Management of Infectious Diseases Manoj Jain, Dilip Mathai
INDEX
Antibiotics/Drugs
A
Acyclovir 3, 5, 1316, 24, 28, 67, 82, 86, 95, 219, 232, 240244, 248, 276, 310, 315, 335
Acyclovir eye drops 15
Adefovir 54, 55, 336
Albendazole 9, 57, 109, 212, 213, 262, 263, 267270, 272, 334
Amantadine 44, 246, 248, 336
Amikacin 9, 18, 20, 23, 34, 37, 47, 59, 61, 65, 72, 74, 80, 92, 94, 101, 106, 111, 112, 116, 118, 121, 129, 138, 144, 148, 152, 154, 155, 301, 307, 311, 328
Aminoglycosides 51, 60, 71, 97, 116, 118, 123, 126, 152
Amodiaquine 169, 175
Amox/clavulanate 117
Amoxicillin 19, 21, 22, 2430, 39, 41, 44, 46, 4951, 53, 57, 58, 61, 62, 64, 67, 71, 72, 7476, 80, 82, 9497, 99, 110, 115, 117, 215, 219, 278, 279, 281, 283, 287, 305, 307, 311, 317
Amoxicillin/clavulanate 19, 21, 22, 2527, 29, 44, 46, 50, 51, 57, 58, 61, 62, 64, 67, 71, 72
Amoxicillin/clavulanic acid 28, 30, 94, 96, 97, 278, 279,
Amphotericin 4, 5, 7, 15, 17, 18, 34, 52, 53, 65, 74, 76, 98, 186, 218, 224, 250, 251, 253256, 259, 263, 264, 273, 276, 282, 308, 309, 336
Ampicillin 1, 3, 4, 5, 7, 18, 27, 3133, 36, 42, 56, 58, 59, 61, 62, 64, 65, 66, 7175, 79, 80, 93, 97, 102, 111, 115, 117, 119, 123, 126, 280, 281, 287, 296, 298, 301, 303, 305, 316, 323
Ampicillin plus cloxacillin 323
Ampicillin plus probenecid 323
Ampicillin plus sulbactam 323
Amprenavir 192, 195, 224
Antacids 28, 53, 124, 125
Antihistamine 19, 109, 124, 197
Antimony 264
Aqueous crystalline penicillin 85, 225
Artemether 165, 166, 169, 173, 174, 335
Artesunate 165, 166, 167, 169, 173, 175, 335
Artesunate-amodiaquine 175
Artesunate-mefloquine 175
Atazanavir 192, 195
Atovaquone 96, 169, 231, 232, 265, 275
Azidothymidine 188
Azithromycin 9, 21, 24, 39, 4143, 50, 69, 77, 82, 85, 87, 90, 94, 96, 111, 115, 117, 196, 220, 226, 232, 258, 287, 311, 328
Aztreonam 64, 116, 118, 120, 123, 126, 236
B
Bacampicillin 115, 323
Bacitracin 11, 13, 100
Benzathine penicillin 24, 36, 37, 67, 84, 85, 108, 109, 115, 117, 216, 282, 283, 323
Benzyl penicillin 117, 217, 323
Bulaquine 335
C
Capreomycin 129, 139, 148, 152, 154, 155, 332
Carbamazepine 124, 198, 208
Carbamazepine/valproic acid 124
Cefaclor 115, 117, 324, 325
Cefadroxil 39, 45, 50, 65, 97, 98100, 115, 117, 287, 324, 325
Cefalexin 27, 29, 49, 115, 117
Cefazolin 8, 14, 18, 27, 31, 3638, 4547, 59, 63, 66, 71, 73, 89, 90, 94, 98, 99, 102, 115, 117, 119, 294302, 316, 324, 325
Cefdinir 324, 326
Cefepime 8, 65, 115, 326
Cefetamet pivoxil HCl 326
Cefixime 12, 41, 65, 67, 77, 115, 117, 324
Cefoperazone 20, 23, 58, 62, 64, 66, 115, 117, 311, 324, 325
Cefoperazone-sulbactam 58, 62, 66
Cefotaxime 14, 7, 8, 12, 18, 21, 27, 42, 4547, 61, 63, 65, 67, 71, 73, 77, 111, 115, 117, 119, 123, 310, 311, 315, 324, 325
Cefpirome 8, 20, 23, 65, 111, 115, 117, 123, 311, 325
Cefpodoxime 41, 115, 324, 325
Cefprozil 42
Ceftazidime 20, 23, 77, 112, 115, 117, 119
Ceftriaxone 1, 2, 4, 6, 7, 9, 12, 19, 21, 22, 27, 31, 32, 36, 38, 42, 46, 49, 50, 61, 6567, 7779, 82, 85, 91, 96, 110113, 115, 117, 123, 218, 299, 305, 306, 311, 315, 324
Cefuroxime 19, 21, 22, 28, 29, 39, 40, 41, 43, 45, 46, 60, 65, 67, 72, 76, 94, 102, 115, 117, 119, 277, 279, 294, 295, 298, 311, 324, 325
Cefuroxime axetil 28, 40, 41, 43, 46, 60, 67, 72, 76, 94, 102, 277, 279, 311
Cephalexin + carbocisteine 324
Cephalexin + probenecid 324
Cephalexin with bromhexine 324
Cephaloridine 325
Cephalosporin 21, 64, 65, 97, 100, 110, 111, 115, 117, 119, 123, 126, 215, 303, 305, 317, 324
Chloramphenicol 1, 7, 12, 16, 17, 27, 110, 112, 113, 116, 118, 120, 123126, 218, 219, 329
Chloroquine 57, 162172, 239, 262, 272, 304, 306, 334
Chloroquine hydrochloride 272
Chloroquine phosphate 164, 170, 272, 334
Chloroquine primaquine 334
Ciprofloxacin 1214, 16, 17, 20, 22, 23, 40, 4446, 51, 52, 56, 58, 6063, 6567, 6972, 74, 75, 7782, 85, 87, 89, 92, 93, 9598, 100, 102, 103, 110112, 116, 118, 120, 123126, 139, 141, 147, 152, 213, 219, 231, 277279, 301, 305, 307, 309, 315, 326
Cisapride 124, 259
Citalopram 208
Clarithromycin 43, 53, 115, 117, 119, 213, 220, 226, 232, 258, 276, 287, 329
Clindamycin 8, 9, 25, 26, 28, 29, 38, 46, 49, 51, 52, 56, 58, 59, 6164, 66, 72, 7981, 83, 88, 89, 9196, 99, 103, 111, 116, 118, 120, 123, 126, 217, 226, 265, 266, 276281, 283, 287, 295, 297, 299, 303, 305, 316, 329
Clindamycin/macrolides 226
Clotrimazole 25, 28, 81, 83, 84, 104, 105, 251253, 260
Clotrimazole troche 28, 256
Clotrimazole vaginal pessaries 83, 84
Cloxacillin 4, 7, 8, 11, 18, 20, 22, 23, 27, 31, 33, 34, 36, 37, 60, 71, 73, 83, 8893, 98, 100, 102, 111, 112, 114, 115, 117, 119, 123, 126, 220, 280, 299, 300, 317, 323, 324
Colistin sulphate 47, 328
Corticosteroids 3537, 176, 245
Cotrimoxazole 43, 47, 196, 330
Crystalline penicillin 3, 5, 81, 85, 89, 91, 92, 225
Cycloserine 139, 148, 152156, 331
D
Dapsone 9, 106108, 124, 125, 139, 231, 232, 257, 265, 276, 332
Daptomycin 118
Darunavir 195
Dehydroemetine 262, 332
Dehydroemetine HCl 332
Delavirdine 190, 195
Demeclocycline 330
Dicloxacillin 11, 27, 36, 115, 117
Didanosine 188, 193, 195, 203
Diethylcarbamazine citrate 334
Diethylcarbamazine 49, 268, 272, 334
Diethylcarbamazine (DEC) 268, 272
Digoxin 124, 125
Dihydroartemisinin/piperaquine 174
Diloxanide 57, 261, 273, 333
Diloxanide furoate 57, 261, 273, 333
Diphtheria antitoxin 24, 35
Doxycycline 3, 6, 13, 16, 21, 30, 39, 40, 41, 49, 50, 52, 66, 67, 69, 7782, 84, 85, 87, 88, 95, 97, 112, 113, 116, 118, 124, 125, 163, 165, 166, 168, 169, 220, 277, 279, 298, 306, 311, 315, 329
Drotrecogin alfa 101, 330
E
Efavirenz 190, 193, 195, 200, 202, 204, 206, 208, 210, 224, 229, 238, 336
Emtricitabine 189, 193, 195
Enfuvirtide 192, 195
Ertapenem 46, 5962, 65, 66, 99, 112, 116, 123
Ertavirine 195
Erythromycin 12, 13, 19, 24, 25, 30, 37, 39, 49, 66, 82, 84, 85, 87, 8991, 95
Erythromycin estolate 117
Erythromycin-tetracycline 6, 35, 48, 138, 140, 141, 143
Ethambutol 6, 35, 48, 138, 140, 141, 143, 144, 146150, 153156, 160, 213, 228, 231, 276, 331, 332
Ethambutol + INH 331
Ethambutol(E) 140
Ethionamide 139, 148, 152156, 331
Ethionamide/ofloxacin 153
Ethionamide/prothionamide 139
F
Famciclovir 14, 86, 241, 242, 244, 248, 335
Fluconazole 4, 5, 15, 17, 25, 28, 34, 53, 65, 74, 76, 81, 83, 103, 105, 124, 125, 186, 196, 208, 214, 218, 224, 225, 233, 250253, 256, 258260, 264, 276, 282, 307, 310, 336, 337
Fluconazole and ornidazole 337
Flucytosine 15, 250, 251, 253, 259
Folinic acid 8, 9, 226, 232, 266
Fosamprenavir 192
Foscarnet 10, 53, 233, 245, 248, 276
Fungemia 250, 305
Furazolidine 273
Furoate 57, 261, 273, 333
Fusidic acid 14, 17
G
Ganciclovir 9, 10, 16, 53, 196, 244, 245, 248, 276, 335
Gatifloxacin 22, 41, 46, 65, 116, 120, 311, 327
Gentamicin 1, 12, 14, 15, 18, 3134, 36, 44, 47, 49, 51, 56, 5866, 68, 7174, 7880, 9294, 98, 99, 111113, 116, 118, 123, 126, 287, 295301, 328
Gentamicin eyedrops 15
Gentamicin or tobramycin 121, 300
Griseofulvin 104, 105, 258, 259, 337
H
Halofantrine 165, 168, 169, 172
HAV immunoglobulin 54
Hetrazan 272, 334
Hydrocortisone 20, 111, 220
Hydroxychloroquine 334
Hydroxyquinolines 333
I
Imidazoles 260
Imipenem 2, 3, 23, 37, 47, 5860, 62, 64, 72, 80, 95, 99, 112, 116, 118, 120, 123, 126, 307, 311
Imipenem cilastatin 3, 47, 64, 72, 118, 123, 311
Imiquimod 246
Indinavir 191, 195, 196, 202, 208, 228, 229, 238, 336
Interferon alfa 5456, 240
Intravitreal vancomycin 18
Isoniazid 124, 125, 129, 138, 140, 141, 143, 144, 146, 147, 149, 154, 155, 160, 228, 276, 330
Isoniazid (INH) 330
Isoniazid(H) 140
Itraconazole 25, 48, 52, 103, 105, 107, 124, 125, 186, 215, 225, 233, 254258, 260, 276, 337
Ivermectin 106, 108, 109, 213, 267, 268, 270, 271, 273, 333
K
Kanamycin 116, 118, 129, 139, 148, 152, 154156, 328
Ketoconazole 28, 53, 103, 104, 124, 125, 233, 253, 259, 263, 264, 276, 336
Ketoconazole shampoo 103, 104
L
Lamivudine 54, 56, 188, 193, 195, 200, 203, 204, 228, 229, 240, 248, 335
Leucovorin 232
Levamisole 333
Levofloxacin 22, 39, 4143, 46, 65, 90, 99, 100, 116, 120, 219, 311
Lincomycin 329
Lindane 270, 271, 315
Linezolid 4, 31, 33, 34, 37, 38, 47, 60, 89, 100, 102, 116, 118, 120, 329
Lipid 4, 194, 195, 198, 209, 259
Lomefloxacin 326
Lopinavir 191, 193, 195, 196, 211, 224
Lovastatin 124, 208
Lumefantrine 174
M
Mafenide acetate 280
Mebendazole 49, 109, 212, 267269, 273, 333
Mefloquin 125, 163, 165, 166, 168, 169, 171173, 175, 273, 334
Mefloquine HCl 334
Mefloquine hydrochloride 171
Meglumine antimonate 273
Mepacrine HCl 335
Meropenem 2, 3, 23, 33, 37, 45, 47, 58, 59, 62, 64, 7274, 80, 91, 116, 118, 120, 126, 307, 309, 311, 329
Metronidazole 79, 2123, 2629, 40, 4447, 49, 51, 53, 5764, 6672, 7981, 83, 84, 93, 94, 99, 100, 102, 111, 116, 118, 120, 123126, 261, 262, 268, 279, 296298, 301, 305, 311, 315, 330, 332
Miconazole 81, 84, 104, 105, 252, 253, 263
Miconazole cream 252
Miconazole or clotrimazole cream 104, 105
Midazolam 208
Miltefosine 264
Minocycline 107, 116, 118, 330
Moxifloxacin 22, 39, 41, 43, 46, 65, 99, 116, 120, 152, 311, 327
Mupirocin 63, 88, 89, 280
N
Nalidixic acid 68, 110, 118, 326
Nelfinavir 191, 195, 196, 211, 224, 228, 229, 238, 336
Neomycin 13, 15, 20, 100, 296, 297, 300
Neomycin/polymyxin 20
Neomycin-gramicidin-polymyxin B 300
Netilmicin 65, 72, 74, 80, 116, 118, 328
Nevirapine 190, 193195, 202, 204206, 208, 210, 221, 223, 224, 228, 238, 336
Niclosamide 270, 273, 333
Nitazoxanide 261, 262, 273, 334
Nitrofurantoin 7476, 306
Norfloxacin 12, 70, 74, 75, 77, 327
Nystatin 25, 28, 214, 220, 251, 253, 260, 336
O
Ofloxacin 8, 1214, 16, 17, 20, 22, 23, 3946, 51, 52, 56, 58, 6063, 6567, 6972, 74, 75, 7783, 85, 87, 89, 90, 92, 93, 95100, 102, 103, 107, 110112, 116, 118, 120, 123, 124126, 139, 141, 147, 148, 150, 152156, 213, 219, 231, 277279, 300, 301, 305, 307, 309, 311, 315, 326, 327
Omeprazole 53
Oral anticoagulant 124, 125, 259
Oral contraceptives 208, 259
Oral hypoglycemics 124
Oral penicillin 108
Oral rehydration 68, 69, 303
Oral rehydration solutions 68
Oral ribavirin 55, 240
Ornidazole 273, 333, 337
Oseltamivir 44, 245, 246, 249
Oxytetracycline 330
P
Para-aminosalicylic acid (PAS) 139
Paromomycin 261, 262, 264, 273
PAS 139, 148, 153, 155, 177, 331
Pefloxacin 116, 120, 326
Pegylated interferon alfa 55
Penicillin 13, 57, 12, 2426, 2932, 34, 36, 37, 41, 42, 44, 49, 52, 67, 81, 84, 85, 8993, 95, 99, 108, 109, 113, 115, 117, 119, 123, 126
Penicillin G 1, 2, 57, 2426, 2932, 34, 41, 42, 44, 46, 49, 52, 84, 85, 8991, 93, 99, 113, 119, 225, 282, 283, 298
Penicillin V 24, 25, 30, 37, 49, 91, 115, 279, 282, 323
Pentamidine 231, 263265, 274, 276
Permethrin 106, 220, 270, 271
Phenobarbitol 208
Phenytoin 124, 125, 208, 259
Phenytoin and barbiturates 124
Piperacillin 18, 23, 33, 37, 38, 44, 45, 47, 51, 5961, 65, 7174, 91, 99, 101, 112, 115, 117, 119, 123, 126, 307, 324
Piperacillin V 24, 25, 30, 37, 49, 91, 115, 279, 282, 323
Piperacillin/tazobactam 18, 23, 37, 38, 47, 5961, 65, 71, 72, 101, 112, 119
Piperazine 274, 333
Piperazine citrate 274, 333
Polymyxin 13, 15, 20, 47, 300, 328
Polymyxin B 13, 15, 47, 300, 328
Polyvalent antitoxin 70
Posaconazole 260
Praziquantel 9, 269, 270, 274, 333
Prednisone 35, 48, 132, 133, 215, 240, 244, 265, 266, 269
Primaquine 164, 165, 168, 169, 171, 173, 265, 274, 334
Primaquine phosphate 171, 274
Probenecid 6, 10, 85, 323, 324
Procaine penicillin 6, 12, 41, 85, 95, 115, 117, 283
Proguanil 163, 169, 274, 335
Proguanil HCl 335
Prothionamide 139, 152, 331
Pyrantel pamoate 267, 274, 333
Pyrazinamide 138, 140, 143, 144, 147, 149, 150, 153156, 160, 228, 276, 331, 332
Pyrazinamide(Z) 140
Pyrazinamide/ethambutol 153
Pyrimethamine 8, 165, 167169, 171173, 175, 217, 226, 232, 263, 266, 274, 276, 334
Pyrimethamine/sulphadoxine 168
Q
Quinidine gluconate 170, 171
Quinine 96, 125, 162, 165, 166, 168172, 274, 306, 334
Quinine dihydrochloride 171
Quinine sulfate 170, 171
R
Ribavirin 40, 55, 240, 247, 248, 276, 335
Rifampicin 2, 6, 26, 3335, 43, 48, 63, 97, 107, 113, 124, 125, 129, 138, 143, 144, 146150, 152155, 160, 191, 194, 208, 224, 228, 231, 260, 263, 276, 280, 283, 311, 330332
Rifampicin + cloxacillin 280
Rifampicin + INH + ethambutol 331
Rifampicin + INH + pyrazinamide 331, 332
Rifampicin + isoniazid 330
Rifampin 141
Rimantadine 246
Ritonavir 191193, 195, 196, 200, 203, 204, 211, 224, 238, 336
Roxithromycin 328
S
Saquinavir 191, 195, 196, 200, 224
Satranidazole 332
Secnidazole 69, 262, 275, 332
Selenium sulfide 20, 103105, 257
Sertraline 208
Silver sulfadiazine 280
Simvastatin 208
Sodium thiosulphate 103
Sparfloxacin 116, 152, 327
Spectinomycin 329
Spiramycin 329
Stavudine 188, 193, 195, 203, 204, 228, 335
Stibogluconate 264, 275
Streptomycin 6, 95, 106, 112, 113, 116, 118, 121, 138, 140, 141, 143, 144, 146, 147, 149, 153155, 160, 228, 331
Sulfa allergy 8, 9, 165
Sulfadiazine 8, 37, 217, 226, 266, 274, 276, 280
Sulfalene/sulphadoxine 166, 167
Sulfisoxazole 48
Sulfonylurea 124, 125
Sulphadiazine + trimethoprim 330
Sulphadoxine + pyrimethamine 334
Sulphalene/sulphadoxine 165
Sulphamethoxazole pyrimethamine 175
Suramin 275
T
Teicoplanin 3, 4, 8, 33, 34, 38, 47, 89, 100, 102, 116, 121, 294, 299, 329
Tenofovir 54, 189, 193, 195, 203, 235
Terbinafine 104, 257, 258, 260, 337
Tetracycline 12, 13, 51, 69, 85, 116, 118, 119, 123126, 165, 170, 172, 216, 262, 281, 329, 330
Tetramicin 105
Theophylline 124, 125, 259
Thiabendazole 268, 275
Thiacetazone 139, 140, 147, 151, 152
Thiacetazone(T) 140
Ticarcillin 23, 38, 44, 45, 51, 58, 60, 61, 65, 73, 74, 80, 99, 100, 111, 115, 117, 119, 296
Ticarcillin/clavulanate 23, 38, 58, 60, 61, 65, 73, 74, 111, 119
Tigecycline 47, 99, 102, 116, 123
Tinidazole 57, 68, 84, 212, 261, 262, 332, 333, 337
Tinidazole and diloxanide furoate 333
Tipranavir 152, 195
TMP-SMX 10, 96, 97, 106, 110, 116, 125, 196, 212, 213, 215, 226, 263, 265, 266, 276
Tobramycin 15, 34, 65, 72, 74, 80, 116, 118, 121, 300, 328
Topical benzoyl peroxide 88
Topical tobramycin eyedrops 15
Triazolam 208
Trimethoprim 9, 10, 123, 126, 231, 330
U
Ureidopenicillin 115, 117
V
Valacyclovir 44, 86, 242, 248
Valagancyclovir 241, 244
Valproate 208
Vancomycin 1, 3, 4, 8, 1618, 23, 3134, 37, 38, 47, 57, 60, 63, 65, 70, 89, 90, 98, 99, 101, 102, 112, 114, 116, 118, 121, 123, 126, 280, 281, 287, 294, 299, 300, 307, 309, 311, 329
Vidarabine 14, 248
Voriconazole 7, 17, 34, 65, 74, 254, 260
Z
Zalcitabine 188, 195, 209, 228
Zanamivir 246, 249
Zidovudine 188, 193, 195, 200, 203, 204, 217, 228, 229, 335
Diseases
A
Absidia infection 7
Acinetobacter infection 2
Actinomycosis 49
Active mycosis 107
Acute encephalopathy 5
Acute epididymo-orchitis 79
Acute hepatitis 146, 147, 150
Acute meningitis 13, 10
Acute pancreatitis 59
Acute pancreatitis or necrotizing pancreatitis 59
Acute parotitis 27
bilateral 27
unilateral 27
Acute pneumonia 41, 42
Acute rheumatic fever 36
AIDS dementia 224
Allergic bronchopulmonary aspergillosis 48
Animal and human bites 94, 96
Anorectal abscess 71
Anthrax 89
Appendicitis 65, 66, 315
appendicular abscess or mass 66
diverticulitis 67
proctitis 67
Ascites 133, 134
Aspergilloma 48, 254
Aspergillosis 48, 254
B
Bacillary angiomatosis 220
Biliary tract 285, 296
Blastomycosis 186
Blepharitis 11, 13
Bone and joint infection 102, 103
acute bursitis 102
acute osteomyelitis 102
acute septic monoarthritis 102
chronic osteomyelitis 103
Brain abscess 610, 310
Breast abscess 88
Bronchiectasis 7, 40, 48, 130, 279
Burn wound 100, 101, 102, 280
severe burns 100
superficial (mild) 100
Bursitis 102
C
Candida oesophagitis 233
Candidiasis 28, 83, 104, 177, 181, 183, 196, 214, 220, 227, 250, 251, 253, 282, 308
Cardiothoracic 294, 295
Cellulitis 18, 89, 90, 93, 94, 99, 100, 109, 127, 128, 283, 309
Cervicitis mucopurulent 82, 83
Chancroid 85, 315
Cholangitis 58
Chronic diarrhoea 180, 182, 212, 213
Chronic herpes simplex virus 183
Chronic liver disease 146, 147
Chronic meningitis 224
Chronic pneumonia 48
CNS symptoms 197, 248
CNS toxoplasmosis 184
Colorectal 296, 297
Community acquired bacteremia 110
typhoid fever 110
Conjunctivitis 1214, 282
Cryptococcosis 185, 196, 219, 224, 225, 233
Cryptosporidiosis 186, 212, 213
Cyclosporiasis 261
Cystitis 7476, 251, 317
Cystitis-recurrent 75
Cytomegalovirus 16, 24, 177, 215219, 233, 244, 311
D
Dacryoadenitis 11
Dengue 114, 239, 304
Dermatophytes 103105, 177, 220
seborrheic dermatitis 105
tinea barbae (beard) 105
tinea capitis (scalp) 104
tinea corporis (body) 104
tinea cruris (groin) 104
tinea manuum (hand) 104
tinea pedis (foot) 104
tinea unguum 105
Diabetic ulcer foot 99, 100
Diarrhoea/dysentery acute gastroenteritis 68
bacillary dysentery 69
non-typhoidal Salmonella 68
parasitic subacute or chronic 69
pediatric dysentery 68
pediatric acute gastroenteritis 68
severe bacterial diarrhoea 69
tropical sprue 69
Diphtheria 24, 35
Discitis 102
Donovanosis 87
Dyslipidemia 194, 195, 198
E
Ectoparasite 106
lice 106
scabies 106
Ehrilichiosis 113
Empyema 7, 8, 51, 132, 133, 181, 215
Empyema and bronchopleural fistula 51
Encephalitis 3, 9, 16, 177, 224, 226, 241
Endocarditis 7, 31, 56, 71, 127, 128, 250, 279, 284286, 304
Endometritis 80, 81
Endophthalmitis 16, 17
Epiglottitis 27, 283
Esophagitis 53, 244, 251
Extrapulmonary cryptococcosis 185
Extrapulmonary TB 129, 183, 200
F
Febrile neutropenia 307309
Fever 307, 322
Fifth disease 102
Filariasis (elephantiasis) 108, 109, 268
Food poisoning 70
Fournier's gangrene 94
G
Gastrointestinal 6570, 112, 135, 136, 204, 205, 287, 295, 297
Genital ulcers 84, 315
Gum abscess 28
H
Headache 16, 113, 134, 162, 164, 169, 175, 185, 188192, 217, 218, 236, 248, 258, 259, 272274, 310
Hepatic abscess 56, 262
Hepatitis 36, 54, 56, 96, 97, 146, 147, 150, 188194, 197, 202, 204, 208, 239, 240, 247, 274, 279, 289, 290, 304
acute 54
chronic 54
Hepatitis A 54, 239
Hepatitis B 5456, 96, 97, 188, 189, 239, 240, 279, 289, 290
acute 237
chronic 238
Hepatitis C 55, 240, 247
chronic 238
Hepatitis E 56, 240
acute 238
Herpes simplex 13, 16, 24, 28, 67, 82, 86, 183, 219, 232, 240, 241
chronic suppression 242, 250, 263
primary 242
recurrent 239
Herpetiform ulcers 28
Histoplasmosis 136, 186, 215, 216
HIV-associated cardiomyopathy 186
HIV-associated nephropathy 186
HIV associated skin diseases 219, 220
HIV encephalopathy 185, 224
Hordeolum (stye) 11
stye external 11
stye internal 11
Hospital acquired peritonitis 63
Hyperglycemia 125, 191, 198
Hypersensitivity reaction (HSR) 195
I
Influenza 21, 35, 36, 40, 44, 45, 245, 246, 311
Inguinal hernia repair 302
Intra-abdominal abscess community acquired 64
Iritis 1315
J
Jaundice 113, 149, 150, 162, 164, 197, 204, 209, 296, 306, 318
K
Keratitis (cornea) 13, 14
L
Lacrimal sac 11
Lactic acidosis 188, 198
Laryngitis 26
acute 26
chronic 26
Legionnaire's disease 41
Lemierre's disease 99
Leprosy 107, 332
paucibacillary 107
multibacillary 107
Lipoatrophy 198, 207
Lipohypertrophy 198
Ludwig's angina 29
Lung abscess 7, 49
Lyell disease 92
Lyme disease 96, 240
Lymphadenopathy 95, 131, 177, 179, 216, 227
M
Management of severe malaria 318
Mastoiditis 21
Measles 246, 288, 289
Mediastinitis 38
Meningitis 110, 127, 128, 134, 143145, 148, 176, 177, 181, 185, 217219, 224, 225, 239, 253, 283, 310, 315
Meningitis and cerebrospinal fluid 283
Microsporidiasis 213
Mucormycosis 18, 255
Mumps 1, 27, 36, 289
Myocarditis 32, 35, 37
bacterial 35
viral 35
N
Necrotizing gingivitis 29
Necrotizing infections 91, 93
Necrotizing pneumonia 45, 52
Neurosurgery 300
cerebrospinal fluid shunt 300
craniotomy 300
ocular 300
spinal surgery 300
Neurosyphilis 85, 217, 218, 225
O
Ophthalmia neonatorum 281, 282
Oral thrush 177, 214
Orbital cellulitis 18
Orthopedic surgery 299
amputation of leg 300
compound fracture 300
joint replacement 299
open reduction of fracture/internal fixation 299
Osteomyelitis of the jaws 30
Otitis externa 20
Otitis media 7, 19
P
Pancreatic abscess phlegmon 59, 60
Pancreatitis 59, 188, 195, 198, 204, 207, 276, 306
Panicilliosis 253
Papillomaviruses 246
Paracoccidiosis 256
Penicilliosis 186, 255, 256
Pericardial effusion 133
Pericarditis 32, 3537, 143, 144
bacterial 35
viral 35
Peripheral abscess 28
Peripheral neuropathy 138, 147, 188, 195, 202, 209, 224, 276
Perirenal and renal abscesses 71
Peritonitis 6163, 133, 250, 251
Peritonsillar abscess 25
Pertussis 24, 39
Pharyngitis 24, 25, 179, 205
Plaque 95, 112
Pleural effusion 42, 48, 50, 132, 215, 311
Pleural infection 50
dry pleurisy 50
parapneumonic effusion 50
pleural effusion 50
Pneumocystis pneumonia 183
Pneumonia–hospital acquired 46, 47
Post-influenza pneumonia 45
Primary spontaneous bacterial peritonitis 61
Prostatitis 78
acute 78
chronic 78
Psittacosis 311
Prosthetic valve 33, 285, 286
early 33
empiric 33
late 34
Psoas abscess 60, 135
Puncture wound 97, 98
Purulent phlebitis 98
Pyelonephritis 72, 76, 317
complicated 73
uncomplicated 72
Q
Q fever 112
R
Rabies 3, 5, 94, 96, 277, 278, 292, 293
Recurrent pneumonia 48, 227
Recurrent severe bacterial pneumonia 183
Renal failure 101, 119, 120, 133, 147, 149, 176, 290
Respiratory conditions 214, 215
Retinitis 16, 177, 184, 225, 233, 245
Retroperitoneal abscess 60
Retropharyngeal abscess 26
Rheumatic fever 36, 37, 282, 286
Rubella 36, 289
S
Scabies 106, 220, 271
Secondary bacterial peritonitis 61, 62
Sepsis syndrome 111
brucellosis 113
community-acquired 111
dengue 114
hospital acquired pathogen 112
leptospirosis 113
malaria 114
meningococcemia 113
rickettsial fever 112
tularemia 113
Severe acute respiratory syndrome 43
Severe peripheral neuropathy 204
Severe rash 151, 197, 202, 205207
Sexually transmitted disease (STD) 227
Sinusitis 7, 2123, 127, 128, 179, 217, 249, 304, 305, 310
Skin structure 88, 90
Sporotrichiosis 109
Sternal wound 37
Stevens-Johnson syndrome 169, 206, 207
Subperiosteal abscess 18
Superficial skin infections fungal dermatophytes 103
Synergistic necrotizing cellulitis 94
Syphilis 15, 67, 80, 84, 85, 134, 216, 218, 224, 225, 310
T
Tonsillitis 25, 26
Toxin mediated 91, 127, 128
toxic shock syndrome (TSS) 91
Toxoplasma encephalitis 177, 224, 226
Toxoplasmosis 184, 196, 215, 217, 218, 232, 266, 304
Tracheobronchitis 39
acute bacterial exacerbation of chronic bronchitis 39
acute laryngotracheobronchitis 39
bronchiolitis 40
Traumatic wound 302
Tropical pulmonary eosinophilia (TPE) 49
Tuberculosis 184, 200, 214216, 219, 227, 228, 231, 234, 304
Tuboovarian abscess 136
Tularemia 95, 113
Typhoid 110, 111, 131, 186, 291, 304
U
Ulcer (duodenal/gastric) 53
Urethritis 77, 127, 128, 317
male/female (STD related) 77
non STD in postmenopausal female 77
Urinary tract infection 127, 128, 317
Urology 301
dilatation of urethra 301
infected urine 301
prostatectomy sterile urine 301
prostatic biopsy 301
Uveitis 16, 225
V
Vaginitis 83, 84, 252
Ventilator-associated 47, 305
Z
Ziehl-Neelsen stain 319
×
Chapter Notes

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Antimicrobial Choice for Disease Conditions1

 
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
2
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.
3
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
4
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
5
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.
6
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.
7
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
8
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
9
(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
10
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.
11
 
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.
12
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
13
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
14
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.
15
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
16
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
17
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).
18
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
19
 
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.
20
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.
21
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
22
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
23
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.
24
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
25
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.
26
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
27
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
28
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.
29
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.
30
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.
31
 
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
32
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
33
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
34
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.
35
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
36
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.
37
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)
38
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.
39
 
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
40
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.
41
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)
42
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
43
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
44
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
45
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.
46
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
47
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.
48
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.
49
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
50
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.
51
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).
52
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:
  • Before starting antibiotics, efforts should be made to obtain pulmonary secretions such as expectorated sputum for gram stain and acid-fast stain. Best and most reliable for cultures are endotracheal secretions obtained using fiberoptic endoscope, protected specimen bronchial brush washings, pleural fluid via needle aspiration. Blood culture yields the organism in about 10–20% of cases.
  • Sputum gram stain with culture and sensitivity studies needed for recurrent or persistent necrotizing pneumonia.
  • Expectorated sputum or induced sputum valid for culture only if >25 polymorphic neutrophils seen per low power field or < 10 squamous epithelial cells per low power field seen on sputum smear stain preparation.
  • BAL (Bronchoalveolar lavage) is significant only if >10,000 to 100,000 colony-forming units/ml in culture occurred.
  • Bronchial washings obtained with protected specimen brush are significant at > 1000 CFU/ml.
  • Most etiological diagnosis of pneumonia is based upon clinical risk factors being present and radiological findings. Bacteriology may not help, since the sputum smear may only reveal colonizers. If gram positive diplococci seen on sputum smear > 90% specificity for S. pneumoniae.
  • Expectorated (orally obtained) sputum is invalid for anaerobic cultures. If Candida species obtained, then likely to be colonizers and no treatment is required.
53
 
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.
54
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.
55
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)
zoom view
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.
56
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
57
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.
58
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
59
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.
60
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
61
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
62
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.
63
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:
  1. Aseptic precautions
  2. HCW treatment of nasal carriers of S. aureus
  3. Intermittent dialysis instead of continuous.
  4. Application of Mupirocin (Bactroban) at catheter exit site, Rifampicin 600 mg PO OD × 5d/month × 3 months. If intra-abdominal abscess present, then do surgical drainage of abscess.
HCW = Health Care Worker
64
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.
65
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
  1. Because increasing resistance of E. coli to Ampicillin has been reported, locally prevalent susceptibility profiles to be used.
  2. Second generation cephalosporins include—Cefuroxime, Cefadroxil.
  3. Third generation cephalosporins include: Cefotaxime, Ceftriaxone, Cefixime, Ceftazidime, Cefepime and Cefpirome. Cefotetan and Cefoxitin are not available in India.
  4. Levofloxacin, Moxifloxacin or Gatifloxacin may be used instead of Ciprofloxacin.
  5. Tobramycin, Netilmicin, or Amikacin may be used instead of Gentamicin.
  6. If Candida spp found Fluconazole, Amphotericin B, Voriconazole or Caspofungin is appropriate when postoperative, or recurrent intra-abdominal, post-transplantation, neoplasm associated infection or while on immuno-suppressive therapy (Complicated intraabdominal infections).
  7. Routine coverage for enterococci is not essential in community-acquired infection. Local susceptibilities should be monitored for Ampicillin and Vancomycin resistance.
  8. Certain community acquired abdominal infections such as appendicitis have a high incidence of P. aeruginosa infections.
  9. Failure rates are higher in colonic infections if empirical choice is not active against all identified isolates.
66
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
67
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
68
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)
69
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
70
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.
71
 
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
72
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
73
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
74
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
75
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.
76
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.
77
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
  1. Ciprofloxacin 500 mg PO × 1 dose
    or Ofloxacin 400 mg × 1 dose
    or Cefixime 400 mg PO × 1 dose
  2. Doxycycline 100 mg PO BD × 7d
    or Azithromycin 1 gm PO × 1 dose
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
78
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
79
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.
80
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
81
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
82
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
83
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
84
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.
85
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)
86
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.
87
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.
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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
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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
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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
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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.
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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
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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
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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.
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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:
  1. Bacillary angiomatosus caused by Bartonella henselae or B. quintana is seen in immunocompromised patients with AIDS.
  2. Erysipeloid caused by Erysipelothrix rhusiopathiae responds to Amoxycillin 500 mg q8h.
  3. Glanders caused by Burkholderia mallei responds to imipenem 500 mg IV q6h + Doxycycline 100 mg BD × 14d. This is to be followed by Azithromycin 250 mg OD and Doxycycline 100 mg BD for additional 6 months.
  4. Bubonic plague caused by Yersinia pestis requires Ciprofloxacin 500 mg BD × 2 weeks.
  5. Tularemia caused by Franciscella tularensis requires Inj Streptomycin 1 gm IM BD × 2 weeks or Doxycycline 100 mg BD × 14d.
  6. Baylisascaris procyonis (from racoons) - only supportive care, mainly presents as Eosinophilia meningoencephalitis.
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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)
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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
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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
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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
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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
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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:
  1. SIRS (Systemic Inflammatory Response Syndrome).
  2. Sepsis.
  3. Severe sepsis.
  4. Septic shock. There is stepwise increase in mortality in these four stages (7%, 16%, 20% and 46%).
SIRS at least two criteria:
  1. Fever or hypothermia
  2. Tachycardia > 100/mt
  3. Tachypnoea > 30/mt
  4. Abnormal WBC count > 12,000 mm3
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.
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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.
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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
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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.
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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
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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.
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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.
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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
109
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.
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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
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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.
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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
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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
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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.