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Antibiogram SAMPLES RECEIVED IN UTI ARE ; URINE OR FOLEY'S TIP Processing of specimen-

Urine is processed by semiquantitative method of i.e. Calibrated loop method. samples are screened for significant bacteriuria by this method. samples which show 105 CFU/ml are processed for identification and susceptibility testing. Urinary tract infections (UTI) Antibiogram Most Esc Enteroco Pseudo Methicilli Citro Klebsie Acineto Can common here ccus spp monas n bacte lla bacter dida pathogens schi aerugino resistant r spp pneum spp spp a sa coagulas oniae coli e negative staphylo cocci Microbiology 18 7.7 7.1 5.6 5 4.5 2.5 _ data (n= 911) IPD Prevalance % Microbiology 12.9 3.9 _ 12.1 3.4 2.4 _ _ data (n= 380) OPD Prevalance % Microbiology 25 15.6 9.4 _ 3.1 3.1 3.1 9.4 data (n= 32) ICU Prevalance % Antibiotic IPD OPD ICU Sensitivity % Amikacin 57.6 85.2 60 4.4 2.5 0 5.9 14.8 0 Co- 33.4 52.9 31.3 trimoxazole Doxycycline 35.7 55.5 28.6 25.4 28.1 0 Nitrofurantoin 77.4 85.2 61.9 Norfloxacin 16.5 27.7 28.6 Ofloxacin 27.5 30.9 13.3 4.9 16.7 0 Piperacillin- 10.8 55.6 20 tazobactum Gentamicin 52.3 71.6 66.7 Carbenecillin 7.7 0 0 3.5 6.8 0 G 1.5 2.7 0 97.8 100 50 100 100 100

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SAMPLES RECEIVED IN BLOOD STREAM INFECTIONS ARE ; BLOOD CULTURE, STERILE BODY FLUIDS LIKE CSF & CENTRAL LINE TIPS Processing of specimen- Blood culutres are processesd by doing 3 alternate day subcultures If growth is present isolate is identified and antibiotic sensitivity testing done

Blood stream infections (BSI) IPD Antibiogram

Most Acineto Pseu Eschere Citroba Klebsiell Nonferm common bacter resistant domo schia cter a enter pathogens spp coagulase nas coli spp pneumo gram negative aerug niae negative staphyloco inosa bacilli cci

Microbiology data (n= 1215) 1.7 0.9 0.7 0.7 0.7 0.5 _ IPD Prevalance % Microbiology data (n= 181) 3.3 1.7 _ _ _ _ 1.1 ICU Prevalance % Antibiotic IPD ICU Sensitivity % Amikacin 50.7 66.6 Ampicillin 4.1 0 Cefotaxime 9.6 0 Co- 30.9 55.5 trimoxazole Chlorampheni col 53.4 77.7 Imipenem 13.6 0

ciprofloxacin 30.9 55.5 Ofloxacin 24.5 55.5 Piperacillin 4.9 0 Piperacillin- 36.9 22.2 tazobactum Gentamicin 54.3 66.6 Cefazolin 0 0 Penicillin G 4.8 0

Teicoplanin 71.4 100 Vancomycin 100 100

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SAMPLES RECEIVED IN RESPIRATORY INFECTIONS ARE ; SPUTUM, BAL, ENDOTRACHEAL SECRETIONS AND ENDOTRACHEAL TIP Processing of specimen Sputum samples are processed after screening for quality of sputum whether saliva or purulent sputum samples which show 105 CFU/ml are processed for identification and antibiotic susceptibility testing.

Respiratory infections Antibiogram

Most common Eschereschia Pseudomonas Citrobacter Klebsiella Acinetobacter pathogens coli aeruginosa spp pneumoniae spp Microbiology data (n= 609) IPD 2.9 9 2.1 7.7 _ Prevalance % Microbiology data (n= 98) OPD _ 3 1.1 5.1 _ Prevalance % Microbiology data (n= 148) ICU _ 13.5 _ 6.1 16.2 Prevalance % Antibiotic IPD OPD ICU Sensitivity % Amikacin 94.8 100 44.4 Ampicillin 0 0 0 Cefotaxime 5.8 50 0 Co-trimoxazole 29.2 50 33.3 Doxycycline 29.2 60 33.3 Imipenem 24.8 20 11.1 Ciprofloxacin 56.2 80 33.3 Ofloxacin 22.6 70 11.1 Piperacillin 38.1 33.3 0 Piperacillin- 50.4 70 55.5 tazobactum Gentamicin 72.3 100 55.5 Carbenecillin 41.8 66.6 0 Cefazolin 26.9 NA NA Penicillin G 0 NA NA Teicoplanin 88.4 NA NA Vancomycin 100 NA NA

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SAMPLES RECEIVED IN SKIN AND SOFT TISSUE INFECTIONS ARE ; PUS, WOUND SWABS, TISSUE

Processing of specimen- Samples are processed by standard microbiological techniques

Skin and Soft Tissue Infections Antibiogram Most common Escheres Pseudomonas Methicillin Klebsiella Acinetobacter pathogens chia coli aeruginosa resistant pneumoniae spp coagulase negative staphylococci Microbiology data (n= 1160) IPD 28.4 10.1 9.22 7.8 10 Prevalance % Microbiology data (n= 120) 10.8 12.1 OPD Prevalance % Microbiology data (n= 208) ICU 23.7 15.6 34.4 Prevalance % Antibiotic IPD OPD ICU Sensitivity % Amikacin 57.4 78.1 18.8 Ampicillin 3.1 6.3 0 Cefotaxime 3.9 12.5 0 Co-trimoxazole 32.3 25 40.9 Doxycycline 30.6 31.3 18.8 Imipenem 15.6 18.8 7.4 Ciprofloxacin 32.6 46.9 24.6 Ofloxacin 17.1 31.3 7.4 Piperacillin 17.9 37.5 7.7 Piperacillin- 27.4 46.9 69.2 tazobactum Gentamicin 48.2 65.6 16.4 Carbenecillin 14.5 25 0 Cefazolin 7.4 25.7 12.5 Penicillin G 0.6 0 0 Teicoplanin 65.2 80 100 Vancomycin 100 100 100

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1. Medicine Clinical Empiric / 1st Alternative Remarks/Comments condition line antibiotics antibiotics 1. Urinary tract Nitrofurantoin 100mg Piperacillin- Get urine cultures before infection orally BD for 7 days 4.5g IV antibiotics & modify (UTI) Cotrimoxazole 960mg 6 hourly therapy based on 12 hourly for 3-5 days OR sensitivities. Amikacin Imipenem 1g IV 8 Monitor renal function if 1g OD IM/IV hourly aminoglycoside is used Gentamicin 7mg/kg/d OR OD IM or IV Ofloxacin 200- Norfloxacin 400mg 12 hourly 400mg BD for 7 days OR Vancomycin 15 mg/kg IV 12 hourly 2. Upper Azithromycin Amoxyclav respiratory 500mg od for 3 days 625mg 1-1-1 for 7 tract OR days infections Roxithromycin CV 300mg od for 5 days 200mg 1-0-1 for 7 Ciprofloxacin 500mg days orally 12 hourly for 3-5 OR days Teicoplanin6-30 Cefazolin mg/kg/day IV 2gm IV stat OR Cotrimoxazole 960mg Cefotaxime 12 hourly for 3-5 days 1-2gm 6-8 hourly 3. Lower Amikacin Imipenem Amikacin max doses respiratory 15mg/Kg/day q 8-12 1g IV 8hourly 1.5mg/Kg tract hours IV OR If a typical pneumonia infection Gentamicin suspected, Doxycycline 7.5mg/kg/day OD i.m or 1g IV 8hourly 100mg bd i.v for 10 days Piperacillin – Inj. Amoxyclav Tazobactam 1gm 1-0-1 for 7 days 4.5gm IV 8 hourly Cefotaxime for 7-10 days. 500mg 1-1-1 for 7 days Ofloxacin Roxythromycin 200-400mg orally 12 300mg I.V. 1-0-1 hourly Cefazoline Vancomycin 0.52 gm 6-8 hourly IV 15mg/kg IV 12 Ciprofloxacin hourly 500mg 12 hourly Doxycycline 100mg 12 hourly orally 4. Enteric Ofloxacin 15mg/kg/d Change empiric regimen fever 1gm IV 8 hours in two divided doses. based on susceptibility Till afebrile then Meropenem testing. Duration of 1gm 1-0-1 for 7 days 1gm IV 8 hourly till treatment: 10-14 days. Chloramphenicol afebrile then 12 Antibiotic therapy should 500mg qid orally hourly for 7 days. be continued till one week Ciprofloxacin 750mg 12 post-fever defervescence hourly 5. Septicemia Amikacin Imipenem 15mg/Kg/day q 8-12 1g IV 8hourly OR 5

hours IV Meropenem Gentamicin 1g IV 8hourly 1mg/kg IM or IV 8 Piperacillin – hourly Tazobactam Ceftriaxone 4.5gm IV 8 hourly for 7- 1gm 8 hourly 10 days. Ciprofloxacin Ofloxacin 15mg/kg/d in 400 mg IV 12 hourly two divided doses Vancomycin 15mg/kg IV 12 hourly Teicoplanin 6-30 mg/kg/day IV 6. Pyrexia of Ceftriaxone unknown 2gm IV orally 24 hourly origin (PUO) OR Cefotaxime 50mg/kg/dose 6 hourly IV Amikacin 15mg/Kg/day 8-12 hourly IV 7. VAP Piperacillin- Meropenem (Ventilator tazobactam 1g IV 8hourly Associated 4.5g IV 6 hourly OR Pneumonia) Amikacin 20mg/Kg/day Teicoplanin 8-12 hourly IV 6-30 mg/kg/day IV Gentamicin 7mg/kg/d IM or IV 8 hourly Tobramycin 7mg/kg/d Ciprofloxacin 400 mg 8 hourly Levofloxacin 750 mg daily Vancomycin 15 mg/kg 12 hourly Imipenem 1g IV 8hourly 8. Meningitis Ceftriaxone Vancomycin 1-2 gm 12-24 hourly IV 15 mg/kg 12 hourly Cefotaxime Meropenem 2gm IV 8 1-2 gm 6-8 hourly IV hourly Amikacin 20mg/Kg/day 8-12 hourly IV Gentamicin 7mg/kg/d IM or IV 8 hourly for 10-14 days 9. Diarrhoea / Doxycycline Ceftriaxone Dysentry 300 mg oral stat only for 2 gm IV OD for 5 days Cholera Ofloxacin Norfloxacin 200-400mg 12 hourly 200-400mg 12 hourly orally Gentamicin 1mg/kg IM or IV 8 hourly Rifaximin 6

200mg 1-0-1 for 5 days Amikacin 15mg/Kg/day q 8-12 hours IV

10 Empiric Cefazolin Amoxicilin-clavulanate Adjust regimen after therapy of 2 g IV q8h 1.2 g IV q8h receipt of culture and suspected Or or susceptibility data. Gram Penicillin G Duration of treatment positive 2 g IV q6h 20 laks IV q4h (if will depend on final infections S.aureus excluded) diagnosis. or Vancomycin (if anaphylactic penicillin allergy or MRSA clinically possible) 11 Empiric Piperacillin- Imipenem Separate anaerobic therapy for tazobactam 1 g IV q8h coverage unnecessary suspected 4.5 g IV q6h or for IAI, when using BL- Gram or Meropenem BLIs or . negative - 1 g IV q8h De-escalate to infections or ciprofloxacin, co- (eg 3 g IV q12h trimoxazole or third pyelonephriti 1 g IV od (carbapenems generation s or intra- preferred for more if isolate abdominal seriously ill patients) is sensitive. infections) Duration of treatment: 10-14 days for pyelonephritis, 4-7 days for IAI. 12 Rickettsial Doxycycline Azithromycin Duration of treatment: infections 100 mg po or IV bd 500 mg po or IV od, 7 days chloramphenicol 500mg qid 13 Leptospirosis Penicillin G Ceftriaxone Duration of treatment: 20 laks IV q4h or 2 g IV od 7 days Doxycycline 100 mg po or IV bd 14 Vivax Chloroquine Artemether- Followed by malaria 25 mg/kg body weight lumefantrine primaquine (0.25 divided over three days (1 tab bd for 3 days) mg/kg daily for 14 i.e. days) 10 mg/kg on day 1, 10 mg/kg on day 2 and 5 mg/kg on day 3.

15 Falciparum Artesunate Artemether- Followed by malaria 4 mg/kg body weight lumefantrine primaquine single dose daily for 3 days (1 tab bd for 3 days) (0.75 mg/kg). Plus All mixed infections Sulfadoxine should be treated with (25 mg/kg body weight) full course of ACT and and Pyrimethamine primaquine 0.25 mg (1.25 mg/kg body per kg daily for 14 weight) on first day. days. 7

16 C. difficile Metronidazole Vancomycin Stop any ongoing Colitis 400 mg orally three 125 mg orally four times antibiotic, if possible. Mild disease times daily for 10 to 14 daily Substitute with low-risk days antibiotic if possible. Correction of fluid and electrolyte imbalance 17 C. difficile Vancomycin If not able to tolerate Monitor organ function Colitis 125 mg orally four times oral vancomycin, closely; Severe daily for 10 to 14 days, vancomycin retention Consider surgery for disease can be increased to 500 enema severe persistent mg 4 times daily (500 mg in 100 ml symptoms, toxic normal saline given six megacolon, severe hourly ) with ileus, or peritonitis. intravenous metronidazole 500 mg 8 hourly.

18 Cholera Doxycycline Azithromycin Rehydration (oral/IV) 300 mg PO stat 1 gm PO stat essential or Antibiotics are Ciprofloxacin adjuvant therapy 500 mg BD for 3 days

19 Bacterial Ceftriaxone Azithromycin dysentery 2 gm IV OD for 5 days 1 gm od x 3d

20 Amoebic Metronidazole Tinidazole Add diloxanide furoate dysentery 500 to 750 mg IV q8h 2 gm PO OD for 3 days 500 mg tds for 10d for 7-10 days 21 Febrile Piperacillin + if fever persists or ANC Neutropenia (150 mg/kg/day in 3div Tazobactam (200-300 remains <200 doses) mg/kg/day IV in 3-4 div parenteral therapy + doses)+ Vancomycin should be continued Amikacin (40 mg/kg/day IV in 4 with 2nd line antibiotics (15-20mg/kg/day in 2 or divided doses) 3 div doses)

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2. Pediatrics Sr. Clinical Empiric antibiotics/1st Alternative Remarks/Comments No. condition line antibiotics antibiotics 1 Urinary Parenteral (for Meropenem Get urine cultures before Tract pylonephritis) 120mg/kg/day 8 antibiotics & modify Infection Inj. Amikacin 15mg/kg/d hourly therapy based on q24h X 10-14 days Vancomycin sensitivities OR 60mg/kg/day 6 Inj. Ceftriaxone hourly for 10-14 75mg/kg/day in divided days doses 10-14 days Piperacillin- Oral for Tazobactam Uncomplicated UTI 300mg/kg/d 8 hourly for 10-14 days Amoxyclav (30-50mg of ) Teicoplanin for 7-10 days 10mg/kg/day OR /dose every 12 Co-trimoxazole hours for 3 doses (8-10mg/kg/d of TMP then 10mg/kg/day component) orally 12 once daily hourly Ofloxacin OR 20mg/kg/d 12 Nitrofurantoin 8mg/kg/d hourly orally 6 hourly for 5-7 days 2 Upper Amoxycillin Respiratory 40mg/kg/d orally 6- 8 Tract hourly for 10 days Infections OR Amoxy-clav (30-50 mg of Amoxicillin) for 7-10 days 3 Lower Amoxy-clav Meropenem respiratory (30-50 mg of 120mg/kg/day tract Amoxicillin) for 7-10 days 8 hourly infection OR Vancomycin Cefotaxime 100mg/kg/d 60mg /kg/day 6 IV 8 hourly for 10- 14 hourly for 10-14 days days OR Piperacillin- Ceftriaxone 100mg/kg/d Tazobactam IV 12 hourly for 10-14 300mg/kg/d 8 days hourly for 10- 14 days 4 Enteric Ceftriaxone 100mg/kg/d Ofloxacin Antibiotic therapy should fever IV 12 hourly for 10-14 15mg/kg/d 12 be continued till one week days hourly for 10-14 post-fever defervescence OR days shift to oral cefixime once Cefixime Azithromycin fever resolves 20mg/kg/d for 14 days 20mg/kg/d for 7 days

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5 Septicemia / Ampicillin Meropenem bacteremia 100-400mg/kg/d IV 6 120 mg/kg/day 8 hourly hourly OR Vancomycin Ceftriaxone 100mg/kg/d 60mg /kg/day 6 IV 12 hourly for 7-10 days hourly OR Piperacillin- Cefotaxime Tazobactam 150mg/kg/d IV 6-8 hourly 300mg/kg/d 8 for 10- 14 days hourly + Ofloxacin Gentamicin 20mg/kg/d 12 5-7.5mg/kg/d IM or IV 24 hourly hourly for 7-10 days Teicoplanin OR 10mg/kg/day Amikacin /dose every 12 15-20mg/kg/d 24 hourly hours for 3 doses then 10mg/kg/day once daily

6 Pyrexia of Ceftriaxone 100mg/kg/d Piperacillin- unknown IV 12 hourly for 7-10 days Tazobactam origin PUO) 300mg/kg/d 8 hourly

7 VAP Piperacillin- Modify based on culture (Ventilator Tazobactam 300mg/kg/d of lower respiratory tract Associated 8 hourly secretions. Pneumonia) OR Vancomycin Stop antibiotics after 5 40-60mg /kg/day 6-8 days of clinical response hourly OR Meropenem 120 mg/kg/day 8 hourly 8 Meningitis Ceftriaxone 100mg/kg/d Vancomycin Discontinue Vancomycin IV 12 hourly for 10-14 60mg /kg/day 6 if rapid latex agglutination days hourly for 10-14 negative for S. days if Staph/ pneumoniae or positive resistant for N. meningitides, or H. pneumococcal influenza disease suspected. 9 Diarrhoea / Co-trimoxazole Dysentery (8-10mg/kg/d of TMP component) orally 12 hourly OR Cefixime 8-10 mg/kg/day in divided doses for 5 days Parenteral Ceftriaxone 100mg/kg/d IV 12 hourly for 5-7 days

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10 Infective Cefotaxime Vancomycin Endocarditis 150mg/kg/d IV 6-8 hourly 60mg /kg/day 6 + hourly Gentamicin + 5-7.5mg/kg/d IM or IV 24 Gentamicin hourly 5-7.5mg/kg/d IM or IV 24 hourly 11 Shunt Vancomycin Infection 60mg /kg/day 6 hourly + Gentamicin 5-7.5mg/kg/d IM or IV 24 hourly

Clinical Empiric Alternative Remarks/Comments condition antibiotics/1st line antibiotics antibiotics EOS Ampicillin Piperacillin - Always send Blood for culture including 70-100mg/kg/day Tazobactam and sensitivity testing before meningitis Gentamicin 100mg/kg/day starting antibiotics 5mg/kg/day Amikacin -Modify therapy based on Duration : 14 days 15mg/kg/day sensitivity (culture positive -Step antibiotics if blood sepsis) culture negative in suspected 21 days (Meningitis) sepsis & baby stable clinically

LOS including Piperacillin - Piperacillin - Always send Blood for culture meningitis Tazobactam Tazobactam and sensitivity testing before Gentamicin 100mg/kg/day starting antibiotics 5mg/kg/day Amikacin -Modify therapy based on Duration - 14 days 15mg/kg/day sensitivity (culture positive -Step antibiotics if blood sepsis) culture negative in suspected 21 days (Meningitis) sepsis & baby stable clinically Gm Positive Cloxacillin Meropenem Always send Blood for culture 50mg/kg/day 20mg/kg/dose and sensitivity testing before Gentamicin Vancomycin starting antibiotics 5mg/kg/day 10-15 mg/kg/dose -Modify therapy based on Duration - 14 days sensitivity (culture positive -Step antibiotics if blood sepsis) culture negative in suspected 21 days (Meningitis) sepsis & baby stable clinically Acinetobacter Meropenem Vancomycin Always send Blood for culture 20mg/kg/dose 10-15 mg/kg/dose and sensitivity testing before Gentamicin Linezoid starting antibiotics 5mg/kg/day 10 mg/kg/dose -Modify therapy based on Duration - 14 days sensitivity (culture positive -Step antibiotics if blood sepsis) culture negative in suspected 21 days (Meningitis) sepsis & baby stable clinically

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Pan Resistant Colestin Always send Blood for culture 25000 units/kg/dose and sensitivity testing before Duration - 14 days starting antibiotics (culture positive -Modify therapy based on sepsis) sensitivity 21 days (Meningitis) -Step antibiotics if blood culture negative in suspected sepsis & baby stable clinically

MDR organisms (Paediatrics) Clinical Empiric antibiotics/ 1st Alternative Remarks/Comments condition line antibiotics antibiotics MRSA infection Vancomycin Linezolid MRSA strains may be 25-30 mg IV loading 600 mg IV/Oral 12 reported as followed by 15-20 mg/kg 8- hourly susceptible to 12 Hourly Fluoroquinolones, OR aminogycogides, Teicoplanin 6mg/kg IV once a chloramphenicol and 12 mg/kg x3 doses followed day doxycycline in-vitro, by 6 mg/kg once a day these drugs are NOT OR to be used alone or Piperacillin – Tazobactam as initial treatment for 4.5gm IV 8 hourly serious MRSA infections MDR infections Meropenem base Enterobactericea 120mg/kg/day divided 8 2.5 – 5 mg/kg/day & non- hourly I/V every 6 – 12 fermenting GNB OR hourly (1mg= Piperacillin – Tazobactam 30000 IU) 4.5gm IV 8 hourly for 7-10 B days 15,000-25,000 Ofloxacin units/kg/day divided 200-400mg orally/IV 12 q12hr; not to hourly exceed 25000 units/kg/ day Tigecycline 100mg followed by 50mg every 12 hourly infusion over 30-60 minutes

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3. SURGERY Sr Clinical Empiric antibiotics/ 1st Alternative antibiotics Remarks/Comment No conditio line antibiotics s n 1 UTI Tab. Nitrofurantoin Inj. Piperacillin with Can Be Changed 100mg 12 hrly Tazobactam According To Urine OR 3.375 IV 6 hourly OR Culture Sensitivity Tab. Cotriamoxazole Tab. Ofloxacin DS 12 hrly 300 mg 12 hourly OR OR Inj. Imipenam Tab Doxycycline 500 mg IV 6hourly 100 mg 12 hrly Meropenam OR 1 gm IV 24 hourly Inj Amikacin 250 mg IV/IM 12 hrly OR Inj. Gentamicin 5mg/kg IV OD 2 Skin soft Tab Cotrimoxazole 12 Inj. Vancomycin Can Be Changed tissue hrly + 15 mg/kg IV12 hrly According To Pus Cellulitis Tab Amoxycillin Culture Sensitivity 500 mg Tab Doxycycline 100 mg 12 hrly OR Inj. Clindamycin 600 mg 6 hrly IV 3 Cutaneo Tab Doxycycline Inj. Vancomycin Can Be Changed us 100 mg 12 hrly, 15 mg/kg IV 12 hrly According To Pus Abcess Tab Cotrimoxazole DS Culture Sensitivity 12 hrly + Tab Cloxacillin 500 mg 6hrly 4 Diabetic Inj. Vancomycin Can Be Changed Foot 15 mg/kg IV 12 hrly According To Pus + Culture Sensitivity Inj. Piperacillin with Tazobactam 3.375 IV 6 hrly + Inj. Metronidazole 500 mg 8 hrly IV

5 Cholecy Inj. Ceftriaxone Severe cases Surgical or stitis, 1 gm 12 hrly IV Inj. Imipenam endoscopic cholangi Inj. Piperacillin with 500 mg IV 6hrly OR intervention to be tis Tazobactam Meropenam considered if there 3.375 IV 6 hourly 1 gm IV 24 hrly + is biliary obstruction. Inj. Metronidazole De-escalate to 500 mg 8 hrly IV narrow spectrum agent on receipt of sensitivities.

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6 Septice Inj. Ceftriaxone Inj. Meropenem mia/ 1 gm 12 hourly IV + 2 gm 8 hrly bactere Inj. Metronidazole 500 + mia mg 8 hrly IV Inj Vancomycin Inj. Cefotaxim 500 mg 1 gm 12 hrly IV, IV 6 hrly Inj. Piperacillin with Inj. Amoxycillin Tazobactam + 1.2 3.375 IV 6 hrly gm BD Inj. Teicoplanin Tab Doxycycline 100 6 mg/kg 12 hrly IV or IM mg 12 hrly, 7 SSI Inj Amoxycillin Inj. Meropenem (Surgical +Clavulanic acid 2 gm 8 hrly site 1.2 gm BD , + infection Inj. Cefotaxim Inj Vancomycin ) 500 mg IV 6 hrly 1 gm 12 hrly IV G.U.T. Tab Cetriaxone Inj. Piperacillin with 1 gm 24 hrly, Tazobactam Inj Pipercillin 3.375 IV 6 hrly +Tazobactam 3.375gm Inj. Teicoplanin every 6 hrly OR 4.5 gm 6 mg/kg 12 hrly IV or IM every 8 hrly IV, Tab Doxycycline 100 mg 12 hrly Tab Metronidazole 500 mg 8 hrly IV 8 Wound Inj. Amoxycillin Inj. Meropenem 2 gm 8 infection +Clavulanic acid hrly + 1.2 gm BD Inj Vancomycin 1 gm 12 Tab Cetriaxone hrly IV 1 gm 24 hrly Inj.Piperacillin with Tazobactam 3.375 iv 6 hrly Inj. Teicoplanin 6 mg/kg 12 hrly IV or IM 9 Acute Piperacillin- TMP/SMX DS PO q12h Obtain urine and prostatiti tazobactam blood cultures s 4.5 gm IV q 6h or before antibiotics & Cefoperazone- switch to narrow sulbactam spectrum agent 3 gm IV q 12h or based on Ertapenem sensitivities. Treat 1 gm IV OD or for 4 weeks. Ciprofloxacin 750 mg po bid Therapy based on urine and prostatic Chronic massage cultures bacterial obtained before prostatiti antibiotics. s Treat for 4-6 weeks

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4 . OBSTETRICS AND GYNAECOLOGY Sr Clinical Empiric Alternative Remarks/Comments no condition antibiotics/ 1st antibiotics line antibiotics 1 Vaginal delivery: in Inj. Cefotaxime Inj. Cefazolin Not recommend routinely the following 2gm IV followed 2 gm iv followed for normal vaginal situations: by 1 gm IV 4 to 6 by 1 gm 8 hourly delivery.  Pr hourly till delivery till delivery. Delivery is considered eterm labour (<37 If allergic then akin to drainage of an wks) Vancomycin 1 abscess as the fetus and  Pr gm iv till delivery placenta is removed olonged rupture of which are the nidus of membranes infection (>18hrs)  F ever during labour or chorioamnionitis  Hi story of previous baby with GBS infection  Bl adder or kidney infection due to GBS 2 3rd or 4th degree Single dose Single dose : Prophylaxis is considered Perineal tear Cefotaxime Inj. Cefazoline to prevent adverse OR 1 gm IV + Inj. outcomes arising from Ceftriaxone Metronidazole infection e.g. fistulas 1 gm IV 500 mg IV OR Single dose of Inj. 1.5gm+ Inj. Metronidazole 500 mg IV OR Inj.Amox+ Clavulanic acid 1.2 gm IV If allergic, single dose IV clindamycin 600- 900mg 3 Preterm pre- IV Cefotaxime If Erythromycin labour rupture of 2gm followed by 333 mg not membranes 1gm 4-6 hourly available, use for 48 hours Erythromycin followed by stearate 250 mg cefixime 200mg 6 hourly for 8 hourly for 5 7days days + oral Erythromycin 333mg 8 hourly for 7 days

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4 Caesarean Single dose If allergic, single Puerperal endometritis is delivery Inj. Cefotaxime dose clindamycin polymicrobial, (aerobic- 2 gm IV 600-900mg IV + anaerobic). Dose is 3 gm if Gentamicin 1.5 These organisms are part patient is >100kg mg/kg IV of vaginal flora and are introduced into the upper genital tract coincident with vaginal examinations during labor and/or instrumentation during surgery Tita et al showed the addition of 500mg azithromycin to cefazolin for (in labour or with membranes ruptured) reduced Endometritis & wound infection significantly (6.1% vs. 12%, p<0.001), endometritis (3.8% vs 6.1%, p=0.02) wound infection (2.4% vs. 6.6% , p<0.001) 5 Rescue cervical Inj. Ampicillin 2 To prevent ascending encerclage gm single dose infection from vaginal flora to exposed membranes 6 Puerperal sepsis/ Inj. Piperacillin Clindamycin Septic abortion/ + Tazobactam 600-900mg IV 8 chorioamnionitis 4.5 gm IV 8 hourly + hourly for 7 - 14 Gentamicin days 60 mg IV 8 hourly + Metronidazole 500 mg IV8 hourly OR Ampicillin – Sulbactam 3gm IV 6 hourly 7 Hysterectomy Inj. Cefotaxime Cefuroxime (AH,VH, 2gm IV single 1.5gm IV single Laparoscopic) dose dose and surgeries for Dose is 3 gm if OR if allergic to pelvic organ patient is >100kg cephalosporin, prolapsed and/or Clindamycin 600 stress urinary -900 mg IV + incontinence Gentamicin 1.5 mg/kg IV

8 Laparoscopy Inj. Cefazolin Cefuroxime (uterus and/or 1 gm single dose 1.5 gm single vagina not IV dose IV entered)/ If allergic use 16

Hysteroscopy/ clindamycin 600 ectopic mg pregnancy 9 Abortions Tab. Doxycycline No prophylaxis for (medical and Azithromycin 100mg orally missed/ incomplete surgical) 1gm orally+ twice daily for 7 abortion Tab days, starting on Metronidazole day of abortion + 800 mg orally at Metronidazole time of abortion 800mg orally at time of abortion 10 Postoperative Inj Amoxycillin Surgical site + Clavulanic infection acid Obstetrics 1.2 gm BD + Inj Metronidazole 500mg TDS OR Gentamicin 5mg/kg IV OD + Inj. Metronidazole 500 mg 8 hrly. 11 HSG Tab Doxycycline continued for Doxycycline twice daily for 5 days if 100 mg orally there is history of PID or before procedure fallopian tubes are dilated at procedure 12 Pelvic NACO: CDC: Inflammatory Tab. Cefixime Levofloxacin disease (mild to 400mg orally stat 500mg OD x 14 moderate) + days Tab. OR Metronidazole Ofloxacin 400mg BD for 14 400 mg OD for days 14 days with or + without Cap. Metronidazole Doxycycline 500 mg BD for 14 100mg BD for 14 days days OR Ceftriaxone 250 mg IM single dose + Doxycycline 100mg orally BD for 14 days with or without Metronidazole 500mg BD for 14 days 13 Pelvic Inj An attempt should be Inflammatory 2 gm IV BD 2gm IV 6 hourly + made to obtain cultures disease ( severe + Doxycycline and deescalate based on 17

) eg tubo-ovarian Doxycycline 100mg orally or that. abscess, 100mg orally or IV 12 hourly Duration is two weeks, but pelvic abscess, IV BD OR can be extended Clindamycin depending upon clinical 900mg IV 8 situation. Antibiotics may hourly be altered after obtaining + Gentamicin culture reports of pus/or loading dose blood 2gm/kg IVor IM followed by maintaince dose 1.5 mg/kg every 8 hours. Single daily dosing (3- 5mg/kg) can be substituted 14 Vaginal Tab Fluconazole Miconazole, Treat for 7 days in candidiasis 150 mg orally Nystatin, vaginal pregnancy, diabetes, single dose tablets/creams Recurrent infections: 150 OR mg Fluconazole on day local 1,4,7 then weekly for 6 Clotrimazole months 500mg vaginal tablet once only 15 Vaginal Tab Secnidazole Alcohol avoided during trichomoniasis 2gm oral single treatment and 24 hours dose after metronidazole or 72 OR hours after completion of Tab Tinidazole tinidazole to reduce 500mg orally BD possibility of disulfiram- for 5 days OR like reaction. Partner Tab.Metronidaz treatment essential ole 400 mg BD for 7 days 16 Bacterial Metronidazole Secnidazole Refrain from sexual vaginosis 400 mg BD for 7 2gm orally OD for activity OR use condoms days one day during the treatment. OR OR Clindamycin cream is oil- Metronidazole Tinidazole based and might weaken gel 2 gm orally OD latex condoms 0.75% one for 2 days applicator(5g) OR intra-vaginal for 5 Tinidazole days 1 gm orally OD OR for 5 days Clindamycin OR cream Clindamycin 2% one Orally 300 mg BD applicator(5 gm) for 7 days intra-vaginal for 7 OR days Clindamycin ovules 100mg intravaginally OD HS for 3 days. 18

17 UTI Tab Uncomplicated Nitrofurantoin 50-100 mg for 4 times Tab Ciprofloxacin 500 mg BD for 14 days OR Tab Norfloxacin 400 mg BD for 14 days 18 Pyelonephritis Piperacillin with Tazobactam 3.375 IV 6 hourly for 14 days 19 Asymptomatic Tab bacteruria in Nitrofurantoin pregnancy 50-100 mg for 4 times

20 Cystitis Tab Nitrofurantoin 50-100 mg for 4 times Tab Ciprofloxacin 500 mg BD for 14 days OR Tab Norfloxacin 400 mg BD for 14 days

9. OPTHALMOLOGY Sr Clinical Empiric antibiotics/ Alternative Remarks/Comments no condition 1st line antibiotics antibiotics 1 Blepharitis e/d Chloramphenicol Lid margin care with baby Anteroir BD for 7 days shampoo and warm Tab Azithromycin compress 24 hrly. 500 mg for 3 days Artificial tears if Posterior Topical e/d associated with dry eye Tobramycin 0.5% OR e/d Gentamicin 0.3% Refractory cases Tab Doxycycline 100 mg BD for 1 week then daily for 6 to 12 weeks 2 External Tab Levofloxacin 500 Hot fomentation Hordeolum mg/day for 5 days. Pus evacuation by (Stye) Tab. Cloxacillin 250- epilation. 500 mg QID 19

Tab Cephalexin 500 mg QID 3 Bacterial e/d Gatifloxacin 0.3% conjunctivitis e/d Levofloxacin 0.5% e/d Moxifloxacin 0.5% 2 hrly for 1 st 2 days then 4-8 hourly upto 7 days 4 Acute bacterial e/d Moxifloxacin 0.5% e/d Gatifloxacin Moxifloxacin t/t may fail keratitis 1 hourly for 48 hrs then 0.3% against MRSA as per response 1 drop 1 hourly for 48 hrs then reduce as per response

5 Acute bacterial e/d Tobramycin 0.5% e/d Ciprofloxacin infection OR 0.3% complicateds Gentamicin 0.3 % e/d or (pseudomonas) + e/d Levofloxacin e/d Piperacillin 0.5% Or Ticarcellin (6-12 mg/ml) 15-60 min around clock 24-72 hr , then slowly reduce frequency 6 Orbital Cellulitis Inj.Cloxacillin If allergic to If MRSA is suspected 2gm IV 4 hrly Penicillin then substitute Cloxacillin + Vancomycin with Vancomycin Inj. Ceftriaxone 1 gm IV 12 hrly 2 gm IV 24 hrly + + Levofloxacin Inj. Metronidazole 750 mg IV od 1 gm IV 12hrly + Metronidazole 1 gm 24 hrly 7 Endophthalmitis Immediate Adjuvant Bacterial ophthalmology systemic consultation. Immediate (doughtful value vitrectomy + intravitreal in post cataract antibiotics (Inj surgery vancomycin + Inj endophthalmitis ) Ceftazidime) Inj Vancomycin + Intravitreal antibiotics Inj Meropenam . Inj. Vancomycin+ Inj Ceftazidine + systemic antibiotics Inj. Meropenam 1 gm IV 8 hrly OR Inj. Ceftriaxone 2gm IV 24 hrly + Inj. Vancomycin 1 gm IV12 hrly

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8 Cataract Sx Tab. Ciplox 500mg BD for 5 days e/d Ciprofloxacin 0.3% OR e/d Moxifloxacin 0.5% QID 9 Acute Tab.Amoxicillin and Dacryocystitis Clavulinic acid 625 mg 12 hourly e/d Moxifloxacin 0.5% 8 hourly

ANTI - VIRAL AND ANTI - FUNGAL Sr Clinical Empiric Alternative Remarks/Comments no condition antibiotics/ 1st antibiotics line antibiotics 1 Herpes simplex Trifluridine Ganciclovir Fluorescein staining shows keratitis ophthalmic 0.15% topical dendritic figures 30 solution 1 drop 2 ophthalmic gel – 50 % re-cure within 2 hour, upto 9 times/ for acute years day until re – herpetic keratitis epithelized then 1 drop 4 hourly upto 5 times / day for duration of 21 days 2 Varicella Zoster Famciclovir Acyclovir ophthalmicus 500 mg BD 800 mg 5 times/ Or TID day for 10 days OR Valacyclovir 1 gm oral TID for 10 days 3 Fungal keratitis Natamycin5% Amphotericin B Empirical therapy is not 1 drop 1- 2 hrly for (0.15%) 1 drop , recommended several days , then 1- 2 hourly for 3 – 4 hourly for several days several days depending on depending on the response response 4 Endophthalmitis Intravitreal Liposomal Duration of treatment 4-6 Mycotic Amphotericin B Amphotericin B weeks or longer depending (Fungal) 0.005- 0.01 mg in 3- 5 mg /kg upon clinical response. 0.1 ml OR Patients with Chorioretinitis Systemic therapy : Voriconazole and ocular involvement Amphotericin B other than 0.7 – 1mg / kg endophthalmitisoften + Flucytosine response to systemically 25 mg/kg QID administered antifungal.

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10. ENT Sr Clinical Empiric antibiotics/ Alternative Remarks/Comments no condition 1st line antibiotics antibiotics 1 Acute otitis media Amoxycillin + Clavulanic Acid (Amoxicillin 45mg/kg/day TDS/50- 60mg/kg/day in two divided doses ) for 7- 10 days Cotrimoxazole 8mg/kg/d 12 hourly 2 Acute mastoiditis Cefotaxime 1–2 g i.m./i.v. 6–12 hourly, children 50– 100mg/kg/day. Inj.Ceftriaxone 75 mg/kg/day OD

3 Acute epiglotitis Cefotaxime Levofloxacin 50 mg/kg IV 8 hourly 10 mg/kg IV 24 Ceftriaxone hourly 50 mg/kg IV 24 hourly

4 Acute tonsillitis/ Penicillin V Penicillin Pharyngitis oral x10 days allergic, OR Clindamycin Benzathine Penicillin 300-450 mg 1.2 MU IM x 1 dose orally 6-8 OR hourly x 5 or days. Azithromycin x 5 days clarithromycin are alternatives. 5 Head and neck Clindamycin Piperacillin- Duration: At least 1 space infections 600 mg IV q8h tazobactam week or 4.5 gm IV q 6h Amox-clav 1.2 gm IV/PO q8h

6 Acute sinusitis Amox-clav Piperacillin- Exclude fungi 1.2 gm IV/PO q8hfor 7 tazobactam (Aspergillus, Mucor) days 4.5 gm IV q 6h 7 Acute bronchitis Antibiotics not required (Viral) 8 Ludwig’s Clindamycin Piperacillin 10-14 days angina 600mg IV 8 hourly tazobactam and then can Vincent’s or 4.5 gm IV 6 be prolonged Angina Amoxicillin hourly based on clavulanate response. 1.2 gm IV

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11. SKIN Sr Clinical Empiric antibiotics/ 1st line Alternative Remarks/Comments no condition antibiotics antibiotics 1 Cellulitis Amoxicillin-Clavulanate Clindamycin Treat for 5-7 days. 1.2gm IV TDS/625 mg oral 600-900mg IV TDS TDS OR Ceftriaxone 2gm IV OD 2 Furunculosis Amoxicillin-Clavulanate Clindamycin Get pus cultures 1.2gm IV/Oral 625 TDS 600-900mg IV before starting OR TDS antibiotics Ceftriaxone 2gm IV OD Duration – 5-7 days 3 Necrotizing Piperacillin-Tazobactam Imipenem Early surgical fasciitis 4.5gm IV 6hourly 1g IV8hourly intervention crucial AND OR Clindamycin Meropenem 600-900mg IV 8 hourly 1gm IV 8hourly Duration depends on the AND progress Clindamycin 600-900mg IV TDS 4 Impetigo Clindamycin Amoxicillin- Local: Mupirocin and skin 300-400 mg qid PO clavulanate ointment Apply to soft-tissue 875/125 mg bid lesions bid infections po

12. RESPIRATORY MEDICINE Sr Clinical Empiric antibiotics/ 1st line Alternative Remarks/Commen no condition antibiotics antibiotics ts 1 Lower Amoxicillin -clavulanate Piperacillin – Amikacin max respiratory 1.2 g IV TDS Tazobactam doses 1.5mg/Kg tract OR 4.5gm IV 8 hourly If atypical infection Ceftriaxone for 7-10 days. pneumonia 2g IV OD Imipenem suspected, Cotrimoxazole 1g IV 8hourly Doxycycline 100mg 960mg 12 hourly OR bd Azithromycin Meropenem 500 mg once daily orally/ IV for 1g IV 8hourly 3-5 days Vancomycin Doxycycline 15mg/kg IV 12 100mg 12 hourly orally hourly Gentamicin Teicoplanin 7.5mg/kg/day OD i.m or i.v for 6-30 mg/kg/day IV 10 days 3 doses 12 hourly Amikacin then 24h 15mg/Kg/day q 8-12 hours IV

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2 VAP Ceftriaxone Modify based on (Ventilator 2g IV once daily for 5-7 days culture of lower Associated Amikacin respiratory tract Pneumonia) 15mg/Kg/day q 8-12 hours IV secretions. Gentamicin 7.5mg/kg/day OD i.m or i.v for Stop antibiotics 10 days after 5 days of Piperacillin – Tazobactam clinical response 4.5gm IV 8 hourly for 7-10 days Imipenem 1g IV 8hourly or Meropenem 1g IV 8hourly Vancomycin 15mg/kg IV 12 hourly 3 Lung Piperacillin-Tazobactam ADD Clindamycin 3-4 weeks abscess 4.5gm IV 6 hourly 600-900mg IV 8 treatment required hourly 4 Acute Amoxicillin-clavulanate Azithromycin bacterial 1gm oral BD for 7 days 500 mg oral OD × exacerbatio 3 days n of COPD

13. MDR organisms Sr Clinical condition Empiric antibiotics/ 1st Alternative Remarks/Comment no line antibiotics antibiotics s 1 MRSA infection Vancomycin Linezolid MRSA strains may 25-30 mg IV loading 600 mg IV/Oral 12 be reported as followed by 15-20 mg/kg hourly susceptible to 8-12 Hourly Fluoroquinolones, Teicoplanin Daptomycin 6mg/kg IV aminogycogides, 12 mg/kg x3 doses once a day chloramphenicol and followed by 6 mg/kg doxycycline in-vitro, once a day these drugs are NOT Piperacillin – to be used alone or Tazobactam as initial treatment 4.5gm IV 8 hourly for serious MRSA infections 2 MDR infections Imipenem Colistin base Enterobactericea & 1g IV 8hourly 2.5– 5mg/kg /day I/V non-fermenting GNB or every 6 – 12 Meropenem hourly(1mg= 30000 1g IV 8hourly IU) Piperacillin – 15,000- Tazobactam 25,000 units/kg/day 4.5gm IV 8 hourly for 7- divided q12hr; not to 10 days exceed 25,000 Ofloxacin units/kg/day 200-400mg orally/IV Tigecycline 100mg 12 hourly followed by 50mg every 12 hurlyinfusion over 30-60 minutes

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ANTIMICROBIAL AGENTS THAT REQUIRE DOSAGE ADJUSTMENT OR ARE CONTRAINDICATED IN PATIENTS WITH RENAL OR HEPATIC IMPAIRMENT Acyclovir, amantadine, aminoglycosides, , carbapenems, (except ceftriaxone), Dosage Adjustment Needed in Renal clarithromycin, colistin, , daptomycin, Impairment didanosine, emtricitabine, ethambutol, ethionamide, famciclovir, fluconazole, flucytosine, foscarnet, ganciclovir, lamivudine, (except & ), pyrazinamide, quinolones (except moxifloxacillin), rimantadine, stavudine, , telbivudine, telithromycin, tenofovir, terbinafine, trimethoprimsulfamethoxazole, valacyclovir, vancomycin, zidovudine Cidofovir, methenamine, nalidixic acid, nitrofurantoin, Contraindicated in Renal Impairment sulfonamides (long-acting), tetracyclines (except doxycycline & possibly minocycline) Amprenavir, atazanavir, chloramphenicol, Dosage Adjustment Needed in Hepatic clindamycin, erythromycin, fosamprenavir, indinavir, Impairment metronidazole, rimantadine, tigecycline, , rifampin Erythromycin estolate, tetracyclines, pyrazinamide, Contraindicated in Hepatic Impairment nalidixic acid, talampicillin, pefloxacin

CHOICE OF DRUGS FOR COMMON PROBLEMS DURING PREGNANCY Drug class Unsafe/ safety uncertain Safer alternative Antibacterials Cotrimoxazole, Fluoroquinolones, Penicillin G, Ampicillin (systemic Tetracycline , Doxycycline, Amoxicillin-clavulanate bacterial Chloramphenicol , Cloxacillin, Piperacillin infections) Gentamicin, Streptomycin, Cephalosporins Kanamycin , Tobramycin, Erythromycin Clarithromycin, Azithromycin, Clindamycin, Vancomycin, Nitrofurantoin Antitubercular Pyrazinamide, Streptomycin Isoniazid, Rifampicin, Ethambutol Antiamoebic Metronidazole, Tinidazole Diloxanide furoate, Paromomycin Quiniodochlor Antimalarial Artemether, Artesunate Chloroquine, Mefloquine, Proguanil Primaquine Quinine (only in 1st trimester), Pyrimethamine + Sulfadoxine (only single dose) Anthelmintic Albendazole, Mebendazole, Ivermectin, Piperazine Pyrantel pamoate, Niclosamide Diethylcarbamazine Praziquantel Antifungal Amphotericin B, Fluconazole Clotrimazole (superficial Itraconazole , Ketoconazole, Griseofulvin, Nystatin Topical and deep Terbinafine Tolnaftate mycosis) Antiretroviral Didanosine, Abacavir, Indinavir Zidovudine, Lamivudine, (HIV-AIDS) Ritonavir, Efavirenz Nevirapine, Nelfinavir, Saquinavir Antiviral Acyclovir, Ganciclovir (other than Foscarnet, Amantadine HIV) Vidarabine , α-interferon

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ANTIMICROBIAL AGENTS THAT ARE SAFE OR ARE CONTRAINDICATED IN BREASTFEEDING WOMEN

Albendazole, Antifungal drugs (topical), Cephalosporins, Cloxacillin, Erythromycin, Safe in ordinary doses Ethambutol, Gentamicin, Mebendazole, Niclosamide, Piperacillin, Piperazine, Praziquantel, Pyrantel, Pyrazinamide Acyclovir, Aminoglycosides, Ampicillin/Amoxicillin, Chloroquine, Clindamycin, Clofazimine, Cotrimoxazole, Dapsone, Isoniazid, Mefloquine, Used with special precaution Metronidazole, Nalidixic acid, Nitrofurantoin, Penicillins, Pyrimethamine-sulfadoxine, Quinidine, Rifampin, Streptomycin, Sulfonamides, Tinidazole, Vancomycin Azithromycin, Chloramphenicol, Ciprofloxacin, Cyclosporine, Fluconazole, Itraconazole, Drugs contraindicated Ketoconazole, Methotrexate, Norfloxacin, Tetracyclines

GERIATRIC PATIENTS Drugs to be Avoided Reasons Safer alternatives Antibiotics Because of the decline in renal Use of ceftriaxone Penicillins functions in elderly, half-life of cefoperazone, which are Cephalosporins these antibiotics is prolonged. excreted through bile, could Fluoroquinolones Elderly are very sensitive to be alternatives. Some trials Nitrofurantoin peripheral neuritis and indicate that half life of pulmonary reaction caused by tobramycin is not prolonged in nitrofurantoin. Gatifloxacin may elderly. This could be other cause episodes of hypo- as alternative. Otherwise dose well as hyperglycaemia adjustment of these drugs is (caution- diabetes) needed.

DRUG INTERACTIONS IN DIABETES MELLITUS

Sulfonamides Enhance sulfonylureas action (may precipitate hypoglycaemia) by displacing protein bound drug Ketoconazole, Enhance sulfonylureas & pioglitazones action (may precipitate hypoglycaemia) by inhibiting metabolism Sulfonamides, Enhance sulfonylurea action (may precipitate hypoglycaemia) by inhibiting metabolism Chloramphenicol Enhance sulfonylurea action (may precipitate hypoglycaemia) by inhibiting metabolism Rifampicin Induce metabolism, decrease action of sulfonylurea & pioglitazones (vitiate diabetes control)

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EMPIRIC ANTIMICROBIAL THERAPY BASED ON MICROBIOLOGICAL ETIOLOGY Suspected or Proven Drugs of First Choice Alternative Drugs Disease or Pathogen Gram-negative cocci (aerobic) Moraxella (Branhamella) TMP-SMZ, cephalosporin Quinolone,3 macrolide4 catarrhalis (second- or third- generation) Neisseria gonorrhoeae Ceftriaxone, cefixime Spectinomycin, azithromycin Neisseria meningitides Penicillin G Chloramphenicol, ceftriaxone, cefotaxime Gram-negative rods (aerobic) E coli, Klebsiella, Proteus Cephalosporin (first- or Quinolone, aminoglycoside secondgeneration),TMP- SMZ Enterobacter, Citrobacter, TMP-SMZ, quinolone, Antipseudomonal penicillin, Serratia aminoglycoside, Shigella Quinolone TMP-SMZ, ampicillin, azithromycin, ceftriaxone Salmonella Quinolone, ceftriaxone Chloramphenicol, ampicillin, TMP- SMZ Campylobacter jejuni Erythromycin or Tetracycline, quinolone azithromycin Brucella species Doxycycline + rifampin or Chloramphenicol + aminoglycoside or Aminoglycoside TMP-SMZ Helicobacter pylori Proton pump inhibitor + Bismuth + metronidazole + amoxicillin tetracycline + proton pump + clarithromycin Inhibitor

Vibrio species Tetracycline Quinolone, TMP-SMZ

Pseudomonas aeruginosa Antipseudomonal penicillin Antipseudomonal penicillin ± ± quinolone, cefepime, Aminoglycoside ceftazidime, antipseudomonal carbapenem, or aztreonam ± aminoglycoside Burkholderia cepacia TMP-SMZ Ceftazidime, chloramphenicol (formerly Pseudomonas cepacia) Stenotrophomonas TMP-SMZ Minocycline, -clavulanate, maltophilia (formerly tigecycline, Xanthomonas maltophilia) ceftazidime, quinolone Legionella species Azithromycin or quinolone Clarithromycin, erythromycin Gram-positive cocci (aerobic) Streptococcus Penicillin Doxycycline, ceftriaxone, pneumoniae antipneumococcal quinolone, macrolide, linezolid Streptococcus pyogenes Penicillin, clindamycin Erythromycin, cephalosporin (first- (group A) generation) Streptococcus agalactiae Penicillin (± Vancomycin (group B) aminoglycoside) Viridans streptococci Penicillin Cephalosporin (first- or third- generation), vancomycin

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Staphylococcus aureus B-Lactamase negative Penicillin Cephalosporin (first-generation), vancomycin B-Lactamase positive Penicillinase-resistant As above penicillin

Methicillin-resistant Vancomycin TMP-SMZ, minocycline, linezolid, daptomycin, tigecycline Enterococcus species10 Penicillin ± aminoglycoside Vancomycin ± aminoglycoside Gram-positive rods (aerobic) Bacillus species (non- Vancomycin Imipenem, quinolone, clindamycin anthracis) Listeria species Ampicillin (± TMP-SMZ aminoglycoside) Nocardia species Sulfadiazine, TMP-SMZ Minocycline, imipenem, amikacin, linezolid Anaerobic bacteria Gram-positive (clostridia, Penicillin, clindamycin Vancomycin, carbapenem, Peptococcus, chloramphenicol Actinomyces, Peptostreptococcus) Clostridium difficile Metronidazole Vancomycin, Bacteroides fragilis Metronidazole Chloramphenicol, carbapenem, β- lactam–β-lactamaseinhibitor combinations, clindamycin Fusobacterium, Prevotella, Metronidazole, lindamycin, As for B fragilis Porphyromonas penicillin Mycobacteria Mycobacterium Isoniazid + rifampin + Streptomycin, moxifloxacin, amikacin, tuberculosis ethambutol + pyrazinamide ethionamide, cycloserine, PAS, linezolid Mycobacterium leprae Multibacillary Dapsone + rifampin + clofazimine Paucibacillary Dapsone + rifampin Mycoplasma pneumoniae Tetracycline, erythromycin Azithromycin, clarithromycin, quinolone Chlamydia C trachomatis Tetracycline, azithromycin Clindamycin, ofloxacin C pneumoniae Tetracycline, erythromycin Clarithromycin, azithromycin C psittaci Tetracycline Chloramphenicol Spirochetes Borrelia recurrentis Doxycycline Erythromycin, chloramphenicol, penicillin Borrelia burgdorferi Early Doxycycline, amoxicillin , penicillin Late Ceftriaxone Leptospira species Penicillin Tetracycline Treponema species Penicillin Tetracycline, azithromycin, ceftriaxone Fungi Aspergillus species Voriconazole Amphotericin B, itraconazole, caspofungin Blastomyces species Amphotericin B Itraconazole, fluconazole 28

Candida species Amphotericin B, echinocandin Fluconazole, itraconazole, voriconazole Cryptococcus Amphotericin B ± flucytosine Fluconazole, voriconazole (5-FC) Coccidioides immitis Amphotericin B Fluconazole, itraconazole, voriconazole, osaconazole Histoplasma capsulatum Amphotericin B Itraconazole Mucoraceae (Rhizopus, Amphotericin B Posaconazole Absidia) Sporothrix schenckii Amphotericin B Itraconazole

References: 1. National Treatment Guidelines for Antimicrobial Use in Infectious Diseases: version 1(2016): NATIONAL CENTRE FOR DISEASE CONTROL 2. Treatment Guidelines for Antimicrobial Use in Common Syndromes: Indian Council of Medical Research (2017) 3. Step-by-step approach for development and implementation of hospital antibiotic policy and standard treatment guidelines: World Health Organization 2011 4. Tripathi KD, editor. Essentials of Medical Pharmacology, 7 th ed. New Delhi: Jaypee Brothers; 2013 5. Trevor AJ, Masters SB, Katzung BG. Basic & clinical pharmacology 13TH ed. New York: McGraw Hill Lange; 2015 6. Sharma HL, Sharma KK, Principles of Pharmacology; 2nd edition: Paras publications;2012

Department Of Surgery Policy for surgical Prophylaxis Surgery Prophylactic Time when Recomm Total Duration antibiotic with Prophylactic ended (>24 HRS) dose anti antibiotic redosing given 130 interval min/60 min hours before Cardiac Inj cefazolin 1 60 min before 12 Hourly 3 doses/3 days/7 gm days depending on the preoperative status of patient. Bariatric, Inj piperacillin 60min before and 8 Hourly 3 doses/3 days/7 pancreatico- +tazobactum to be repeated ………… days depending on 4.5 gm Inj intraoperatively if ……….. the preoperative metro 100cc surgery duration 8 Hourly status of patient. exceeds 6 hrs Duodenectomy Inj piperacillin 60min before and 8 Hourly 3 doses/3 days/7 +tazobactum to be repeated ………… days depending on 4.5 gm intraoperatively if ……….. the preoperative Inj metro 100cc surgery duration 8 Hourly status of patient. exceeds 6 hrs Biliary tract Inj cefazolin 1 60min before 8 Hourly 3 doses/3 days/7 gm or infected 12 Hourly days depending on case- …8 Hourly the preoperative Inj piperacillin status of patient. +tazobactum 29

4.5 gm Inj metro 100cc

Laparoscopic Inj cefazolin 1 60min before 12 Hourly 3 doses/3 days/7 Procedure gm days depending on Elective, low- the preoperative risk status of patient. Elective high Inj. Monocef 1g 60min before 12 Hourly 3doses/3 days/7 days risk Inj. Metro 100cc 8 Hourly depending on the preoperative status of patient. Appendectomy Inj cefazolin 1 60min before 12 Hourly 3 doses/3 days/7 gm Inj. …… days depending on Metro 100cc 8 Hourly the preoperative status of patient. Small intestine Inj cefazolin 1 60min before 12 Hourly 3 doses/3 days/7 Nonobstructed gm Inj. 8 Hourly days depending on Metro 100cc 12 Hourly the preoperative Inj piperacillin ………… status of patient. +tazobactum 8 Hourly 4.5 gm 12 Hourly metro 100cc Inj cefazolin 1 gm Obstructed Inj cefazolin 1 60min before 12 Hourly 3 doses/3 days/7 gm Inj. 8 Hourly days depending on Metro 100cc 12 Hourly the preoperative Inj piperacillin 8 Hourly status of patient. +tazobactum 12 Hourly 4.5 gm metro 100cc Inj cefazolin 1 gm Hemia repair Inj cefazolin 1 60min before 12 Hourly 3 doses/3 days/7 gm Inj. 8 Hourly days depending on Metro 100cc 12 Hourly the preoperative Inj piperacillin 8 Hourly status of patient. +tazobactum 12 Hourly 4.5 gm metro 100cc Inj cefazolin 1 gm Colorectal Inj cefazolin 1 60min before 8 Hourly 3 doses/3 days/7 gm or ………… days depending on infected case- ……… the preoperative Inj piperacillin 12 Hourly status of patient. +tazobactum 8 Hourly 4.5 gm Inj metro 100cc Head and neck Inj. Cefazolin 60min before 12 Hourly 3 doses/3 days/7 1g days depending on the preoperative status of patient.

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Skin and soft Inj. Clindamycin 60min before 12 Hourly 3 doses/3 days/7 tissue infections 600mg days depending on the preoperative status of patient. Minor ot Inj cefazolin 1 60 min before 1 Dose only procedures gm or Inj. Clindamycin 600mg Urological Inj. Cefazolin 60 min before 12 Hourly 3 doses/3 days/7 procedures 1g Inj 12 Hourly days depending on amikacin 500 the preoperative mg status of patient. Breast Inj cefazolin 1 60 min before 12 Hourly 3 doses/3 days/7 Procedures gm days depending on the preoperative status of patient.

Department Of OBGY

Policy for surgical Prophylaxis Surgery Prophylactic antibiotic Time when Recommended Total with dose Prophylactic redosing Duratio antibiotics interval hours n (>24 given (30 Hrs) min/60 min before) Caesarian Inj. CefaTaxime 30 Min. before 12 Hourly 48 Hrs section 1 gm i.v. (Elective) Hysterectomy Inj. CefaTaxime 30 Min. before 12 Hourly 48 Hrs 1 gm i.v. Vaginal repair Inj. CefaTaxime 30 Min. before 12 Hourly 48 Hrs 1 gm i.v.

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Department Of Orthopaedic

Policy for surgical Prophylaxis Time when Recomme Prophylactic nded Total Prophylactic antibiotic antibiotic Surgery redosing Duration with dose given [30 interval [>24 Hrs] min / 60 min hours before] Implantation of Inj. Cefuroxime 1.5 gm 30 min 12 hrly 48 hrs Post op internal fixation devices & Inj. Amikacin 750 mg OD 30 min 24 hrly 48 hrs Post op Arthroscopy Inj. Cefuroxime 1.5 gm 30 min 12 hrly 48 hrs Post op Total Joint Inj. Teicoplanin 400 mg 30 min Single shot _ Replacement Inj. Amikacin 750 mg OD 30 min 24 hrly 48 hrs Post op Since Inj. Cefuroxime 1.5 gm 12 hrly > 24 hrs Admission Since Compound Inj. Amikacin 750 mg OD 24 hrly > 24 hrs Fracture Admission (+/-) Inj. Metronidazole 100 Since 8 hrly > 24 hrs ml Admission 30 Min before Inj. Cefuroxime 1.5 gm 12 hrly 3 days Spine Surgery Inj. Amikacin 750 mg OD Not Given

Department Of Ophthalmology

Policy for surgical Prophylaxis Surgery Prophylactic Time when Recommended Total antibiotic with Prophylactic anti redosing interval Duration dose antibiotic given hours (>24 HRS) 130 min/60 min before Ophthalmic Orally Ciprofloxacin 24 hours before 12 HOURLY Oral Surgery 500mg BD surgery medicine for 5 days. Topically 24 hours before Topically Topical Moxifloxacin 0.5% surgery Moxifloxacin medicine eye drop Qid 0.5%Qid for 8 days for 8 days. Intracameral At the time of _ _ Moxifloxacin 0.5% surgery one dose Antiseptic One drop prior to providone Iodine surgery _ _ 5%

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Department Of ENT Policy for surgical Prophylaxis Surgery Prophylactic Time Recom Total duration (more antibiotic with dose when mende than 24 hours) prophylac d tic redosi antibiotic ng to be interval given hours Head and Inj Augmentin (AMOX+ One hour Twelve 48 hours followed by Neck Surgery Clav)1.2 gm before hours oral antibiotics for 5 surgery days Thyroidectom Inj Augmentin (AMOX+ One hour Twelve 48 hours followed by y Clav)1.2 gm before hours oral antibiotics for 5 surgery days Parotidectomy Inj Augmentin (AMOX+ One hour Twelve 48 hours followed by Clav) 1.2 gm before hours oral antibiotics for 5 surgery days Neck Inj Augmentin (AMOX+ One hour Twelve 48 hours followed by Dissection Clav) 1.2 gm before hours oral antibiotics for 5 surgery days Tonsillectomy Inj Augmentin or Inj One hour Twelve - followed by oral Taxim before hours antibiotics for 5 days Acc to body weight surgery Tympanoplast Inj Augmentin (AMOX+ One hour Twelve - followed by oral y Clav) 1.2 gm Or Inj. before hours antibiotics for 5 days Taxim 1 gm surgery Masoidectomy Inj Augmentin (AMOX+ One hour Twelve - followed by oral Clav) 1.2 gm before hours antibiotics for 5 days Or Inj. Taxim 1 gm surgery Endoscopic Inj Augmentin (AMOX+ One hour Twelve 48 hours and followed Sinus Surgery Clav) 1.2 gm Or Inj. before hours by oral antibiotics for 5 Taxim 1 gm surgery days Deep Neck Inj Augmentin (AMOX+ Half an Eight 72 hours and followed Space Clav) 1.2 gm Or Inj. hour hours by oral antibiotics for 5 Infection/ Taxim 1 gm before days Abscess And Inj. Metronidazole surgery 100 cc Septoplasty Inj Augmentin (AMOX+ One hour Twelve 48 hours and followed Clav) 1.2 gm Or Inj. before hours by oral antibiotics for 5 Taxim 1 gm surgery days Endonasal Inj Augmentin (AMOX+ One hour Twelve 48 hours DCR Clav) 1.2 gm Or Inj. before hours followed by oral Taxim 1 gm surgery antibiotics for 5 days Rhinoplasty Inj Augmentin (AMOX+ One hour Twelve 48 hours Clav) 1.2 gm Or Inj. before hours followed by oral Taxim 1 gm surgery antibiotics for 5 days

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CONTRIBUTORS

Dr. A. V. Bhore Dr. P.S. Chawla Director Dean

Dr. Rajendra Harnagle, Dr. Uma A. Bhosale Medical Superintendent Prof.& Head, Dept of Pharmacology

Dr. Sachin V. Wankhede Dr. Rajendra S. Bangal Prof.& Head, Dept of Microbiology Prof.& Head, Dept of FMT

Dr. Shripad M. Bhat Dr. Pramod Lokhande Prof.& Head, Dept of Medicine Prof.& Head, Dept of Orthopedics

Dr. Girish Saundattikar Dr. Gauri Godbole Prof.& Head, Dept of Anaesthesia Prof.& Head, Dept of Resp.Medicine

Dr. Gulabsing Shekhavat Dr. Kiran Shinde Prof.& Head, Dept of OBGY Prof.& Head, Dept of ENT

Dr. Suvarna Gokhale Dr. Snehal Purandare Prof.& Head, Dept of Ophthamology Prof. Dept of Surgery

Dr. Sanjay Natu Dr. Neeta Gokhale Prof. Dept of Paediatrics Prof.& Head, Dept of Skin

Dr. Archana C. Choure Dr. Vinod S. Shinde Assist. Prof. Microbiology Assist. Prof. Pharmacology

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