | Amantadine 100 mg BD Oseltamivir 75 mg BD × 5d | ventilation and IV steroids. Oseltamivir (within two days of infection and as prophylactic 75 mg OD × 6 wks) has been found useful in avian (bird) influenza A (H5 N1) and swine flue (H1 N1) in adults and adolescents for five days. | |
Influenza virus B | Oseltamivir 150 mg BD for 5d and 75 mg BD for 6 wks prophylaxis. Parenteral Acyclovir 5–7 mg/kg q8h + 7–10d | |||
Herpes virus | HSV or VZV | Acyclovir 800 mg PO × 7d, 5 times/d | Valacyclovir 1000 mg PO × 5d, 3 times/d | |
Aspiration pneumonia | Anaerobes, gram-negative organisms | Penicillin G 20 lac units IV q4h + Ciprofloxacin 750 mg PO BD × 14d or Amoxicillin/Clavulanate 1 gm PO/IV BD × 14d | Clindamycin 600/900 mg IV q8h + Ciprofloxacin 400 mg IV q12h or Cephalexin 500 mg PO QID + Metronidazole 500 mg PO TDS or Ciprofloxacin 750 mg PO BD + | Among patients with history of alcohol use, diabetes mellitus and in the elderly, consider Klebsiella spp and S. aureus. Aspiration uncommon into the upper lobes; More likely to occur into the posterior segment of the right lower lobe. Can also use Ticarcillin-Clavulanate or Piperacillin-Tazobactam along with Gentamicin if progressive. If Ps. aeruginosa is considered use |
Metronidazole 500 mg PO TID | Ceftazidime. Newer respiratory quinolones can also be used. | |||
Necrotizing pneumonia | Klebsiella spp, anaerobes | Metronidazole 500 mg IV/PO q6–8h + Ciprofloxacin 500 mg PO BD × 14d or Cefuroxime 0.75–1.5 gm IV q8h + Metronidazole 500 mg IV/PO q8h × 14d | Cefotaxime 1 gm IV q8h + Metronidazole 500 mg PO/IV q8h | Duration of therapy must be individualized. Most commonly seen in upper lobe. Rapidly progressive pneumonia with micro abscess formation. Can also use Ticarcillin-Clavulanate 3.1 gm IV q4h or Piperacillin-Tazobactam 3.375 gm IV q6h if progressive (gram-negative suspected). Use Meropenem if ESBL producing organism |
Post-influenza pneumonia | S. aureus, gram-negative organisms | Cefadroxil 500 mg PO BD × 14d | Cefazolin 1 gm IV q8h × 3–7d followed by oral Cephalexin 500 mg q6h × 10d | Occurs in the elderly. |
There is no agent with established efficacy for pulmonary infections involving Adenovirus, Hanta virus, Metapneumo virus, Parainfluenza virus or SARS. CMV pneumonitis can be considered in patients with HIV, but requires histologic evidence. | ||||
PNEUMONIA—HOSPITAL ACQUIRED | ||||
NON-VENTILATED | ||||
Hospital stay < 4 days | S. pneumoniae H. influenzae M. catarrhalis, Anaerobes | Cefuroxime axetil 750–1500 mg IV q8h or Cefotaxime 1 gm IV q8h or Ceftriaxone 1–2 gm IV q24h or Cefazolin 1–2 gm IV q8h + Metronidazole 500 mg IV q8h or As single agent Amoxicillin/Clavulanate 1 gm IV/PO BD × 10–14d | Penicillin G 10 lac units IV q4h + Ciprofloxacin 750 mg PO BD × 10–14d or Clindamycin 300 mg PO QID + Ciprofloxacin 750 mg PO BD or Moxifloxacin IV 400 mg followed by oral 400 mg OD × 10–14d or Ertapenem 1 gm IV OD | Most pneumonias occurring in comatose or post-surgical situations follow aspiration. In such situations add anaerobic coverage. Obtain sputum to determine predominance of either gram-positive or gram-negative organism and cover with appropriate antibiotics. Blood cultures are preferable. Switch to peroral therapy when clinically stable. Levofloxacin or Moxifloxacin can be substituted for Ciprofloxacin |
(1 million units = 10 lac units); Newer respiratory quinolones: Levofloxacin, Moxifloxacin, Gatifloxacin | ||||
Hospital stay > 4 days | Gram-negative organisms, Anaerobes | Cefotaxime 1–2 gm IV q8h + Metronidazole 500 mg IV/po TDS | Cefazolin 1 gm IV q8h + Gentamicin 3–5 mg/kg/d + Metronidazole 500 mg IV q8h | If Pseudomonas spp, add Amikacin or Ceftazidime. Imipenem, or Meropenem as single agent is used only for ESBL producing organisms |
VENTILATOR-ASSOCIATED | ||||
Pseudomonas aeruginosa, S. aureus, Klebsiella spp. Enterobacter spp. E. coli | Piperacillin/Tazobactam 3.375 gm IV q6h along with Amikacin 7.5 mg/kg/q8h especially when extended spectrum beta lactamase-producing organisms are suspected Add: Vancomycin 1 gm IV q12h or Tigecycline 100 mg IV slow infusion then 50 mg IV q12h if MRSA suspected | Imipenem/Cilastatin 500 mg IV q6h or Meropenem 1 gm IV q8h for multiple drug-resistant gram-negative bacilli | Organisms such as Acinetobacter need to be considered as nosocomial pathogen Cotrimoxazole, Colistin or Polymyxin B may have to be used. Dose: Colistin Sulphate (Walamycin) Adults—25–100 mg PO TDS; Children and infants—5–15 mg/kg in 3 divided doses PO. Polymyxin B Adults and Children—15000–25000 units/kg/day IV for 7–10 days. Infants—upto 40000 units/kg/day (IV). Vancomycin or Teicoplanin to be added for MRSA. IV Linezolid can also be considered. | |
CHRONIC PNEUMONIA-(for >1 month)—If recurrent pneumonia, consider underlying foreign body aspiration, tumor, or bronchiectasis. | ||||
Pulmonary TB Sputum +/-ve HIV +/-ve Newly diagnosed | M. tuberculosis | INH, Rifampicin, PZA, and (SM or Ethambutol) × 2 months then INH, Rifampicin for 4 more months *This can be administered daily or thrice weekly (supervised) | Refer to detailed table on treatment of tuberculosis. RNTCP DOTS. | |
Aspergilloma | Aspergillus spp. | May benefit from Itraconazole 200 mg PO OD × 3 months | Occurs in post-tuberculous cavity. Surgical excision if hemoptysis life-threatening or hemoptysis recurrent. | |
Allergic Broncho Pulmonary Aspergillosis (ABPA) | Aspergillus spp. | Prednisone 20 mg PO × 6 wks | May benefit from Itraconazole 200 mg PO BD | Seen in patients with bronchial asthma (usually). |
Nocardiosis | Nocardia spp. | Sulfisoxazole 2 gm PO q6h × 6 months | TMP/SMX 1 DS PO BD × 6 months | Cavitation and pleural effusion common. |
Actinomycosis | Actinomyces spp. | Penicillin G 10–20 lac units IV q4h × 4–6 wks then Penicillin V 500 mg PO QID or oral Amoxicillin 500 mg TID × 6 months | Amoxicillin 500 mg PO tid or Doxycycline 100 mg PO BD or Erythromycin 500 mg PO QID or Clindamycin 600 mg PO QID × 6 wks | Can also use Ceftriaxone once a day as daily regimen for 6 wks. |
Tropical Pulmonary Eosinophilia (TPE) | Allergic reaction to presence of helminths Toxocara spp, Dirofilaria immitis | Diethylcarbamazine 6 mg/kg/d in divided doses × 14–21d + Tab Mebendazole 100 mg bd × 3d | Steroids may be used if eosinophil count is greater than 2,500 eosinophils per microliter. This pneumonia does not affect gas exchange even though interstitial. It is a hypersensitive reaction due to presence of intestinal helminths. | |
LUNG ABSCESS | ||||
Anaerobes Gram negative organism | Penicillin G 20 lac units IV q4h + Gentamicin 5 mg/kg IV q24h | Clindamycin 600–900 mg IV q8h + Gentamicin 5 mg/kg IV q24h | Postural drainage: Consider changing to PO options such as: Cefalexin + Metronidazole or, Cipro + Metronidazole or Doxycycline or, AM/CL for 6 wks to 3 months or until X-ray clears | |
PLEURAL INFECTION | ||||
Dry pleurisy | Viral | Analgesics | Rarely TB; consider DOTS | |
Pleural effusion | M. tuberculosis | Treatment as for pulmonary TB | Refer to detailed table on treatment of TB—Dots | |
Parapneumonic effusion | S. pneumoniae S. aureus Klebsiella spp | Amoxicillin 500 mg PO TID or Azithromycin 750 mg PO and then 250–500 PO OD or Doxycycline 100 mg PO BD or Ceftriaxone 2 gm IV q24h × 7d | Cefadroxil 500 mg PO BD 10–12d or Amoxicillin/clavulanate 1 gm PO BD 12d | If underlying consolidation is present, consider co-existence of community- acquired bacterial strains. Then choose treatment protocol as in community acquired pneumonia. Duration of therapy should be individualized. Mostly infective cases of pleural effusion are exudative. If pleural fluid pH <7.0, or gram- stain shows organisms or loculated, requires intercostal tube placement for drainage, otherwise repeated needle aspiration may be tried. |
Empyema and Bronchopleural fistula (infected pleural fluid) | Anaerobes Gram-negative organisms, MTB | Ciprofloxacin 750 mg PO BD/400 mg IV q12h* + Metronidazole 500 mg IV q8h × 4 wks or Cephalexin 500 mg PO QID + Metronidazole 500/400 mg PO TDS × 4 wks | Amoxicillin/Clavulanate 1 gm PO BD or Clindamycin 600–900 mg IV q8h + Gentamicin 5 mg/kg IV q24h × 14–28d or Ticarcillin-Clavulanate 3.1 gm IV q4h or Piperacillin-Tazobactam 3.375 gm IV q6h 10–14d If Pseudomonas aeruginosa is identified add Aminoglycosides or Ceftazidime | Consider intercostal tube drainage (ICD) based on pleural fluid analysis. Can be primary or secondary. Primary can be anaerobic, Secondary is usually due to contiguous spread from lung parenchyma or in postoperative states. If pleural fluid pH < 7.0 or thick and viscous or if bronchopleural fistula present, or lung is collapsed, intercostal drainage required with underwater seal and suction pump. If pH between 7.0 and 7.3 can be repeatedly aspirated. Antibiotics given for 2–4 wks. Check fluid for AFB. If bronchopleural fistula exists, then ICD and suction to continue until the lung expands fully and drainage ceases (< 30 ml/day) for 48 hours. Clamp tube and if lung does not collapse (check with X-ray), then instill intrapleurally 5 gm Tetracycline or talcum powder (pleurodesis). |
Mediastinum infection | Bacillus anthracis | Penicillin G 4MU IV q4h or Clindamycin 600 mg IV q8h | Ciprofloxacin 500 mg PO OD or Doxycycline 100 mg PO OD | It is a zoonosis caused by inhalation of the aerosol containing bacilli |
Histoplasma capsulatum | Amphotericin B 0.7–1 mg/kg IV per day for 1–2 week then Itraconazole 200 mg × 6d BD PO for 12 wks | Prednisolone 10 mg for 1–2 wks if no response to nonsteroidals | Monitor hepatic and renal function | |
Comments on pneumonia:
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GASTROINTESTINAL INFECTIONS
GASTROINTESTINAL DISEASE | ORGANISMS | INITIAL TREATMENT | ALTERNATIVES | COMMENTS |
---|---|---|---|---|
ESOPHAGITIS | ||||
HIV | Candida spp | Fluconazole 200 mg PO OD × 21d | Amphotericin B 0.3 mg/ kg/d IV × 5d | Endoscopy and biopsy for definitive diagnosis. Avoid antacids or H2 blockers with Ketoconazole. |
HSV | Acyclovir 400 mg PO QID × 21d | Consider HAART | ||
CMV | Ganciclovir 5 mg/kg IV q12h for 21 days | Foscarnet 90 mg/kg IV q12h for 14–21 days | Consider HAART as Ganciclovir is expensive, maintenance therapy required only for relapses. | |
ULCER (Duodenal/Gastric) | ||||
Helicobacter pylori | Clarithromycin 500 mg PO BD × 14d + Metronidazole 500 mg PO QID × 14d + Omeprazole 20 mg BD or (Lansoprazole 30 mg BD) × 14–30d | Clarithromycin 500 mg PO BD × 14d + Amoxicillin 1 gm PO BD × 14d + Omeprazole 20 mg PO BD (or Lansoprazole 30 mg BD) × 14–30d | Associated peptic ulcer disease must be present on endoscopy, tissue urease test to be done. Detection of Helicobacter pylori antigen test in stool is useful. | |
ART: Antiretroviral therapy; Clarithro + Amox is better for H. pylori. High degree of metronidazole resistance in India. | ||||
HEPATITIS ACUTE and CHRONIC | ||||
Fecal/oral contact-Food and water borne | Hepatitis A virus (HAV) | Self-limited. Symptomatic treatment with a high-calorie diet and abstinence from alcohol and hepatotoxic medications | Prophylaxis: HAV immunoglobulin 0.02 ml/kg IM stat after exposure. Active immunization with HAV vaccine 1 ml IM into deltoid stat, booster after 6 months before exposure. | Infection to other household members can be avoided with scrupulous hand washing with soap, care about quality of drinking water and immunization. |
Spread via Blood/Sexual contact Mother to offspring* IVDU (Intravenous Drug Use) | Hepatitis B virus (HBV) Carriers (Persistence of HBsAg 6 months) Chronic active (HBV-DNA > 105 copies/ml) | Lamivudine 100 mg PO BD × 1 year + Interferon alfa 2a 5 million units SC daily or interferon alfa 2b 10 million three times/week for 6 months* (may be prolonged to 1 year) | Active immunization with Hepatitis B vaccine 3 doses: 1 ml IM into the deltoid at 0, 28, 120 or 180d. Adefovir and Tenofovir can successfully treat mutants produced after prolonged Lamivudine therapy. (persistence of IgM anti HBc is clue to chronic infection). | Postexposure prophylaxis with HBIG 5 ml IM once. Active immunization at another site. Clinical symptoms—raised (two times above normal) liver enzymes, AST, ALT and presence of viral markers e antigen and HBV-DNA (> 105 copies/ml) viral load suggesting replication to be monitored. Liver histology to be assessed before starting therapy |
HBIG: Hepatitis B immunoglobulin | ||||
All pregnant women should be screened for HBsAg. Infants born to HBsAg positive (even if HBeAg negative) women should receive hepatitis B immunoglobulin to prevent fulminant hepatic failure in infants and hepatitis B vaccine within 12 hours of birth with second and third doses at 1 and 6 months of age. | ||||
Adefovir (10 mg) 1 tab OD Entecavir (0.5 mg) 1 tab OD 2 hrs before or 2 hrs after meals | with interferons. One third will clear HBe antigen and in 80–90% response is durable for 4 to 8 years. Periodic screening with liver ultrasound scan and alpha-feto protein in children with chronic HBV infection is recommended. | |||
Blood contact percutaneous or transfusion related Chronic active hepatitis | Hepatitis C virus (HCV) | No vaccine available. Clinical symptoms raised liver enzyme AST, ALT, HCV antibody, HCV viral load and liver histology documented before starting therapy. Virologic response ≥ two-fold decrease in HCV viral load at end of 12 weeks. Pts who fail to achieve this at 12 weeks therapy continuing treatment is futile. | ||
* IFN α is the better initial therapy and pegylated forms are better, but expensive.*Peg IFN α2A 180 μg once a week. If Hep C is Genotype 2 or 3 treat for 24 wks. | ||||
* The risk of developing chronic HBV infections is 90% in neonates (highest in those whose mothers are both HBsAg and HBeAg positive). | ||||
* In patients with HIV/HBV/HCV co-infection, consideration for HAART should be the first priority. If HAART is not required then treatment for HCV should be considered before HBV, as interferon treatment for HCV may clear HBV infection. All patients should be advised to cease or limit consumption of alcohol. See also treatment of hepatitis-algorithm. | ||||
Hepatitis D-only in those infected with Hepatitis B (HBV) | Interferon alfa 2a 5 million units daily SC or 10 million unit 3 times/week for 6 months (May be prolonged to 1 year) + Lamivudine (3TC) 100 mg OD × 1 year | No vaccine available. Avoid exposure (needle sharing). High prevalence among IV drug users. Check HIV status Rapid progression to cirrhosis in Hepatitis B and C virus associated with HIV. HAART to be considered when such co-infections are present. | ||
Fecal/oral contact food and water borne | Hepatitis E virus (HEV) | Self-limited. Symptomatic treatment with a normal (usual) diet that patient can tolerate and abstinence from alcohol and hepatotoxic medications is advisable No vaccines available. | High mortality in pregnant women No vaccines available | |
HEPATIC ABSCESS | ||||
Pyogenic | E. coli, Pseudomonas spp, Klebsiella spp, Enterobacter spp, Proteus spp. Bacteriodes spp. | Ampicillin 1–2 gm IV q4h + Gentamicin 1 mg/kg IV q8h + | Clindamycin 600–900 mg IV q8h + Ciprofloxacin 500–750 mg IV q12h or | Surgical drainage required. Mortality can be high. S. aureus an important pathogen among IV drug users or in endocarditis. Consider |
Pyogenic Continued… | Enterococcus spp, Anaerobes | Metronidazole 500 mg TID iv × 2–3 wks | Amoxicillin/Clavulanate 1.5–3 gm IV q8h × 2–3 wks | Vancomycin if MRSA suspected Burkholderia spp (melioidosis) is an important pathogen causing septicemia; will need Ceftazidime 1–2 gm IV q8h × 2 to 6 wks followed by oral Bactrim DS one BD for 6 wks to 6 months. |
Parasitic Amoebic | Entamoeba histolytica | Metronidazole 800 mg PO TID × 10d followed by Diloxanide furoate 500 mg PO QID × 10d | Tinidazole 800 mg PO TDS × 5d followed by Diloxanide furoate 500 mg PO QID × 10d | Addition of Chloroquine of no proven benefit. May take up to 7 months to clear lesion based upon ultrasound. Cavity drainage is required with pigtail catheter inserted under ultrasound guidance. Surgery reserved for cases with impending rupture or failure to respond to medical management. |
Hydatid | Echinococcus granulosus | Albendazole 400 mg PO BD × 28d × 3 monthly cycles with 14d drug free intervals between cycles. | Surgical drainage may be required. If body wt < 60 kg Albendazole 15 mg/kg/d divided BD. | |
Cholangitis | E. coli, Proteus spp., Klebsiella spp., Enterococcus spp Anaerobes* | Ampicillin 1–2 gm IV q4h + Gentamicin 1 mg/kg IV/IM q8h** + Metronidazole 500 mg IV q8h × 14d or Amoxicillin/Clavulanate 1.5–3 gm IV q8h × 14d or Cefoperazone-sulbactam 4 gm IV BD × 14d | Clindamycin 600–900 mg IV q8h + Gentamicin 1 mg/kg IV/IM q8h × 14d or Clindamycin 600–900 mg IV q8h + Ciprofloxacin 400 mg IV q12h × 14d or Gentamicin 1 mg/kg IV/IM q8h + Ticarcillin/Clavulanate 3.1 gm IV q4h | If associated with gall stones conventional or laparoscopic cholecystectomy may be needed. May use Imipenem or Meropenem. |
* Gentamicin has very poor biliary concentration, Ciprofloxacin achieves a higher concentration | ||||
**Anaerobes very rarely cause cholangitis | ||||
PANCREATITIS | ||||
Acute pancreatitis or necrotizing pancreatitis | Not bacterial | Supportive therapy | Some give prophylaxis or early antibiotic therapy in some cases. Amoxycillin/Clavulanate 1 gm IV q12h | Acute pancreatitis or necrotizing pancreatitis and pseudocyst treatment is similar. For serious cases with necrotizing pancreatitis, e.g. more than 30% of pancreas affected on CT imaging, leucocytosis > 15,000, C-reactive protein elevated, serum calcium low. Piperacillin/Tazobactam or Imipenem or Ertapenem may be used. |
Pancreatic abscess phlegmon | Enterobacteriaceae Enterococcus spp. S. aureus* | Cefazolin 2 gm IV q8h + Metronidazole 500 mg IV q8h × 14d or Ampicillin 2–4 gm IV q4h + Gentamicin 1 mg/kg IV q8h + | Clindamycin 600–900 mg IV q8h + Gentamicin 1 mg/kg IV/IM q8h × 14d or Clindamycin 600–900 mg IV q8h + | Surgical intervention is essential, fine needle aspirate for culture will help guide therapy. Amikacin or Meropenem may also be added for a wider Gram negative cover, especially in those who have received previous therapy with other antibiotics Consider candidal infection in long- standing cases of abscess. |
Pancreatic abscess phlegmon Continued… | Metronidazole 500 mg IV q8h × 14d or Imipenem 500 mg IV q6h × 14d or Ertapenem 1 gm IV OD × 14d | Ciprofloxacin 400 mg IV q12h × 14d or Gentamicin 1 mg/kg IV/IM q8h + Ticarcillin/Clavulanate 3.1 gm IV q4h or Piperacillin/Tazobactam 3.375 gm IV q6h or Cefuroxime axetil 750 mg IV q8h (Monotherapy) | * In randomized trials the two antibiotics that have been used are Imipenem and Cefuroxime. Aminoglycosides not useful pancreatic infections as studies show poor concentration in pancreas. * Psoas abscess (uncommon) due to any infectious process of ureters, renal pelvis, spine, appendix, ascending colon, spine. In children staph most common Adults underlying Crohn disease/osteomyelitis diverticulitis/intraabd. abscess/staph. | |
Psoas abscess | S. aureus | Cloxacillin if MSSA and Vancomycin or Linezolid if MRSA | Consider open or percutaneous drainage | |
* Treatment target Staphylococcus. * Broad specimen antibodies can also be used. * Consider open or percutaneous drainage | ||||
* Retroperitoneal abscess (uncommon) E. coli and Bacteroides species common (blood culture) | ||||
* Treatment - drainage and iv antibiotics | ||||
PERITONITIS (Community acquired) | ||||
Primary or spontaneous bacterial peritonitis | E. coli, Klebsiella spp, S. pneumoniae, group A Streptococci, Enterococcus spp, Bacteriodes spp, endogenous bacterial flora* | Cefotaxime 2 gm IV q6h × or q8h 7–14d or Ceftriaxone 2 gm IV q24h × 7–14d or Ertapenem 1 gm IV OD | Amoxicillin/Clavulanate 1.5–3 gm IV q8h × 7–14d (monotherapy) + Ciprofloxacin 500 mg IV q12h × 7–14d or Ofloxacin 400 mg PO q12h × 14d + Ampicillin 2 gm IV q4h × 7–14d | Tends to occur in children and splenectomized individuals. Pneumococcal vaccine is preventive for S. pneumoniae infection. An absolute neutrophil count in peritoneal fluid > than 250 cells/mm3 indicates peritoneal infection. In limited intraperitoneal infections duration may be shortened to 2–5 days. |
Secondary bacterial peritonitis | Cefotaxime 2 gm IV q6h-q8h + Metronidazole 500 mg IV q8h × 10–14d or Ertapenem 1 gm IV OD or | Clindamycin 600–900 mg IV q8h + Gentamicin 1 mg/kg IV q8h × 14d | Surgery may be required if perforation suspected. Ticarcillin/Clavulanate 3.1 gm IV q4h or Piperacillin/Tazobactam 3.375 gm IV q6h plus Amikacin 7.5 mg/kg once daily may be considered if | |
* Almost always polymicrobial | ||||
Secondary bacterial peritonitis Continued… | Ampicillin 2–4 gm IV q4h + Gentamicin 1 mg/kg/d IV q8h + Metronidazole 500 mg IV q8h × 14d | Inj Cefoperazone-Sulbactam 4 gm IV BD or | patient is severely ill (see intra-abdominal abscess). | |
E. coli, Pseudomonas spp., Klebsiella spp., Enterobacter spp., Proteus spp., Bacteroides spp., Enterococcus spp., other Anaerobes. | Ampicillin 1–2 gm IV q6h + Gentamicin 1 mg/kg IV/IM q8h + Metronidazole 500 mg IV q8h × 10–14d or Ertapenem 1 gm IV OD | Amoxicillin/Clavulanate 1.5–3 gm IV q6–8h or Metronidazole 500 mg IV q6–8h + Ciprofloxacin 400 mg IV q12h Clindamycin 600–900 mg IV q8h + Gentamicin 1 mg/kg IV/IM q8h | Imipenem 500 mg IV q6h or Meropenem 1 gm q8h for life-threatening situations such as postoperative hospital-acquired infections, tertiary peritonitis. | |
With Continuous Ambulatory Peritoneal Dialysis (CAPD) Tertiary peritonitis | Coagulase negative Staphylococci S. aureus, P. aeruginosa, E. coli, Proteus spp, Klebsiella spp, B. fragilis, Candida spp. | Cefazolin 500 mg initial loading dose then 125 mg/L in each exchange or Clindamycin 300–600 mg IV q6–8h + Gentamicin 1 mg/kg IV q8h × 14–21d or Cefotaxime 1 gm IV q8h + Metronidazole 500 mg IV q8h × 14–21d + Gentamicin 0.9 mg/kg/L × 1 L then 0.5 mg/kg/L q24h × 14–21d or Ciprofloxacin 500 mg PO BD + Metronidazole 500 mg PO TDS × 14–21d | In severely ill patients Vancomycin 1 gm IV + Gentamicin 80 mg IV, add to dialysis fluid | Peritonitis defined when dialysate fluid contains > 100 WBC/mm3 Prevent infection with:
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HCW = Health Care Worker | ||||
Intra-abdominal Abscess Community Acquired | Anaerobes (95% of intestinal bacterial population is obligate anaerobes), E. coli, Clostridium spp., Klebsiella spp., Bifidobacterum spp., Fusobacterum spp., Peptococcus spp., Peptostreptococcus spp., Bacteroides spp. | Ampicillin 1–2 gm IV q6h + Gentamicin 1 mg/kg IV/IM q8h + Metronidazole 500 mg IV q8h × 14–21d or Second or third generation cephalosporin + Metronidazole 500 mg IV q8h × 14–21d or Amoxicillin/Clavulanate 1.5–3 gm IV q6–8h × 14–21d or Ampicillin sulbactam 1 gm IV q6h or | Clindamycin 600–900 mg IV q6h + Gentamicin 1 mg/kg IV/IM q8h × 14–21d or Cefoperazone sulbactam 2 gm IV/IM BD × 14d or Imipenem cilastatin 500 mg IV q6h or Meropenem 1 gm IV q8h for life-threatening hospital acquired infections × 14–21d or Aztreonam 500 mg IV q6h + Metronidazole 500 mg IV q8h. | Surgery may be required. Drainage is critical. For health care associated infections antibiotic therapy guided by knowledge of nosocomial flora and susceptibilities. Blood culture do not provide additional clinical relevant information. Specimen should be collected from intra-abdominal focus of infection aerobic and anaerobic culture at least 0.5 cc of fluid or tissue. Swabs do not provide appropriate specimen for anaerobis cultures. |
Intra-abdominal Abscess Community Acquired Continued… | Ertapenem 1 gm IV OD or Ticarcillin/Clavulanate 3.1 gm IV q4h or Piperacillin/Tazobactam 3.375 gm IV q6h | |||
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Actinomycosis oral-cervicofacial, thoracic, abdominal, pelvic, brain disseminated | Actinomyces israelii | Pen G 10–20 million units/d for 2–6 wks then Pen V 500 mg po qid for 6–12 months or Ampicillin 50 mg/kg/d for 4–6 wks then 500 mg PO TID × 6 months | Doxycycline, Erythromycin, Clindamycin or Ceftriaxone | Shorter duration therapy for less intensive disease. With IUDs tubo-ovarian abscess a concern; requires removal of IUD and possible surgery. |
APPENDICITIS | ||||
Appendicular abscess or mass | E. coli, Pseudomonas spp., Klebsiella spp, Enterobacter spp, Proteus spp, Enterococcus spp, Anaerobes, Bacteroides | Cefazolin 2 gm IV q8h + Metronidazole 500 mg IV q8h × 14d or Ampicillin 2 gm IV q4h + Gentamicin 1 mg/kg IV q8h + Metronidazole 500 mg IV q8h × 14d | Ciprofloxacin 400 mg IV q12h + Metronidazole 500 mg IV q8h × 14d or Cefoperazone-Sulbactam 4 gm IV q12h × 14d or Ertapenem 1 gm IV OD × 7–10d | Surgery (appendectomy) is the treatment of choice. Immediate or interval; conventional, or laparoscopic. Culturing of perforated or gangrenous appendicitis have failed to identify any beneficial effect |
Diverticulitis | E. coli, Proteus spp., Klebsiella spp., Anaerobes | TMP/SMX 1DS PO BD + Metronidazole 400 mg PO TID × 10–14d or Amoxicillin/Clavulanate 1.5 gm IV q6h × No. of days | Cefuroxime axetil 250 mg BD or Cefotaxime 1–2 gm IV q6h + Metronidazole 500 mg IV q8h × 10–14d or Amoxicillin/Clavulanate 1 gm PO BD | Avoid constipation, High fiber diet. |
Proctitis | N. gonorrhoeae | Ciprofloxacin 500 mg PO once or Ofloxacin 400 mg PO once | Ceftriaxone 125 mg IM once or Cefixime 250 mg once | Check HIV sero status |
C. trachomatis | Doxycycline 100 mg BD × 10d | Check HIV sero status | ||
T. pallidum (Syphilis) | Benzathine penicillin 24 lac units IM single dose | Doxycycline 100 mg PO BD × 14d (if Penicillin allergic) | Check HIV sero status | |
Herpes simplex (HSV) | Acyclovir 400 mg 5 times/d × 10d | Check HIV sero status | ||
DIARRHOEA/DYSENTERY ACUTE GASTROENTERITIS | ||||
Pediatric dysentery | S. dysenteriae, S. flexneri, S. boydii, S. sonnei | Oral rehydration solutions + Nalidixic acid 50 mg/kg/d PO QID × 5d | ||
Pediatric Acute gastroenteritis | Rotavirus, ETEC | Oral rehydration fluids | Check for disaccharide intolerance if Diarrhea persists. | |
Giardia lamblia, E. histolytica | Metronidazole 50 mg/kg/d PO in three divided doses × 5–7d | Tinidazole 50 mg/kg/PO (max 2 gm) OD × 3d | In children Furazolidone 50 mg/kg PO single dose. | |
Adult Mild | Viral ETEC | Oral rehydration solution (ORS) | ORS: 3.5 gm NaCl + 2.5 gm NaHCO3 + 1.5 gm KCl + 20 gm glucose in 1 litre of boiled cooled water (WHO). Rice-based formulation can also be used. | |
Non-typhoidal Salmonella | S. typhimurium | No antibiotic except in those who are malnourished or extremes of age young infant, elderly or immunocompromised | Gentamicin 1 mg/kg/d tDS × 5–7d | |
ETEC: Enterotoxigenic Escherichia coli * Ancyclostomiasis causative Org. Ancyclostoma duodenale | ||||
* Calicivirus (including Norwalk virus) to be managed supportively with fluid replacement (Including Hawaii virus) | ||||
Severe bacterial diarrhoea | V. cholerae Salmonella spp., Campylobacter spp. | Oral rehydration fluids | Doxycycline 100 mg PO 1 dose (V. cholera) or Ciprofloxacin 500 mg PO BD × 5–7d (Salmonella) or TMP/SMX 1DS PO BD × 5–7d (Campylobacter) | If patient is immunocompromised or those in extremes of age, Ciprofloxacin 500 mg BD × 14 days. Single dose Azithromycin 250 mg can be given for V. cholera and for 5–7 days in Campylobacter. |
Bacillary dysentery | E. coli, Shigella spp. | Oral rehydration solution (ORS) | ||
Parasitic subacute or chronic | Giardia lamblia, E. histolytica | Secnidazole 1 gm PO once | Metronidazole 250–750 mg PO tid × 7–10d | |
Tropical sprue | Specific pathogen not identified. | Oral rehydration | Bacterial overgrowth is treated with Tetracycline 250 mg OD × 7d along with Folic acid 5 mg OD × 3 mts. Inj Vit B12 100 micro gm IM once a week for 1 month and then once monthly for 5 months to 12 months | |
Hospital acquired or antibiotic associated | C. difficile | Metronidazole 500 mg PO TDS × 10d | Vancomycin 125 mg PO four times daily × 10d | Discontinue other antibiotics if possible. Probiotics (Yoghurts) containing Lactobacillus, and Bifidobacterium, Saccharomyces boulardi are probiotic yeasts Rifaximin gives no additional benefit. |
FOOD POISONING | ||||
Bacterial toxins | S. aureus (toxin) C. botulinum (toxin) | ORS + supportive treatment | Polyvalent antitoxin. | |
Travelers visiting India | E. coli, Shigella, Salmonella, Non-cholera Vibrio, C. jejuni, Giardia spp. | TMP/SMX DS BD × 3d or Ciprofloxacin 500 mg PO BD × 3d or Norfloxacin 400/500 mg PO BD × 3d | Prevention by paying attention to quality of drinking water and avoiding raw uncooked food. Loperamide 4 mg once then 2 mg after each loose stool max 12 mg/d × 2d or Bismuth subsalicylate 2 tabs (262 mg) every 30 min × 5 doses in non-infective cases. |
UROGENITAL INFECTIONS
UROGENITAL INFECTIONS | ORGANISMS | INITIAL TREATMENT | ALTERNATIVES | COMMENTS |
---|---|---|---|---|
PERIRENAL AND RENAL ABSCESSES | ||||
Secondary to UTI | E. coli, Proteus spp., Klebsiella spp., Enterobacter, Enterococcus spp. | Ampicillin 500 mg IV q8h + Gentamicin 1 mg/kg IV q8h × 14d or Cefotaxime 1 gm q8h IV × 14d | Ciprofloxacin 500 mg IV q12h, followed by PO BD × 14d or Piperacillin/Tazobactam 3.375 gm IV q6h + Aminoglycosides can be used | Nosocomial (hospital) strains may be multiple resistant and ESBL-producing gram-negative organisms may require combination antibiotics. Can cause both renal and perirenal abscesses. |
Hematogenous seeding | S. aureus | Cloxacillin 1 gm IV q4h × 4–6 wks | Cefazolin 1 gm IV q8h × 4–6 wks | Screen for endocarditis and local extent of lesion. Abdominal ultrasound or CT scan. May need drainage. Can cause both renal and perirenal abscesses. |
Contiguous from GI tract | Gram negative organisms, Anaerobes | Ampicillin 1–2 gm IV q6h + Gentamicin 1 mg/kg IV/IM q8h + Metronidazole 500 mg IV q8h | Amoxicillin/Clavulanate 1.5–3 gm IV 8h 4 wks | Can be bilateral. Usually causes perirenal abscess. |
* Also applies to anorectal abscess | ||||
Contiguous from GI tract Continued… | Metronidazole 500 mg IV q8h × 4–6 wks | Clindamycin 600–900 mg IV q8h + Gentamicin 1 mg/kg IV/IM q8h × 4 wks | Imipenem cilastatin 500 mg IV q6h or Meropenem for life-threatening hospital-acquired infections × 4 wks | |
PYELONEPHRITIS | ||||
Uncomplicated (classical) | E. coli, Enterococcus spp., S. saprophyticus | Amoxicillin/Clavulanate 500 mg PO TDS × 14d or Ciprofloxacin 500 mg PO BD × 14 days | Ampicillin 500 mg IVq8h + Gentamicin 1 mg/kg IV q8h × 10–14d | For hospitalized patients, give IV antibiotics. Cefuroxime axetil 750 mg IV q8h × 10–14d as initial therapy. Nosocomial or hospital strain if drug resistant will need combination antibiotics. Piperacillin/Tazobactam or Meropenem. Monotherapy can also be used. |
Gentamicin can be substituted by Amikacin, Tobramycin, or Netilmicin. Gentamicin can be given as a single dose 3–5 mg/kg once in 24 hours. | ||||
ESBL: (Extended Spectrum Beta Lactamase) is seen in hospital-acquired infections | ||||
Complicated | E. coli, other Enterobacteriaceae Candida spp | Ampicillin 500 mg IV q8h + Gentamicin 1.5 mg/kg IV q8h × 10–14d or Cefotaxime 1 gm q8h IV × 10–14d | Ticarcillin/Clavulanate 3.1 gm IV q4–6h or Piperacillin-Tazobactam 3.375 gm IV q6h + Gentamicin 1 mg/kg/d tid IV/IM × 10–14d (Single dose 5 mg/kg/d IV/1 hr × 10–14d) or Meropenem 1 gm IV q8h | In those with severe illness needing hospitalization and in men with obstructive uropathy and significant residual urine, urinary drainage via a catheter is needed. In those with bladder outlet obstruction, calculus, post-bladder surgery, instrumentation, malignancy, etc. choice of antibiotic should be guided by urine culture and sensitivity reports. Those with continuous bladder drainage need no antibiotic therapy, unless associated with fever or signs of urosepsis. Intermittent self-catheterization or change of indwelling catheter may be required. Stents should be removed in all symptomatic cases (i.e. fever, sepsis). |
S. aureus | Cloxacillin 1–2 gm IV q4h or Cefazolin 1–2 gm IV q8h | |||
Urosepsis | E. coli, Pseudomonas spp., Proteus spp., Enterobacter spp., Klebsiella spp., | Ampicillin 500 mg IV q8h + Amikacin 15 mg/kg IV q24h × 14d or Meropenem 1 gm IV q8h | Ticarcillin/Clavulanate 3.1 gm IV q4h + Gentamicin 1 mg/kg/d IV/IM tid × 10–14d or Amikacin 15 mg/d/IV/IM OD × 10–14d | If there is no response (fever defervescence) in 72 hours, evaluate for presence of an obstruction or abscess. Need for urinary diversion exists. Can also use Piperacillin-Tazobactam 3.375 gm IV q6h or Cefaperazone/Sulbactam 2 gm IV BD |
Candida, spp. | Fluconazole 200–400 mg QD × 14d | Amphotericin B 0.5 to 0.7 mg/kg/× 7–10d (Total of 1 gm IV) | Voriconazole or Caspofungin may be used | |
CYSTITIS | ||||
Cystitis-simple (in sexually active female aged 15–45 yrs) | E. coli, other Enterobacteria Enterococcus spp., S. saprophyticus | TMP/SMX 1 DS PO BD × 5–7d or Amoxicillin 500 mg PO TDS × 5–7d or Norfloxacin 400 mg PO BD × 5–7d | Nitrofurantoin 50–100 mg PO TDS × 7d or Ciprofloxacin 500 mg PO BD × 5–7d | Single dose therapy with Amoxicillin 3.5 gm is not preferred. Do not use a 3-day regimen in the elderly. Amoxicillin preferred in pregnant women. Nitrofurantoin 100 mg BD can be used. Treat asymptomatic bacteriuria in elderly, in patients with diabetes mellitus and immunocompromised. |
Gentamicin can be substituted by Amikacin, Tobramycin, Netilmicin 3–5 mg/kg/day IV over one hour | ||||
Cystitis-“honeymoon” | E. coli, Enterococcus spp. S. saprophyticus | TMP/SMX 1 DS PO BD × 3d or Amoxicillin 500 mg PO TDS × 3d or Single dose Amoxycillin 3.5 gm PO | Nitrofurantoin 50–100 mg PO TDS × 7d or Ciprofloxacin 250–500 mg PO BD × 3d or Norfloxacin 400 mg PO BD × 3d Quinolones preferred if E. coli drug resistance is high to Ampicillin or Sulphamethoxazole | Occurs among newly sexually active females. Most often due to trauma. To prevent recurrence, suggest frequent emptying of the bladder, void before and after sexual intercourse, wipe tissue or wash from front to back after defecation. TMP/SMX 1 DS or Nitrofurantoin 100 mg can be taken prophylactically just before intercourse. |
Cystitis-recurrent | E. coli, Enterococcus spp., Klebsiella spp. | Ciprofloxacin 250–500 mg PO BD × 7d or Amoxicillin 500 mg PO TDS × 10d | Norfloxacin 400 mg PO BD × 7d or TMP/SMX 1 DS PO BD × 10d | Recurrent is defined as >3 episodes of UTI per year. Do not give short course. Usually long-term suppressive therapy needed. (TMP/SMX 1 DS or nitrofurantoin 100 mg hs od) × 6–12 months for women. |
Cystitis in pregnancy E. coli, Other gram negative organisms | Enterococcus spp. grop B Streptococci | Amoxicillin 500 mg PO TDS × 10d | Nitrofurantoin 50–100 mg PO TDS or Cefuroxime 250 mg PO BD × 5–10d | To prevent re-occurrence, frequent emptying of the bladder and wipe from front to back after toileting. For critically ill patients, e.g. pyelonephritis, urosepsis use parenteral antimicrobials. |
Asymptomatic bacteriuria of pregnancy | E. coli Enterococcus spp. S. saprophyticus | Amoxicillin 500 mg PO TDS × 5/10d or Cefuroxime axetil 250 mg BD × 10d | Nitrofurantoin 100 mg PO TDS × 10d | Follow-up culture is essential. |
Candida cystitis | Candida spp. | If asymptomatic, no treatment required. Remove catheter. | Fluconazole 200 mg PO OD × 7–10d in postrenal transplant patient or Irrigation with Amphotericin B solution or Amphotericin B 0.5–0.7 mg/kg/d IV × 7–10d | Bladder irrigation with 50 milligrams of Amphotericin B per 100 ml water instilled into bladder and urinary catheter clamped for 2 hours to ensure contact time with antifungal agent. Continue for 5–7 days. |
Asymptomatic Indwelling catheter-related | P. aeruginosa E. coli Enterococcus spp., Klebsiella spp. | No antibiotics | If symptoms then: Norfloxacin 400 mg PO BD × 5d or Cefotaxime 1–2 gm IV q8h × 5d or Ceftazidime 2 gm IV q8h × 5d Chronic indwelling catheter | Needs no antibiotic therapy unless associated with fever or urosepsis. Intermittent self-catheterization or change of catheter may be required. Culture should be obtained. Symptoms may be vague. |
URETHRITIS | ||||
Male/Female (STD related) Non STD in postmenopausal female | Chlamydia trachomatis, N. gonorrhoeae | Ceftriaxone 125 mg IM one dose + Doxycycline 100 mg PO BD × 7d | Treat with a + b
| Sexual partners should be aggressively followed and treated. Condoms should be used during intercourse until treatment is completed. Urethral dilatation may be required for urethral narrowing. Estrogen cream may be applied on vagina near external urethral meatus to relieve urethral narrowing in postmenopausal women. |
STD: Sexually Transmitted Disease | ||||
PROSTATITIS | ||||
Acute | E. coli, E. fecalis, Klebsiella spp., Pseudomonas spp, N. gonorrhoeae. | TMP/SMX 1ds PO BD × 21d or Ceftriaxone 250 mg IM once then followed by Doxycycline 100 mg PO BD × 21d | Ciprofloxacin 500 mg PO BD × 3–4 wks or Amoxycillin 500 mg PO TDS + Gentamicin 1 mg/kg IV q8h × 21d | For < 35 yr. old Rx for N. gonorrhoeae and C. trachomatis |
Chronic | E. coli, E. fecalis, Klebsiella spp., Pseudomonas spp. | TMP/SMX 1 ds PO BD × 2–3 months | Ciprofloxacin 250–500 mg PO BD or Ofloxacin 400 mg PO OD × 2–3 months | If urine or expressed prostatic secretions are culture negative, treat with Doxycycline 100 mg BD × 3 months. Prophylaxis considered if symptoms or second recurrence occurs. Consider non-bacterial prostatitis if persists. Advise prostatic massage. |
Granulomatous | M. tuberculosis, Fungus | Specific therapy | See section on TB | |
ACUTE EPIDIDYMO-ORCHITIS | ||||
< 35 yrs. old | N. gonorrhoeae, C. trachomatis, Coliforms, H. influenzae | Ciprofloxacin 500 mg BD × 7d or Ofloxacin 400 mg OD × 7d | Ceftriaxone 250 mg IM once + Doxycycline 100 mg PO BD × 10d | Check for torsion of testes. Evaluate sexual partners for treatment. |
>35 yrs. old | E. coli, M. tuberculosis, Brucella spp. | TMP/SMX 1 DS PO BD × 14d or Ciprofloxacin 500 mg PO BD × 14d or Ofloxacin 400 mg PO od × 14d | Ampicillin 500 mg IV q8h + Gentamicin 1 mg/kg IV q8h × 14d | Should receive Doxycycline 100 mg PO BD × 14d if mulltiple sex partners. Evaluate other sexual partners for treatment consideration. Cryptococcus spp and Candida spp to be suspected in immunocompromised. |
PELIVIC INFLAMMATORY DISEASE | ||||
Acute salpingitis. | N. gonorrhoeae C. trachomatis, Mycoplasma Other gram-negative organisms, anaerobes | Ciprofloxacin 500 mg PO one dose or Ceftriaxone 250 mg IM one dose + Doxycycline 100 mg PO BD × 14d | Ofloxacin 400 mg PO BD + Clindamycin 450 mg QID × 14d or Ofloxacin 400 mg PO BD + Metronidazole 400 mgm tds × 14d | Drain abscess, remove products of conception. |
Tubo-ovarian abscess | Anaerobes, Gram-negative organisms such as E. coli, Klebsiella spp | Clindamycin 900 mg IV q8h + Gentamicin 1 mg/kg IV q8h (3 mg/kg q24h once daily until clinical improvement) Metronidazole 500 mg IV q8h | Test for HIV and syphilis. Surgical drainage of an abscess should be considered | |
Endometritis Postpartum or Postabortive | Gram negative bacilli E. coli, Klebsiella spp, Anaerobes | Clindamycin 300 mg PO QID × 14d + Ciprofloxacin 500 mg PO BD × 14d or Ampicillin 1 gm IV q4h + Gentamicin 1 mg/kg/q8h + Metronidazole 500 mg IV q8h × 14d | In severe cases Ticarcillin Clavulanate 3.1 gm q4h IV × 7–10 days | Often post partum. Other options (Amoxicillin/Clav. + Doxycycline) or Imipenem + Doxycline or Meropenem + Doxycycline Avoid Doxy if postpartum (Lactating mother) and substitute with Metronidazole. |
Gentamicin can be substituted by Amikacin, Tobramycin or Netilmicin | ||||
IUCD-associated endometritis | Gardnerella vaginalis | Metronidazole 500 mg PO TDS × 7d | Removal of device for all infections. | |
Actinomyces spp. | Crystalline penicillin 10–20 lac units IV q4h × 4–6 wks | Doxycycline 100 mg PO BD × 4–6 wks or Clindamycin 900 mg PO q8h × 4–6 wks | ||
Candida spp | Vaginal pessaries of Clotrimazole (nightly) OD × 7d | Fluconazole 150 mg PO once daily × 14d | Treat partner; for males Miconazole ointment to prepucial skin and glans. Check for Diabetes mellitus and educate on penile hygiene. If paraphimosis present, may need circumcision. | |
Staphylococci spp. Streptococci spp. | Cloxacillin 500 mg PO q6h × 10–14d | Ciprofloxacin 500 mg PO BD × 10–14d | ||
CERVICITIS MUCOPURULENT | ||||
STD associated | Chlamydia trachomatis, N. gonorrhoeae | Ceftriaxone 125 mg IM one dose + Doxycycline 100 mg PO BD × 7–14d or Ofloxacin 400 mg PO × one dose + Doxycycline 100 mg PO BD × 7–14d | Ciprofloxacin 500 mg PO × one dose + Azithromycin 1 gm PO × one dose | In pregnancy, Amoxicillin 500 mg PO TID or Erythromycin 500 mg PO QID × 10d Trichomoniasis and genital herpes HSV-2 infection can accompany cervicitis. Consider concurrent treatment if prevalence of gonorrhoea is high (>5%). Presumptive treatment for chlamydia is with Doxycycline or Azithromycin. Despite repeated courses of antimicrobial therapy cervicitis can persist. Consider other determinants douching or exposure to chemical irritants as cause. |
Herpes simplex virus (HSV) | Acyclovir 400 mg PO TID × 7–10d | Recurrence needs only symptomatic therapy | ||
N. gonorrhoeae | Ceftriaxone 125 mg IM one dose | Ciprofloxacin 500 mg one dose or | Sexual partners should be followed up and treated. Condoms should be used until | |
Ofloxacin 400 mg one dose | the treatment is complete or avoid for 7 days after single dose regimen or after completion of 7 day regimen. | |||
VAGINITIS (Vaginal discharge and/or vulvar itching ± vaginal odour) | ||||
Bacterial vaginosis (BV) (polymicrobial) replacement of normal vaginal flora | Gardnerella vaginalis, Mobiluncus spp., Prevotella spp. M. hominis, Coliforms, Bacteroides spp. | Metronidazole 500 mg PO BD × 7d or Local application of Metronidazole impregnated sponge or 0.75% gel 5 gm intravaginally × 5d | Clindamycin 300 mg BD × 7d or Clindamycin cream 2% (5 gm) intravaginally at bedtime × 5d | Metronidazole can be given in pregnancy. All pregnant women who have symptomatic diseases require treatment as BV has been associated with adverse pregnancy outcomes. “Clue cells” are seen in vaginal smears. |
Vulvovaginal candidiasis | Candida albicans | Miconazole 2% 5 gms intravaginally for 7d or Clotrimazole 1% cream 5 gms intravaginally hs od × 7d or | Fluconazole 150 mg PO once or 50 mg PO BD × 3d | Recurrent infections occurring at the time of menstruation, treatment with clotrimazole vaginal pessaries for 2–5d every month after cessation of bleeding is indicated. If recurrent, consider HIV sero |
Clotrimazole vaginal pessaries 100 mg HSOD × 7d or Miconazole vaginal pessaries 200 mg × 3d | testing, check for diabetes mellitus. Usually not transmitted sexually. Treatment of partner not recommended. | |||
Trichomoniasis | Trichomonas spp | Metronidazole 500 mg PO BD × 7d or Tinidazole 2 gm PO single dose | Metronidazole 2 gm PO in a single dose. Avoid alcohol for 24–48 hrs in lactating mothers withhold breast feeding for 12–24 hour. Tinidazole contraindicated in pregnancy | Sexual partner(s) should be followed up and treated. Condoms should be used until the treatment is complete in both partners. |
GENITAL ULCERS | ||||
Syphilis Primary or Secondary, early latent (< 1 year) | T. pallidum | Benzathine Penicillin G 2.4 million units IM in a single dose | Doxycycline 100 mg PO BD × 14d or Erythromycin 500 mg PO QID × 14d | Follow up VDRL titres 4 wks after therapy. Check HIV status. Syphilis during pregnancy treated appropriate for age. Benzathine Penicillin 2.4 mega units IM weekly × 3 wks. Partner follow-up essential. |
Latent (late) > 1 year or Tertiary Gumma + cardiovascular syphillis | T. pallidum | Benzathine Penicillin 24 lac units IM weekly × 3 wks | Doxycycline 100 mg PO BD × 14d or Erythromycin 500 mg PO QID × 4 wks | Avoid Tetracyclines in pregnancy and during breastfeeding. If nonpenicillin regimens are used for treatment of syphilis in pregnancy, consider infant as untreated. |
Neurosyphilis | T. pallidum | Acqueous crystalline Penicillin G 40 lacs units IV q4h × 10–14d | Procaine penicillin 2.4 million units IM OD × 10–14d + Probenecid 500 mg PO QID × 14d | Desensitize penicillin allergic patient. Can give Doxycycline 100 mg BD for 4 wks or Ceftriaxone 2 gm IM OD for 2 wks. If CSF pleocytosis present initially should be followed up every six months until cell count normal. If not cleared in 6 months or if CSF proteins not normal after 2 years. Consider retreatment. |
Chancroid | H. ducreyi | Ceftriaxone 250 mg IM one dose or Azithromycin 1 gm PO one dose. Erythromycin 500 mg PO TID × 7d. | Ceftriaxone 250 mg IM single dose or Erythromycin 500 mg PO TID × 7d | Single dose regimen ineffective if the patient is HIV positive; need Ciprofloxacin 250 mg BD 3 days |
24 lacs = 2.4 million units (10 lacs = 1 million) | ||||
Genital herpes | Herpes simplex virus-2 (HSV-2) (recurrence) HSV-1 (first episode) | For first clinical episode Acyclovir 400 mg PO TDS × 7–10d or Severe disease necessitate hospitalization acyclovir 5–7 mg/kg/every 8 hrs × 7–10d or Episodic therapy for recurrent genital herpes Acyclovir 800 mg PO TID × 2 days or Famciclovir 1000 mg PO BD × 1 day or Valacyclovir 1 gm PO for 5 days or Acyclovir 200 mg five times a day for 7–10d | Famciclovir 250 mg PO TID × 7–10d or Valacyclovir 1 gm BD × 7–10d | For recurrent (≥ 6 episodes/yr) suppressive therapy with Acyclovir 400 mg BD × 6 years. Valacyclovir 500 mg or 1 gm OD × 1 year or Famciclovir 250 mg BD × 1 year. If associated with HIV dose is doubled for daily suppressive therapy or episodic infections. |
Lymphogranuloma venereum | Chlamydia trachomatis | Doxycycline 100 mg PO BD × 21d | Erythromycin 500 mg PO QID × 21d | Check HIV once. Patient may require re-treatment. |
Granuloma Inguinale (Donovanosis) | Calymmatobacterium granulomatis (now called Klebsiella granulomatis) | Doxycycline 100 mg PO BD × 4 wks or Azithromycin 1 gm orally once weekly for 3 weeks or Ciprofloxacin 750 mg BD PO × 3 weeks | TMP/SMX 1 DS PO BD × 21d Continue treatment untill all lesions heal. |
SKIN AND SOFT TISSUE INFECTIONS
SKIN/SOFT TISSUE | ORGANISMS | INITIAL TREATMENT | ALTERNATIVES | COMMENTS |
---|---|---|---|---|
SKIN STRUCTURE | ||||
Folliculitis (superficial) | S. aureus | Hot packs and drainage | Topical treatment with Mupirocin 3 times/d × 7d | No antibiotics required. Use moist heat. Cloxacillin 250 mg PO q6h × 7–10d if recurrent. |
Acne Vulgaris | Propionibacterium acnes | Topical benzoyl peroxide | If recurrent and nodular Doxycycline 100 mg PO BD × 10d | Systemic Isotretinoin 0.5–1 mg for 4–6 months |
Sweat folliculitis | S. aureus, Anaerobes | Cloxacillin 250 mg PO QID × 7–10d | Cephalexin 250 mg PO QID × 7–10d | |
Hidradenitis suppurativa | S. aureus, S. pyogenes, Anaerobes, Pseudomonas spp. Enterobacteriaceae | Cloxacillin 500 mg PO QID × 4–6 wks | Clindamycin 300 PO QID × 4–6 wks or Doxycyclline 100 gm PO BD × 4–6 wks | Long-term therapy 4–6 wks is required and consider surgical drainage. Surgical excision, Isotretinoin therapy are options. |
Pyoderma cutaneous abscesses | S. aureus, S. pyogenes | Cloxacillin 250–500 mg PO QID × 7–10d | Cephalexin 250–500 mg PO QID × 7–10d | |
* Breast abscess seen in full-term infants; (girls more predominant) S. aureus most common org; Streptococci and coliformsRx begins with pencillinase-resistant pencillin and an aminozlycoside and continue for 10 days | ||||
Furunculosis (Boils) deeper infection of hair follicle | S. aureus | Cloxacillin 500 mg PO QID × 7d if cellulitis present; otherwise hot packs drainage should suffice | Cephalexin 500 mg PO QID × 7d or Cefazolin 2 gm IV of 8h for sepsis × 7d | Eliminate carriage of MRSA with nasal applications of Mupirocin BD × first 5d of month or Clindamycin if susceptible 150 ml |
Carbuncle | S. aureus, Gram negative bacilli | Cloxacillin 500 mg PO q6h × 7–10d | Cephalexin 500 mg PO QID or If severe Cefazolin 1 gm IV q8h × 7–10d | Commonly sited on backs of patients with diabetes; drainage is necessary if large. If MRSA, then consider use of parenteral Teicoplanin/Vancomycin. Oral Linezolid 600 mg BD may eventually replace other second line agents for oral therapy of MRSA infection. |
Paronychia | S. aureus | Cephalexin 500 mg PO QID or Cloxacillin 250–500 mg PO QID × 7–10d | Cephalexin 500 mg q8h × 5–7d | Drainage may be required; if located on digit may try soaking it in hypertonic saline (3 gm common salt in one ounce of water) to relieve pain and swelling. |
Impetigo, ecthyma | Streptococcus and Staphylococcus spp | Cloxacillin 250–500 mg PO QID 7d or | Penicillin G 10–20 lac units IV q6h × 7d or | Clindamycin 300–450 mg TID may be used. Potential of cross resistance to erythromycin- |
Anthrax—Bacillus Anthracis for inhalational Anthrax Injection Crystalline Penicillin 10 Las IV q4h, Ciprofloxacin 400 mg IV q12h. Once patient is stable oral monotherapy with cip 500 mg bd or doxy 100 mg bd × 60 days. For Cutaneous anthrax - cipro 500 mg bd (oral)/Doxy 100 mg bd (oral) × 60 days | ||||
SKIN STRUCTURE | ||||
Cephalexin 250–500 mg PO QID × 7d | Azithromycin 500 mg stat and followed by 250 mg OD × 7d or Amoxycillin/Clavulanate 1 gm PO BD × 7d | inducible resistance among MRSA by Erythromycin | ||
Cellulitis (deeper dermis) | S. pyogenes Other Streptococci S. aureus | Cephalexin 500 mg PO QID × 7–10d or Cloxacillin 500 mg IV/PO q6h × 7–10d | Cefazolin 1–2 gm IV q8h × 7–10d or Vancomycin 1 gm IV q12h + Levofloxacin 500 mg IV/PO OD × 7–10d | Use IV antibiotics if cellulitis is extensive and not responding to PO antibiotics. Cat or dog bites can cause cellulitis. Aeromonas spp. following immersion in fresh water.Erysipelothrix rhusiopathiae in butchers. Periobital cellulitis due to H. influenzae can occur in children. In neutropenic host Pseudomonas and other gram negative bacilli and, in HIV infected Helicobacter cinaedi or Cryptococcus neoformans may cause cellulitis. |
Erysipeloid—Erysipelothrix Rhusiopathiae org. enters through breaks in skin, usually self limiting (after 2–3 weeks). Use of Penicillin G or Amino Penicillin can hasten recovery | ||||
Erysipelas (upper dermis) (seen in face or lower extremities) | Group A beta hemolytic Streptococci, S. aureus | Penicillin V 250–500 mg PO QID × 10–14d or Cloxacillin 500 mg IV/PO q6h × 10–14d | Erythromycin 500 mg PO QID 7–10d or Cephalexin 500 mg PO QID 7–10d | Hospitalize if lesion is located in dangerous area of face, head or hand is involved. Change to Cloxacillin 1–2 gm IV q4h if not responding to Penicillin G. The lesions are raised above the level of the surrounding skin and there is a clear line of demarcation between involved and uninvolved tissue. |
TOXIN MEDIATED | ||||
Toxic shock syndrome (TSS) | Group A Streptococci, S. aureus | Crystalline Penicillin10 lac units IV q6h × 10–14d + Clindamycin 450 mg PO q8h is added to decrease production of inflammatory mediators | Ceftriaxone 2 gm IV/IM q24h × 10–14d or Erythromycin 500 mg PO q6h × 10–14d | Rationale for clindamycin is based on in vitro studies demonstrating both toxin suppression and modulation of cytokine (i.e. TNF) production. Additional studies needed for IV immunoglobulin for treatment of TSS. |
NECROTIZING INFECTIONS | ||||
Necrotizing skin and soft tissue infections | Clostridium spp., Aeromonas spp., | Crystalline Penicillin 10 lac units IV q6h + | Surgical debridement required. May also use Meropenem 1 gm IV q8h or Piperacillin/Tazo 3.375 gm | |
Erysipelas: The lesions are raised above the level of the surrounding skin and there is a clear line of demarcation between involved and uninvolved tissue. | ||||
Necrotizing fasciitis (Deep fascial, involving muscle compartments) | Klebsiella, E. coli | Clindamycin 600–900 mg IV q8h + Gentamicin 1.5 mg/kg IV q8h × 10–14d | IV q6h instead of Gentamicin. CT scan or MRI may show edema extending along the fascial plane. Exploratory incision may be needed. | |
Monomicrobial anaerobic Streptococci, i.e. Peptostreptococcus Group A beta hemolytic Streptococci, S. pyogenes, V. vulnificus, Aeromonas hydrophila, Clostridium spp, Klebsiella spp. Enterococcus spp. | Crystalline Penicillin 20 lac units IV q4h + Clindamycin 600–900 mg IV q8h + Ciprofloxacin 400 mg IV q12h × 10–14d | Ciprofloxacin 400 mg q12h (or Gentamicin 1–1.5 mg/kg/IV q8h) for 10–14d | Surgical debridement of all non-viable tissue daily. Hyperbaric oxygen therapy is controversial. Can substitute Amikacin IV 15 mg/kg/d for Ciprofloxacin. High mortality 50–70% in patients with hypotension and organ failure. If polymicrobial 15 different pathogens an average of five is seen. Consider such infections following surgical procedures on bowel, decubitus ulcer or perianal abscess, site of injection in IV drug use or spread from Bartholin gland or minor vulvo-vaginal infections. | |
* Lyell disease → Staphylococci → Rx with IV Cloxacillin and fluid therapy | ||||
Pyomyositis | Anaerobic Streptococcal S. aureus P. aeruginosa (rarely) | Cloxacillin 1 gm IV q4h + Gentamicin 1 mg/kg IV q8h + Metronidazole 500 mg IV q6h × 10–14d (Add if anaerobes suspected) | Clindamycin 600 mg IV q8h + Ciprofloxacin 400 mg IV q12h × 14d | Aspirate for culture (including anaerobic from deep seated pus) to be obtained in all cases to guide choice. |
Anaerobic Streptococcal Myositis | Anaerobic | Penicillin G 10 lac units IV q4h × 10d or Ampicillin 1 gm IV q4h × 10d | Consider necrotizing infections when (i) Severe, constant pain (ii) Bullae or skin necrosis or ecchymosis present (iii) Cutaneous gas that is palpable and signs of systemic toxicity. | |
Gas Gangrene (clostridial cellulitis) | Cl. perfringenes, Cl. novyii, Cl. septicum, Cl. histiolyticum | Penicillin G 20–40 lac units IV q4h + Clindamycin 600–900 mg IV q8h | Clindamycin decreases toxin production | Surgical debridement is important. Hyperbaric oxygen adjunctive efficacy debated |
Synergistic necrotizing cellulitis, Fournier's gangrene(scrotum penis or vulva), Meleney's (post-surgical) | Streptococci, Staphylococci, Anaerobes, Gram-negative organisms (polymicrobial) | Cefazolin 1 gm IV q8h + Gentamicin 1.5 gm/kg IV q8h + Metronidazole 500 mg IV q8h × 10–14d | Clindamycin 600–900 mg IV q8h + Amikacin 7.5 mg/kg IV q12h × 10–14d | Perirectal and ischiorectal abscesses are predisposing causes. 20% mortality. Surgical debridement should be done. Duration of therapy usually prolonged when infection extends to the perineum and anterior abdominal wall through the fascial planes |
ANIMAL AND HUMAN BITES | ||||
Cat | Pasteurella multocida S. aureus and S. pyogenes are secondary invaders | Amoxicillin/Clavulanic acid 1 gm PO BD × 10d | Metronidazole 500 mg PO TID × 10–14d or Cefuroxime axetil 250 mg PO BD × 10–14d | Wound care needed. Follow anti-rabies prophylaxis schedule. Tetanus Immunization is essential as prophylaxis. Treat for 3–5 days only. In pregnant women Azithromycin 250–500 mg OD may be used. |
Cat Scratch Disease | Bartonella henselae | Doxycycline 100 mg PO BD × 10–14d or Azithromycin 500 mg single dose and then 250 mg for 4d | Erythromycin 500 mg PO QID × 10–14d | Commonly kittens. If Erythromycin is not tolerated, substitute other Macrolides. Treat only if infection (with lymphadenopathy) is present (no indication for prophylaxis if cat scratches) |
Rat Bite Fever | Streptobacillus moniliformis | Procaine Penicillin 8 lac units IM BD × 7d | Amoxicillin 500 mg PO q8h or Doxycycline 100 mg PO BD or Clindamycin 300 mg PO QID × 10d | Presentation is as a relapsing fever. |
Monkey bite | Herpes B virus (Herpes simian) | Acyclovir 800 mg PO five times/d for prolonged duration 4–6 wks | Tetanus prophylaxis | |
Rare causes:
| ||||
Dog | Streptococci spp, Pasteurella, DF-2 Capnocytophaga spp. | Amoxicillin 500 mg PO TID or TMP-SMX DS 1 BD × 3–5d | Amoxicillin/Clavulanic acid 500/125 mg PO TID or Clindamycin 300 mg PO QID + Ciprofloxacin 750 mg PO BD × 10–14d | For prophylaxis treat for 3–5 days, along with wound care; Rabies and tetanus prophylaxis (refer). |
Pig | Streptococcus spp., anaerobes, Pasteurella multocida | Amoxicillin 500 mg PO TID × 3–5d or TMP-SMX DS 1 BD × 3–5d | Amoxicillin/Clavulanic acid 500/125 mg PO TID or Clindamycin 300 mg PO QID + Ciprofloxacin 500 mg PO BD × 3–5d | For prophylaxis treat for 3–5 days. Wound care, tetanus prophylaxis and Hepatitis B. |
Snake | GNB and Anaerobes | Amoxicillin 500 mg PO TID or TMP-SMX DS 1 BD × 10–14d | Amoxicillin/Clavulanic acid 500/125 mg PO TID × 10–14d or Ceftriaxone 1 gm 1M OD × 10–14d | For prophylaxis treat for 3–5 days Wound care needed. Tetanus prophylaxis. |
Babesiosis—Babesia microtii (mainly US) reservoir - whitefooted mouse Rx with Clindamycin (1.2 g IV bd or 600 mg tds oral) + oral Quinine (650 mg tds) × 7 days/Atovaquone (750 mg/bd oral) + Azithromycin (500 mg oral day 1), 250 mg/day oral × 7 days. Lyme disease - Borrelia burgdorferi (mainly US) | ||||
Human (including clenched—fist injuries in mouth) | S. viridans, S. aureus, Anaerobes (Eikenella corrodens, Peptostreptococcus, Bacteroides) | Amoxicillin/Clavulanic acid 1 gm PO BD × 10–14d | Doxycycline 100 mg PO BD × 10–14d or TMP-SMX DS 1 PO BD × 10–14d | Wound can be devastating to limbs. Can lead to osteomyelitis. Tetanus and Hepatitis-B immunization indicated depending on host immunization status. Consider Eikenella corrodens (add Ciprofloxacin). For prophylaxis treat for 3–5 days. Suggest postexposure prophylaxis for HIV if either (recepient and traumatiser) serostatus is unknown, especially if cuts and tendon injury occur. Can transmit herpes virus. |
PUNCTURE WOUND | ||||
Bare foot | S. aureus, Streptococci, GNB | Cefadroxil 500 mg PO BD until asymptomatic × 7–10d Any 1st or 2nd generation Cephalosporin can be used | Ciprofloxacin 400 mg IV q12h or 750 mg PO BD + Rifampicin 600 mg PO OD × 7–10d | |
Capnocytophagia canimorsus can cause fulminant sepsis after dogbite injuries, resistant to Aminoglycosides and TMP-SMX. Use Quinolones or β-lactams. Edwardsiella tarda—exposure to contaminated water-Rx with Ampicillin/Cephalosporins/Aminoglycosides/Fluroquinolones/TMP-SMX | ||||
Through shoes | Pseudomonas aeruginosa, S. aureus, Streptococcus spp., Gram-negative bacilli (GNB) Other | Cloxacillin 500 mg PO QID + Ciprofloxacin 750 mg PO BD | Cefadroxil 500 mg PO BD + Ciprofloxacin 750 mg PO BD × 7–10d or Cloxacillin 500 mg PO QID + Gentamicin 1 mg/kg IV/IM q8h × 7–10d | |
PURULENT PHLEBITIS | ||||
With or without IV line (peripheral or central vein) | S. aureus, coagulase negative Staphylococci, Candida spp. | Cefazolin 1 gm IV q8h × 7–14d or Cephalexin 500 mg q6h × 14d | Remove catheter. Do culture and gram stain before starting therapy. If purulent, then 4 wks therapy need. If Candida, add Amphotericin B 0.5–0.6 mg/kg/d (total dose 1.5 gm). Vancomycin 1 gm IV q12h for MRSA. | |
GNB = Gram negative bacilli: Klebsiella spp, E. coli | ||||
Jugular vein septic thrombophlebitis (Lemierre's disease) | Fusobacterium spp. | Penicillin G 24 million units/day divided IV q4h or Clindamycin 600 mg IV q8h × 10–14d | Surgical drainage and if necessary vein ligation may be required. | |
DIABETIC ULCER FOOT | ||||
Non-limb threatening | Streptococci, Staphylococci, Anaerobes, Gram-negative bacilli (GNB) | Cephalexin 500 mg PO QID 7–10d or Amoxicillin/Clav. 1 gm PO BD × 7–10d | Cefadroxil 500 mg PO BD × 7–10d or Levofloxacin 500 mg OD + Metronidazole 500 mg PO TID × 7–10d | Local wound care. Moxifloxacin 500 mg OD PO × 7–10d can be used. |
Severe limb threatening with extensive gangrene, cellulitis | Polymicrobial Streptococcus, Anaerobes, GNB | Cefazolin 1 gm IV q8h + Gentamicin 1 mg/kg IV q8h + Metronidazole 500 mg IV q8h × 10–14d | Ticarcillin/Clavulanic acid 3.1 gm IV q4h or Piperacillin/Tazo. 3.375 gm IV q6h or Imipenem 500 mg IV q6h. Add Vancomycin 1 gm IM BD if MRSA suspected. Oral | Surgical debridement is important. Use of hyperbaric oxygen is controversial. Inj Ertapenem 1 gm IV OD or Inj Tigecycline 100 mg IV stat and 50 mg BD × 10 day |
Linezolid 600 mg OD can be used or Teicoplanin 400 mg IM OD | ||||
Decubitus ulcer | Streptococci, Staphylococci, Anaerobes, Gram-negative organisms. | Cefadroxil 500 mg PO BD + Metronidazole 500 mg PO TID × 10–14d or AMCL 1 gm PO BD | Cloxacillin 500 mg PO QID + Ciprofloxacin 500 mg PO BD or Levofloxacin 500 mg OD + Metronidazole 500 mg PO TID × 10–14d | For severe infection local wound care and debridement may be needed. Mild infection (Bed sores) Stage I and II need only local ointment such as Neomycin or Bacitracin. Treat with systemic antibiotics only if surrounding cellulitis present, otherwise only local wound care and dry dressing |
BURN WOUND | ||||
Superficial (mild) | S. aureus | Silver nitrate 5% cream topical | First generation cephalosporin given orally for 5d | Look for signs of spreading cellulitis, abscess formation or systemic symptoms such as fever, hypotension, etc. Patient can progress from SIRS to sepsis. indicating severity. |
Severe burns | P. aeruginosa, S. aureus, S. pyogenes | Ticarcillin/Clavulanic acid 3.1 gm IV q4h or | ||
Enterobacter spp. E. fecalis, E. coli | Piperacillin/Tazobactam 3.375 gm q6h + Amikacin 7.5 mg/kg IV BD × 10d | Vancomycin 1 gm IV q12h for MRSA. To observe for Adult Respiratory Distress Syndrome (ARDS), acute renal failure and shock. Empirical antibiotics are started soon. Biologic response to infection include:
SIRS at least two criteria:
| ||
Recombinant human Drotrecogin alfa (activated) (Xigris; Eli Lilly) given as an adjunct to antiinfective therapy can improve rate of survival for patients who develop sepsis. It is a coagulation inhibitor that modulates coagulapathy in sepsis. It is very expensive. | ||||
Perianal Abscess (Thrombosed and infected “pile” mass) hemorrhoids | Streptococcus spp., Staphylococcus spp., GNB Enterococcus spp., Anaerobes | Cefuroxime axetil 250 mg BD + Metronidazole 500 mg q8h × 7–10d | Cloxacillin 500 mg PO QID + Ciprofloxacin 500 mg BD + Metronidazole 500 mg TDS × 10–14d | Sitz bath twice a day. Laxatives to ease stool movement and lessen discomfort. If hospital acquired: Pip/Tazo 3.375 gm IV q6h or Ampicillin/Sulbactam 3 gm IV q6h |
BONE AND JOINT INFECTION | ||||
Acute septic monoarthritis | S. aureus | Cloxacillin 500 mg PO q6h or Cephalexin 500 mg q6h × 10–14d | Cloxacillin 1 gm IV q4h × 10–14d | |
Acute bursitis | S. aureus | Cloxacillin 500 mg q6h × 7–10d | Cephalexin 500 mg q8h × 7–10d | Culture may be needed to identify organism. |
Acute osteomyelitis | S. aureus | Cefazolin 1 gm IV q8h or Cloxacillin 500 mg-1 gm IV q6h × 10–14d | Teicoplanin 400 mg IM q24h or Vancomycin 1 gm q12h or Tigecycline 100 mg IV slow infusion then 50 mg IV q12h if MRSA | Total duration will need to be for 4–6 wks. Switch to per oral antibiotics when acute phase subsides. Linezolid 600 mg BD PO may be used in ambulatory therapy (Monitor blood count if duration > 2 wks). |
* Discitis—children < 5 years, mainly lumbar region S. aureus trauma, etc. Mainly—first step-immobilization of spine, consider antimicrobials if symptoms do not subside. * Fifth disease—Human parvovirus B19, women, symmetrical arthritis, in winter, self-limited course. | ||||
Chronic osteomyelitis | Gram-negative organism or mixed infection with more than one organism | Base treatment on basis of deep dermal biopsy and culture | If polymicrobial (mixed) Clindamycin 600 mg q8h + Ciprofloxacin 500 mg BD × 4–6 wks | |
SUPERFICIAL SKIN INFECTIONS FUNGAL DERMATOPHYTES | ||||
Tinea versicolor (Body) | Malassezia furfur | 20% sodium thiosulphate daily for 6 wks | 5–10% selenium sulfide before bath × 7–14d or Ketoconazole shampoo applied as a lotion to the area for 10 mins before a bath od × 2 wks then weekly × 1 month or Fluconazole 400 mg single dose or Itraconazole 200 mg OD × 3–7d | |
DERMATOPHYTES | ||||
Tinea corporis (body) | Microsporum canis, Trichophyton rubrum Trichophyton mentagrophytes | Miconazole or Clotrimazole cream or solution rubbed in well, BD for 2–4 wks (at least for 1 wk beyond clearing of lesions) | Continue antifungal powder as recurrences are common. Avoid tight undergarments, use cotton socks. | Differential diagnosis include candidiasis and erythrasma |
Tinea cruris (groin) Tinea pedis (foot) Tinea manuum (hand) | Trichophyton rubrum Trichophyton interdigitale Epidermophyton floccosum | Miconazole or Clotrimazole cream or solution rubbed in well twice a day for 2–4 wks (at least 1 wk beyond clearing) | Griseofulvin 10 mg/kg/d BD × 2 wks beyond apparent cure (may need usually 2 months therapy) | Avoid using tight under garments. Careful drying between toes: an antifungal powder can be applied as well, avoidance of occlusive footwear and use of cotton socks is advocated to absorb skin moisture. |
Tinea capitis (scalp) | Microsporum canis Trichophyton rubrum Trichophyton tonsurans | Griseofulvin 10 mg/kg/d PO BD × 2 wks beyond apparent cure (usually 6–8 wks) or Terbinafine 250 mg PO OD × 4–8 wks (Children 125 mg PO OD) or | Miconazole or Clotrimazole cream or solution rubbed in well twice a day for 2–4 wks (at least 1 wk beyond clearing) | Do not give Griseofulvin for more than 3 months. Use topical selenium sulfide or Ketoconazole shampoo. |
Fluconazole Adults 150 mg PO/wk × 8–12 wks | ||||
Tinea barbae (beard) | T. verrucosum T. mentagrophytes | Griseofulvin 7.5–10 mg/kg/d BD × 2 wks beyond apparent cure | Miconazole or Clotrimazole cream or solution rubbed in well twice a day for 2–4 wks (at least 1 wk after clearing) | |
Tinea unguinum (finger or toe nail) Onychomycosis | Tetramicin 250 mg PO OD × 125 mg or Itraconazole 200 mg PO OD × 3 month or Itraconazole 200 mg PO BD × 1 wk/month × 6–12 months | Terbinafine 250 mg PO OD × 6 wks or Fluconazole 150–300 mg/wk × 3–6 months or Fluconazole 150–300 mg PO/wk × 6–12 month | Nail avulsion can be considered WBC count and LFT to be monitored. Topical application of antifungal ointment is of no value. | |
Seborrheic dermatitis | 5–10% Selenium sulfide before bath | |||
ECTOPARASITE | ||||
Lice | Pediculosis capitis | Permethrin 1% lotion | 1% (Gamma Benzene hexachloride) | Use as shampoo, leave for 10 minutes, rinse with water. Apply after 7 days if needed. |
Scabies | Sarcoptes scabiei | Permethrin 5% cream or Ivermectin 200 μg/kg PO × 1 dose | 1% Gamma Benzene hexachloride | Wash with soap and water after 8–14 hours. Treat all other family members especially children, as well. |
MISCELLANEOUS | ||||
Myiasis | Larva | Local anaesthetics and removal with fingers | Frequent change of dressing for wound myiasis. Myiasis of nose and throat need surgical intervention. | |
Madura foot Mycetoma | Nocardia spp Actinomadura spp | TMP-SMX 15 mg/kg 1 DS PO BD | Dapsone 3 mg/kg/d | For Actinomadura add Streptomycin 15 mg/kg/d to either dapsone or TMP-SMX. For severe Nocardia infections add Amikacin 15 mg/kg/day IM/IV × 3 wks with 2 wks of therapy interval for 2–3 courses. |
Eumycetoma | Active mycosis | Itraconazole 100–400 mg/d × 1 year or according to clinical response | ||
LEPROSY | ||||
Single lesion | Mycobacterium leprae | Rifampicin 600 mg PO single dose + Ofloxacin 400 mg PO single dose + Minocycline 100 mg PO single dose | ||
Paucibacillary > 1 lesion | Mycobacterium leprae | Rifampicin 600 mg PO once a month + Dapsone 100 mg PO OD × 6 months | ||
Multibacillary | (Dapsone 100 mg PO OD + Clofazimine 50 mg PO OD) unsupervised + (Rifampicin 600 mg PO + Clofazimine 300 mg PO) | If reversal reaction ENL (erythema nodosum leprosum) occurs, give NSAID for mildly symptomatic Type 1 reaction or ENL. In severe ENL 40–60 mg Prednisolone or 300 mg | ||
NSAID = Non steroidal anti-inflammatory drug, e.g. Ibuprofen, Indomethacin, Naproxen, etc. | ||||
supervised once a month for 24 months | Clofazimine or 300–400 mg Thalidomide (tapered to 100 mg) and discontinued in 4 weeks. Prednisolone may be gradually tapered. Treatment must be completed in 18 months. If sensitive Dapsone can be omitted from regime for 3–6 months | |||
FILARIASIS (ELEPHANTIASIS) | ||||
Acute exacerbations, (adenolymphangitis) [ADL] | Wuchereria bancrofti Brugia malayi | Diethycarbamazine (DEC) 6–8 mg/d in divided doses × 14d) | Ivermectin 100–200 mg/kg/po × 1 dose | For tropical pulmonary eosinophilia may need treatment to be repeated along with course of anti-helminthics. |
Acute epididymo-orchitis with or without hydrocele | Benzathine Penicillin 24 lac units IM single dose or Oral Penicillin 250 mg Qid × 10d | Local (affected) limb care with soap and water; drying and application of antifungal cream or antibiotic cream and elevation of limb may be needed during acute attack. A course of DEC may also | ||
be given. Some give Benzathine Penicillin once in 3 wks × 6–12 months (for recurrent cellulitis or ADL). May need Antihistamine or Steroids for allergic reactions. Local limbs care to be continued to prevent recurrence | ||||
OTHERS | ||||
Cutaneous larva migrans (creeping eruption) | Ancylostoma brazilensis or A. carinum, Necator americanus | Albendazole 400 mg OD × 3d | Ivermectin 200 mg/kg PO × 1 dose | Can cause serpiginous, erythematous, elevated and pruritic skin lesions |
Toxocariasis (visceral larva migrans) | Toxocara cani (dog) T. cati (cats) | Albendazole 400 mg BD × 5d | Mebendazole 100–200 mg BD × 5d | For relief of symptoms steroids and antihistaminics can be used. Self-limited. |
SYSTEMIC FEBRILE ILLNESSES
SYSTEMIC FEBRILE INFECTION | ORGANISMS | INITIAL TREATMENT | ALTERNATIVES | COMMENTS |
---|---|---|---|---|
COMMUNITY ACQUIRED BACTEREMIA | ||||
Typhoid Fever (Commonest) | S. typhi, S. paratyphi A or B | Ciprofloxacin 750 mg PO BD × 14d or Ofloxacin 400 mg od × 14d Continue for 5 afebrile days | Chloramphenicol 500 mg PO QID × 14d or TMP-SMX 1 DS BD × 14d or Amoxicillin 500 mg q8h × 14d If prevalence of MDR S. typhi, (i.e., resistant to these three conventionally used antimicrobials) is high, these will not be effective. Susceptibility studies will be needed | Though Ceftriaxone, and other 3rd generation cephalosporins exhibit 100% in vitro susceptibility may not always have good efficacy. Ciprofloxacin resistant S. typhi (MIC ≥ 4 mg/L) has not been reported from India. S. typhi strains with increasing MICs to Ciprofloxacin and resistance to Nalidixic acid have been reported with observed clinical failure (fever for > 7 days while on Quinolone therapy) along with microbiological recovery of organism from blood). In such cases, may double dose of Quinolone to increase serum drug levels Ofloxacin 400 mg |
Typhoid Fever Continued… | twice daily or change to 3rd generation Cephalosporin Cefotaxime 1 gm q8h or Ceftriaxone 2 gms IV OD × 14d or Azithromycin 500 mg OD × 7d) In typhoid with shock: Give Dexamethasone 3 mg/kg stat then 1 mg/kg IV q6h × 2d | |||
SEPSIS SYNDROME (includes Systemic Inflammatory Response Syndrome, Sepsis, Severe Sepsis and Shock; refer section on burns) | ||||
Community-acquired sepsis (no primary source identified) not hospitalized in previous 6 wks | E. coli, Klebsiella spp. S. pneumoniae, S. aureus | Ampicillin 1–2 gm IV q4h + Gentamicin 5 mg/kg IV OD + Metronidazole 500 mg IV q8h or Ceftriaxone 1 gm IV q12h + Metronidazole 500 mg IV q8h | Clindamycin 600–900 mg IV q8h + Ciprofloxacin 400 mg IV q12h or Ticarcillin/Clavulanate 3.1 gm IV q4h + Amikacin 7.5 mg/kg IV q12h or Cefpirome 1 gm q12h IV BD + | Consider adding Hydrocortisone 50 mg IV q6h × 7 day. In the splenectomized patient aggressive treatment for suspected H. influenzae and S. pneumoniae with Ampicillin 1 gm IV q4h. Antibiotic choice will depend on primary source for bacteremia; if genitourological origin consider E. coli, Enterococcus spp. If skin origin use Cloxacillin. |
Community-acquired sepsis Continued… | Amikacin 7.5 mg/kg/IV q12h or Cefoperozone Sulbactam 4 gm IV BD or Ertapenem 1 gm IV OD | If gastrointestinal—Consider E. coli, Klebsiella, Shigella, if gallbladder Enterococcus spp. If respiratory—S. pneumoniae, methicillin susceptible, S. aureus and Klebsiella spp. | ||
Hospital acquired pathogen (non-neutropenic) (previous hospitalization within 6 wks) | E. coli, Klebsiella spp., Enterobacter spp., S. aureus, Pseudomonas spp. | Ceftazidime 1–2 gm IV q8h + Amikacin 7.5 mg/kg IV q12h × 10–14d | Imipenem 500 mg IV q6h + Vancomycin + 1 gm IV q12h or Piperacillin/Tazobactam 3.375 gm q6h + Amikacin 15 mg/kg/14d | Pip/Tazo and Amikacin to cover hospital strain of gram-negative organism including Pseudomonas spp. Consider source IV catheter line sepsis remove line and treat with Cloxacillin, if MRSA suspected use Vancomycin. |
Rickettsial Fever | Coxiella burnetii Rickettsia spp. R. tsutsugamushi R. conori R. prowazeki | Doxycycline 100 mg PO BD × 7d or Ceftriaxone 1 gm IM OD × 7–10d | Chloramphenicol (50–75 mg/kg/d) 500 mg PO QID × 7d | Suspect if rash or eschar present. |
Plague—Yersinia pestis, Rx Individual approach Streptomycin 15 mg/kg IM bd or Gentamicin 5 mg/kg. IM/IV od or doxy 100 mg IV bd/200 mg/day IV or Ciprofloxacin 400 mg IV bd × 10 days. Gentamicin preferred in pregnancy. In mass approach—Doxycycline 100 mg bd (oral)/Cipro 500 mg bd oral × 10 days. Postexposure prophylaxis × 7 days. Q fever caused by Coxiella burnetii, Rx with Doxycycline or Chloramphenicol | ||||
Meningococcemia | N. meningitidis | Penicillin G 40 lac units IV q4h × 7d or Chloramphenicol 1 gm IV q6h × 7d | Consider Rifampicin 600 mg BD prophylaxis for close contacts (members of family or HCW involved in care of patients following procedures such as intubation) | |
Leptospirosis | Leptospira interrogans | Penicillin G 20 lac units q4h × 7–14d or Doxycycline 100 mg PO BD × 7–14d | Ceftriaxone 1 gm IM OD × 7–14d | Exposure to rats and farm animals. Presents with fever (which is biphasic) headache, myalgia, conjunctival suffusion, rash, jaundice. May also have CNS, GI, and respiratory symptoms. |
Brucellosis | Brucella spp. | Doxycycline 100 mg PO BD × 6 wks + Rifampicin 600 mg PO OD × 6 wks | Doxycycline 100 mg PO BD × 6 wks + Streptomycin 1 gm IM OD × 3 wks | Exposure to unpasteurized milk of cattle, pigs, goats or dogs. Presents with fever, malaise, headache, hepatosplenomegaly, osteoarticular involvement. |
Tularemia | Francisella tularensis | Gentamicin 1 mg/kg IV q8h × 7–14d or Streptomycin 7.5–10 mg/kg q12h IM × 7–14d | Add Chloramphenicol for CNS involvement | Exposure to ticks, fleas, lice or mosquitoes. May present as ulceroglandular, oculoglandular, oropharyngeal, typhoidal, or pneumonic forms. |
Ehrilichiosis Ehrilichia chaffeensis, phagocytophilia mainly in United States, Rx is with Tablet doxy 100 mg bd × 7–10 days | ||||
Malaria | Plasmodium falciparum P. vivax | Refer malaria section | ||
Dengue | Dengue virus 1–4 | Supportive Maintain blood pressure with crystalloids or colloids infusion. Peripheral edema is due to third spacing owing to capillary leak syndrome. Overinfusion of fluids could result in pulmonary edema when fluid is reabsorbed. | Aedes aegypti mosquito eradication. Dengue hemorrhagic fever and Dengue hemorrhagic shock needs supportive treatment. Platelet transfusion indicated for non-cutaneous bleeding or if platelet count < 20,000 mm3 | |
HOSPITAL ACQUIRED | ||||
Line Infection | S. epidermidis, S. aureus, gram negatives, Candida | Cloxacillin 1–2 gm IV q6h × 7d | Vancomycin 1 gm IV q12h (if MRSA) | Consider line removal and send tip for culture. |