Bugs & Drugs Antimicrobial Pocket Reference 2001 FOREWORD Authors (unless otherwise noted) & Editors: Edith Blondel-Hill, MD, FRCP(C) Associate Medical Officer of Health Infectious Diseases Specialist/Medical Microbiologist Capital Health/DKML and Susan Fryters, B.Sc.Pharm. Antimicrobial Utilization/Infectious Diseases Pharmacist Capital Health in collaboration with: · Regional Antimicrobial Advisory Subcommittee · Antimicrobial Working Group (Dr. E. Blondel-Hill, S. Fryters, Dr. M. Foisy, Dr. E. Friesen, M. Gray, R. Muzyka, Dr. P. Robertson, C. Zenuk) · Therapeutic Drug Monitoring (TDM) Task Force (Dr. G. Blakney, Dr. E. Blondel-Hill, S. Fryters, M. Gray, Dr. D. LeGatt, Dr. N. Yuksel) · Antibiotics in Dentistry Working Group (Dr. E. Blondel-Hill, Dr. T. Carlyle, Dr. K. Compton, Dr. T. Debevc, S. Fryters, Dr. D. Gotaas, Dr. K. Kowalewska-Grochowska, Dr. K. Lung, Dr. T. Mather, Dr. H. McLeod, M. Mehta, Dr. J. Nigrin, Dr. S. Ponich, Dr. B. Preshing, Dr. J. Robinson, Dr. S. Shafran) · Divisions of Adult and Paediatric Infectious Diseases · Dynacare Kasper Medical Laboratories (DKML) · UAH Medical Microbiology Department · Regional Pharmacy Services · Regional Public Health · Antibiotics Working Group of AMA Clinical Practice Guidelines Program

Secretarial Support: L. Clarke The authors are indebted to Laura Lee Clarke for her outstanding preparation of this manuscript.

Editorial Contributions: Dr. J. Galbraith, Infectious Diseases/Medical Microbiologist Ms. M. Gray, BSP Dr. A. Joffe, Paediatric Infectious Diseases Dr. J. Nigrin, Medical Microbiologist Dr. S. Shafran, Adult Infectious Diseases Ms. C. Zenuk, BSP

Cover Design: A. Hill

Funding provided by: Capital Health Regional Pharmacy Services & Dynacare Kasper Medical Laboratories

While every effort has been made to ensure the accuracy of the information presented, the authors, Capital Health, and DKML cannot accept liability for errors or any consequences arising from its use.

Copyright © 2000 Capital Health All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means - electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors. PREFACE

The information presented in this book is solely for educational purposes. Recommendations made in this book are based on our experience in infectious diseases, microbiology, and pharmacotherapy; an extensive review of the literature; consultation with multiple specialists; local antibiotic formularies; and local susceptibility patterns.

We are extremely indebted to all our colleagues for their contributions. We would especially like to thank our secretary, Laura Lee Clarke.

With this book we have attempted to provide physicians, pharmacists, and other health care professionals with sound recommendations for the management of patients with infectious diseases.

The release of this 2001 edition coincides with the launch of the Do Bugs Need Drugs? project in Capital Health. This project attempts to address solutions to antibiotic resistance by promoting three key messages:

1. Handwashing is the most important way to stop the spread of infections. 2. and viruses are different and antibiotics do not work against viruses. 3. Antibiotic resistance is a problem therefore antibiotics must be used wisely.

As before, the work that has gone into this book is dedicated to our children. It is for all children that solutions to antibiotic resistance must be found.

Edith Blondel-Hill Susan Fryters CLINICAL ANTIBIOTIC GUIDELINES†

ACYCLOVIR IV*/PO *RESTRICTED TO ANTIBIOTIC FORM

Predictable activity: Unpredictable activity: No activity: Herpes Simplex Cytomegalovirus Epstein Barr Virus Herpes Zoster

Indicated: IV: 1. Therapy for suspected or documented Herpes simplex encephalitis 2. Therapy for suspected or documented Herpes simplex infection of a newborn or immunocompromised patient 3. Therapy for primary varicella infection in immunocompromised patients 4. Therapy for severe or disseminated varicella-zoster infections in immunocompromised or immunocompetent patient 5. Therapy for primary genital herpes with neurologic complications

Oral: 1. Therapy for primary Herpes simplex infections (oral/genital) 2. Suppressive (preventative) therapy for recurrent (³ 6 episodes/year) severe Herpes simplex infections (oral/genital) 3. Episodic therapy for recurrent (³ 6 episodes/year) Herpes simplex genital infections (initiate within 24 hours of prodrome onset) 4. Prophylaxis for HSV in bone marrow transplants where patient is seropositive 5. Therapy and suppressive therapy for Eczema Herpeticum 6. Therapy for varicella-zoster infections in immunocompetent and immunocompromised patients (if not severe) 7. Therapy for primary varicella infections in pregnancy 8. Therapy for varicella in immunocompetent patients > 13 years old (initiate within 24 hours of rash onset) 9. Therapy for varicella in patients < 13 years old (initiate within 24 hours of rash onset) if there is a chronic cutaneous or pulmonary disorder, long term salicylate therapy, or short, intermittent or aerosolized corticosteroid use

Not Indicated: 1. Therapy for acute Epstein-Barr infections (acute mononucleosis) 2. Therapy for documented CMV infections CLINICAL ANTIBIOTIC GUIDELINES†

AMIKACIN RESTRICTED TO ANTIBIOTIC FORM

Predictable activity: Unpredictable activity: No activity: Staphylococcus spp Streptococcus spp Pseudomonas spp Enterococcus spp some Mycobacterium spp Alcaligenes spp Anaerobes

Indicated: 1. Therapy of gram-negative organisms that are resistant to and tobramycin but susceptible to amikacin 2. As combination therapy for the treatment of some Mycobacteria spp.

Not Indicated: 1. First line therapy CLINICAL ANTIBIOTIC GUIDELINES†

AMOXICILLIN-CLAVULANATE

Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Pen-I Streptococcus pneumoniae Methicillin-resistant S. aureus (MRSA) Pen-S Streptococcus pneumoniae Enterobacteriaceae producing inducible Pen-R Streptococcus pneumoniae b-haemolytic Streptococci b-lactamases* Enterococcus faecium Enterococcus faecalis Pseudomonas spp Stenotrophomonas maltophilia Klebsiella spp Chlamydia spp Mycoplasma spp influenzae Neisseria spp Pasteurella spp Anaerobes

* Enterobacter spp, complex, Serratia spp, Morganella spp, Providencia spp, , Proteus penneri, and some Hafnia spp

Indicated: 1. Therapy of animal and human bite wound infections 2. Second line therapy of 3. Second line therapy of acute exacerbations of chronic bronchitis and acute sinusitis 4. Therapy/stepdown therapy of polymicrobial infections (e.g. skin and soft tissue, odontogenic, aspiration , intra-abdominal) 5. Therapy of periorbital cellulitis in paediatric patients 6. Second line therapy of urinary tract infections in paediatric, elderly, or catheterized patients, where there is failure/resistance of first line agents

Not Indicated: 1. Therapy of pneumonia where there is no suspicion of aspiration 2. First line therapy of upper respiratory tract infections (otitis media, pharyngitis, acute exacerbation of chronic bronchitis, acute sinusitis) 3. First line therapy of urinary tract infection 4. Therapy of chronic/asymptomatic bacteriuria in elderly or catheterized patients CLINICAL ANTIBIOTIC GUIDELINES† AMPHOTERICIN B, LIPID-COMPLEXED NON-FORMULARY – REQUIRES COMPLETION OF ANTIBIOTIC FORM Lipid-complexed amphotericin B formulations may minimize nephrotoxicity when compared to conventional amphotericin B. To date, there exists no strong evidence that these formulations are more efficacious than the conventional formulation. A therapeutic course may cost in excess of $30,000. Criteria for Lipid-Complexed Amphotericin B 1. Evidence of Systemic Fungal Infections · Culture positive for Candida at a normally sterile site (e.g. blood, CSF, deep tissue sample) OR · Evidence of Candida from > 3 separate body sites in patients at risk for disseminated Candidiasis (i.e. patients with neutropenia, patients on broad spectrum antibiotics, or patients with central venous lines) with clinical signs of active infection (e.g. fever and leucocytosis despite antibacterial therapy) OR · Histology proven evidence of disseminated Candidiasis OR · Histologic and/or culture evidence of another invasive fungal infection (e.g. aspergillosis, mucormycosis) OR · Compelling radiographic and clinical evidence of invasive fungal infection in consultation with Infectious Diseases (ID) specialists. AND

2. Evidence of deteriorating renal function · A tripling of the serum creatinine from the patient’s baseline value OR · A serum creatinine of greater than or equal to 250 mmol/L. AND

3. Procedure to be followed · To be ordered by an Infectious Diseases physician only. · Requests for lipid-complexed Amphotericin B require completion of the Antibiotic Form. · If criteria are met, Pharmacy will obtain and dispense a commercial preparation of lipid-complexed Amphotericin B for an initial 72 hours only. The lipid formulation dispensed will be decided based on discussions between Infectious Diseases and Pharmacist. · Each case will need to be reassessed, and the drug ordered, by an ID physician twice weekly. · Within one week of the initial order, an ad hoc Utilization Review group will review each case of lipid-complexed amphotericin B use. Membership on this group will consist of the following individuals or their designate: prescribing ID physician, Director of ID, Chair of the Antimicrobial Advisory Subcommittee, an Antimicrobial Utilization pharmacist, and a representative from the specific program involved. CLINICAL ANTIBIOTIC GUIDELINES†

AZITHROMYCIN IV/PO

Predictable activity: Unpredictable activity: No activity: Streptococcus pneumoniae Staphylococcus aureus (MSSA) Staphylococcus aureus (MRSA) b-haemolytic Streptococci Enterococcus spp Moraxella catarrhalis Enterobacteriaceae * Pseudomonas spp Legionella spp Anaerobic gram-negative bacilli Mycobacterium avium complex Chlamydia trachomatis Chlamydia pneumoniae Mycoplasma pneumoniae * Better coverage than erythromycin, however not recommended for serious documented Haemophilus infections

Indicated: 1. Therapy of community acquired pneumonia where bacteremia is not suspected 2. Second line therapy of otitis media, acute exacerbation of chronic bronchitis, and acute sinusitis 3. Therapy of nongonococcal urethritis/cervicitis or documented Chlamydia trachomatis infections (single 1 gram PO dose) 4. First line agent for prophylaxis of infections due to Mycobacterium avium complex in HIV patients

Not Indicated: 1. First line therapy of upper respiratory tract infections (otitis media, pharyngitis, acute exacerbation of chronic bronchitis, acute sinusitis) 2. Monotherapy of community acquired pneumonia associated with bacteremia or where central nervous system involvement suspected 3. Therapy of hospital acquired pneumonia 4. Therapy of skin and soft tissue infections 5. Therapy of Helicobacter pylori CLINICAL ANTIBIOTIC GUIDELINES†

CEFACLOR

Predictable activity: Unpredictable activity: No activity: Pen-S Streptococcus pneumoniae Staphylococcus aureus (MSSA) Methicillin-resistant S. aureus (MRSA) Escherichia coli Pen-I, Pen-R Streptococcus pneumoniae Klebsiella spp Enterococcus spp Proteus mirabilis Enterobacteriaceae producing inducible Haemophilus influenzae* b-lactamases** Moraxella catarrhalis Pseudomonas spp Anaerobic gram-negative bacilli Chlamydia spp Mycoplasma spp

* Cefaclor is less stable against b-lactamase producing H. influenzae than cefuroxime axetil, cefixime, or amoxicillin-clavulanate. ** Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp

Not Indicated: 1. Therapy of community acquired pneumonia 2. Therapy of upper respiratory tract infections (otitis media, pharyngitis, acute exacerbation of chronic bronchitis, acute sinusitis) 3. Therapy of skin and soft tissue infections 4. Therapy of urinary tract infections CLINICAL ANTIBIOTIC GUIDELINES†

CEFAZOLIN

Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Pen-I Streptococcus pneumoniae Methicillin-resistant S. aureus (MRSA) Pen-S Streptococcus pneumoniae Viridans group Streptococci Pen-R Streptococcus pneumoniae b-haemolytic Streptococci Enterococcus spp Escherichia coli Listeria spp Klebsiella spp Haemophilus spp Proteus mirabilis Enterobacteriaceae producing Moraxella spp inducible b-lactamases* Pseudomonas spp Anaerobic gram-negative bacilli Pasteurella spp Eikenella spp Chlamydia spp Mycoplasma spp

* Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp

Indicated: 1. Surgical prophylaxis 2. Therapy of skin & soft tissue and bone & joint infections where Staphylococcus and Streptococcus are predominant pathogens 3. Therapy of post-operative wounds not involving GI/GU tract NB: For wounds involving GI/GU tract, add metronidazole 4. Alternative agent to cloxacillin for gram positive non-central nervous system infections 5. Therapy of line-related sepsis +/- gentamicin

Not Indicated: 1. Therapy of respiratory tract infections 2. Therapy of animal and human bite wound infections 3. Empiric therapy of skin and soft tissue infections in patients < 5 years 4. Therapy of complicated intraabdominal infections, regardless of concomitant anaerobic coverage CLINICAL ANTIBIOTIC GUIDELINES†

CEFIXIME

Predictable activity: No activity: Pen-S Streptococcus pneumoniae Staphylococcus aureus (MSSA, MRSA) b-haemolytic Streptococci Pen-I, Pen-R S. pneumoniae Escherichia coli Enterococcus spp Klebsiella spp Enterobacteriaceae producing Proteus mirabilis inducible b-lactamases* Haemophilus influenzae Pseudomonas spp Moraxella catarrhalis Stenotrophomonas maltophilia Neisseria gonorrhoeae Anaerobic gram-negative bacilli Pasteurella spp Chlamydia spp Mycoplasma spp

* Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp

Indicated: 1. Therapy of uncomplicated urethral, cervical, rectal, and pharyngeal (single 400mg dose) 2. Therapy of infections due to documented Haemophilus influenzae 3. Second line therapy of urinary tract infections in paediatric patients 4. Second line therapy of gastroenteritis due to Shigella in paediatric patients

Not Indicated: 1. Therapy of pneumonia 2. Therapy of upper respiratory tract infections (otitis media, pharyngitis, acute exacerbation of chronic bronchitis, acute sinusitis) 3. Therapy of skin and soft tissue infections (NO staphylococcal coverage) 4. First line therapy of uncomplicated urinary tract infections 5. Therapy of urinary tract infections where Enterococcus is a potential pathogen such as in elderly or catheterized patients NB: Chronic/asymptomatic bacteriuria in elderly or catheterized patients should NOT be treated CLINICAL ANTIBIOTIC GUIDELINES†

CEFPROZIL NON-FORMULARY - REQUIRES COMPLETION OF ANTIBIOTIC FORM

Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Pen-I Streptococcus pneumoniae Staphylococcus aureus (MRSA) Pen-S Streptococcus pneumoniae Pen-R S. pneumoniae b-haemolytic Streptococci Enterococcus spp Escherichia coli Enterobacteriaceae producing Klebsiella spp inducible b-lactamases* Proteus mirabilis Pseudomonas spp Haemophilus influenzae** Anaerobic gram-negative bacilli Moraxella spp Chlamydia spp Pasteurella spp Mycoplasma spp

* Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp **Haemophilus coverage not as good as cefuroxime.

Indicated: 1. Second line therapy of otitis media 2. Second line therapy of urinary tract infections in paediatric patients

Not Indicated: 1. Therapy of pneumonia 2. Therapy of upper respiratory tract infections (otitis media, pharyngitis, tonsillitis, acute exacerbation of chronic bronchitis, acute sinusitis) 3. Therapy of skin and soft tissue infections 4. First line therapy of urinary tract infections 5. Therapy of documented Haemophilus infection (single pathogen) CLINICAL ANTIBIOTIC GUIDELINES†

CEFTAZIDIME RESTRICTED TO ANTIBIOTIC FORM

Predictable activity: Unpredictable activity: No activity Pen-S Streptococcus pneumoniae Viridans group Streptococci Staphylococcus aureus (MSSA, MRSA) b-haemolytic Streptococci Leuconostoc spp Coagulase negative Staphylococci Escherichia coli Pediococcus spp Pen-I, Pen-R S. pneumoniae Klebsiella spp Enterobacteriaceae producing: Enterococcus spp Proteus mirabilis - inducible b-lactamases* Listeria spp Pseudomonas spp - extended spectrum b-lactamases Stenotrophomonas maltophilia Acinetobacter spp Anaerobic gram-negative bacilli Alcaligenes spp Chlamydia spp Mycoplasma spp * Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp

Indicated: 1. Alternative to piperacillin for suspected or documented infections with in combination with an aminoglycoside 2. Empiric therapy in febrile neutropenic patients (absolute neutrophil count < 0.5 x 109/L) +/- aminoglycoside 3. Alternative to TMP/SMX or quinolones for serious infections with selected non-fermentative gram negative bacilli 4. Empiric therapy of meningitis post-neurosurgical procedures or post-cranial/spinal trauma in combination with vancomycin

Not Indicated: 1. Therapy of community-acquired infections (including respiratory, genitourinary, skin/soft tissue infections) 2. Monotherapy of documented nonurinary Pseudomonas aeruginosa infections 3. Monotherapy of nonurinary infections due to Enterobacteriaceae producing inducible b-lactamases or extended spectrum b-lactamases CLINICAL ANTIBIOTIC GUIDELINES†

CEFOTAXIME & RESTRICTED TO ANTIBIOTIC FORM

Predictable activity: Unpredictable activity: No activity: Pen-S, Pen-I Streptococcus pneumoniae Staphylococcus aureus (MSSA) Staphylococcus aureus (MRSA) b-haemolytic Streptococci Pen-R Streptococcus pneumoniae Coagulase negative Staphylococci Viridans group Streptococci* Leuconostoc spp Enterococcus spp Escherichia coli Pediococcus spp Listeria spp Klebsiella spp Enterobacteriaceae producing: Pseudomonas spp Proteus mirabilis - inducible b-lactamases** Stenotrophomonas maltophilia Haemophilus influenzae - extended spectrum b-lactamases Acinetobacter spp Moraxella spp Nocardia spp Alcaligenes spp Neisseria spp Actinomyces spp Chryseobacterium (Flavobacterium) spp Anaerobic gram-negative bacilli * Some resistance reported. **Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp

Indicated: 1. Empiric therapy of bacterial meningitis (add in neonates, elderly, immunosuppressed) 2. Empiric therapy of sepsis in neonates 1-3 months of age in combination with ampicillin 3. Alternative to amoxicillin for febrile paediatric patients 3-36 months with no focus of infection and who look well (ONLY after blood and CSF cultures taken) 4. Empiric therapy of nosocomial gram-negative infections (except Pseudomonas) +/- aminoglycoside 5. Empiric therapy of severe (ICU) pneumonia from community or nursing homes in combination with erythromycin 6. Alternative to ampicillin + gentamicin for therapy of pyelonephritis in pregnancy 7. Empiric therapy of spontaneous bacterial in patients with hepatic cirrhosis (cefotaxime only) 8. Alternative to ciprofloxacin or cefixime for therapy of Neisseria gonorrhoeae 9. Alternative to G for neurosyphilis in patients with severe/anaphylactic penicillin allergy

Not Indicated: 1. Therapy of community acquired infections (including respiratory, genitourinary and skin and soft tissue infections) 2. Monotherapy of nonurinary infections due to Enterobacteriaceae with inducible b-lactamases or extended spectrum b-lactamases 3. Therapy of skin and soft tissue infections CLINICAL ANTIBIOTIC GUIDELINES†

CEFUROXIME AXETIL

Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Pen-I Streptococcus pneumoniae Methicillin-resistant S. aureus (MRSA) Pen-S Streptococcus pneumoniae Pen-R Streptococcus pneumoniae b-haemolytic Streptococci Enterococcus spp Escherichia coli Enterobacteriaceae producing Klebsiella spp inducible b-lactamases* Proteus mirabilis Pseudomonas spp Haemophilus influenzae Anaerobic gram-negative bacilli Moraxella catarrhalis Chlamydia spp Pasteurella spp Mycoplasma spp

* Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp

Indicated: 1. Therapy of community/nursing home acquired pneumonia in patients > 65 years old and/or with comorbid factors* in combination with erythromycin 2. Second line therapy of otitis media, acute exacerbation of chronic bronchitis, and acute sinusitis 3. Therapy of periorbital cellulitis in paediatric patients

Not Indicated: 1. Monotherapy of community acquired pneumonia 2. First line therapy of otitis media, acute exacerbations of chronic bronchitis, and acute sinusitis 3. Therapy of pharyngitis or tonsillitis 4. Therapy of skin and soft tissue infections in patients > 5 years 5. First line therapy of uncomplicated urinary tract infections 6. Therapy of urinary tract infections where enterococcus is a potential pathogen such as in elderly or catheterized patients NB: Chronic/asymptomatic bacteriuria in elderly or catheterized patients should NOT be treated * Comorbid factors: asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition, hospitalization in past 3 months.

CLINICAL ANTIBIOTIC GUIDELINES†

CEFUROXIME IV

Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Pen-I Streptococcus pneumoniae Methicillin-resistant S. aureus (MRSA) Pen-S Streptococcus pneumoniae Pen-R Streptococcus pneumoniae b-haemolytic Streptococci Enterococcus spp Escherichia coli Enterobacteriaceae producing Klebsiella spp inducible b-lactamases* Proteus mirabilis Pseudomonas spp Haemophilus influenzae Anaerobic gram-negative bacilli Moraxella catarrhalis Chlamydia spp Pasteurella spp Mycoplasma spp * Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp

Indicated: 1. Therapy of community/nursing home acquired pneumonia in patients > 65 years old and/or with comorbid factors* in combination with erythromycin 2. Therapy of hospital acquired pneumonia +/- gentamicin 3. Therapy of aspiration pneumonia in combination with metronidazole 4. Therapy of acute bacterial epiglottitis and tracheitis 5. Therapy of empyema and pneumonia in paediatric patients > 1 month. For the treatment of pneumonia, add erythromycin in paediatric patients > 5 years. 6. Therapy of facial cellulitis in paediatric patients < 5 years 7. Therapy of periorbital cellulitis in paediatric patients 8. Therapy of septic arthritis in paediatric patients

Not Indicated: 1. Therapy of meningitis 2. Monotherapy of community acquired pneumonia in patients > 5 years 3. Therapy of skin and soft tissue infections in patients > 5 years * Comorbid factors: asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition, hospitalization in past 3 months. CLINICAL ANTIBIOTIC GUIDELINES†

CEPHALEXIN

NB: Cephalothin (not cefazolin) susceptibility correlates with cephalexin susceptibility. Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Viridans group Streptococci Methicillin-resistant S. aureus (MRSA) b-haemolytic Streptococci Escherichia coli Pen-I, Pen-R Streptococcus pneumoniae Proteus mirabilis Klebsiella spp Enterococcus spp Moraxella spp Haemophilus spp Enterobacteriaceae producing inducible b-lactamases* Eikenella spp Pseudomonas spp Anaerobic gram-negative bacilli Pasteurella spp Chlamydia spp Mycoplasma spp * Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp

Indicated: 1. Therapy of mild skin and soft tissue infections where Staphylococcus and Streptococcus are predominant pathogens 2. Therapy of mild postpartum wound infections/postpartum breast /mastitis 3. Therapy of mild post-operative surgical wound infections NB: For wounds involving GI/GU tract, consider adding metronidazole 4. Therapy of urinary tract infections in paediatric and pregnant patients 5. Therapy of mild to moderate bursitis 6. Therapy of mild acute cervical adenitis in paediatric patients

Not Indicated: 1. Therapy of animal and human bite wound infections 2. Monotherapy of polymicrobial skin and soft tissue infections (e.g. diabetic foot infections) 3. Therapy of periorbital/facial skin and soft tissue infections in patients < 5 years old 4. Therapy of respiratory tract infections (otitis media, pharyngitis, acute exacerbation of chronic bronchitis, acute sinusitis, pneumonia) 5. Empiric therapy of urinary tract infections in non-pregnant adults 6. Therapy of urinary tract infections where Enterococcus is a potential pathogen such as in elderly or catheterized patients CLINICAL ANTIBIOTIC GUIDELINES†

CIPROFLOXACIN IV RESTRICTED TO ANTIBIOTIC FORM

NB: Ciprofloxacin should be used orally in patients able to tolerate oral medications or enteral feeds as the oral absorption is excellent (achieves same drug serum levels as IV within 2 hours of administration). Predictable activity: Unpredictable activity: No activity: Enterobacteriaceae (excluding Serratia spp) Staphylococcus aureus (MSSA, MRSA)** Enterococcus spp*** Pseudomonas aeruginosa* Coagulase negative Staphylococci Stenotrophomonas maltophilia Haemophilus influenzae Streptococcus pneumoniae Burkholderia cepacia Moraxella catarrhalis b-haemolytic Streptococci Anaerobes Neisseria gonorrhoeae Viridans group Streptococci Chlamydia spp Serratia spp Mycoplasma spp Acinetobacter spp Actinomyces spp Legionella spp Alcaligenes spp Nocardia spp

* Ciprofloxacin has best antipseudomonal coverage of all quinolones. ** Despite in vitro susceptibility, resistance may develop. Monotherapy not recommended. *** Some urinary isolates may be susceptible to ciprofloxacin however increased resistance noted locally.

Indicated: 1. Therapy of hospital acquired gram negative infections 2. Therapy of polymicrobial infections in combination with clindamycin or metronidazole 3. Therapy of complicated urinary tract infections where oral route not possible 4. Empiric therapy in febrile neutropenic patients (absolute neutrophil count < 0.5 x 109/L) with severe penicillin or allergy

Not Indicated: 1. Patients able to tolerate drug orally 2. Therapy of community acquired pneumonia 3. Monotherapy of infections due to suspected or documented gram-positive or anaerobic organisms 4. Monotherapy of documented Pseudomonas aeruginosa infections of respiratory or intraabdominal source 5. Monotherapy of polymicrobial infections (odontogenic, skin and soft tissue infections, intraabdominal) CLINICAL ANTIBIOTIC GUIDELINES†

CIPROFLOXACIN PO

NB: Ciprofloxacin should be used orally if patient is able to tolerate oral medications or enteral feeds as the oral absorption is excellent. Predictable activity: Unpredictable activity: No activity: Enterobacteriaceae (excluding Serratia spp) Staphylococcus aureus (MSSA, MRSA)** Enterococcus spp*** Pseudomonas aeruginosa* Coagulase negative Staphylococci Stenotrophomonas maltophilia Haemophilus influenzae Streptococcus pneumoniae Burkholderia cepacia Moraxella catarrhalis b-haemolytic Streptococci Anaerobes Neisseria gonorrhoeae Viridans group Streptococci Chlamydia spp Neisseria meningitidis Serratia spp Mycoplasma spp Pasteurella multocida Acinetobacter spp Actinomyces spp Legionella spp Alcaligenes spp Nocardia spp * Ciprofloxacin has best antipseudomonal coverage of all quinolones. ** Despite in vitro susceptibility, resistance may develop. Monotherapy not recommended. *** Some urinary isolates may be susceptible to ciprofloxacin however increased resistance noted locally. Indicated: 1. Therapy of community/hospital acquired gram negative infections 2. Therapy/stepdown therapy of polymicrobial infections in combination with clindamycin or metronidazole 3. Therapy of genitourinary tract infections 4. Prophylaxis of transurethral surgical procedures 5. Therapy of suspected bacterial gastroenteritis (Most cases of diarrhea are self-limiting and do not require antimicrobial therapy) 6. Prophylaxis of adult contacts of cases of invasive 7. Prophylaxis in patients at risk of gram negative infections (cirrhosis, neutropenia) NB: Ciprofloxacin prophylaxis may predispose to gram positive infections. Not Indicated: 1. Therapy of community acquired pneumonia 2. Therapy of upper respiratory tract infections (otitis media, pharyngitis, acute exacerbation of chronic bronchitis, acute sinusitis) 3. Therapy of uncomplicated cellulitis 4. Monotherapy of polymicrobial infections (odontogenic, skin and soft tissue, intraabdominal) 5. Monotherapy of infections due to suspected or documented gram positive or anaerobic organisms 6. Monotherapy of documented Pseudomonas aeruginosa infections of respiratory or intraabdominal source 7. Surgical prophylaxis of non-urological procedures CLINICAL ANTIBIOTIC GUIDELINES† CLARITHROMYCIN

Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Haemophilus influenzae* Staphylococcus aureus (MRSA) Streptococcus pneumoniae Enterococcus spp b-haemolytic Streptococci Enterobacteriaceae Moraxella catarrhalis Pseudomonas spp Bordetella pertussis Anaerobic gram-negative bacilli Helicobacter pylori Legionella spp Mycobacterium avium complex Mycoplasma pneumoniae Chlamydia trachomatis Chlamydia pneumoniae * Better coverage than erythromycin, however not recommended for serious documented Haemophilus infections

Indicated: 1. Therapy of community acquired pneumonia 2. Second line therapy of otitis media, acute exacerbation of chronic bronchitis, and acute sinusitis 3. Therapy of documented Helicobacter pylori in patients with duodenal or gastric ulcers in combination with amoxicillin or metronidazole plus an acid suppression agent 4. Therapy of selected Mycobacterium infections usually in combination with other agents

Not Indicated: 1. First line therapy of upper respiratory tract infections (otitis media, pharyngitis, acute exacerbation of chronic bronchitis, acute sinusitis) 2. Therapy of hospital acquired pneumonia 3. Therapy of skin and soft tissue infections CLINICAL ANTIBIOTIC GUIDELINES†

CLINDAMYCIN IV

NB: Clindamycin should be used IV only if patient is NPO as the oral absorption is excellent. Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Peptostreptococcus spp Methicillin-resistant S. aureus (MRSA) Streptococcus pneumoniae Clostridium spp Enterococcus spp b-haemolytic Streptococci Anaerobic gram-negative bacilli Enterobacteriaceae Viridans group Streptococci Pseudomonas spp Corynebacterium spp (other than C. jeikium) Haemophilus spp Bacillus spp Moraxella spp Gardnerella vaginalis Pasteurella spp Capnocytophaga spp Eikenella spp Propionibacterium spp Actinomyces spp Nocardia spp Chlamydia trachomatis

Indicated: 1. Alternative to cloxacillin or cefazolin in b-lactam allergic patients for the treatment/prophylaxis of gram positive organisms 2. Alternative to metronidazole for the treatment of anaerobic infections 3. Therapy of polymicrobial infections in combination with an agent effective against aerobic gram negative organisms (skin and soft tissue, hospital acquired aspiration pneumonia, intraabdominal, pelvic) 4. Therapy of odontogenic infections in b-lactam allergic patients 5. Therapy of lung abscess or empyema 6. Therapy of Group A Streptococcal fasciitis/myositis and C. perfringens gas gangrene in combination with penicillin 7. Alternative to amoxicillin for bacterial prophylaxis

Not Indicated: 1. Therapy of central nervous system (CNS) infections except CNS toxoplasmosis 2. First line therapy of aspiration pneumonia 3. Therapy of otitis media, acute exacerbation of chronic bronchitis, and acute sinusitis 4. Monotherapy of polymicrobial infections CLINICAL ANTIBIOTIC GUIDELINES† CLINDAMYCIN PO

Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Peptostreptococcus spp Methicillin-resistant S. aureus (MRSA) Streptococcus pneumoniae Clostridium spp Enterococcus spp b-haemolytic Streptococci Anaerobic gram-negative bacilli Enterobacteriaceae Viridans group Streptococci Pseudomonas spp Corynebacterium spp (other than C. jeikium) Haemophilus spp Bacillus spp Moraxella spp Gardnerella vaginalis Pasteurella spp Capnocytophaga spp Eikenella spp Propionibacterium spp Actinomyces spp Nocardia spp Chlamydia trachomatis

Indicated: 1. Alternative to cloxacillin or cefazolin in b-lactam allergic patients for the treatment/prophylaxis of gram positive organisms 2. Alternative to metronidazole for the treatment of anaerobic infections 3. Therapy of polymicrobial infections in combination with an agent effective against aerobic gram negative organisms 4. Therapy of odontogenic infections in b-lactam allergic patients 5. Therapy of recurrent/unresponsive streptococcal pharyngitis 6. Alternative to metronidazole for bacterial vaginosis 7. Alternative to amoxicillin for bacterial endocarditis prophylaxis

Not Indicated: 1. First line therapy of aspiration pneumonia 2. Therapy of acute exacerbation of otitis media, chronic bronchitis, and acute sinusitis 3. Monotherapy of polymicrobial infections 4. In combination with antibiotics having an overlapping spectrum of activity (e.g. penicillin, cloxacillin, cefazolin, cephalexin, cefoxitin, metronidazole) CLINICAL ANTIBIOTIC GUIDELINES†

FLUCONAZOLE IV/PO RESTRICTED TO ANTIBIOTIC FORM

NB: This agent is well absorbed. Should be given orally in majority of cases.

Predictable activity: Unpredictable activity: No activity: Candida albicans Candida glabrata Candida krusei Candida tropicalis Blastomycosis Aspergillus spp Candida parapsilosis Histoplasma spp Rhizopus spp Candida pseudotropicalis Coccidioides Pseudallescheria spp Candida lusitaniae (resistant to Ampho B) Sporotrichosis Candida guillermondi (resistant to Ampho B) Cryptococcus neoformans Trichophyton spp

Indicated: IV: 1. Therapy of systemic candidiasis. See Empiric Therapy Recommendations. 2. Initial therapy for meningitis due to Coccidioidomycosis 3. Stepdown from Amphotericin B for cryptococcal meningitis 4. Therapy for severe mucocutaneous Candida infections where patient unable to take drugs orally

Oral: 1. Therapy of mucocutaneous/vaginal candidiasis 2. Therapy, prophylaxis and suppressive therapy for mucocutaneous candidal infections in immunocomprised patients 3. Stepdown therapy for systemic infections due to Candida 4. Therapy of urinary tract infections due to Candida 5. Therapy of Coccidioidomycosis 6. Stepdown therapy from Amphotericin B for severe cryptococcal infections 7. Suppressive therapy for cryptococcal infections in immunocompromised patients 8. Therapy of Candida esophagitis 9. Alternative therapy of selected dermatophytoses

Not Indicated: 1. First line therapy for mild to moderate candidal mucositis CLINICAL ANTIBIOTIC GUIDELINES†

FOSCARNET RESTRICTED TO ANTIBIOTIC FORM

Indicated:

1. Alternative to ganciclovir for therapy and maintenance of invasive CMV disease in immunocompromised patients 2. Therapy of acyclovir/ganciclovir resistant Herpes simplex and varicella-zoster infections in immunocompromised hosts 3. As combination therapy with ganciclovir for recurrent CMV retinitis in immunocompromised patients

GANCICLOVIR RESTRICTED TO ANTIBIOTIC FORM

Indicated: 1. Therapy of documented acute CMV infections (e.g. pneumonia, hepatitis, enteritis, retinitis) in immunocompromised patients 2. Therapy and maintenance of suspected CMV radiculopathy in immunocompromised patients 3. Prophylaxis for CMV infections in lung, heart/lung, and allogeneic bone marrow transplants if recipient seropositive or donor seropositive and recipient seronegative 4. Therapy for Epstein-Barr Virus Lymphoproliferative Syndrome in immunocompromised host 5. Therapy and maintenance of clinically suspected Rasmussen’s encephalitis 6. Prophylaxis (pre-emptive therapy) in renal transplant patients (except CMV donor-negative/recipient-negative) when OKT3 or ALG is used

Not Indicated: 1. In documented acyclovir-resistant Herpes simplex or varicella-zoster infections 2. Routine prophylaxis of CMV infections in transplants other than lung, heart/lung, or bone marrow CLINICAL ANTIBIOTIC GUIDELINES†

IMIPENEM RESTRICTED TO ANTIBIOTIC FORM

Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Pen-R Streptococcus pneumoniae Methicillin-resistant S. aureus (MRSA) Pen-S, Pen-I Streptococcus pneumoniae Burkholderia cepacia Coagulase negative Staphylococci b-haemolytic Streptococci Enterococcus faecium (most) Viridans group Streptococci Stenotrophomonas maltophilia Enterococcus faecalis Chryseobacterium (Flavobacterium) Bacillus spp meningosepticum Enterobacteriaceae Chlamydia spp Pseudomonas spp Mycoplasma spp Haemophilus influenzae Moraxella spp Neisseria spp Acinetobacter spp Alcaligenes spp Anaerobes

Indicated: 1. Second line therapy of intraabdominal sepsis where there is documented failure of first line therapy (e.g. ampicillin + gentamicin + metronidazole) 2. Second line therapy of severe polymicrobial skin and soft tissue infections (e.g. limb threatening diabetic foot) 3. Empiric therapy of mixed synergistic necrotizing gangrene (Fournier’s gangrene) 4. Empiric therapy of severe nosocomial polymicrobial infections 5. Therapy of severe ventilator-associated pneumonia where Pseudomonas and S. aureus coverage is needed 6. Second line therapy of nosocomial infections due to gram-negative organisms producing inducible b-lactamases (Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp) or extended spectrum b-lactamases where there is resistance to first line agents (TMP/SMX, ciprofloxacin, and )

Not Indicated: 1. Therapy of community acquired infections (including respiratory, genitourinary, and skin/soft tissue infections) 2. First line therapy of nosocomial respiratory tract infections 3. Monotherapy of documented Pseudomonas aeruginosa infections 4. First line therapy of intraabdominal sepsis CLINICAL ANTIBIOTIC GUIDELINES†

LEVOFLOXACIN IV RESTRICTED TO ANTIBIOTIC FORM

NB: Levofloxacin should be used orally in patients able to tolerate oral medications or enteral feeds as the oral absorption is excellent (99% bioavailability). Predictable activity: Unpredictable activity: No activity: Streptococcus pneumoniae Staphylococcus aureus, methicillin-susceptible* Staphylococcus aureus, methicillin- Enterobacteriaceae Coagulase negative Staphylococci resistant Haemophilus influenzae b-haemolytic Streptococci Enterococcus spp Moraxella catarrhalis Viridans group Streptococci Pseudomonas aeruginosa Neisseria gonorrhoeae Stenotrophomonas maltophilia Chlamydia spp Burkholderia cepacia Mycoplasma spp Anaerobes Legionella spp Actinomyces spp Nocardia spp

Indicated: 1. Empiric therapy of community acquired pneumonia in hospitalized patients unable to tolerate oral intake 2. Empiric therapy of nursing home acquired pneumonia only in patients unable to tolerate oral intake 3. Empiric therapy of severe (increased sputum volume and purulence, and increased dyspnea) acute exacerbations of chronic bronchitis in patients who have failed first/second line therapy and are unable to tolerate oral intake

Not Indicated: 1. Patients able to tolerate drug orally 2. Therapy of skin and soft tissue infections, including bite wound infections 3. Empiric therapy of complicated urinary tract infections and pyelonephritis. Ciprofloxacin is the most appropriate quinolone. 4. Monotherapy of infections due to suspected or documented anaerobic organisms 5. * Monotherapy of S. aureus infections. Resistance of S. aureus may develop rapidly. CLINICAL ANTIBIOTIC GUIDELINES†

LEVOFLOXACIN PO

NB: Levofloxacin should be used orally in patients able to tolerate oral medications or enteral feeds as the oral absorption is excellent (99% bioavailability). Predictable activity: Unpredictable activity: No activity: Streptococcus pneumoniae Staphylococcus aureus, methicillin-susceptible* Staphylococcus aureus, methicillin- Enterobacteriaceae Coagulase negative Staphylococci resistant Haemophilus influenzae b-haemolytic Streptococci Enterococcus spp Moraxella catarrhalis Viridans group Streptococci Pseudomonas aeruginosa Neisseria gonorrhoeae Stenotrophomonas maltophilia Chlamydia spp Burkholderia cepacia Mycoplasma spp Anaerobes Legionella spp Actinomyces spp Nocardia spp

Indicated: 1. Empiric therapy of community acquired pneumonia in hospitalized patients 2. Empiric therapy of community acquired pneumonia in patients > 60 years old with comorbid factors** 3. Second line therapy of community acquired pneumonia in young otherwise healthy patients who have failed first line agents (macrolides, tetracyclines) or are intolerant/allergic to these agents 4. Empiric therapy of nursing home acquired pneumonia 5. Empiric therapy of severe (increased sputum volume and purulence, and increased dyspnea) acute exacerbations of chronic bronchitis in patients who have failed first/second line therapy

Not Indicated: 1. Therapy of upper respiratory tract infections (otitis media, pharyngitis) 2. First line therapy of acute sinusitis 3. First line empiric therapy of community acquired pneumonia in young otherwise healthy outpatients 4. Therapy of odontogenic infections 5. Therapy of skin and soft tissue infections, including bite wound infections 6. Empiric therapy of complicated urinary tract infections and pyelonephritis. Ciprofloxacin is the most appropriate quinolone. 7. * Monotherapy of S. aureus infections. Resistance of S. aureus may develop rapidly ** Comorbid factors: asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition, hospitalization in past 3 months. CLINICAL ANTIBIOTIC GUIDELINES†

MEROPENEM NON-FORMULARY - REQUIRES COMPLETION OF ANTIBIOTIC FORM IN CAPITAL HEALTH REGION HOSPITALS, MUST MEET INDICATIONS BELOW OR IMIPENEM WILL BE SUBSTITUTED Predictable activity: Unpredictable activity: No activity: Staphyloccus aureus (MSSA) Pen-R Streptococcus pneumoniae Methicillin-resistant S. aureus (MRSA) Pen-S, Pen-I S. pneumoniae Enterococcus faecalis Coagulase negative Staphylococci b-haemolytic Streptococci Enterococcus faecium Viridans group Streptococci Stenotrophomonas maltophilia Listeria spp Chryseobacterium (Flavobacterium) spp Bacillus spp Chlamydia spp Enterobacteriaceae Mycoplasma spp Pseudomonas spp Haemophilus influenzae Moraxella spp Neisseria spp Acinetobacter spp Alcaligenes spp Burkholderia cepacia Anaerobes Indicated: 1. Alternative to imipenem for severe nosocomial polymicrobial infections involving gram-negative organisms resistant to first line agents in patients with documented seizure disorder/CNS abnormality 2. Therapy of severe nosocomial polymicrobial infections involving gram-negative organisms resistant to first line agents and to imipenem but susceptible to meropenem 3. Therapy of meningitis due to gram-negative organisms producing inducible b-lactamases (Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp) 4. Alternative to ceftazidime for central nervous system (CNS) infections due to Pseudomonas aeruginosa Not Indicated: 1. Therapy of community-acquired infections (including respiratory, genitourinary, and skin/soft tissue infections) 2. First line therapy of nosocomial infections 3. Monotherapy of documented Pseudomonas aeruginosa infections 4. Empiric therapy of meningitis CLINICAL ANTIBIOTIC GUIDELINES†

MOXIFLOXACIN NON-FORMULARY - REQUIRES COMPLETION OF ANTIBIOTIC FORM

Predictable activity: Unpredictable activity: No activity: Streptococcus pneumoniae Staphylococcus aureus, methicillin-susceptible* Staphylococcus aureus, methicillin- Enterobacteriaceae Coagulase negative Staphylococci resistant Haemophilus influenzae b-haemolytic Streptococci Enterococcus spp** Moraxella catarrhalis Viridans group Streptococci Pseudomonas aeruginosa Neisseria gonorrhoeae Anaerobes Stenotrophomonas maltophilia Chlamydia spp Burkholderia cepacia Mycoplasma spp Legionella spp Actinomyces spp Nocardia spp ** High local quinolone resistance.

Indicated: 1. Empiric therapy of community acquired pneumonia in patients > 60 years old with comorbid factors*** 2. Second line therapy of community acquired pneumonia in young otherwise healthy patients who have failed first line agents (macrolides, tetracyclines) or are intolerant/allergic to these agents 3. Empiric therapy of nursing home acquired pneumonia 4. Empiric therapy of severe (increased sputum volume and purulence, and increased dyspnea) acute exacerbations of chronic bronchitis in patients who have failed first/second line therapy 5. Second line therapy of acute bacterial sinusitis in â-lactam allergic patients who have failed first line therapy

Not Indicated: 1. Therapy of upper respiratory tract infections (otitis media, pharyngitis) 2. First line therapy of acute sinusitis 3. First line empiric therapy of community acquired pneumonia in young otherwise healthy outpatients 4. Therapy of odontogenic infections 5. Therapy of skin and soft tissue infections, including bite wound infections 6. Therapy of complicated urinary tract infections and pyelonephritis. Ciprofloxacin is the most appropriate quinolone. 7. * Monotherapy of S. aureus infections. Resistance of S. aureus may develop rapidly. *** Comorbid factors: asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition, hospitalization in past 3 months CLINICAL ANTIBIOTIC GUIDELINES†

NEURAMINIDASE

INHIBITORS OSELTAMIVIR - FORMULARY ZANAMIVIR – NON-FORMULARY; REQUIRES COMPLETION OF ANTIBIOTIC FORM

The neuraminidase inhibitors will not be made available at any Capital Health institution until influenza has been isolated in the laboratory. NB: Prevention of influenza infections with current-season influenza vaccine is preferred to treatment with neuraminidase inhibitors (or amantadine), particularly in high risk patients§

Predictable activity: Unpredictable activity: No activity: Influenza A Rhinovirus Influenza B Coronavirus Respiratory syncytial virus (RSV) Adenovirus Enterovirus Parainfluenza Indicated: 1. Once influenza has been documented in the Capital Health region, as empiric treatment of influenza A or B in febrilef patientsb who have been symptomatic for no more than TWO days. 2. Alternative to amantadine for treatment of influenza A in patients unable to tolerate amantadine. Not Indicated: 1. As a replacement for the influenza vaccine. 2. Therapy for the common cold. 3. Empiric treatment of influenza-like symptoms when there is no laboratory evidence of circulating influenza in the Capital Health region. 4. In patients who have been symptomatic for more than TWO days. f Efficacy in patients who do not present with fever has not been established. b Zanamivir is indicated in patients ³ 12 years of age. Oseltamivir is indicated in adults. § High risk patients include: · People > 65 years of age · People with: § chronic cardiac or pulmonary disorders (bronchopulmonary dysplasia, cystic fibrosis, asthma) § chronic conditions (diabetes mellitus and other metabolic diseases) § cancer, immunodeficiency (including patients infected with HIV), immunosuppression § renal disease, anemia, hemoglobinopathy · Residents of nursing homes and other chronic care facilities CLINICAL ANTIBIOTIC GUIDELINES† · Children & adolescents (6 mos – 18 yrs) with conditions requiring chronic acetylsalicyclic acid (ASA) as this therapy may increase the risk of Reye’s syndrome after influenza · Patients hospitalized in acute care facilities. CLINICAL ANTIBIOTIC GUIDELINES†

PIPERACILLIN - TAZOBACTAM RESTRICTED TO ANTIBIOTIC FORM

Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Pen-I Streptococcus pneumoniae Methicillin-resistant S. aureus (MRSA) Pen-S Streptococcus pneumoniae Enterobacteriaceae producing inducible Coagulase negative Staphylococci b-haemolytic Streptococci b-lactamases* Pen-R Streptococcus pneumoniae Viridans group Streptococci Enterococcus faecium (most) Enterococcus faecalis Stenotrophomonas maltophilia Escherichia coli Chlamydia spp Klebsiella spp Mycoplasma spp Proteus mirabilis Pseudomonas spp Haemophilus influenzae Moraxella spp Neisseria spp Acinetobacter spp * Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus Bordetella spp penneri, and some Hafnia spp Anaerobes

Indicated: 1. Second line therapy of intraabdominal sepsis where there is documented failure of first line therapy (e.g. ampicillin + gentamicin + metronidazole) 2. Second line therapy of severe polymicrobial skin and soft tissue infections (e.g. limb threatening diabetic foot) 3. Empiric therapy of severe nosocomial polymicrobial infections 4. Therapy of severe ventilator-associated pneumonia where Pseudomonas and S. aureus coverage is needed

Not Indicated: 1. Therapy of community acquired infections (including respiratory, genitourinary and skin/soft tissue infections) 2. First line therapy of intraabdominal sepsis 3. Monotherapy of documented Pseudomonas aeruginosa infections 4. Therapy of piperacillin-resistant Pseudomonas aeruginosa 5. Monotherapy of infections due to Enterobacteriaceae producing inducible b-lactamases CLINICAL ANTIBIOTIC GUIDELINES†

QUINUPRISTIN-DALFOPRISTIN IV NON-FORMULARY - REQUIRES COMPLETION OF ANTIBIOTIC FORM

Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA, MRSA) Haemophilus influenzae Enterococcus faecalis Coagulase negative Staphylococci Enterococcus durans Streptococcus pneumoniae Enterococcus casseliflavus b-haemolytic Streptococci Enterococcus gallinarum Viridans group Streptococci Gram negative enteric bacilli Enterococcus faecium Pseudomonas spp Moraxella catarrhalis Acinetobacter spp Neisseria gonorrhoeae Neisseria meningitidis Anaerobes Indicated: 1. Therapy of vancomycin-resistant Enterococcus faecium infections 2. Therapy of MRSA/MRSE infections unresponsive to vancomycin Not Indicated: 1. Therapy of Enterococcus faecalis infections 2. Routine therapy of Enterococcus faecium infections 3. Routine therapy of staphylococcal infections (including MRSA/MRSE) where alternative therapies exist 4. Therapy of skin and soft tissue infections where alternative therapies exist 5. Decolonization of patients with vancomycin-resistant Enterococcus spp and/or MRSA CLINICAL ANTIBIOTIC GUIDELINES†

RIBAVIRIN RESTRICTED TO ANTIBIOTIC FORM

Within the Capital Health region, ribavirin is NOT recommended even for severe RSV, including those ventilated in PICU, except possibly in the severely immunocompromised (e.g. transplant).

According to the AAP and CPS, ribavirin “may be considered” for proven lower respiratory tract infection due to respiratory syncytial virus (RSV) in certain circumstances: · mechanically ventilated for RSV infection · severe disease, such as PaO2 < 65 mmHg or increasing PaO2 · underlying conditions such as BPD, CF, chronic pulmonary disease, congenital heart disease with pulmonary hypertension or increased pulmonary blood flow, multiple congenital anomalies, severe neurological or metabolic disease, infants < 6 weeks old, or severe immune deficiency. Still, the CPS recognizes that “there are insufficient data to justify routine use of ribavirin” in these situations, and with underlying conditions “there is poor evidence to support the use of ribavirin.” CLINICAL ANTIBIOTIC GUIDELINES†

TICARCILLIN-CLAVULANIC ACID RESTRICTED TO ANTIBIOTIC FORM

Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA) Pen-I Streptococcus pneumoniae Methicillin-resistant S. aureus (MRSA) Pen-S Streptococcus pneumoniae Enterobacteriaceae producing inducible Pen-R Streptococcus pneumoniae b-haemolytic Streptococci b-lactamases* Enterococcus faecium (most) Viridans group Streptococci Stenotrophomonas maltophilia Enterococcus faecalis Escherichia coli Klebsiella spp Proteus mirabilis Pseudomonas spp Haemophilus influenzae Moraxella spp Neisseria spp Pasteurella spp Bordetella spp Anaerobes

* Enterobacter spp, Citrobacter freundii complex, Serratia spp, Morganella spp, Providencia spp, Proteus vulgaris, Proteus penneri, and some Hafnia spp

Regionally this drug is restricted to the therapy of documented infections due to susceptible Stenotrophomonas maltophilia.

NB: Because of high resistance of S. maltophilia to ticarcillin-clavulanic acid locally (> 70%): · ensure that organism is true pathogen rather than colonizer · empiric monotherapy of S. maltophilia with this agent is NOT recommended · if S. maltophilia is susceptibile, combination therapy is recommended CLINICAL ANTIBIOTIC GUIDELINES†

VANCOMYCIN IV RESTRICTED TO ANTIBIOTIC FORM

Predictable activity: Unpredictable activity: No activity: Staphylococcus aureus (MSSA, MRSA) Lactobacillus spp Gram-negative organisms Coagulase negative Staphylococci (aerobic & anaerobic) Streptococcus pneumoniae Leuconostoc spp b-haemolytic Streptococci Pediococcus spp Viridans group Streptococci Enterococcus spp Listeria spp Bacillus spp Corynebacterium spp Indicated: 3. Treatment of serious infections due to b-lactam resistant gram-positive organisms. Clinicians should be aware that b-lactams are more rapidly bactericidal than vancomycin for b-lactam susceptible gram-positive organisms. 4. Treatment of infections due to gram-positive microorganisms in patients with serious allergy to b-lactam antimicrobials 5. Empiric therapy for serious infections where S. epidermidis is suspected (i.e. post neurosurgery, VP shunt, prosthetic joint and tunnel-related infections) 6. Prophylaxis, as recommended by the American Heart Association, for endocarditis following certain genitourinary or gastrointestinal (excluding esophageal) procedures in penicillin-allergic patients at moderate or high risk for endocarditis 7. Prophylaxis for selected surgical procedures in penicillin-anaphylactic/cephalosporin-allergic patients. See Antimicrobial Surgical Prophylaxis Recommendations. Not Indicated: 6. Routine surgical prophylaxis 7. Empiric antimicrobial therapy for febrile neutropenia (unless evidence of central venous line/tunnel-related infection) 8. Treatment in response to a single blood culture positive for coagulase negative Staphylococci 9. Continued empiric use for presumed infections in patients whose cultures are negative for b-lactam resistant gram-positive organisms 10. Systemic or local prophylaxis for infection or colonization of central/intravascular catheters/vascular grafts 11. Eradication of MRSA colonization 12. Routine prophylaxis of very low birth weight infants 13. Routine prophylaxis for patients on CAPD or hemodialysis 14. Treatment chosen for dosing convenience of infections due to b-lactam sensitive gram-positive microorganisms in patients with renal failure 15. Use of vancomycin solution for topical application (except as indicated under vancomycin PO for antibiotic-associated diarrhea) or irrigation CLINICAL ANTIBIOTIC GUIDELINES†

VANCOMYCIN PO RESTRICTED TO ANTIBIOTIC FORM

NB: This drug is not absorbed and must NEVER be used to treat systemic infections. IN CAPITAL HEALTH REGION HOSPITALS, MUST MEET ONE OR MORE OF THE INDICATIONS BELOW OR METRONIDAZOLE 250MG PO QID WILL BE SUBSTITUTED.

This drug is used solely for the treatment C. difficile enteritis only if there is: a) documented failure or clinical deterioration on metronidazole therapy b) laboratory confirmed relapse of C. difficile enteritis with symptoms after 2 courses of metronidazole therapy (see Empiric Therapy Recommendations) c) documented or impending toxic megacolon d) intolerance or side effects to metronidazole therapy

Not Indicated: 1. First line therapy of C. difficile enteritis 2. Treatment of systemic infections (includes superficial skin infections) 3. Prophylaxis for gram-positive infections 4. Eradication of MRSA colonization 5. Selective decontamination of digestive tract

†Notes: 1. The organism lists for antibiotic activity are not all inclusive. Empiric therapy should be guided by site-specific antibiograms and empiric therapy recommendations. Tailor antibiotics to susceptibility results or consult microbiology lab.

2. Unpredictable activity denotes that some strains may be susceptible, however empiric therapy with the specified antibiotic is not recommended.

3. Indications for use are not all inclusive. Refer to the Recommended Empiric Therapy sections for specific treatment regimens.

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Antimicrobial Recommended Cost ($)/Day2 Adult Dose1 amoxicillin 500mg PO tid 0.60 amoxicillin-clavulanate 875mg PO bid 4.30 ampicillin 1-2g IV/IM q6h 10.60-12.60 penicillin VK 300mg PO qid 0.16 penicillin G Na 2MU IV/IM q4-6h 7.20-10.80 cloxacillin 500mg PO qid 0.78 1-2g IV/IM q6h7 9.00-11.60 piperacillin 4g IV/IM q6h3 60.00 piperacillin-tazobactam4 4.5g IV q8h3 63.60 ticarcillin-clavulanate4 3.1g IV q6h 41.32 Carbapenems imipenem4 500mg IV q6h 98.68 meropenem5,6 1-2g IV q8h 141.84-283.68 cephalexin 500mg PO qid 1.19 cefazolin 1g IV/IM q8h 9.68 cefoxitin 1-2g IV/IM q8h 24.45-48.90 cefuroxime axetil 500mg PO bid 5.91 cefuroxime 750mg IV/IM q8h 20.07 cefixime 400mg PO daily 3.09 cefotaxime4 1g IV/IM q8h7 29.67 ceftriaxone4 1g IV/IM daily7 35.00 ceftazidime4 1-2g IV/IM q8h 60.80-119.64 Aminoglycosides8 gentamicin 7mg/kg/day IV or 24.75 1.5-2mg/kg IV/IM q8h 15.84-20.79 tobramycin 7mg/kg/day IV or 32.38 1.5-2mg/kg IV/IM q8h 19.43-27.20 ADULT ANTIMICROBIAL DOSING GUIDE AND DAILY COSTS

Antimicrobial Recommended Adult Cost ($)/Day2 Dose1 Macrolides erythromycin 250-500mg PO qid 0.18-0.36 0.5-1g IV q6h 42.80-70.80 azithromycin 500 mg PO first day, 4.93 (250mg) then 250mg PO daily x 4 days 500 mg IV daily 20.00 clarithromycin 250-500mg PO bid 2.96-5.92 Quinolones 250-750mg PO bid ciprofloxacin 4 4.44-9.45 200-400mg IV q12h 33.00-66.00 levofloxacin 250-500mg PO daily 4.77-5.39 250-500mg IV daily4 17.00-34.00 moxifloxacin5 400mg PO daily 5.01 norfloxacin9 400mg PO bid 4.36 Tetracyclines tetracycline 250-500mg PO qid 0.08-0.15 doxycycline 100mg PO daily-bid 0.59-1.17 100mg IV daily-bid10 - Other clindamycin 150-450mg PO qid 2.17-6.52 600mg IV/IM q8h 31.50 metronidazole 500mg PO bid11 0.06 500mg IV q12h 3.78 co-trimoxazole 1 D.S. tab PO bid 0.24 160-240mg TMP (10- 23.68-71.04 15mL) q6, 8, or 12h trimethoprim 100mg PO bid 0.60 nitrofurantoin 50-100mg PO qid 0.09-0.10 quinupristin- 7.5mg/kg IV q8-12h 184.15-276.22 dalfopristin5 vancomycin4 1g IV q12h 112.76 ADULT ANTIMICROBIAL DOSING GUIDE AND DAILY COSTS

Antimicrobial Recommended Adult Cost ($)/Day2 Dose1 Antiviral acyclovir HSV 400mg PO tid 5.19 VZV 800mg PO 5x/day 14.28 HSVE 10mg/kg IV q8h4 300.61 famciclovir HSV 250mg PO tid 10.71 VZV 500mg PO tid 19.48 valacyclovir5 HSV 500mg-1g PO bid 6.22-12.44 VZV 1g PO tid 18.66 amantadine 100-200mg PO daily 0.52-1.04 oseltamivir 75mg PO bid 8.40 zanamivir5 10mg inhaled orally bid 7.00 Antifungal amphotericin B 0.5-0.7mg/kg/day IV 26.15-37.35 fluconazole4 100-400mg PO daily 8.61-34.46 200-400mg IV daily 53.02-106.04 ketoconazole 200-400mg PO daily 2.02-4.04 itraconazole5 100-200mg PO daily 3.76-7.53 1. Based on a 70kg adult with normal renal and hepatic function. For disease- specific dosing, see Recommended Empiric Therapy in Adult Patients. 2. Based on Alberta Health Drug Benefit List price, October 2000. Prices in the hospital setting may be significantly different due to contract pricing. Check with pharmacy for actual prices. Does not include administration, supplies, or serum level costs. 3. For infections with documented Pseudomonas aeruginosa, increase dose to 3g IV q4h (piperacillin)/4.5g IV q6h (piperacillin-tazobactam). 4. Restricted = Antibiotic form must be completed. 5. Non-formulary (NF) = Antibiotic form must be completed. 6. If indication for use does not meet clinical guidelines, meropenem will be substituted to an equivalent dose of imipenem. 7. For central nervous system infections, higher doses at more frequent intervals should be used. 8. See extended interval or conventional aminoglycoside dosing guidelines. 9. Norfloxacin is non-formulary in Capital Health Region hospitals and is automatically substituted to an equivalent dose of oral ciprofloxacin. 10.Doxycycline IV is available through the HPB Special Access Program (Emergency Release). Contact pharmacy for assistance when ordering. 11.For antibiotic associated colitis use 250mg PO qid. HSV = Herpes simplex virus VZV = Varicella zoster virus HSVE = Herpes simplex virus encephalitis PAEDIATRIC ANTIMICROBIAL DOSING GUIDE AND DAILY COSTS

Antimicrobial Recommended Paediatric Cost ($) / Dose1,2 Day3,4 Penicillins amoxicillin 40mg/kg/d PO div tid 0.48 amoxicillin-clavulanate 40mg/kg/d PO div tid 3.04 ampicillin 100-200mg/kg/d IV div q6h 7.20-14.40 penicillin VK 40mg/kg/d PO div tid or qid 0.43 penicillin G Na 100,000-250,000u/kg/d IV div 4.30-10.75 q4-6h5 cloxacillin 40-50mg/kg/d PO div qid 0.64-0.80 100mg/kg/d PO div qid6 0.784a-1.604b 100-200mg/kg/d IV div q4-6h 4.50-9.00 piperacillin 250-300mg/kg/d IV div q4-6h 25.00-30.00 piperacillin- 250-300mg/kg/d IV div q4-6h 23.56-28.27 tazobactam7 ticarcillin-clavulanate7 300mg/kg/d IV div q4-6h 20.66 Carbapenems imipenem7 60-100mg/kg/d IV div q6h 59.21-98.68 meropenem8,9 60-120mg/kg/d IV div q8h10 56.74-113.47 Cephalosporins cephalexin 40mg/kg/d PO div qid 1.05 100mg/kg/d PO div qid6 1.194a-2.624b cefazolin 75-100mg/kg/d IV div q8h 4.83-6.45 cefoxitin 80-160mg/kg/d IV div q6h 13.04-26.08 cefaclor 30-40mg/kg/d PO div bid-tid 1.61-2.14 cefuroxime axetil 40mg/kg/d PO div bid 5.12 cefuroxime 100-150mg/kg/d IV div q8h 17.84-26.76 cefixime 8mg/kg/d PO div q12-24h 2.65 cefotaxime7 100-200mg/kg/d IV div q6-8h 19.78-39.56 ceftriaxone7 50-100mg/kg/d IV div q12-24h 35.00-70.00 ceftazidime7 150mg/kg/d IV div q8h 60.80 PAEDIATRIC ANTIMICROBIAL DOSING GUIDE AND DAILY COSTS

Antimicrobial Recommended Paediatric Cost ($)/ Dose1,2 Day3,4 Aminoglycosides gentamicin 5-7.5mg/kg/d IV div q8h 4.95-7.43 tobramycin 5-7.5mg/kg/d IV div q8h 6.48-9.72 Macrolides erythromycin 40mg/kg/d PO div qid 1.15 40mg/kg/d IV div q6h 17.12 azithromycin 10mg/kg PO first day, then 3.78 5mg/kg PO daily x 4 days (5mg/kg) clarithromycin 15mg/kg/d PO div bid 3.11 Others clindamycin 30-40mg/kg/d PO div qid 2.174a-6.354b 40mg/kg/d IV div q8h 14.00 metronidazole 15-30mg/kg/d PO div bid 0.03-0.07 30mg/kg/d IV div q12h 2.27 co-trimoxazole 6-10mg TMP/kg/d PO div bid 0.30-0.50 20mg TMP/kg/d IV div q6h for 29.60 PCP 10mg TMP/kg/d IV div q6h for 14.80 other infections trimethoprim 4mg/kg/d PO div bid 0.24 doxycycline11 2-4mg/kg/d PO div q12-24h 0.23-0.46 2-4mg/kg/d IV div q12-24h12 - nitrofurantoin 5-7mg/kg/d PO div qid 0.54-0.75 vancomycin7 40-60mg/kg/d IV div q6-12h 45.11-67.66 Antiviral acyclovir HSV 40mg/kg/d PO div 5x/d 4.72 VZV 80mg/kg/d PO div 4x/d 9.45 HSVE 30mg/kg/d IV div q8h7 85.89 VZV immuno- 30-45mg/kg/d IV div q8h7 85.89-128.83 compromised Neonatal HSV 60mg/kg/d IV div q8h7 171.78 PAEDIATRIC ANTIMICROBIAL DOSING GUIDE AND DAILY COSTS

Antimicrobial Recommended Paediatric Cost ($)/ Dose1,2 Day3,4 Antifungal amphotericin B 0.25-1.5mg/kg/d IV daily 3.74-22.41 ketoconazole 5-10mg/kg/d PO div q12-24h 1.01-2.02 fluconazole7 3-12mg/kg/d PO div q12-24h 5.17-20.67 3-12mg/kg/d IV div q12-24h 15.90-63.62

1. Usual doses for paediatric patients with normal renal and hepatic function. Paediatric dose should not exceed recommended adult dose (except for cefuroxime where maximum is 1.5g IV q8h). For disease-specific dosing, see Recommended Empiric Therapy in Neonatal/Paediatric Patients. 2. These doses do not apply to neonates, except where noted. 3. Based on a 20kg child. 4. Based on Alberta Health Drug Benefit List price, October 2000. Prices in the hospital setting may be significantly different due to contract pricing. Check with pharmacy for actual prices. Does not include preparation, administration, supplies, or serum level costs. a. price for tablet/capsule b. price for suspension 5. For neonatal Group B Streptococcus meningitis, 500,000u/kg/d IV div q4h should be used. 6. For completion of therapy. 7. Restricted = Antibiotic form must be completed. 8. Non-formulary (NF) = Antibiotic form must be completed. 9. If indication for use does not meet clinical guidelines, meropenem will be substituted to an equivalent dose of imipenem. 10.For meningitis and other CNS infections, 120mg/kg/d IV div q8h ($113.47) should be used. 11.Children > 8 years old. 12. Doxycycline IV is available through the HPB Special Access Program (Emergency Release). Contact pharmacy for assistance when ordering. HSV = Herpes simplex virus VZV = Varicella zoster virus HSVE = Herpes simplex virus encephalitis EXTENDED INTERVAL AMINOGLYCOSIDE DOSING/MONITORING GUIDELINES Developed by TDM Task Force

Studies indicate that extended interval dosing (EID) of aminoglycosides (AGs) may result in decreased nephrotoxicity and ototoxicity, and should be less expensive in terms of serum level monitoring.

1. Contraindications/Precautions to EID of AGs

Contraindications · allergy or sensitivity to aminoglycosides · patients requiring hemodialysis, hemoperfusion or peritoneal dialysis · patients with gram positive infections where AG is used for synergy · patients with rapid clearance of drug (e.g. cystic fibrosis, burns > 20% BSA) · endocarditis · neonates · severely ill paediatric patients · surgical prophylaxis

Precautions · patients with chronic ascites or serious liver disease · patients with known auditory or vestibular disease · pregnancy · paediatric patients with a nonurinary focus of infection

2. Recommended Gentamicin/Tobramycin Dose

7 mg/kg (based on ideal body weight [IBW])*

· Round dose to nearest 20mg · Administer over 60 minutes

IBW (females) = 45.5kg + (2.3 x inches > 5 feet)** IBW (males) = 50kg + (2.3 x inches > 5 feet)**

* Malnourished: If actual body weight (ABW) < IBW, use ABW Obese: If ABW > 30% of IBW, use dosing weight (DW) DW = 0.4 (ABW - IBW) + IBW

**or (0.92 x cm > 150cm) EXTENDED INTERVAL AMINOGLYCOSIDE DOSING/MONITORING GUIDELINES 3. Creatinine Clearance (Clcr)

a) Calculated creatinine clearance (mL/min) Clcr (females) = (140 - age) x IBW* Scr (mmol/L)

Clcr (males) = Clcr (female) x 1.2 * If ABW < IBW, use ABW in Clcr calculations

b) Measured creatinine clearance (mL/s) · Quantitative urine collection (24h) NB: Laboratory values for creatinine clearance are reported in SI units of mL/s.

4. Dosing Interval Determination

Calculated Clcr Measured Clcr Dosing Interval (mL/min) (mL/s) ³ 60 ³ 1 q24h 40 - 59 0.66 - 0.99 q36h 20 - 39 0.33 - 0.65 q48h < 20 < 0.33 Obtain pharmacokinetic consult

5. Monitoring

a) Serum creatinine · Baseline · Every 3 days

b) Aminoglycoside serum concentrations · DO NOT ORDER serum peak and trough concentrations · Interval levels should be ordered in patients: i. receiving > 5 days of aminoglycoside therapy ii. with significant changes in renal function iii. with a large volume of distribution (e.g. third spacing, ascites) iv. > 65 years of age v. < 16 years of age · If levels are indicated, order an 8 hour interval level after first dose and at least once weekly. (May need more frequently if patient requires q36h or q48h dosing, if renal function changing, or patient on concurrent nephrotoxic drugs.) EXTENDED INTERVAL AMINOGLYCOSIDE DOSING/MONITORING GUIDELINES c) Guidelines for Aminoglycoside Therapeutic Drug Monitoring

Antibiotic Specimen Order on Sampling Notes Requisition Times 8 hour Interval - 8h 7-9 hours after DO NOT collect interval* after dose START of < 6 hours or > 14 (recommen- start infusion hours after Gentamicin ded) START of and infusion. Result OR will be Tobramycin Other 6-6.9 or 9.1-14 6-14 hour uninterpretable. interval* hours after START of infusion

Notes: 1. USE ROUTINE REQUISITION ONLY. DO NOT USE STAT REQUISITION. 2. Complete ALL dosing information on requisition. 3. DO NOT request interval specimens as “post-dose”. * Interpret in conjunction with Hartford Nomogram (DKML/CH Laboratory Bulletin, October 1999; Vol 4, No 10 or page 43) EXTENDED INTERVAL AMINOGLYCOSIDE DOSING/MONITORING GUIDELINES

6. Interpretation of Aminoglycoside Concentrations

· Plot aminoglycoside concentration on following nomogram (Hartford Nomogram: Antimicrob Agents Chemother 1995; 39(3): 650-5):

Extended Interval Aminoglycoside Nomogram Concentration (mg/L)

Time between start of infusion and sample draw (h)

· This nomogram applies only with doses of 7mg/kg. If other dose used - consult pharmacy.

· If the interval level falls in the areas marked as q24h, q36h, or q48h, the dosing interval should be every 24, 36, 48h respectively · If the interval level falls on one of the sloping lines, choose the longer interval · If above the q48h dosing interval area, DISCONTINUE extended interval dosing and switch to conventional dosing of aminoglycosides (See Conventional Aminoglycoside Dosing Guidelines on page 44 or consult pharmacy.) · If below the nomogram ( i.e. < 2 mg/L), consult pharmacy CONVENTIONAL AMINOGLYCOSIDE DOSING/MONITORING GUIDELINES

1. Loading Dose

2 mg/kg (IBW*) to provide peak serum levels between 4 - 10 mg/L

2. Maintenance Dose

1.5 - 2 mg/kg (IBW*) per dose

· Round dose to nearest 10mg · Administer over 30 minutes

IBW (females) = 45.5kg + (2.3 x inches > 5 feet)** IBW (males) = 50kg + (2.3 x inches > 5 feet)** * Malnourished: If actual body weight (ABW) < IBW, use ABW Obese: If ABW is > 30% of IBW, use dosing weight (DW) DW = 0.4 (BW- IBW) + IBW **or (0.92 x cm > 150cm)

3. Creatinine Clearance (Clcr)

a) Calculated creatinine clearance (mL/min)

Clcr (females) = (140 - age) x IBW* Scr (mmol/L)

Clcr (males) = Clcr (female) x 1.2 * If ABW < IBW, use ABW in Clcr calculations

b) Measured creatinine clearance (mL/s)

· Quantitative urine collection (24h) NB: Laboratory values for creatinine clearance are reported in SI units of mL/s.

4. Dosing Interval Determination

Calculated Clcr Measured Clcr Dosing Interval (mL/min) (mL/s) ³ 80 ³ 1.33 q8h 50 - 79 0.83 - 1.32 q12h 20 - 49 0.33 - 0.82 q24h < 20 < 0.33 Use serum levels to adjust dosing CONVENTIONAL AMINOGLYCOSIDE DOSING/MONITORING GUIDELINES

5. Monitoring

a) Serum creatinine

· Baseline · Every 3 days

b) Aminoglycoside serum concentrations

· Order pre (trough) and post (peak) levels with 3rd dose of aminoglycoside (referral hospitals) or with next AM dose (community hospitals) · If using gentamicin for synergy in the treatment of gram-positive infections (e.g. endocarditis), recommend serum concentration monitoring only in patients: Þ with poor renal function Þ on concurrent nephrotoxic drugs Þ receiving prolonged therapy (> 5 days). These patients require only a trough (pre) level to rule out toxicity.

c) Guidelines for Aminoglycoside Therapeutic Drug Monitoring

Antibiotic Specimen Order on Sampling Notes Requisition Times Pre(trough) Pre (trough) 0-30 minutes DO NOT collect before START DURING of infusion infusion. Gentamicin AND and Post (peak) Post (0.5-1h 30-60 minutes DO NOT collect Tobramycin after dose after END of sooner than 30 end) infusion minutes after END of infusion. Result will be uninterpretable.

Notes: 1. USE ROUTINE REQUISITION ONLY. DO NOT USE STAT REQUISITION. 2. Complete ALL dosing information on requisition. CONVENTIONAL AMINOGLYCOSIDE DOSING/MONITORING GUIDELINES

6. Desired Serum Levels

Antibiotic Desired Trough Desired Peak* (mg/L) (mg/L) Gentamicin < 2 5 - 10 Tobramycin < 2 5 - 10 Amikacin < 8 20 - 30

* Please note that the desired peak may vary according to the clinical condition of the patient and the infectious process being treated:

Infection Gent/Tobra Desired Peak (mg/L) Cystic Fibrosis 12 - 14 Sepsis Neutropenia Burns Pneumonia 8 - 11 Pseudomonas (non-urinary) infections Pyelonephritis Peritonitis 6 - 7 Soft tissue Synergy for gram-positive infections (e.g. endocarditis) 3 - 4 Lower UTI

Contact pharmacy if assistance needed in determining appropriate peak level.

7. Frequency of Serum Levels

· Once weekly (may need more frequently if renal function changing or concurrent nephrotoxic drugs) VANCOMYCIN DOSING GUIDELINES

Developed by TDM Task Force

Vancomycin is a restricted drug. See Clinical Antibiotic Guidelines.

Recommended Initial Dose and Dosing Interval

A. Paediatrics

· CNS infections: 60mg/kg/day divided q6h maximum of 2g/day · Other infections: 40mg/kg/day divided q6h maximum of 2g/day · Administration: < 1g – infuse over 60 minutes > 1g – 1.5g – infuse over 90 minutes > 1.5g – infuse over 120 minutes

B. Adults

1. Dose:

· 15mg/kg*/dose * Malnourished: If actual body weight (ABW) < IBW, use ABW Obese: If ABW > 30% of IBW, use dosing weight (DW) DW = 0.4 (ABW - IBW) + IBW

· Doses > 500mg - round off to nearest 250mg Doses < 500mg - round off to nearest 50mg

· Administration: < 1g – infuse over 60 minutes > 1g – 1.5g – infuse over 90 minutes > 1.5g – infuse over 120 minutes

2. Dosing interval determination:

i) Determination of ideal body weight (IBW)

IBW (females) = 45.5kg + (2.3 x inches > 5 feet)* IBW (males) = 50kg + (2.3 x inches > 5 feet)*

* or (0.92 x cm > 150cm) VANCOMYCIN DOSING GUIDELINES

ii) Determination of creatinine clearance (Clcr):

a. Calculated creatinine clearance (mL/min)

Clcr (females) = (140 - age) x IBW* Scr (mmol/L)

Clcr (males) = Clcr (females) x 1.2

* If ABW < IBW, use ABW in Clcr calculations

b. Measured creatinine clearance (mL/s)

· Quantitative urine collection (24h) NB: Laboratory values for creatinine clearance are reported in SI units of mL/s.

iii) Choose dosing interval based on chart:

Calculated Clcr Measured Clcr Dosing Interval (mL/min) (mL/s) ³ 80 ³ 1.33 q12h 50 - 79 0.83 - 1.32 q24h 35 - 49 0.58 - 0.82 q36h 25 - 34 0.42 - 0.57 q48h < 25 < 0.42 Obtain pharmacokinetic consult VANCOMYCIN MONITORING GUIDELINES Developed by TDM Task Force

· Routine monitoring of vancomycin levels is NOT recommended because there is: § little literature evidence to support it § no clear evidence that nephrotoxicity and ototoxicity associated with vancomycin would have been prevented by stricter adherence to specific concentration ranges. · Peak (post) levels are NOT needed because: § vancomycin exhibits time-dependent (time > MIC) killing rather than concentration-dependent killing (as in aminoglycosides) § vancomycin has slow distribution into peripheral tissues making it difficult to identify the true peak § they have not been correlated with improvements in clinical outcome

1. Inclusion Criteria for Vancomycin Serum Trough Concentration Monitoring

· deteriorating/unstable renal function · morbidly obese patients [> 190% IBW] (measure trough before 2nd dose) · patients with anticipated therapy > 2 weeks · infants and children with serious infections · cerebrospinal fluid shunt infections, meningitis · patients with rapid clearance of drug (e.g. cystic fibrosis, burns > 20% BSA) · selected dialysis patients [e.g. high flux and continuous arteriovenous hemodialysis/filtration (CAVH)] Note: Continuous ambulatory peritoneal dialysis (CAPD) and conventional hemodialysis does not remove vancomycin from serum therefore these patients do not require routine serum concentration monitoring.

2. Monitoring a) Serum creatinine · Baseline · Once weekly (more frequently if renal function changing or if concurrent nephrotoxic drugs) · If creatinine changes, refer to dosing interval chart (adults) for appropriate adjustment b) Vancomycin trough level · Order only if patient meets inclusion criteria above · Collect serum specimen 30 minutes or less before next dose · Frequency of collection: § first level at steady state (3rd - 5th dose) § subsequent levels once/week (may need more frequently if renal function changing or concurrent nephrotoxic drugs) VANCOMYCIN MONITORING GUIDELINES

3. Interpretation of Trough Level

Therapy Measured Trough Dosing Interval Level (mg/L) Adjustment · If patient on > q24h, decrease < 5 interval by a 12h increment VANCOMYCIN · If patient on q12h, obtain pharmacokinetic consult 5 - 15 No change 15 - 20 Increase interval by a 12h increment > 20 Obtain pharmacokinetic consult

Therapy Measured Trough Dosing Interval Level (mg/L) Adjustment · If patient on > q24h, decrease < 5 interval by a 12h increment · If patient on q12h, obtain VANCOMYCIN pharmacokinetic consult with AMINOGLYCOSIDE 5 - 10 No change 10 - 20 Increase interval by a 12h increment > 20 Obtain pharmacokinetic consult

Note: These recommendations for interpretation of trough levels were developed locally based on pharmacokinetic data. These guidelines have been adopted and supported by the Antimicrobial Advisory Subcommittee and the Regional Laboratory Test Optimization Committee.

(DKML/CH Laboratory Bulletin, April 1998; Vol.3, No.4) ADULT DOSING RECOMMENDATIONS IN RENAL IMPAIRMENT* Prepared by Ms. S. Fryters, B.Sc.Pharm

Antimicrobial Normal Adult Dose & Interval Adjustment Dose for Renal Impairment

Creatinine Clearance (mL/min)**

>50 10-50 <10 (Anuric)

Penicillins Amoxicillin 500mg PO q8h q8h q8-12h q12-24h Amoxicillin- 875mg PO q12h q12h q12h q12-24h clavulanate Ampicillin 1-2g IV q6h q6h q6-12h q12-24h Penicillin VK 300mg PO q6h q6h q8h q12h Penicillin G Na 2MU IV q4-6h q6h q8h q12h Cloxacillin 500mg PO q6h NO CHANGE NECESSARY Cloxacillin 1-2g IV q6h NO CHANGE NECESSARY Piperacillin 4g IV q6h q6h q6-12h q12h Piperacillin- 4.5g IV q8h > 20 mL/min: <20 mL/min: tazobactam NO CHANGE NECESSARY 4.5g q12h Ticarcillin- 3.1g IV q4-6h q4-6h 2.067-3.1g 2.067g q12h clavulanate q6-8h Carbapenems Imipenem 500mg IV q6h q6h q6-12h 250-500mg q24h Meropenem 1-2g IV q8h q8h 25-50mL/min: 50% dose q24h q12h 10-25mL/min: 50% dose q12h Cephalosporins Cephalexin 500mg PO q6h q8h q8-12h q12-24h Cefazolin 1g IV q8h q8h q8-12h q24h Cefoxitin 1-2g IV q8h q8h q8-12h q24h Cefuroxime axetil 500mg po q12h NO CHANGE NECESSARY 250mg q24h Cefuroxime 750mg IV q8h q8h q8-12h q24h Cefixime 400mg PO daily NO CHANGE NECESSARY 200mg daily Cefotaxime 1g IV q8h q8h q8-12h q24h Ceftriaxone 1g IV daily NO CHANGE NECESSARY Ceftazidime 1-2g IV q8h q8-12h q12-24h q24-48h Aminoglycosides Refer to Aminoglycoside Dosing Guidelines, Conventional or Extended Interval. Macrolides Erythromycin 250-500mg PO q6h NO CHANGE NECESSARY 50-75% dose q6h Erythromycin 0.5-1g IV q6h NO CHANGE NECESSARY 50-75% dose q6h Azithromycin 250mg PO daily NO CHANGE NECESSARY unknown Azithromycin 500mg IV daily NO CHANGE NECESSARY unknown Clarithromycin 250-500mg PO q12h q12h q12-24h q24h Quinolones Ciprofloxacin 250-750mg PO q12h q12h < 30mL/min: q24h Ciprofloxacin 200-400mg IV q12h q12h < 30mL/min: q24h Levofloxacin 500mg PO/IV daily q24h 500mg once then 500mg once then 250mg q24h 250mg q48h Moxifloxacin 400mg PO daily NO CHANGE NECESSARY Norfloxacin 400mg PO q12h q12h q12-24h q24h ADULT DOSING RECOMMENDATIONS IN RENAL IMPAIRMENT*

Antimicrobial Normal Adult Dose & Interval Adjustment Dose for Renal Impairment

Creatinine Clearance (mL/min)**

>50 10-50 <10 (Anuric)

Other Doxycycline 100mg PO q12-24h NO CHANGE NECESSARY Doxycycline 100mg IV q12-24h NO CHANGE NECESSARY Clindamycin 150-450mg PO q6h NO CHANGE NECESSARY Clindamycin 600mg IV q8h NO CHANGE NECESSARY Metronidazole 500mg PO q12h NO CHANGE NECESSARY Metronidazole 500mg IV q12h NO CHANGE NECESSARY Co-trimoxazole 1DS tab PO q12h q12h 15-30mL/min: q24-48h or avoid*** q18-24h Co-trimoxazole 160-240mg TMP (10- q6-12h 15-30mL/min: q24-48h or avoid*** 15mL) IV q6, 8, or 12h q18-24h Trimethoprim 100mg PO q12h > 30mL/min: 15-30mL/min: < 15mL/min: NO CHANGE 50mg PO q12h DO NOT USE NEEDED Nitrofurantoin 50-100mg PO q6h < 60mL/min: CONTRAINDICATED - DO NOT USE Quinupristin- 7.5mg/kg IV q8-12h NO CHANGE NECESSARY dalfopristin Vancomycin 15mg/kg IV q12h q12-24h q24-72h use serum levels to assist dosing Antiviral Acyclovir 400mg PO tid NO CHANGE NECESSARY q12h Acyclovir 5-10mg/kg IV q8h q8h 25-50mL/min: 50% dose q24h q12h 10-25mL/min: q24h Amantadine 100mg PO bid or 100mg See Prophylaxis for Influenza A, page 260. PO daily Oseltamivir 75mg PO bid > 30mL/min: 10-30mL/min: USE WITH NO CHANGE 75mg PO daily CAUTION NEEDED Zanamivir 10mg inhaled orally bid NO CHANGE NECESSARY Antifungal Amphotericin B 0.5-0.7mg/kg IV daily q24h q24h q24-36h Fluconazole 100-400mg PO daily q24h q24-48h q48-72h Fluconazole 200-400mg IV daily q24h q24-48h q48-72h Itraconazole 100-200mg PO daily NO CHANGE NECESSARY Ketoconazole 200-400mg PO daily NO CHANGE NECESSARY * For dosage adjustment in hepatic impairment, see Adult Dosing Recommendations in Hepatic Impairment. ** > 50mL/min = > 0.83mL/s; 10-50mL/min = 0.17-0.83mL/s; < 10mL/min = < 0.17mL/s ***Manufacturer recommends to avoid when Clcr < 15mL/min; however some references suggest using the drug at q24h3 or q48h2. Modified from: 1. Bennett WM, et al. Drug prescribing in renal failure: Dosing guidelines for adults. 4th ed. Philadelphia, PA: American College of Physicians; 1999. 2. Mandell GL, et al. Principles & practice of infectious diseases. 5th ed. New York: Churchill Livingstone Inc.; 2000. 3. Sanford JP, et al, eds. Guide to antimicrobial therapy 2000. Dallas, Texas: Antimicrobial Therapy, Inc.; 2000. 4. Product monographs. Compendium of Pharmaceuticals and Specialties 2000. ADULT DOSING RECOMMENDATIONS IN HEPATIC IMPAIRMENT* Prepared by Ms. M. Gray, BSP

· The effect of hepatic dysfunction on drug clearance depends on several factors: degree of protein binding, hepatic blood flow, extent of first pass metabolism, whether the drug undergoes Phase I or Phase II metabolism, and degree to which other routes of metabolism/elimination compensate. · Unless otherwise stated, recommendations are for dosage adjustments in cases of severe hepatic dysfunction caused by cirrhosis.

Antimicrobial Dosage Adjustment Penicillins Amoxicillin No change necessary Amoxicillin-clavulanate No change necessary Ampicillin No change necessary Penicillin No change necessary Cloxacillin Consider dosage reduction in combined renal and hepatic impairment. No specific dosing information available. Piperacillin No change necessary Piperacillin-tazobactam No change necessary Ticarcillin-clavulanate No change necessary Carbapenems Imipenem No change necessary Meropenem No change necessary Cephalosporins Cephalexin No change necessary Cefazolin No change necessary Cefoxitin No change necessary Cefuroxime No change necessary Cefixime No change necessary Cefotaxime No change necessary Ceftriaxone Dosage reduction recommended in combined renal and hepatic impairment Ceftazidime No change necessary

Aminoglycosides Amikacin Monitoring is strongly recommended as Gentamicin patients may be more prone to nephro- or Tobramycin ototoxicity. Refer to conventional/extended interval* aminoglycoside (AG) dosing/monitoring guidelines. An increase in dose may be required to compensate for increased volume of distribution (Vd) because of ascites. * Cannot use extended interval AG nomo- gram to interpret levels in these patients

due to higher Vd. ADULT DOSING RECOMMENDATIONS IN HEPATIC IMPAIRMENT*

Antimicrobial Dosage Adjustment

Erythromycin Lengthen dosing interval to q12h. in patients with hepatic dysfunction. Use with caution. Clarithromycin Quinolones Ciprofloxacin Levofloxacin No change necessary No change necessary in patients with mild to Pugh A or B) impairment. No information available for patients with not recommended. No change necessary Ofloxacin Tetracyclines Doxycycline Minocycline Significant excretion via accumulation noted with hepatic dysfunction. No change necessary Do not use with severe hepatic impairment Other Reduce dose 25% when used chronically at high doses Lengthen dosing interval to q12-24h. Monitor serum levels to maintain between 5-20 mg/L. Lengthen dosing interval to q12h Co- Use with caution in hepatic impairment Metronidazole Nitrofurantoin No change necessary Reduce dose from 7.5 mg/kg to 5 mg/kg (same interval) Pugh A or B hepatic dysfunction. No information

hepatic impairment therefore not

Trimethoprim No change necessary Monitoring of trough levels is strongly recommended. Monitoring Guidelines. ADULT DOSING RECOMMENDATIONS IN HEPATIC IMPAIRMENT*

Antimicrobial Dosage Adjustment

Acyclovir No change necessary No change necessary Famciclovir Ganciclovir No change necessary Has not been studied in patients with hepatic

Valacyclovir No change necessary No change necessary Antituberculosis No change necessary Isoniazid acetylation) is more important in dete disease. Consider lengthening dosing interval or deferral of in patients with acute liver disease. Dosage reduction recommended Rifampin Consider deferral of rifampin therapy patients with jaundice. Antifungals No change necessary Fluconazole Ketoconazole Dosage reduction recommended No change necessary Terbinafine function tests. * For dosage adjustment in renal impairment, see Adult Dosing Recommendations in Renal Impairment. ANTIMICROBIAL AUTOMATIC THERAPEUTIC SUBSTITUTION LIST

The Capital Health Regional Pharmacy and Therapeutics (P&T) Committee has authorized hospital pharmacists to automatically substitute the following medications with a current formulary preparation at the most equivalent dosage, form, and ingredient. A change of order must be indicated on the Physician’s Order form by the pharmacist.

Where the automatic therapeutic substitution is not appropriate, the physician may add “Do Not Substitute” (DNS) after the medication order. The patient may then receive the order as written after the non-formulary process is undertaken.

Following is the list of antimicrobial drugs approved for therapeutic substitution as of September, 2000.

Original Order Substitution Amoxicillin-clavulanate 250mg PO tid Amoxicillin-clavulanate 500mg PO bid in adults Amoxicillin-clavulanate 500mg PO Amoxicillin-clavulanate 875mg PO bid tid in adults Ampicillin PO qid Amoxicillin PO tid at same dose and form (except ) Cefaclor 250mg PO tid in adults Cefuroxime axetil 250mg PO bid

Cefaclor 500mg PO tid in adults Cefuroxime axetil 500mg PO bid Cefadroxil PO bid Cephalexin PO qid at same dose and form Cefamandole 1g IV q6h Cefuroxime 750mg IV q8h Cefazolin 2g in surgical prophylaxis Cefazolin 1g in surgical prophylaxis excluding patients with TBW > 100 kg (recommend 1g for moderate infections excluding osteomyelitis, septic arthritis, endocarditis) Cefazolin IV q6h Cefazolin IV q8h at same dose Cefotaxime IV q4h Cefotaxime IV q6h Cefotaxime 2g IV Cefotaxime 1g IV excluding meningitis/CNS infections Cefoxitin in surgical prophylaxis Cefazolin 1g IV + other than O&G metronidazole 500mg IV

Cefoxitin in O&G surgical Cefazolin 1g IV prophylaxis ANTIMICROBIAL AUTOMATIC THERAPEUTIC SUBSTITUTION LIST

Original Order Substitution Ceftriaxone 1-2g IV q12-24h* Cefotaxime 1g IV q8h† § excluding meningitis/CNS infections (Clcr>50 Ceftriaxone 1-2g IV q12-24h* mL/min) Cefotaxime 2g IV q6h† § for meningitis/CNS infections (Clcr>50 mL/min) † For patients whose Clcr < 50 § Adult doses. Automatic substitution mL/min (0.83 mL/s), the dosing also applies to pediatric and neonatal interval will be automatically patients. See page 38, Neofax, or site substituted to q12h or daily, based references for pediatric/neonatal doses. on renal function. * Excludes HPT/Outpatient IV Clinic/IM route Salmonella typhi/ Ceftriaxone 1g IV q12h Ceftriaxone 1g IV daily except in For orders not substituted with meningitis or other CNS infections, cefotaxime paediatrics, endophthalmitis Ceftriaxone 2g IV q12h Ceftriaxone 2g IV once only, then 1g IV For orders not substituted with daily except in meningitis or other CNS cefotaxime infections, paediatrics, endophthalmitis Ceftriaxone 2g IV daily Ceftriaxone 2g IV once only, then 1g IV For orders not substituted with daily cefotaxime Cefuroxime doses of > 750mg IV or Cefuroxime 750mg IV q8h maximum intervals of < q8h dosage, excluding paediatrics Cephalothin IV q4-6h Cefazolin IV q8h at same dose Ciprofloxacin 200mg IV q12h where Ciprofloxacin 500mg PO (or via tube) * patient is on enteral feeds or oral/NG q12h† (Clcr>30 mL/min) medications1

Ciprofloxacin 400mg IV q12h where Ciprofloxacin 750mg PO (or via tube) * patient is on enteral feeds or oral/NG q12h† (Clcr>30 mL/min) medications1 † For patients whose Clcr < 30 * Tube feeds should be stopped for 1 mL/min (0.5 mL/s), the dosing hour prior to and 2 hours following dose. interval of the ciprofloxacin will be Where tube feeds cannot be automatically substituted to daily. discontinued, recommend continue with IV ciprofloxacin or use 1g via tube q12h†. (Physician approval is required to dose to 1g.) Clindamycin IV q6h Clindamycin IV q8h at same dose Clindamycin IV > 600mg per dose Clindamycin IV 600mg excluding obstetrics and gynecology patients Clindamycin IV where patient is on Clindamycin 300mg PO qid* excluding enteral feeds or oral/NG medications obstetrics and gynecology patients NB: For rapidly progressive skin and soft tissue infections, stepdown can only occur after debridement/surgery. ANTIMICROBIAL AUTOMATIC THERAPEUTIC SUBSTITUTION LIST

* Prescriber can increase to 450mg PO. Original Order Substitution Clindamycin PO > 450mg per dose Clindamycin PO 300mg qid* For obstetrics and gynecology patients, call prescriber re: oral dose. * Prescriber can increase to 450mg PO. Levofloxacin IV daily where patient is Levofloxacin PO daily* on enteral feeds or oral/NG medications1 * Tube feeds should be stopped for 2 hours prior to and 2 hours following dose. Lincomycin 500mg PO Clindamycin 150mg PO Meropenem 1-2g IV q8h Imipenem 500mg IV q6h* if doesn’t meet clinical guidelines** * Dosage individualized for renal function and clinical condition Metronidazole IV q6-8h Metronidazole IV q12h at same dose Nitrofurantoin macrocrystal Current nitrofurantoin microcrystal formulation formulation at same dose and frequency e.g. MacrodantinÒ e.g. NovofuranÒ Nitrofurantoin macrocrystal/ Current nitrofurantoin microcrystal monohydrate formulation formulation at equivalent dose and frequency 100mg PO bid 50mg PO qid e.g. MacroBIDÒ e.g. NovofuranÒ Norfloxacin ophthalmic solution Ciprofloxacin ophthalmic solution at same dose and frequency Norfloxacin 400mg PO bid Ciprofloxacin 500mg PO bid Penicillin G K+ PO Penicillin V K+ PO at equivalent dosage and form Penicillin V benzathine Penicillin V K+ at same dosage and form Ticarcillin Piperacillin at same dose and interval Vancomycin PO at any dose if Metronidazole 250mg PO qid doesn’t meet clinical guidelines2 Vancomycin PO doses of > 125mg Vancomycin 125mg PO qid qid if meets clinical guidelines2 1 Automatic substitution will NOT occur until pharmacist has resolved potential drug interaction issues, if they exist. 2 See Clinical Antibiotic Guidelines. ANTIMICROBIAL FORMULARY AND GENERIC/TRADE NAME LISTING

Capital Health Region Generic Name Common Trade Hospitals’ Name(s) Formulary Status* Penicillins amoxicillin Amoxil F amoxicillin-clavulanate Clavulin F ampicillin PO Apo-ampi NF1 Novo-ampicillin Nu-ampi ampicillin IV Ampicin F Penbritin penicillin VK Ledercillin VK F penicillin G Na IV Crystapen F cloxacillin PO Orbenin F cloxacillin IV Orbenin F Tegopen piperacillin Pipracil F piperacillin-tazobactam Tazocin R ticarcillin-clavulanate Timentin R Carbapenems imipenem Primaxin R meropenem Merrem NF2 Cephalosporins 1st generation cephalexin Keflex F cefazolin Ancef F Kefzol cefaclor Ceclor F 2nd generation cefoxitin Mefoxin F cefprozil Cefzil NF cefuroxime axetil Ceftin F cefuroxime IV Kefurox F Zinacef ANTIMICROBIAL FORMULARY AND GENERIC/TRADE NAME LISTING

Capital Health Region Generic Name Common Trade Hospitals’ Name(s) Formulary Status* Cephalosporins (cont’d) 3rd generation cefixime Suprax F cefotaxime Claforan R ceftriaxone Rocephin R ceftazidime Fortaz R Tazidime Aminoglycosides amikacin Amikin R gentamicin Garamycin F tobramycin Tobrex F Macrolides azithromycin PO/IV Zithromax F clarithromycin Biaxin F erythromycin base PO Erybid F Eryc Erythromid PCE erythromycin estolate Ilosone F(paediatrics) PO erythromycin EES F(paediatrics) ethylsuccinate PO erythromycin gluceptate Illotycin NF3 IV Gluceptate erythromycin Erythrocin F3 lactobionate IV Quinolones ciprofloxacin PO Cipro F ciprofloxacin IV Cipro R levofloxacin PO Levaquin F levofloxacin IV Levaquin R moxifloxacin Avelox NF norfloxacin Noroxin NF4

Generic Name Common Trade Capital Health ANTIMICROBIAL FORMULARY AND GENERIC/TRADE NAME LISTING

Name(s) Region Hospitals’ Formulary Status* Tetracyclines doxycycline PO Doxycin F Doxytec Vibra-tabs tetracycline Tetracyn F Other clindamycin Dalacin C F metronidazole Flagyl F co-trimoxazole Bactrim F Septra trimethoprim Proloprim F nitrofurantoin Novo-furantoin F microcrystal nitrofurantoin Macrodantin NF5 macrocrystal nitrofurantoin MacroBID NF5 macrocrystal/ monohydrate quinupristin-dalfopristin Synercid NF vancomycin PO/IV Vancocin R Antivirals acyclovir PO Avirax F Zovirax acyclovir IV Zovirax R famciclovir Famvir F ganciclovir PO Cytovene NF ganciclovir IV Cytovene R valacyclovir Valtrex NF amantadine Symmetrel F oseltamivir Tamiflu F zanamivir Relenza NF foscarnet Foscavir R(ER) ribavirin Virazole R

Generic Name Common Trade Capital Health Name(s) Region ANTIMICROBIAL FORMULARY AND GENERIC/TRADE NAME LISTING

Hospitals’ Formulary Status* Antifungals amphotericin B Fungizone F fluconazole PO/IV Diflucan R griseofulvin Fulvicin NF Grisovin ketoconazole Nizoral F itraconazole Sporanox NF terbinafine Lamisil NF

* F = Formulary NF = Non-formulary - Antibiotic Form must be completed. R = Restricted - Antibiotic Form must be completed. See Clinical Antibiotic Guidelines. ER = Emergency Release

1. Automatic substitution to amoxicillin PO tid (except shigellosis). 2. If indication for use does not meet clinical guidelines, meropenem will be substituted to an equivalent dose of imipenem. 3. Erythromycin lactobionate is IV formulation on formulary. 4. Norfloxacin is non-formulary in Capital Health Region hospitals and is automatically substituted to an equivalent dose of oral ciprofloxacin. 5. Automatic substitution to current nitrofurantoin microcrystal formulation. STEPDOWN RECOMMENDATIONS

Parenteral Regimen 1 Cost($)/Day 2,3 Oral Regimen 1 Cost($)/Day 2

Ampicillin Amoxicillin 1g q6h 10.60 500mg q8h 0.60

Cefazolin Cephalexin 1g q8h 9.68 500mg q6h4 1.19

Cefuroxime Cefuroxime axetil 750mg q8h 20.07 500mg q12h 5.91

Genitourinary tract: Ciprofloxacin 5,6 Ciprofloxacin 200mg q12h 33.00 250-500mg q12h 4.44-5.01

Nosocomial pneumonia, Gram-negative bone/joint infections: Ciprofloxacin 5,6 Ciprofloxacin 200-400mg q12h 33.00-66.00 500-750mg q12h 5.01-9.45

Clindamycin 6 Clindamycin 600mg q8h 31.50 300mg q6h 4.35

Fluconazole 5 Fluconazole 5 200mg daily 53.02 200mg daily 17.23

Fluconazole 5 Fluconazole 5 400mg daily 106.04 400mg daily 34.46

Levofloxacin 5,6 Levofloxacin 250-500mg daily 17.00-34.00 250-500mg daily 4.77-5.39

Metronidazole Metronidazole 500mg q12h 3.78 500mg q12h 0.06 1. Usual adult dose in patients with normal renal and hepatic function. 2. Based on Alberta Health Drug Benefit List price, October 2000. Prices in the hospital setting may be significantly different due to contract pricing. Check with pharmacy for actual prices. 3. Drug cost only. Does not include costs of all components of drug therapy i.e. ancillary supplies and preparation 4. If organism sensitive to cephalothin (applies to gram-negative organisms) 5. Restricted = Antibiotic form must be completed. 6. Automatic stepdown by decentralized pharmacist if patient tolerating oral/NG medications or enteral feeds and potential drug interactions resolved. CSF PENETRATION OF ANTIMICROBIALS

· Ability of antimicrobials to penetrate into CSF is dependent on: Þ degree of meningeal inflammation (• inflammation ® • penetration) Þ lipid solubility (• lipid solubility ® • penetration) Þ degree of ionization (• ionization ® ¯ penetration) Þ molecular weight (• molecular weight ® ¯ penetration) Þ protein binding (• protein binding ® ¯ penetration) Þ susceptibility to active transport systems (which pump antibiotics out of the CSF; can be inhibited by probenecid) within the choroid plexus · Bactericidal effect maximal when CSF antibiotic concentrations exceed the in vitro MBC of the pathogen by 10 - 30 times.

Therapeutic CSF Levels with or without Meningeal Inflammation

ANTIMICROBIAL COMMENTS Chloramphenicol CSF concentration is usually bactericidal for N. meningitidis, H. influenzae, and S. pneumoniae; bacteriostatic for other susceptible organisms. Co-trimoxazole Not bactericidal against Enterobacteriaceae. Metronidazole Isoniazid Rifampin Pyrazinamide CSF PENETRATION OF ANTIMICROBIALS

Therapeutic CSF Levels WITH Meningeal Inflammation

ANTIMICROBIAL COMMENTS Penicillins Ampicillin Penicillin G Risk of seizures and encephalopathy with CSF concentrations > 5mg/L. Cloxacillin Piperacillin +/- tazobactam CSF concentration is lower than the MBC for the majority of P. aeruginosa strains. Borderline for other Enterobacteriaceae; may need to add intrathecal aminoglycoside. Ticarcillin +/- clavulanate Carbapenems Imipenem Not recommended for CNS infections – diminishes seizure threshold. Meropenem CSF concentration is lower than the MBC for the majority of P. aeruginosa strains. Cephalosporins Cefuroxime Not recommended for CNS infections – associated with delayed sterilization of CSF. Cefotaxime CSF concentration adequate for most susceptible organisms, except certain gram negative bacilli, such as Acinetobacter, Enterobacter, Flavobacterium, and Serratia. Ceftriaxone CSF concentration adequate for most susceptible organisms, except certain gram negative bacilli, such as Acinetobacter, Enterobacter, Flavobacterium, and Serratia. Achieves sustained reliable bactericidal activity within the CSF despite its high protein binding. Ceftazidime CSF concentration is lower than the MBC for the majority of P. aeruginosa strains. CSF PENETRATION OF ANTIMICROBIALS

Therapeutic CSF Levels WITH Meningeal Inflammation (cont’d)

ANTIMICROBIAL COMMENTS Quinolones Ciprofloxacin CSF concentrations inadequate for streptococci. Potentially neurotoxic. Levofloxacin Potentially neurotoxic. Other Vancomycin Large molecular size. CSF concentration often subtherapeutic. In some cases, may have to use IT/IVent* administration [adults - 10-20mg/day, paediatrics - 5-10mg/day] along with IV. Trough serum concentrations should be monitored to maintain level between 10 and 20mg/L. Quinupristin-dalfopristin Animal studies show negligible distribution of IV quinupristin-dalfopristin across noninflamed meninges but greater penetration when inflammation is present. No human pharmacokinetic data are available. In 4 patients with vancomycin-resistant E. faecium central nervous system infections, improvement (bacteriologic and clinical) was seen with IT dosing of 1 or 2 mg/day x 5- 33 days (4/4 patients) +/- IV dosing of 7.5 mg/kg q8h x 10-33 days (3/4 patients). In all cases, patients received other IV and/or IT antibiotics concomitantly. Ethambutol For M. tuberculosis, CSF concentration is usually lower than the MIC. Antivirals Acyclovir Amantadine Foscarnet Ganciclovir Ribavirin Antifungals Fluconazole Distributes readily into the CSF following IV or PO administration. CSF concentration may be 50- 90% of plasma concentration regardless of degree of meningeal inflammation. Flucytosine CSF PENETRATION OF ANTIMICROBIALS

Nontherapeutic CSF Levels with OR without Meningeal Inflammation

ANTIMICROBIAL COMMENTS Cephalosporins Cefazolin Not recommended in CNS infections. Cefoxitin Not recommended in CNS infections. Aminoglycosides Monotherapy not recommended. Amikacin Difficult to achieve adequate CSF concentrations with IV dosing alone. Extended interval dosing Gentamicin increases CSF penetration. Acidic nature of purulent CSF decreases antimicrobial activity of Tobramycin aminoglycosides. For adults with CNS infections, concomitant IT/IVent* aminoglycoside may be required [adults – 5-10mg/day (gentamicin, tobramycin), 20-30mg/day (amikacin)]. Macrolides Not recommended in CNS infections. Bacteriostatic. Acidic nature of purulent CSF decreases antimicrobial activity. Other Clindamycin Not recommended in CNS infections. Bacteriostatic. When administered at high IV doses, CSF concentrations up to 4mg/L may be achieved in patients with parenchymal cerebral . Antifungals Amphotericin B Achieves therapeutic concentrations for cryptococcal meningitis. For other mycoses, can be given IT at a dose of 0.2-0.5mg on alternate days. Itraconazole Achieves therapeutic concentrations for cryptococcal meningitis. Not recommended for other CNS fungal infections. Ketoconazole Not recommended in CNS infections. CSF = cerebrospinal fluid CNS = central nervous system IT = intrathecal IVent = intraventricular IV = intravenous MBC = minimum bactericidal concentration * IT administration unlikely to provide therapeutic concentrations in the ventricles due to the unidirectional flow of CSF. IVent administration is preferred for this reason, however this mode of administration requires the placement of an Ommaya or Rickham reservoir. NB: These modes of administration are seldom necessary given the systemic antimicrobials currently available. b-LACTAM ALLERGY Prepared by Ms. S. Fryters, B.Sc.Pharm

Penicillin Allergy

Incidence: · 1-10% of patients treated with penicillin will have an adverse reaction, including allergy. · 0.01% of patients experience life-threatening anaphylactic reactions to penicillin, of which 10% are fatal.

History of Penicillin Allergy: · It is very important to determine the nature of the patient's reaction, in order to differentiate between allergic and other adverse reactions, and the onset of the allergic reaction, which will help to classify the reaction (see below). · Only about 10% of patients with a history of penicillin allergy actually have an IgE mediated allergy (skin test positive).

Classification of Penicillin Allergic Reactions:

Type of Reaction Clinical Manifestations Usual Onset I Immediate Anaphylaxis, bronchial asthma, within 1 hour allergic rhinitis, early onset (anaphylaxis) < urticaria, angioedema 24 hours II Cytotoxic Hemolytic anemia, 5-12 hours agranulocytosis, leukopenia, thrombocytopenia III Immune Complex Serum sickness, drug-induced 7-14 days fever, allergic vasculitis, interstitial nephritis IV T-cell mediated Contact dermatitis 24-48 hours Idiopathic Exfoliative dermatitis, > 72 hours maculopapular drug eruptions, fever, late onset urticaria

Risk Factors for Penicillin Allergy: · History of previous reaction to penicillin - Six times more likely to react on subsequent exposure than patients with a negative history. · Route of administration - More likely with the parenteral route than with the oral route. · Age - Most common in patients between 20 and 49 years. True penicillin allergy is uncommon in the pediatric population. b-LACTAM ALLERGY

Cross Reactivity: · Cephalosporins - The incidence of cross reactivity is less than 2%. · Third-generation cephalosporins - Less cross reactivity with penicillin than first and second generation cephalosporins because of their structural differences. · Imipenem - Extensive cross reactivity with penicillins. Use same degree of caution as if penicillin was to be given.

Management of b-Lactam Allergy: · Avoid all b-lactams (penicillins, cephalosporins, carbapenems) in patients with a documented history of severe allergic reactions to penicillin, such as: · urticaria/angioedema · serum sickness · hemolytic anemia · exfoliative dermatitis · organ dysfunction. Alternative antibiotics should be chosen.

· Penicillin Skin Testing: · The clinical role of skin testing for penicillin allergy is unclear. While it is 99% effective in predicting penicillin allergic reactions if both the major and minor determinants are used, skin testing has several limitations to its use: - Only predictive of IgE-mediated allergic reactions to penicillin. - The minor determinant mixture needed for the test is not commercially available. - Although usually safe, fatalities have occured when done improperly. Therefore, penicillin skin testing should only be performed and interpreted by a qualified allergist.

· Desensitization: · Indicated when the patient has a history of IgE mediated penicillin allergy and/or is skin test positive, and has a serious infection where alternatives to penicillin are not suitable, e.g. syphilis in pregnancy. · Will not prevent non-IgE mediated reactions. · Once complete, treatment with penicillin must be started immediately. · Usually lost within two days after cessation of penicillin therapy. · An oral method of penicillin desensitization has been approved by the Regional Antimicrobial Advisory Subcommittee and P&T. For the complete guidelines, contact pharmacy. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Developed by the Division of Paediatric Infectious Diseases Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Skin & Soft Tissue Impetigo* Group A Streptococci Mild * Epidemics must be reported S. aureus Mupirocin 2% or tid topically 7 days to Public Health. Fusidic acid 2%1 tid-qid topically 7 days - Systemic antibiotics Moderate-severe recommended if: Cloxacillin or 40-50mg/kg/d PO div qid 7 days · multiple/extensive/ Cephalexin 40mg/kg/d PO div qid 7 days recurrent lesions b-lactam allergy · immunocompromised Erythromycin or 40mg/kg/d PO div qid 7 days · fever/constitutional 30-40mg/kg/d PO div qid 7 days symptoms Clindamycin · . Folliculitis/ S. aureus Hot compresses + - Usually self-limiting. Furunculosis Antiseptic cleanser - Drainage is occasionally Unresponsive to above required. or extensive - Systemic antibiotics (see Mupirocin 2% or tid topically 7 days Carbuncles) recommended if Fusidic acid 2%1 tid-qid topically 7 days scalp folliculitis. Whirlpool/hot Pseudomonas aeruginosa Hot compresses + - Self-limiting. tub Antiseptic cleanser Recurrent S. aureus Requires eradication of furunculosis carrier state: Mupirocin 2% bid intranasally 5 days Carbuncles S. aureus Mild * Systemic antibiotics Hot compresses + recommended if: Antiseptic cleanser · surrounding cellulitis Moderate-severe* · fever/constitutional Cloxacillin or 40-50mg/kg/d PO div qid 7 days symptoms Cephalexin 40mg/kg/d PO div qid 7 days · located in central area of b-lactam allergy face. Clindamycin 30-40mg/kg/d PO div qid 7 days - Drainage is often necessary. 1 Non-formulary in Capital Health Region hospitals; automatic substitution to mupirocin 2%. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Skin & Soft Tissue MRSA nasal S. aureus, methicillin-resistant Eradication of carrier - Continue isolation carriage state precautions until minimum Mupirocin 2% bid intranasally 14 days of 2 repeat cultures, taken 2 Consider also* and 9 days after completion TMP/SMX + 6-10mg TMP/kg/d PO div 14 days of therapy, are negative and bid Infection Control has Rifampin + 10mg/kg PO bid 14 days approved. Chlorhexidine 4% full body wash daily 14 days * Recommended only for institutionalized patients to attempt to eradicate carriage and thus discontinue isolation. Vesicular lesions Chickenpox - Notify Public Health at 413-7949 (after hours/weekends 413-7991). - For contact prophylaxis recommendations, see Prophylaxis for Contacts of Communicable Diseases. Children

Immuno- Varicella zoster None - Consider treatment with oral competent acyclovir within 24h of rash onset if: · chronic cutaneous or pulmonary disorder · long term salicylate therapy or · short, intermittent or aerosolized courses of corticosteroids. Immunocom- Varicella zoster Acyclovir 30-45mg/kg/d IV div q8h 7-10 days promised

RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Skin & Soft Tissue Vesicular lesions (cont’d) Chickenpox (cont’d) Adolescents

Immuno- Varicella zoster Acyclovir 80mg/kg/d PO div qid 5 days - Must initiate therapy within competent (max. 800mg/dose) 24h of rash onset. - May consider treatment started later than 24 hours if new lesions forming and: · pneumonia (treat x 10 days) · pregnancy (see Antimicrobials in Pregnancy). Immunocom- Varicella zoster Acyclovir 30-45mg/kg/d IV div q8h 7-10 days promised

Zoster (Shingles)

Immunocom- Varicella zoster None - Therapy indicated if cranial petent nerve V1 involvement. - Therapy should be started within 72h of rash onset. Immunocom- Varicella zoster Mild - Therapy should be started promised Acyclovir 80mg/kg/d PO div 5x/d 7-10 days within 72h of rash onset. (max. 800mg/dose) Moderate-severe Acyclovir 30-45mg/kg/d IV div q8h 7-10 days RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Skin & Soft Tissue Vesicular lesions (cont’d) Mucocutaneous (fever blisters) Immunocom- petent Primary Herpes simplex Mild - No role for topical acyclovir. None Severe Acyclovir 40-60mg/kg/d PO div 4- 5-10 days 5x/d or 30mg/kg/d IV div q8h Recurrent Herpes simplex No therapy indicated* * If recurrences are: · severe and · > 6 episodes/year can give acyclovir 5-10mg/kg PO bid-tid as suppressive therapy. Immunocom- Herpes simplex Acyclovir 40-60mg/kg/d PO div 5x/d 7-14 days promised or 30mg/kg/d IV div q8h Cellulitis NeonatesB S. aureus [Cefazolin or 75-100mg/kg/d IV div q8h 10-14 days - If meningitis is possible (e.g. Group B Streptococci Cloxacillin] + 150-200mg/kg/d IV div fever, lethargy, or poor Enterobacteriaceae q6h feeding), do a lumbar Group A Streptococci Gentamicin 7.5mg/kg/d IV div q8h puncture and use cloxacillin + [gentamicin or B Omphalitis S. aureus ClindamycinC + 40mg/kg/d IV div q8h 10-14 days cefotaxime]. Group B Streptococci Cefotaxime 200mg/kg/d IV div q6h Enterobacteriaceae Anaerobes RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Skin & Soft Tissue Cellulitis (cont’d) Children · facial S. aureus Mild/Afebrile Group A Streptococci Cephalexin 40mg/kg/d PO div qid 10-14 days +/- if < 5 years old: Moderate-severe · H. influenzae < 5 years old - Cefuroxime 100-150mg/kg/d IV div 10-14 days q8h > 5 years old - Cefazolin 75-100mg/kg/d IV div q8h 10-14 days · periorbital Refer to Recommended · orbital Empiric Therapy of Ophthalmic Infections · extremities S. aureus Mild * Less than 2% of pen-allergic Group A Streptococci Cephalexin or 40mg/kg/d PO div qid 7-10 days patients are allergic to Cloxacillin 40-50mg/kg/d PO div qid 7-10 days cephalosporins. Avoid b-lactam allergy* cephalosporins if the patient Clindamycin 30-40mg/kg/d PO div qid 7-10 days has a severe allergy (See b- Moderate-severe lactam allergy section). Cefazolin or 75-100mg/kg/d IV div q8h 10-14 day - Stepdown to oral agent Cloxacillin or 150-200mg/kg/d IV q6h 10-14 days when: C 40mg/kg/d IV div q8h/ 10-14 days Clindamycin IV/PO · resolution of systemic 30-40mg/kg/d PO div qid symptoms · no further progression of cellulitis. Peri-rectal Polymicrobial: Mild - Incision/drainage necessary cellulitis/abscess · Anaerobes Amoxicillin-clavulanate 40mg/kg/d PO div tid 10-14 days for abscesses. · Enterobacteriaceae Moderate-severe · S. aureus ClindamycinC + 40mg/kg/d IV div q8h 10-14 days · Group A Streptococci Gentamicin 7.5mg/kg/d IV div q8h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Skin & Soft Tissue Animal bites - If animal unknown or escaped, contact Environmental Health (Capital Health 413-7928) or Medical Officer of Health (Capital Health 413-7600) [after hours/weekends 433-3940] re: risk/management of rabies and tetanus. (Rabies prophylaxis not required for rodents or rabbits.) - Irrigation and debridement necessary. - Primary closure of wound(s) NOT recommended if: · puncture wounds · > 12 hours post injury. - Amoxicillin-clavulanate is drug of choice. - Cephalexin/cefazolin and clindamycin NOT indicated (no coverage of Pasteurella spp or Eikenella spp). - Cultures recommended in established infections. Cats Polymicrobial: Prophylaxis* * Prophylaxis is · Pasteurella spp Amoxicillin-clavulanate 40mg/kg/d PO div tid 3-5 days recommended for all · Streptococcus spp b-lactam allergy, > 8 significant cat bites because · Staphylococcus spp years old of high rate of infection. · Oral anaerobes Doxycycline 2-4mg/kg/d PO div q12- 3-5 days · CDC-Group EF-4 24h Treatment * Prolonged therapy is Amoxicillin-clavulanate 40mg/kg/d PO div tid 10-14 days required if associated Moderate-severe osteomyelitis/septic arthritis. Penicillin 150,000-250,000u/kg/d IV 10-14 days* + div q6h Cloxacillin 150-200mg/kg/d IV div q6h Severe/Limb- threatening Piperacillin-tazobactam 250-300mg/kg/d IV div 10-14 days* q4-6h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Skin & Soft Tissue Animal bites (cont’d) Dogs Polymicrobial: Prophylaxis* *Prophylaxis is recommended · Pasteurella spp Amoxicillin-clavulanate 40mg/kg/d PO div tid 3-5 days if: · Streptococcus spp · moderate/severe · Staphylococcus spp b-lactam allergy, > 8 · crush injury/edema · Oral anaerobes years old · puncture wounds · Capnocytophaga spp Doxycycline 2-4mg/kg/d PO div q12- 3-5 days · bone/joint involvement · Eikenella spp 24h · hand or facial injuries · Weeksella spp · splenectomized · immunocompromised. · CDC-Group EF-4 Treatment * Prolonged therapy is Amoxicillin-clavulanate 40mg/kg/d PO div tid 10-14 days* required if associated Moderate-severe osteomyelitis/septic arthritis. Penicillin 150,000-250,000u/kg/d IV 10-14 days* + div q6h Cloxacillin 150-200mg/kg/d IV div 10-14 days* q6h Severe/Limb- threatening Piperacillin-tazobactam 250-300mg/kg/d IV div 10-14 days* q4-6h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Skin & Soft Tissue Human bites - Irrigation and debridement necessary. - Immobilization and wound elevation, if possible, are beneficial. - Risk factors for developing osteomyelitis: · delay in initial treatment · inadequate debridement · initial suturing of wound. - Amoxicillin-clavulanate is drug of choice. - Cephalexin/cefazolin and clindamycin NOT indicated (inadequate coverage of pathogens involved). - Cultures recommended in established infections. Polymicrobial: Prophylaxis* * Prophylaxis is · Streptococcus spp Amoxicillin-clavulanate 40mg/kg/d PO div tid 3-5 days recommended if: · S. aureus · moderate/severe · Eikenella spp b-lactam allergy, > 8 · crush injury/edema · Haemophilus spp years old · puncture wounds · Oral anaerobes Doxycycline 2-4mg/kg/d PO div q12- 3-5 days · bone/joint involvement 24h · hand injuries. Treatment * Prolonged therapy is Amoxicillin-clavulanate 40mg/kg/d PO div tid 10-14 days* required if associated Moderate-severe osteomyelitis/septic arthritis. Penicillin 150,000-250,000u/kg/d IV 10-14 days* + div q6h 150-200mg/kg/d IV div Cloxacillin q6h Severe/Limb- threatening 250-300mg/kg/d IV div 10-14 days* Piperacillin-tazobactam q4-6h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Skin & Soft Tissue Scabies Sarcoptes scabiei Permethrin 5% Infants one application - Scabies can affect the (subsp hominis) lotion or creme1 Apply on head and body, head/scalp of infants and wash off in 8-14 hours young toddlers. Children - Wash clothes and bedding. Apply over entire body one application - Consider treatment of entire below the head, wash off household. in 8-14 hours - Retreat after 1 week if no clinical improvement. - Pruritus may persist for several weeks even with successful treatment. Lice Pediculus humanus Permethrin 1% Apply, wash off after 10 one application* * Some recommend a second capitis creme rinse1 minutes. application on Day 7. Alternative - Lindane should not be used Lindane 1% shampoo Apply, wash off after 8 one application in children < 2 years old due minutes. on day 1, then to neurotoxicity. repeat on day 7. 1 Non-formulary in Capital Health Region hospitals. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Skin & Soft Tissue Post-operative wounds Not involving S. aureus Mild - Surgical drainage may be GU/GI tract Group A Streptococci Cephalexin or 40mg/kg/d PO div qid 10 days indicated. Occasionally: Cloxacillin 40-50mg/kg/d PO div qid 10 days · Enterobacteriaceae b-lactam allergy Clindamycin 30-40mg/kg/d PO div qid 10 days Moderate-severe [Cefazolin or 75-100mg/kg/d IV div q8h 10-14 days Cloxacillin or 150-200mg/kg/d IV div q6h 40mg/kg/d IV div q8h ClindamycinC] +/- 7.5mg/kg/d IV div q8h Gentamicin Involving GU/GI S. aureus Mild tract Group A Streptococci Amoxicillin-clavulanate 40mg/kg/d PO div tid 10-14 days - Surgical drainage may be Enterobacteriaceae Alternative indicated. Anaerobes Cephalexin 40mg/kg/d PO div qid 10-14 days - Cephalosporins and Occasionally: Moderate-severe clindamycin do not cover C · Enterococcus spp Clindamycin +/- 40mg/kg/d IV div q8h 10-14 days Enterococcus. · Pseudomonas spp Gentamicin or 7.5mg/kg/d IV div q8h Cefazolin + 75-100mg/kg/d IV div q8h 10-14 days MetronidazoleC +/- 30mg/kg/d IV div q12h 7.5mg/kg/d IV div q8h Gentamicin Burn wound S. aureus Cefazolin + 75-100mg/kg/d IV div q8h 10-14 days Group A Streptococci Gentamicin 7.5mg/kg/d IV div q8h Enterobacteriaceae Severely ill Pseudomonas spp Piperacillin-tazobactam 250-300mg/kg/d IV div 10-14 days + q4-6h Tobramycin 7.5mg/kg/d IV div q8h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Skin & Soft Tissue Post-operative wounds (cont’d) Mediastinitis S. aureus Vancomycin 40mg/kg/d IV div q6h ³ 4 weeks - Surgical debridement Enterobacteriaceae (pending cultures) + required. Coagulase negative Staph Gentamicin 7.5mg/kg/d IV div q8h Occasionally: Severely ill · Candida spp Vancomycin 40mg/kg/d IV div q6h ³ 4 weeks · Pseudomonas spp (pending cultures) + Piperacillin + 250-300mg/kg/d IV div q4-6h Tobramycin 7.5mg/kg/d IV div q8h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Skin & Soft Tissue Rapidly Group A Streptococci Clindamycin + 40mg/kg/d IV div q8h minimum 10 - Preoperatively and before progressive (necrotizing fasciitis type II) Gentamicin + 7.5mg/kg/d IV div q8h days* cultures it is very difficult to skin/soft tissue OR Penicillin 300,000u/kg/d IV div q4h differentiate the different infections Mixed aerobic/anaerobic flora types of infections listed. (necrotizing fasciitis type I, - All require surgical crepitant cellulitis, synergistic debridement for diagnosis necrotizing cellulitis, and therapy. anaerobic streptococcal - Infectious Diseases consult myonecrosis) is strongly recommended. OR * Duration of therapy Clostridium perfringens (gas dependent on clinical gangrene, crepitant cellulitis) picture. If proven Group A Clindamycin + 40mg/kg/d IV div q8h minimum 10 - Preoperatively and before Streptococcus Penicillin 300,000u/kg/d IV div q4h days cultures, see above. - Invasive GAS is reportable to the Medical Officer of Health (Capital Health 413- 7600; after hours/weekends 433-3940). Public Health will do contact investigation and follow-up. - Prophylaxis of invasive Group A Streptococci is recommended by Public Health. See Prophylaxis for Contacts of Communicable Diseases. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Bone & Joint Osteomyelitis NeonatesB S. aureus Cloxacillin 150-200mg/kg/d IV div 4-6 weeks - Bone cultures Group B Streptococci + q6h recommended as Enterobacteriaceae Cefotaxime 200mg/kg/d IV div q6h occasionally other organisms may be involved. - If meningitis is possible (e.g. fever, lethargy, or poor feeding), do a lumbar puncture. Children S. aureus Cloxacillin IV 200mg/kg/d IV div q6h 4-6 weeks - If unresponsive to cloxacillin Streptococcus spp Stepdown IV after 3-5 days, consider H. influenzae Cloxacillin PO or 100mg/kg/d PO div q6h to complete 4-6 bone biopsy for pathology Cephalexin PO 100mg/kg/d PO div q6h weeks and cultures. - Infectious Diseases consult is strongly recommended. - Consider change to oral therapy if: · at least 10-14 days of IV antibiotics · clinically well · falling ESR · compliance of patient and parents excellent. · with sickle S. aureus Cloxacillin + 200mg/kg/d IV div q6h 4-6 weeks cell anemia Salmonella spp Cefotaxime 150-200mg/kg/d IV div q6-8h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Bone & Joint Osteomyelitis (cont’d) Post-operative S. aureus - All require surgical Group A Streptococci Cefazolin +/- 100mg/kg/d IV div q8h 6 weeks debridement for therapy and Occasionally: Gentamicin 7.5mg/kg/d IV div q8h C&S of bone. · Enterobacteriaceae - Hardware should be removed if possible. If not possible, consider adding rifampin if S. aureus. · spinal rods/ S. aureus Vancomycin 40mg/kg/d IV div q6h 6 weeks sternotomy Coagulase negative Staph (pending cultures) + Group A Streptococci Gentamicin 7.5mg/kg/d IV div q8h Enterobacteriaceae Pseudomonas spp Post-nail Pseudomonas aeruginosa Piperacillin + 250-300mg/kg/d IV div 7-14 days for - All require surgical puncture of foot q4-6h Pseudomonas debridement for therapy and Tobramycin 7.5mg/kg/d IV div q8h osteochondritis C&S. or Ceftazidime + 150mg/kg/d IV div q8h 7-14 days for Tobramycin 7.5mg/kg/d IV div q8h Pseudomonas osteochondritis RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Bone & Joint Septic arthritis - Joint should be aspirated for therapy and C&S. - If sepsis/meningitis suspected in the infant (e.g. fever, lethargy, or poor feeding), recommend blood culture/lumbar puncture. - Infectious Diseases consult is strongly recommended. NeonatesB S. aureus Cloxacillin + 150-200mg/kg/d IV div 3-4 weeks Group B Streptococci q6h Enterobacteriaceae Cefotaxime 200mg/kg/d IV div q6h Children S. aureus < 5 years old - Change to oral therapy if: Streptococcus spp Cefuroxime 150mg/kg/d IV div q8h 3-4 weeks · at least 7-10 days of IV Rare: > 5 years old antibiotics · Haemophilus influenzae Cloxacillin or 200mg/kg/d IV div q6h 3-4 weeks · clinically well type B Cefazolin 75-100mg/kg/d IV div q8h 3-4 weeks · falling ESR · compliance of patient and parents excellent. · Sexually Neisseria gonorrhoeae* Cefotaxime 150mg/kg/d IV div q8h 7 days * Consider concomitant active therapy for Chlamydia. Stepdown Cefixime 8mg/kg/d PO div q12-24h to complete 7 days Septic bursitis S. aureus Mild - Aspirate for therapy and Group A Streptococci Cephalexin or 40mg/kg/d PO div qid 2-3 weeks C&S recommended. Cloxacillin 40-50mg/kg/d PO div qid 2-3 weeks Moderate-severe Cefazolin or 75-100mg/kg/d IV div q8h 2-3 weeks Cloxacillin 150-200mg/kg/d IV div 2-3 weeks q6h b-lactam allergy Clindamycin IV/POC 40mg/kg/d IV div q8h/ 2-3 weeks 30-40mg/kg/d PO div qid RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Pharyngitis - Majority of cases of pharyngitis are of viral etiology and do not require antimicrobial therapy. The following suggests a viral etiology: · · cough · hoarseness · rhinorrhea. - Group A Strep pharyngitis is uncommon in children < 3 years old. - The role of Chlamydia pneumoniae and Mycoplasma pneumoniae has been suggested but not substantiated. Empiric therapy for these organisms is not recommended. - Occasionally pharyngitis is caused by Group C, G. Streptococci and Arcanobacterium haemolyticum. A. haemolyticum causes pharyngitis in young adults (12-30 years old). Majority of patients have scarlatiniform rash most marked on the extremities. Notify laboratory if clinically suspected. - If sexually active, consider N. gonorrhoeae. For treatment, see Adult Empiric Therapy Recommendations, page 146. - Accurate diagnosis of Group A Streptococci cannot be made based on clinical presentation alone. Throat swab recommended. Rapid antigen detection test for Group A Strep is not recommended (low sensitivity, negative result must be confirmed with culture). - Treat according to C&S results as: · Group A Strep is a self-limited disease (3-4 days) · antimicrobial therapy can be delayed while awaiting throat culture results and still prevent acute · delay in antibiotic therapy may diminish reinfection rates. - Follow up cultures not routinely recommended except if there is: · family history of rheumatic fever · outbreak of rheumatic fever or glomerulonephritis · outbreak of pharyngitis in a closed community · repeat transmission within families (“ping-pong” spread). Acute Group A Streptococci* Penicillin VK 40mg/kg/d PO div bid 10 days * Resistance: · no in vitro resistance to Alternative penicillin Erythromycin 40mg/kg/d PO div tid 10 days · up to 5% macrolide or resistance. Clindamycin 40mg/kg/d PO div tid - If treated empirically (NOT recommended), & 48 hour throat swab culture is negat- ive, discontinue antibiotics. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Pharyngitis * Consider: (cont’d) · noncompliance Non- Group A Streptococci Non-responders* · concurrent viral infection responders Change in antibiotic in a Group A Strep carrier (after 72 hours therapy may not be · suppurative complication of therapy*) required. of Group A Strep pharyngitis (e.g. or peritonsillar, tonsillar, and retropharyngeal abscess). † Early relapse* † Early relapse Early relapse: repeat throat Clindamycin 40mg/kg/d PO div tid 10 days swab necessary – only treat (2-7 days post- or if culture positive for Group therapy*) Erythromycin 40mg/kg/d PO div tid 10 days A Strep. Late relapse Group A Streptococci Penicillin VK 40mg/kg/d PO div bid 10 days * Consider: or · concurrent viral infection Recurrent* Alternative in a Group A Strep carrier Clindamycin 40mg/kg/d PO div tid 10 days · new infections with or Group A Strep. Erythromycin 40mg/kg/d PO div tid 10 days - If > 3 culture confirmed symptomatic episodes per year consider: · throat swab during an asymptomatic period to document carrier status · throat swab of all family members if suspect “ping-pong” spread from an asymptomatic carrier. - Family pets are not carriers of Group A Strep. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Pharyngitis (cont’d) Asymptomatic - Up to 20% of the population may carry Group A Strep asymptomatically. carrier - Chronic carriers are not significant in the spread of Group A Strep and are at little risk of rheumatic fever. Group A Streptococci No therapy required * Eradication of asymptomatic High risk* carriers is recommended Clindamycin 40mg/kg/d PO div tid 10 days only if high risk: or · family history of Penicillin VK** + 40mg/kg/d PO div bid or 10 days rheumatic fever tid · outbreak of rheumatic Rifampin 10mg/kg PO bid 4 days fever (max 300mg/dose) · outbreak of pharyngitis in a closed community · repeat transmission within families · multiple (> 3/year) culture confirmed symptomatic episodes of pharyngitis. **Consider using benzathine pen G (50,000U/kg IM x 1 dose) if compliance is questionable. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Otitis Media - It is critical to distinguish between: i) acute otitis media (AOM) ii) myringitis iii) otitis media with effusion (OME) AOM: - AOM is very common in young children. AOM presents with fever, irritability, and otalgia, with a bulging, inflamed tympanic membrane. (The redness and light reflex of a tympanic membrane are nonspecific and often misleading signs.) Acute inflammation with decreased mobility on pneumatoscopic exam confirms diagnosis of AOM. Minimally symptomatic AOM does not always require antibiotics, providing good follow-up is provided. - Routine follow-up post-therapy is not necessary for asymptomatic patients. Three month follow-up post-AOM recommended to rule out persistent OME (occurs in10% of children) and associated risk of hearing loss. Myringitis: - Myringitis is inflammation of the tympanic membrane alone or in association with otitis externa and does not require antibiotics. OME: - OME is defined as fluid in the middle ear without signs or symptoms of acute inflammation of the eardrum. - OME is common. Up to 50% of children will have an effusion for 1 month post AOM. Antibiotic therapy is not required.

- Prophylactic antibiotics no longer recommended for recurrent AOM. - Prevention: · Handwashing · Breastfeeding · Avoidance of environmental tobacco smoke · Avoidance of feeding in a supine, flat position. - Decongestants/antihistamines are not routinely recommended in the treatment of AOM (may be of benefit if allergic etiology). - Topical corticosteroid/antibiotic preparations are not recommended. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Otitis Media (cont’d) Agents not routinely recommended in AOM:

Cephalexin - Poor activity against Pen I/R S. pneumoniae. - No activity against Haemophilus/Moraxella spp. Cefaclor - No activity against Pen I/R S. pneumoniae. - Marginal activity against Haemophilus influenzae. Cefixime - No activity against Pen I/R S. pneumoniae. - Excellent activity against Haemophilus spp. Ceftriaxone - Routine use of this agent is not recommended in otitis media due to potential for increased resistance to 3rd generation cephalosporins. - May be an option in severe cases who have failed therapy, in immunocompromised patients, or neonates. NB: Three days of IM/IV therapy are recommended. (single dose not as effective in eradicating penicillin resistant S. pneumoniae) Clindamycin - No activity against Haemophilus/Moraxella spp. Erythromycin - Poor activity against Haemophilus influenzae.

RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Otitis Media (cont’d) AOM - healthy S. pneumoniae Mild, ³ 2 years old - In children > 2 years old, child Moraxella catarrhalis Acetaminophen 10-15mg/kg/dose PO q4h 48 hours consider withholding H. influenzae prn (max 650mg/dose) antibiotics 48-72 hours from Occasionally: symptom onset if symptoms · Group A Streptococci are manageable with · S. aureus systemic analgesics providing adequate follow-up can be assured and no Moderate-severe Standard dose deterioration. Amoxicillin 40mg/kg/d PO div tid or 5 days* - If symptoms worsen or fail High dose** to respond to symptomatic 90mg/kg/d PO div tid 5 days* treatment after 48-72 hours, treat with antibiotics. * 10 days recommended if: Penicillin-allergic · < 2 years old Cefuroxime axetil 40mg/kg/d PO div bid 5 days* · perforated eardrum. Severe pen-allergy or **Higher amoxicillin dose cephalosporin allergy recommended if both: Erythromycin- 40mg erythro/kg/d PO div 5 days* · recent (< 3 months) sulfisoxazole or tid antimicrobial exposure 6-10mg TMP/kg/d PO div 5 days* TMP/SMX and bid · day care centre attendance. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Otitis Media (cont’d) AOM - failure of S. pneumoniae Failure of standard dose - S. pneumoniae: first line agents: Moraxella catarrhalis amoxicillin* · 17.4% penicillin resistance · persistent H. influenzae Amoxicillin PLUS 40mg/kg/d PO div tid 10 days · 13% macrolide resistance. (symptomatic Occasionally: Amoxicillin-clavulanate 40mg/kg/d PO div tid 10 days * Combination of amoxicillin + at 48 - 72 h) · Group A Streptococci amoxicillin-clavulanate · S. aureus Failure of high dose recommended to provide amoxicillin high dose of amoxicillin (for Amoxicillin-clavulanate 40mg/kg/d PO div tid 10 days pen-I S. pneumoniae) and or regular dose of amoxicillin- Cefuroxime axetil** 40mg/kg/d PO div bid 10 days clavulanate (for b-lactamase producing H. influenzae and b-lactam allergy M. catarrhalis) without Erythromycin- 40mg erythro/kg/d PO div 10 days excessive clavulanate tid sulfisoxazole (which may cause excessive or diarrhea). 10mg/kg PO first day, 5 days Azithromycin*** **Due to poor taste of then 5mg/kg PO daily x 4 or suspension, recommend days tablets if possible; can crush 15mg/kg/d PO div bid 10 days and put in palatable fluid. If Clarithromycin*** not tolerated, cefprozil (30mg/kg/d PO div bid x 10 days) can be considered. Compared to cefuroxime, it has a better taste but inferior coverage of Haemophilus and pen-I S. pneumoniae. ***Macrolides have been shown to be less efficacious than amoxicillin-clavulanate. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Otitis Media (cont’d) AOM – failure S. pneumoniae See comments - Consider: of second line Moraxella catarrhalis · I.D. consult agents H. influenzae · tympanocentesis by an Occasionally: expert · Group A Streptococci · ceftriaxone IM/IV x 3 days · S. aureus or · add clindamycin to 2nd line agent. AOM - S. pneumoniae Cefuroxime 150mg/kg/d IV div q8h ³ 14 days - ENT consult with complicated Moraxella catarrhalis tympanocentesis +/- more · mastoiditis H. influenzae extensive drainage required. · vertigo Occasionally: - Infectious Diseases consult · facial · Group A Streptococci is strongly recommended. paralysis · S. aureus RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Otitis Media (cont’d) AOM – - Observation over time is reasonable because of a decreasing incidence of AOM with advancing age. recurrent - Given increasing antibiotic resistance, antibiotic prophylaxis is no longer recommended. · ³ 3 episodes - Consider ENT referral for tympanostomy tubes if: in 6 months · OME for ³ 3 months with bilateral hearing loss ³ 20 dB or · ³ 3 episodes in 6 months · ³ 4 episodes · ³ 4 episodes in 12 months · retracted tympanic membrane in 12 months · cleft palate or craniofacial malformations. S. pneumoniae > 6 weeks from last * Use high dose amoxicillin x Moraxella catarrhalis episode 10 days. H. influenzae See AOM – healthy 10 days **Due to poor taste of Occasionally: child* suspension, recommend · Group A Streptococci < 6 weeks from last tablets if possible; can crush · S. aureus episode and put in palatable fluid. If Amoxicillin PLUS 40mg/kg/d PO div tid 10 days not tolerated, cefprozil Amoxicillin-clavulanate 40mg/kg/d PO div tid 10 days (30mg/kg/d PO div bid x 10 or days) can be considered. Cefuroxime axetil** 40mg/kg/d PO div bid 10 days Compared to cefuroxime, it has a better taste but inferior b-lactam allergy coverage of Haemophilus Erythromycin- 40mg erythro/kg/d PO div 10 days and pen-I S. pneumoniae. sulfisoxazole tid ***Macrolides have been or shown to be less efficacious 10mg/kg PO first day, 5 days than amoxicillin-clavulanate. Azithromycin*** then 5mg/kg PO daily x 4 or days 15mg/kg/d PO div bid 10 days Clarithromycin*** RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Otitis Media (cont’d) OME Usually sterile > 3 months* * Up to 50% of children will Observation only. No have an effusion 1 month antibiotics. post AOM. Further antibiotic > 3 months with therapy not required. bilateral hearing loss ³ Up to 10% of children will 20 dB. have an effusion 3 months Bilateral myringotomy post AOM. Perform hearing and tympanostomy test in these children and tubes refer to ENT if hearing loss.

Whooping cough Bordetella pertussis Treatment - Notify Public Health at 413- Erythromycin estolate 40mg/kg/d PO div qid 7-10 days 7949 (after hours/weekends (max 1g/day) 413-7991). Alternative - For contact prophylaxis Azithromycin or 10mg/kg PO first day then 5 days recommendations, see 5mg/kg PO daily x 4 days Prophylaxis for Contacts of Clarithromycin or 15mg/kg/d PO div bid 7-10 days Communicable Diseases. TMP/SMX 8mg TMP/kg/d PO div bid 7-10 days Public Health will do contact investigation & notification. Epiglottitis H. influenzae type B Cefuroxime 150mg/kg/d IV div q8h 7-10 days - If suspected, call PICU, anaesthesia, and ENT, without distressing the child. - DO NOT attempt IV for antibiotics. - Keep in position of comfort (usually sitting). Croup Viruses No antibiotic therapy recommended. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Bacterial S. aureus Cefuroxime 150mg/kg/d IV div q8h 10 days - Uncommon. Presents as tracheitis Group A Streptococci croup, but with more rapid H. influenzae onset and higher fever. Bronchitis - Bacterial bronchitis does NOT occur in children. Only occurs as a part of tracheobronchitis with viral infections. - Green/yellow sputum production is indicative of inflammatory reaction and does not necessarily imply bacterial infection. - Mycoplasma pneumoniae and Chlamydia pneumoniae have been implicated but not fully established as pathogens in acute bronchitis. Empiric therapy for these organisms is not recommended. - Viral URTI can result in cough >14 days in 20% of children. Prolonged (> 10-14 days) cough may be evaluated for Mycoplasma pneumoniae or Bordetella pertussis, or asthma. - In most patients the respiratory exam is normal (few patients may have wheezes). Chest x-ray is indicated if there is any suspicion of pneumonia on history or physical exam. - Follow-up not recommended unless: · symptoms worsen or new symptoms develop (dyspnea, persistent fever, vomiting) · cough not improving at 14 days or cough lasting > 1 month · symptoms recur (> 3 episodes/year). Viruses No antibiotic therapy * Meta-analyses have shown recommended* no benefit of antibiotics in patients with acute bronchitis. Bronchiolitis - NP aspirate for viral detection recommended in hospitalized patients. - DDx includes: · Chlamydia trachomatis (in £ 16 weeks old) (consider NP swab for Chlamydia) · Pertussis (consider NP swab for pertussis) · if very ill, secondary bacterial pneumonia (uncommon). Viruses: No antibiotic therapy - Ribavirin is NOT · RSV recommended (see recommended even for · Parainfluenza Comments) severe RSV, except possibly · Influenza in the severely immuno- · Adenovirus compromised (e.g. transplant). See Clinical Guidelines for ribavirin. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Rhinitis - Children can have 6-10 viral URTIs per year. - Up to 25% have purulent discolored nasal discharge for as long as 14 days. - Counsel parents/patients on: · importance of handwashing in preventing transmission of RTIs · washing toys that are shared frequently. Viruses No antibiotic therapy * Salt-water drops or spray (Up to 200 different viruses) recommended. are available commercially, or or can be made at home. Allergic Salt water drops*/spray Salt water drops recipe and/or 125 mL (4 oz or ½ cup) Decongestants** warm water ¼ tsp table salt · Mix well. · Prepare fresh every day. · Position child so that head is slightly back. · Use a medicine dropper to instill 1-2 drops per nostril. · Repeat 4 to 5 times per day. ** May alleviate symptoms but will not shorten duration of symptoms. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Sinusitis - The benefit of antibiotic therapy in sinusitis is controversial (up to 60% resolve spontaneously). - Most common predisposing factor is viral upper respiratory tract infection. Preschool and school age children can have 6-10 viral URTIs per year. Bacterial sinusitis complicates only <5% of these. Common presentation - Persistent symptoms of URTI without improvement after 10-14 days with purulent nasal discharge +/- fever, cough, irritability, lethargy, facial pain. Severe presentation (uncommon) - Severely ill child with fever ³ 39oC (unresponsive to appropriately dosed antipyretics) and purulent nasal discharge usually associated with facial swelling, sinus tenderness, headache. Diagnosis - Nasopharyngeal cultures are not helpful in identifying sinus pathogen(s). - Sinus x-rays are not recommended as they will not differentiate between viral URTI and bacterial sinusitis. - CT scan is only recommended for complications of acute sinusitis, chronic sinusitis not responding to treatment, and severe presentations where hospitalization is required. - MRI not recommended due to poor bone definition.

- The role of Mycoplasma pneumoniae and Chlamydia pneumoniae in acute sinusitis has been suggested but not substantiated. Empiric therapy for these organisms is not recommended. - Adjunctive therapy with short term topical or systemic decongestant and/or irrigation with saline solution may be helpful. NB: Antihistamines have no role in the management of acute sinusitis.

Prevention: · Handwashing · Avoidance of environmental tobacco smoke · Reduction of allergen exposure. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Sinusitis (cont’d) Acute - S. pneumoniae Standard dose * Amoxicillin retains best symptoms < 4 M. catarrhalis Amoxicillin* 40mg/kg/d PO div tid 10 days coverage of all oral b-lactam weeks H. influenzae High dose** agents against S. Occasionally: Amoxicillin 90mg/kg/d PO div tid 10 days pneumoniae (including · S. aureus b-lactam allergy intermediate strains). · Group A Streptococci Erythromycin- 40mg erythro/kg/d PO div 10 days **This higher dose might be · Anaerobes sulfisoxazole tid considered in high risk or children: TMP/SMX*** 6-10mg TMP/kg/d PO div 10 days · recent (< 3 months) bid antibiotic exposure and · daycare centre attendance (extrapolated from AOM data). ***TMP/SMX ~21% resistance to S. pneumoniae in Northern/Central Alberta. If b-lactam allergy and previous antimicrobial exposure use a 2nd line agent (next page). RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Sinusitis (cont’d)

Failure of first S. pneumoniae Amoxicillin-clavulanate 40mg/kg/d PO div tid 10 days - Need to consider resistant line agents: M. catarrhalis PLUS organisms, especially · no improve- H. influenzae Amoxicillin* 40mg/kg/d PO div tid 10 days penicillin-resistant S. ment or Occasionally: or pneumoniae and b- clinical · S. aureus Cefuroxime axetil** 40mg/kg/d PO div bid 10 days lactamase producing H. deterioration · Group A Streptococci b-lactam allergy influenzae. after 72 hours · Anaerobes Erythromycin- 40mg erythro/kg/d PO div 10 days * If patient has failed high of antibiotic sulfisoxazole tid dose amoxicillin therapy, therapy or amoxicillin-clavulanate alone 10mg/kg PO first day, 5 days · recurrence Azithromycin*** is adequate to cover b- then 5mg/kg PO daily x 4 within 3 months or lactamase producing days organisms. 15mg/kg/d PO div bid 10 days **If cefuroxime suspension/ Clarithromycin*** tablets not tolerated, cefprozil (30mg/kg/d PO div Severe 100-150mg/kg/d IV div 10 days bid) can be considered. It Cefuroxime q8h has a better taste than cefuroxime but inferior coverage of Haemophilus and penicillin-intermediate S. pneumoniae. ***Macrolide use should be restricted as: · macrolide resistance is increasing in Alberta · macrolides have been shown, in AOM, to be less efficacious than amoxicillin-clavulanate. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Sinusitis (cont’d)

Hospital acquired < 4 days hosp- See Sinusitis - Acute italization

> 4 days hosp- S. aureus Cefuroxime + 150mg/kg/d IV div q8h 10-14 days - Surgical drainage usually italization Enterobacteriaceae Gentamicin 7.5mg/kg/d IV div q8h needed. Occasionally: - Risk factors: · Anaerobes Severe · mechanical ventilation · Pseudomonas spp Piperacillin-tazobactam 250-300mg/kg/d IV div 10-14 days · facial fractures · Yeast + q4-6h · nasal packing Tobramycin 7.5mg/kg/d IV div q8h · nasogastric tubes · otitis media post head trauma. - Recommend: · Remove nasogastric tube · Semi-recumbent positioning · Sinus aspiration for C&S: Þ tailor antibiotics to C&S results Þ if Pseudomonas/ Acinetobacter cultured, recommend combination therapy with tobramycin. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Parapharyngeal Polymicrobial: Penicillin + 150,000-250,000u/kg/d IV 10-14 days - Surgical drainage often space infections · Streptococcus spp div q6h necessary. · Anaerobes Metronidazole IV/POC 30mg/kg/d IV div q12h/ - is · Eikenella corrodens 15-30mg/kg/d PO div bid resistant to clindamycin and Alternative metronidazole. ClindamycinC 40mg/kg/d IV div q8h 10-14 days Odontogenic See Recommended Empiric Therapy of Dental Infections Acute cervical S. aureus Mild - Surgical drainage of adenitis Group A Streptococci Cephalexin 40mg/kg/d PO div qid 10-14 days abscess may be required. Oral anaerobes Alternative Clindamycin or 40mg/kg/d PO div qid 10-14 days Amoxicillin-clavulanate 40mg/kg/d PO div tid 10-14 days Moderate-severe Cefazolin or 75-100mg/kg/d IV div q8h 10-14 days ClindamycinC or 40mg/kg/d IV div q8h 10-14 days Cloxacillin 150mg/kg/d IV div q6h 10-14 days Cystic Fibrosis < 5 years old: Cefuroxime 150mg/kg/d IV div q8h 10-14 days - Sputum culture exacerbation · S. aureus recommended to identify · H. influenzae patients with chronic . ³ 5 years old: Piperacillin 250-300mg/kg/d IV div 14 days · Pseudomonas aeruginosa + q4-6h Tobramycin 7.5mg/kg/d IV div q8h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Pneumonia Neonates - If sepsis/meningitis < 1 monthB Group B Streptococci Ampicillin + 200mg/kg/d IV div q6h 10-14 days suspected (e.g. fever, Enterobacteriaceae Gentamicin 7.5mg/kg/d IV div q8h lethargy, or poor feeding), Listeria monocytogenes strongly consider blood Occasionally: culture/lumbar puncture. · S. aureus 1-3 months Viral: None · RSV · Parainfluenza · Influenza · Adenovirus Bacterial: Cefuroxime +/- 150mg/kg/d IV div q8h 10-14 days · Group A, B Streptococci Erythromycin IV/PO 40mg/kg/d IV/PO div q6h 10-14 days · Enterobacteriaceae Severely ill and · S. pneumoniae meningitis possible · H. influenzae Cloxacillin + 200mg/kg/d IV div q6h 10-14 days · S. aureus Cefotaxime 200mg/kg/d IV div q6h · Listeria monocytogenes · Chlamydia trachomatis RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Community acquired pneumonia > 3 months - Viruses: No antibiotic therapy 5 years · RSV recommended · Parainfluenza · Influenza · Adenovirus Bacterial: Mild - S. pneumoniae is most common · S. pneumoniae Amoxicillin 40mg/kg/d PO div tid 10-14 days pathogen: · H. influenzae b-lactam allergy · resistance: 40mg/kg/d PO div qid 10-14 days - 17.4% penicillin · S aureus Erythromycin or - 13% macrolide. 10mg/kg PO first day, 5 days · Group A Streptococci Azithromycin · Amoxicillin retains best · Mycoplasma pneumoniae or then 5mg/kg PO daily x 4 coverage of all oral b- · Chlamydia pneumoniae days lactam agents against S. Clarithromycin 15mg/kg/d PO div bid 10-14 days pneumoniae (including Alternative if failure intermediate strains). 45mg/kg/d PO div bid 10-14 days - In sickle cell anemia, [Cefuroxime axetil or 40mg/kg/d PO div tid Mycoplasma common and can Amoxicillin-clavulanate] cause severe pneumonia; use +/- cefuroxime + erythromycin. - Amoxicillin has no activity Erythromycin 40mg/kg/d PO div qid 10-14 days Moderate-severe against: · S. aureus Cefuroxime +/- 150mg/kg/d IV div q8h 10-14 days · b-lactamase (+) H. Erythromycin IV/PO 40mg/kg/d IV/PO div q6h influenzae (16% of Alternative in PICU isolates). admission - Stepdown to oral therapy if : Cloxacillin + 200mg/kg/d IV div q6h 10-14 days · afebrile Cefotaxime +/- 200mg/kg/d IV div q6h · clinically improving · tolerating oral intake Erythromycin IV/PO 40mg/kg/d IV/PO div q6h · no complications (e.g. empyema). RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Community acquired pneumonia (cont’d) Children > 5 Mycoplasma pneumoniae Mild - In sickle cell anemia, years S. pneumoniae Erythromycin or 40mg/kg/d PO div qid 10-14 days Mycoplasma common and H. influenzae Azithromycin 10mg/kg PO first day 5 days can cause severe S. aureus or then 5mg/kg PO daily x 4 pneumonia; use cefuroxime Group A Streptococci days + erythromycin. Chlamydia pneumoniae Clarithromycin 15mg/kg/d PO div bid 10-14 days - Stepdown to oral therapy if : Viruses Alternative if failure · afebrile [Cefuroxime axetil or 40mg/kg/d PO div bid 10-14 days · clinically improving Amoxicillin- 40mg/kg/d PO div tid · tolerating oral intake clavulanate] · no complications (e.g. + empyema). 40mg/kg/d PO div qid 10-14 days Erythromycin Moderate-severe 150mg/kg/d IV div q8h 10-14 days Cefuroxime + 40mg/kg/d IV/PO div q6h Erythromycin IV/PO PICU admission 200mg/kg/d IV div q6h 10-14 days Cloxacillin + 200mg/kg/d IV div q6h Cefotaxime + 40mg/kg/d IV/PO div q6h Erythromycin IV/PO Hospital acquired S. pneumoniae Mild - Blood cultures pneumonia S. aureus Amoxicillin-clavulanate 40mg/kg/d PO div tid 10-14 days recommended. H. influenzae Moderate-severe - For immunocompromised Enterobacteriaceae Cefuroxime +/- 150mg/kg/d IV div q8h 10-14 days patients, recommend Gentamicin 7.5mg/kg/d IV div q8h Infectious Diseases consult.

RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Pneumonia - Ventilated £ 4 days: Cefuroxime +/- 150mg/kg/d IV div q8h 10-14 days - ETT aspirates are Paediatric · S. pneumoniae Gentamicin 7.5mg/kg/d IV div q8h nonspecific; only indicated if Intensive Care · S. aureus Severe or ventilated > 4 pneumonia is diagnosed · H. influenzae days clinically. · Enterobacteriaceae Piperacillin-tazobactam 250-300mg/kg/d IV div 10-14 days Ventilated > 4 days: + q4-6h · Enterobacteriaceae and Tobramycin 7.5mg/kg/d IV div q8h Pseudomonas becomes Alternative more likely. Cloxacillin + 200mg/kg/d IV div q6h 10-14 days Ceftazidime + 150mg/kg/d IV q8h 7.5mg/kg/d IV div q8h Tobramycin Aspiration - For severe immunosuppression, consultation with an Infectious Diseases specialist is recommended. pneumonia Community Oral anaerobes [Penicillin VK or 40mg/kg/d PO div qid or 10-14 days acquired Streptococci spp tid Eikenella corrodens Penicillin IV] +/- 150,000-250,000u/kg/d IV div q6h Metronidazole IV/POC 30mg/kg/d IV div q12h/ 10-14 days 15-30mg/kg/d PO div bid b-lactam allergy C 40mg/kg/d IV div q8h/ 10-14 days Clindamycin IV/PO 30-40mg/kg/d PO div qid RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Respiratory Aspiration pneumonia (cont’d) Hospital S. aureus Mild-moderate * If recent ventilatory support C acquired Enterobacteriaceae Clindamycin + 40mg/kg/d IV div q8h 10-14 days and/or prior multiple Oral anaerobes Gentamicin 7.5mg/kg/d IV div q8h antibiotics, use this regimen. Occasionally: Severely ill* - Suspect aspiration · Pseudomonas spp Piperacillin-tazobactam 250-300mg/kg/d IV div 10-14 days pneumonia if: · H. influenzae + q4-6h · predisposing factors: · S. pneumoniae Tobramycin 7.5mg/kg/d IV div q8h Þ ¯ level of consciousness Þ dysphagia Þ Þ mechanical interference (ET/NG tubes) · insidious onset of symptoms (cough, sputum, fever) · infiltrates in dependent pulmonary segments. Lung abscess S. aureus ClindamycinC + 40mg/kg/d IV div q8h minimum 3 - Treat until pulmonary Oral anaerobes Cefotaxime 150mg/kg/d IV div q8h weeks infiltrate has cleared. Enterobacteriaceae Empyema S. aureus Mild-moderate - Criteria for empyema: Group A Streptococci Cefuroxime 150mg/kg/d IV div q8h minimum 3 · Gram stain (+) S. pneumoniae Severely ill weeks · pH < 7.0 H. influenzae Clindamycin IV/POC + 40mg/kg/d IV div q8h/ minimum 3 · glucose < 2.3 mmol/L Enterobacteriaceae 30-40mg/kg/d PO div qid weeks · grossly purulent. Oral anaerobes Cefotaxime 150mg/kg/d IV div q8h - Chest tube drainage If chronic, consider M. recommended. May require tuberculosis. surgical decortication. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Gastrointestinal Gastroenteritis Mild-moderate Viral: Fluid replacement - If persistent, do stool for · Rotavirus electron microscopy and · Norwalk O&P (1 sample only). · Enteric adenovirus - For treatment of enteric Parasitic: parasites, see · Giardia Recommended Empiric · Cryptosporidium Therapy of Enteric Parasitic Infections. Severe Bacterial: If severe, consider - Do stool for C&S once. · > 6 diarrheal · E. coli O157:H7 (EHEC) [TMP/SMX or 6-10mg TMP/kg/d PO div 3-5 days - Therapy for EHEC not episodes/day · Campylobacter spp bid recommended. · bloody · Shigella spp Cefixime] +/- 8mg/kg/d PO div q12-24h 3-5 days - Therapy for Salmonella only diarrhea · Salmonella spp Erythromycin 40mg/kg/d PO div qid recommended if: · fever Uncommonly: · age < 3 months · Aeromonas spp If Campylobacter spp · immunocompromised · Pleisiomonas spp Erythromycin 40mg/kg/d PO div qid 3-5 days · hemoglobinopathy · Vibrio spp · chronic GI tract disease · Yersinia spp · severe colitis. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Gastrointestinal Travellers’ diarrhea Mild Enterotoxigenic E. coli Fluid replacement - Self-limiting. Usual duration Viruses of diarrhea £ 5 days. Parasites Other bacteria Severe Bacterial: [TMP/SMX or 8mg TMP/kg/d PO div bid 3-5 days - Do stool for C&S once. · > 6 diarrheal · Campylobacter spp Cefixime] +/- 8mg/kg/d PO div q12-24h - Therapy for Salmonella only episodes/day · Shigella spp Erythromycin 40mg/kg/d PO div qid 3-5 days recommended if: · bloody · Salmonella spp · age < 3 months diarrhea Parasitic: · immunocompromised · fever · Entamoeba spp · hemoglobinopathy · chronic GI tract disease. - For treatment of enteric parasites, see Recommended Empiric Therapy of Enteric Parasitic Infections. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Gastrointestinal Antibiotic- - AAD suspected if: associated · antibiotic therapy in last 2 months diarrhea (AAD) · onset of diarrhea > 72 hours after hospitalization. - Submit one stool sample for C. difficile toxin (culture not recommended). · if negative and still suspect AAD, submit another stool specimen. - Discontinue antibiotics if possible. If not possible, consider changing to lower AAD risk group of antibiotics if appropriate (e.g. aminoglycosides, TMP/SMX, and/or metronidazole). - Do NOT use antidiarrheals, e.g. loperamide (Imodium®), diphenoxylate (Lomotil®). - Metronidazole IV of uncertain efficacy (only use in combination for severe/toxic megacolon). - Vancomycin IV not effective. Acute Clostridium difficile Metronidazole 20-30mg/kg/d PO div qid 7-10 days - Unless severe clinical (max 250mg PO qid) deterioration, should not assume therapeutic failure of metronidazole until minimum of 6 days of therapy completed without symptomatic improvement. Recurrent Clostridium difficile Metronidazole 20-30mg/kg/d PO div qid 7-10 days * Recurrence occurs in 15- (max 250mg PO qid) 20% of patients. Retreat- Alternative* ment with metronidazole is Vancomycin** 50mg/kg/d PO div qid 10 days recommended as majority of (max 125mg PO qid) recurrences are reinfections (not relapses). **Vancomycin restricted to: · documented failure or clinical deterioration on metronidazole · documented/impending toxic megacolon · intolerance or side-effects on metronidazole therapy. Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Therapy Paediatric DoseB Duration Gastrointestinal Antibiotic- associated diarrhea (AAD) (cont’d) Severe/toxic Clostridium difficile Metronidazole IV + 30mg/kg/d IV div q12h 10 days megacolon (max 500mg IV q12h) Metronidazole PO + 20-30mg/kg/d PO div qid (max 250mg PO qid) Vancomycin PO/NG/PR 50mg/kg/d PO/NG/PR div qid (max 125mg PO qid) Necrotizing Enterobacteriaceae Ampicillin + 200mg/kg/d IV div q6h 7-14 days enterocolitis Streptococcus spp Gentamicin 7.5mg/kg/d IV div q8h (NEC)B Coagulase negative Staph Perforation Perforation add: add MetronidazoleC 30mg/kg/d IV div q12h 7-14 days Anaerobes Severely ill Piperacillin-tazobactam 250-300mg/kg/d IV div 7-14 days + q6h Gentamicin 7.5mg/kg/d IV div q8h Appendicitis Enterobacteriaceae Uncomplicated * Complicated: Anaerobes Empiric therapy not · gangrene +/- Enterococcus spp recommended. Refer to · perforation Surgical Prophylaxis. · abscess Complicated* · peritonitis. See 2o Peritonitis RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Gastrointestinal Peritonitis Spontaneous S. pneumoniae Ampicillin + 150-200mg/kg/d IV div 10-14 days - Occurs in the setting of bacterial Group A. Streptococci q6h cirrhosis or nephrotic peritonitis (SBP) Enterobacteriaceae Gentamicin 7.5mg/kg/d IV div q8h syndrome, but can rarely Occasionally: Alternative occur in healthy children, · S. aureus Cefotaxime 150mg/kg/d IV div q8h 10-14 days especially school age girls. · Enterococcus spp - Carefully consider possible o · Anaerobes 2 peritonitis. SBP is usually monomicrobial. Polymicrobial infections suggest bowel perforation. See 2o peritonitis. Secondary - All abscess collections require drainage. peritonitis - Enterococcus is of uncertain significance but coverage should be strongly considered if: · abscess · distal colon surgery · bowel · hepatobiliary/pancreatic infection perforation · patients with chronic illness or immunosuppression · ruptured · previous antibiotic therapy (excluding surgical prophylaxis) · Enterococus is a predominant organism in culture. appendix - Duration of therapy: · Uncomplicated: short course (3-5 days) if penetrating trauma with surgery within 12 hours of injury. · Complicated/ established intraabdominal infections: minimum 7 days (IV/PO) and until: Þ afebrile Þ normal WBC/ differential Þ no residual fluid collections and Þ clinically resolved peritonitis. Enterobacteriaceae Ampicillin + 150-200mg /kg/d IV div Duration of * Alternative regimen does Anaerobes q6h therapy not have enterococcal +/- Enterococcus spp Gentamicin + 7.5mg/kg/d IV div q8h dependent on coverage. MetronidazoleC 30mg/kg/d IV div q12h clinical picture Alternative* (see above). ClindamycinC + 40mg/kg/d IV div q8h Gentamicin 7.5mg/kg/d IV div q8h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Gastrointestinal Peritonitis (cont’d) Tertiary Enterobacteriaceae As in 2o peritonitis - All abscess collections peritonitis Pseudomonas spp Severely ill require drainage. Anaerobes Piperacillin + 250-300mg/kg/d IV div 10-14 days and - Ideally, treat according to Occasionally: q4-6h until: culture results (prior to · Enterococcus spp Tobramycin + 7.5mg/kg/d V div q8h · afebrile antibiotics), if possible. · Candida spp MetronidazoleC or 30mg/kg/d IV div q12h · normal WBC/ - Amphotericin B should Piperacillin-tazobactam 250-300mg/kg/d IV div differential usually be used only with an + q4-6h · no residual Infectious Diseases consult. Tobramycin 7.5mg/kg/d V div q8h fluid collections and · clinically resolved peritonitis. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Gastrointestinal Peritonitis (cont’d) CAPD S. aureus Mild - The tenckhoff catheter peritonitis Coagulase negative Staph Cefazolin IP 500mg/L load then 10-14 days should be removed if Streptococcus spp 125mg/L to each infection is: Enterobacteriaceae exchange · due to fungi or Pseudomonas spp Moderate-severe Pseudomonas Occasionally: Cefazolin IP + 500mg/L load then 10-14 days · persistent or recurrent · Anaerobes 125mg/L to each · associated with tunnel or · Candida spp exchange persistent exit site Gentamicin IP 2mg/kg load to one 10-14 days infection. exchange Day 1 then - If systemically very ill, use IV 1mg/kg dose to one antibiotics. exchange on Day 2 then - For positive cultures other 4mg/L to each exchange than Pseudomonas, see from Day 3 on IF still Adult Recommendations for indicated CAPD peritonitis (Table 1). Pseudomonas spp: 150mg/kg IV q12h To complete 21- - For CCPD consult Piperacillin IV + 6-8mg/L to each 28 days. Paediatric Nephrology. Tobramycin IP exchange x 3 days then 6mg/L RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Genital Vulvovaginitis Prepubertal Non sexually transmitted Treat according to - DDx includes: vaginitis diseases: cause. · local irritation (e.g. · Group A Streptococci bubblebath) · Shigella spp · foreign body · Candida spp · trauma. · Other - If discharge present do: Sexually transmitted · careful history and diseases: physical to rule out · Gonorrhea ( > 1 month*) suspected abuse and · Trichomoniasis (> 6 · swabs of vagina for: months*) · Gram stain · Chlamydia (> 6 months*) · C&S · HSV (> 3 months*) · gonorrhea culture · chlamydia culture · wet mount * Age at which nonvertical · KOH/whiff test. transmission becomes most - Follow-up cultures likely. recommended for test of cure: · gonorrhea - at 5 days · chlamydia - at 3-4 weeks. - If bloody discharge, consult paediatrics or gynecology to rule out foreign body or tumor. - Do not do speculum exam in children. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Urinary Tract Asymptomatic Enterobacteriaceae Mild - Consider treating bacteriuria Enterococcus spp TMP/SMX or 6-10mg TMP/kg/d PO div 7-10 days asymptomatic patients if bid bacteriuria is found in two Amoxicillin-clavulanate 40mg/kg/d PO div tid 7-10 days consecutive appropriately or collected urines Nitrofurantoin 5-7mg/kg/d PO div qid 7-10 days (controversial), unless it is associated with chronic catheterization. Cystitis or - Bag urine specimens are usually contaminated and cannot be relied upon to diagnose UTI. If negative, then UTI is absent. If pyelonephritis positive, it must be confirmed with a proper specimen BEFORE antibiotics. In young children who are to receive antibiotic therapy, a catheter urine specimen is recommended if UTI is suspected. - Investigations recommended are: · abdominal U/S in all and · £ 2 years: at 4-6 weeks either a VCUG (boys) or nuclear cystogram (girls) · > 2 years: nuclear cystogram with second UTI. - E. coli resistance: · amoxicillin 73% · cephalexin 68% · TMP/SMX 16%. - Cephalothin (not cefazolin) correlates with cephalexin susceptibility of E.coli. - Prophylaxis with TMP/SMX (4mg/kg/dose PO daily) or nitrofurantoin (2mg/kg/dose PO daily) recommended at least until investigations complete. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Urinary Tract Cystitis or pyelonephritis (cont’d) Enterobacteriaceae Mild - Fever, toxicity, or CVA Enterococcus spp TMP/SMX or 6-10mg TMP/kg/d PO div 10-14 days tenderness suggests bid pyelonephritis and need for Amoxicillin-clavulanate 40mg/kg/d PO div tid 10-14 days IV therapy. or Nitrofurantoin 5-7mg/kg/d PO div qid 10-14 days Moderate-severe Ampicillin + 100-200mg/kg/d IV div 10-14 days q6h Gentamicin 5-7.5mg/kg/d IV div q8h Severe with underlying abnormality and recurrent UTIs Piperacillin + 250-300mg/kg/d IV div 10-14 days q4-6h Tobramycin 5-7.5mg/kg/d IV div q8h Recurrent Enterobacteriaceae Mild - Prophylaxis with TMP/SMX Enterococcus spp TMP/SMX or 6-10mg TMP/kg/d PO div 10-14 days (4mg/kg/dose PO daily) bid recommended for ³ 6 Amoxicillin-clavulanate 40mg/kg/d PO div tid 10-14 days months. or Nitrofurantoin 5-7mg/kg/d PO div qid 10-14 days Moderate-severe Ampicillin + 100-200mg/kg/d IV div 10-14 days q6h Gentamicin 5-7.5mg/kg/d IV div q8h Severe with underlying abnormality and recurrent UTIs Piperacillin + 250-300mg/kg/d IV div 10-14 days q4-6h Tobramycin 5-7.5mg/kg/d IV div q8h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Urinary Tract Chronic Enterobacteriaceae Asymptomatic - Can be polymicrobial. indwelling Enterococcus spp None - Do not treat unless catheterization Pseudomonas spp Symptomatic evidence of systemic Occasionally: Mild infection: · Candida spp TMP/SMX or 6-10mg TMP/kg/d PO div 10-14 days · catheter often colonized bid with bacteria Amoxicillin-clavulanate 40mg/kg/d PO div tid 10-14 days · increased risk of or resistant organisms Nitrofurantoin 5-7mg/kg/d PO div qid 10-14 days · modify empiric therapy to Moderate-severe most narrow spectrum Ampicillin + 100-200mg/kg/d IV div 10-14 days option based on C&S q6h results. 5-7.5mg/kg/d IV div q8h Gentamicin *Amoxicillin-clavulanate has Severe with underlying no activity against abnormality and Pseudomonas. recurrent UTIs 250-300mg/kg/d IV div 10-14 days Piperacillin + q4-6h 5-7.5mg/kg/d IV div q8h Tobramycin RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Central Nervous System Meningitis Recommendations for the Addition of Vancomycin to Cefotaxime in Meningitis in the Capital Health Region - S. pneumoniae resistance in Northern/Central Alberta: · Penicillin 17.4% ~ Intermediate 16% ~ High level 1.4% · Cefotaxime/Ceftriaxone < 1%

- Empiric vancomycin is indicated for pneumococcal meningitis until cefotaxime resistance can be excluded. It should be given, in addition to cefotaxime, if: · gram positive cocci in pairs or chains on CSF gram stain · no organisms seen on CSF gram stain, but bacterial meningitis is strongly suspected based on either CSF parameters or clinical presentation · an LP must be delayed or is contraindicated, but bacterial meningitis is strongly suspected based on clinical presentation. NB: Vancomycin has slow distribution and poor CSF penetration. It should be given as soon as possible AFTER the first dose of cefotaxime, and continued ONLY if the C&S results indicate cefotaxime resistant S. pneumoniae. - Empiric vancomycin is not routinely indicated for: · sepsis without meningitis · viral meningitis · neonatal meningitis (unless a VLBW neonate in the NICU, particularly those with a central line). - Lumbar puncture recommended prior to antibiotic therapy except if: · S&S of focal neurological deficit · papilledema · uncorrected coagulopathy · GCS < 11 · hemodynamically unstable. - Do not delay antibiotics if LP cannot be performed expediently. - Blood culture recommended. - Directigen of CSF not recommended. - For prophylaxis of H. influenzae and N. meningitidis, refer to Prophylaxis for Contacts of Communicable Diseases. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Central Nervous System Meningitis (cont’d) Neonates Group B Strep, - Repeat LP recommended at < 1 month Group B Streptococci Ampicillin + 200mg/kg/d IV div q6h Listeria spp, day 5. E. coli [Gentamicin or 7.5mg/kg/d IV div q8h Coag neg Staph - Consider need for acyclovir Listeria spp Cefotaxime] 200mg/kg/d IV div q6h - 2-3 weeks. if HSV encephalitis possible. Enterobacteria- ceae - ³ 3 weeks. 1-3 months Group B Streptococci Ampicillin + 200mg/kg/d IV div q6h S. pneumoniae, - Consider need for acyclovir E. coli Cefotaxime 200mg/kg/d IV div q6h N. meningitidis, if HSV encephalitis Listeria spp H. influenzae - possible. S. pneumoniae 7-10 days. N. meningitidis Group B Strep, H. influenzae type B Listeria spp - 2-3 weeks. Enterobacteria- ceae - ³ 3 weeks. Children > 3 months S. pneumoniae Cefotaxime + 200mg/kg/d IV div q6h 7-10 days - Consider need for acyclovir N. meningitidis Vancomycin* 60mg/kg/d IV div q6h if HSV encephalitis H. influenzae type B Alternative only if possible. severe/ anaphylactic b- * See comments in box on lactam allergy previous page. Vancomycin Chloramphenicol + 75-100mg/kg/d IV div q6h 7-10 days should be stopped as soon Vancomycin 60mg/kg/d IV div q6h as cefotaxime resistance excluded. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Central Nervous System Meningitis (cont’d) Nosocomial in Group B Streptococci Ampicillin + 200mg/kg/d IV div q6h ³ 14 days neonatesB Enterobacteriaceae [Gentamicin or 7.5mg/kg/d IV div q8h Listeria spp Cefotaxime] 200mg/kg/d IV div q6h If VLBW in NICU (particularly If high risk for CNS with CVL) add: Vancomycin 60mg/kg/d IV div q6h ³ 14 days · Coagulase negative Staph (pending cultures) + (CNS) Cefotaxime 200mg/kg/d IV div q6h

Very severe Vancomycin 60mg/kg/d IV div q6h ³ 14 days (pending cultures) + 150mg/kg/d IV div q8h Ceftazidime + 7.5mg/kg/d IV div q8h Gentamicin Shunt or EVD Coagulase negative Staph Vancomycin 60mg/kg/d IV div q6h ³ 14 days - Shunt removal should be S. aureus (pending cultures) + ³ 21 days for considered ASAP. Enterobacteriaceae Ceftazidime 150mg/kg/d IV div q8h Enterobacteria- Pseudomonas spp ceae. Basilar skull S. pneumoniae Cefotaxime 200mg/kg/d IV div q6h ³ 10 days fracture H. influenzae Very severe S. aureus Vancomycin 60mg/kg/d IV div q6h ³ 10 days Enterobacteriaceae (pending cultures) + Ceftazidime 150mg/kg/d IV div q8h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Central Nervous System Brain Abscess - Surgical therapy usually required with either stereotactic aspiration or open drainage with gram stain and culture. - Rule out: ·sinusitis · otitis · dental infection · endocarditis · congenital heart disease · lung abscess. - At least 2 blood cultures are recommended before antibiotics. Viridans Group Streptococci Depends on specific * Use ceftazidime in place of Anaerobes source. cefotaxime if increased risk Enterobacteriaceae If very ill without a of Pseudomonas: S. aureus specific source · post neurosurgery or Cloxacillin + 200mg/kg/d IV div q4h 6 weeks trauma Cefotaxime* + 200mg/kg/d IV div q6h · prolonged ventilatory MetronidazoleC 30mg/kg/d IV div q8h** support · prolonged hospitalization **Automatic substitution · previous broad spectrum policy of IV q8h ® q12h antibiotics therefore indicate “No · burns. substitution”. Encephalitis Enteroviruses Acyclovir < 2 months old * Herpes simplex is the most Herpes simplex virus* 60mg/kg/d IV div q8h 3 weeks if common cause of sporadic Arboviruses confirmed HSV fatal encephalitis and is one Postinfectious: · mumps encephalitis of the few treatable causes. · measles > 2 months old - Infectious Diseases consult · rubella 30mg/kg/d IV div q8h 3 weeks if recommended. · influenza confirmed HSV - CSF should be sent for HSV · varicella Mycoplasma spp encephalitis PCR. Contact Provincial (Cat scratch Lab. disease) Other RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Vascular Viral: No therapy for viral · usually Enterovirus pericarditis. Mycoplasma spp Treat according to Bacterial - spread from: suspected underlying · severe pneumonia cause. · mediastinitis · endocarditis · bacteremic sepsis Noninfectious: · trauma · postpericardiotomy · uremia · vasculitis Endocarditis - Draw 3 blood cultures BEFORE considering antibiotic therapy. * For gram positive organisms, desired gentamicin peak = 3-4mg/L. Only need to continue gentamicin for > 4 weeks if Enterococcus, or selected HACEK organism. Native valve Viridans Group Streptococci Ampicillin + 200mg/kg/d IV div q6h ³ 4 weeks S. aureus Gentamicin* 7.5mg/kg/d IV div q8h Enterococcus spp Very ill HACEK organisms add Cloxacillin 200mg/kg/d IV div q4h Others Penicillin allergy Vancomycin + 40-60mg/kg/d IV div q6h ³ 4 weeks Gentamicin* 7.5mg/kg/d IV div q8h Prosthetic valve Viridans Group Streptococci Vancomycin 40-60mg/kg/d IV div q6h ³ 4 weeks S. aureus (pending cultures) + Enterococcus spp Gentamicin* 7.5mg/kg/d IV div q8h Coagulase negative Staph Enterobacteriaceae HACEK = Haemophilus aprophilus/H. parainfluenzae, actinomycetemcomitans, hominis, Eikenella corrodens, spp. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Sepsis without a focus Neonates Group B Streptococci Ampicillin + 200mg/kg/d IV div q6h > 10 days - Recommend: < 1 monthB E. coli Gentamicin 7.5mg/kg/d IV div q8h · blood cultures Listeria spp · catheter/suprapubic urine · lumbar puncture · admission for IV antibiotics. 1-3 months - Low risk: · previously healthy – term, uncomplicated perinatal course, no chronic illness or surgery, no prior antibiotics · no focal bacterial infection on exam · non-toxic – no lethargy, good perfusion, normal respiratory rate, no cyanosis · negative laboratory screen – WBC 5,000-15,000, bands < 1500, urinalysis < 10 WBC/hpf, if diarrhea < 5 WBC/hpf. - In the low risk group, admission with IV antibiotics versus discharge with IM ceftriaxone and guaranteed followup in 24 hours is controversial. Group B Streptococci Ampicillin + 200mg/kg/d IV div q6h > 10 days - Recommend: E. coli Cefotaxime 200mg/kg/d IV div q6h · blood cultures Listeria spp · catheter/suprapubic urine S. pneumoniae · lumbar puncture N. meningitidis · admission for IV Occasionally: antibiotics. · H. influenzae type B Children 3-36 Viruses If temperature ³ 39.50C - Follow-up in 24 hours is months S. pneumoniae and WBC ³ 15,000 essential. · with fever N. meningitidis consider: - If treated with amoxicillin, do · no focus of Occasionally: Amoxicillin 70-90mg/kg/d PO div tid 48 hours a blood culture first. infection, and · H. influenzae type B pending blood - Consider a urine culture in · look well. culture the young infant with temperature ³ 390C for ³ 48 hours. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Sepsis Children S. pneumoniae If no concern of N. meningitidis meningitis S. aureus Cefuroxime 150mg/kg/d IV div q8h Group A Streptococci Very severe Occasionally: Cloxacillin + 200mg/kg/d IV div q4h · H. influenzae type B Cefotaxime 200mg/kg/d IV div q6h Bacterial meningitis strongly suspected Cefotaxime + 200mg/kg/d IV div q6h Vancomycin 60mg/kg/d IV div q6h Alternative only if severe/anaphylactic b-lactam allergy 75-100mg/kg/d IV div q6h Chloramphenicol +/- 60mg/kg/d IV div q6h Vancomycin Nosocomial S. aureus [Cefazolin or 75-100mg/kg/d IV div q8h > 7 days without a focus Enterobacteriaceae Cloxacillin] 150-200mg/kg/d IV div + q6h Gentamicin 7.5mg/kg/d IV div q8h Severely ill Piperacillin- 250-300mg/kg/d IV div > 7 days tazobactam q4-6h + 7.5mg/kg/d IV div q8h Tobramycin Post op heart Vancomycin 40mg/kg/d IV div q6h > 7 days (pending cultures) + Gentamicin 7.5mg/kg/d IV div q8h Severely ill add Piperacillin 250-300mg/kg/d IV div q4-6h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Sepsis Nosocomial without a focus (cont’d) NeonatesB S. aureus Ampicillin + 200mg/kg/d IV div q6h > 7 days - Strongly consider an LP. Enterobacteriaceae Gentamicin 7.5mg/kg/d IV div q8h Group B Streptococci If post op heart or high If VLBW in NICU or with CVL risk of CNS add: Vancomycin 40mg/kg/d IV div q6h > 7 days · Coagulase negative Staph (pending cultures) + (CNS) Gentamicin 7.5mg/kg/d IV div q8h Severely ill Vancomycin 40mg/kg/d IV div q6h > 7 days (pending cultures) + Gentamicin + 7.5mg/kg/d IV div q8h Ceftazidime 150mg/kg/d IV div q8h Line-related - Line must be removed if any Central line Coagulase negative Staph [Cefazolin or 75-100mg/kg/d IV div q8h 10-14 days of: S. aureus Cloxacillin] + 150-200mg/kg/d IV div · tunnel infection Enterobacteriaceae q6h · failure to respond within Gentamicin 7.5mg/kg/d IV div q8h 72 hours (persistent Definite tunnel infection positive daily blood cultures) Vancomycin 40mg/kg/d IV div q6h 10-14 days · fungal (with a (pending cultures) + percutaneous CVL). Gentamicin 7.5mg/kg/d IV div q8h - Avoid treatment in If severely ill response to single add Piperacillin 250-300mg/kg/d IV div positive blood culture for q4-6h CNS. Repeat culture recommended. Peripheral IV S. aureus Phlebitis - Remove IV. Streptococcus spp Cefazolin +/- 75-100mg/kg/d IV div q8h 7-10 days Enterobacteriaceae Gentamicin 7.5mg/kg/d IV div q8h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Febrile neutropenia Recommendations for the Use of Vancomycin in Febrile Neutropenia - Empiric vancomycin should not be used routinely in febrile neutropenics. - Vancomycin therapy should be considered empirically in: · clinically obvious central venous catheter-related infections (i.e. tunnel infection) · patients with positive blood culture for gram-positive organisms not yet identified (Leuconostoc, Pediococcus resistant to vancomycin.) · known colonization with MRSA or Pen-R S. pneumoniae. - Vancomycin therapy should be discontinued on day 3-5 if cultures negative for b-lactam resistant gram-positive organisms. No focus Gram-positive cocci Piperacillin + 250-300mg/kg/d IV div > 7 days and Enterobacteriaceae q4-6h until AGC > 0.5 x 9 Occasionally: Tobramycin 7.5mg/kg/d IV div q8h 10 /L · Anaerobes Alternative in · Pseudomonas spp nonanaphylactic penicillin allergy Ceftazidime +/- 150mg/kg/d IV div q8h > 7 days and Tobramycin 7.5mg/kg/d IV div q8h until AGC > 0.5 x 109/L

PICU admission 80mg/kg/d IV div q6h > 7 days and Imipenem + 7.5mg/kg/d IV div q8h until AGC > 0.5 x Tobramycin 109/L CVL tunnel Coagulase negative Staph Vancomycin 40mg/kg/d IV div q6h > 10-14 days - Must remove CVL or infection S. aureus (pending cultures) + and until AGC > broviac. 9 Streptococcus spp Piperacillin + 250-300mg/kg/d IV div 0.5 x 10 /L Enterobacteriaceae q4-6h Pseudomonas spp Tobramycin 7.5mg/kg/d IV div q8h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Febrile neutropenia Pneumonia · non-interstitial S. pneumoniae Piperacillin-tazobactam 250-300mg/kg/d IV div > 10-14 days - Infectious Diseases consult S. aureus + q4-6h and until AGC > recommended. 9 H. influenzae Tobramycin +/- 7.5mg/kg/d IV div q8h 0.5 x 10 /L - If prolonged neutropenia Gram negative bacilli Erythromycin 40mg/kg/d IV div q6h and/or broad spectrum Mycoplasma pneumoniae antibiotic therapy, consider Legionella spp fungal etiology and empiric Fungi Amphotericin B. · interstitial S. pneumoniae Piperacillin-tazobactam 250-300mg/kg/d IV div Dependent on - Infectious Diseases consult S. aureus + q4-6h etiology recommended. H. influenzae TMP/SMX + 20mg/kg/d IV div q6h - On the day of presentation, Gram negative bacilli Erythromycin 40mg/kg/d IV div q6h bronchoalveolar lavage for Mycoplasma pneumoniae opportunistic pathogens is Legionella spp indicated. Send for: gram Fungi stain/C&S, fungal stain & PCP culture, AFB stain & culture, Viruses PCP stain, viral culture including CMV, Legionella DFA & culture, Mycoplasma culture. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN NEONATAL/PAEDIATRIC PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Paediatric DoseB Duration Febrile neutropenia Typhlitis Enterobacteriaceae Piperacillin + 250-300mg/kg/d IV div > 10-14 days Anaerobes q4-6h and until AGC > 9 Pseudomonas spp Tobramycin + 7.5mg/kg/d IV div q8h 0.5 x 10 /L MetronidazoleC 30mg/kg/d IV div q12h or Piperacillin-tazobactam 250-300mg/kg/d IV div > 10-14 days q6h and until AGC > + 9 Tobramycin 7.5mg/kg/d IV div q8h 0.5 x 10 /L Very severe 80mg/kg/d IV div q6h > 10-14 days Imipenem + 7.5mg/kg/d IV div q8h and until AGC > Tobramycin 9 0.5 x 10 /L Fever for ³ 5-7 Add fungi add at least until - Should also do CXR, urine days Amphotericin B 0.5-1mg/kg/d IV daily AGC > 0.5 x R&M and C&S, consider 109/L sinus X-rays, and consider any of CT chest/abdomen/ sinuses. - Infectious Diseases consult recommended.

1 Non-formulary in Capital Health Region hospitals. FOOTNOTES A. These are empiric antibiotic recommendations based on local susceptibility patterns, Capital Health hospitals’ antimicrobial formulary, and need to restrict and rationalize antibiotic use. Antibiotics listed for each condition are not all inclusive, or are they all approved by HPB for the list indication. Choice of empiric antibiotic therapy should be based on the patient’s age, allergies, co-morbidities, and clinical condition, as well as cost and convenience of the dosage regimen. Empiric antibiotic therapy should be modified to more narrow spectrum antibiotic(s) according to culture and susceptibility (C&S) results.

B. Usual paediatric dose in patients with normal renal and hepatic function.

Neonates: If very low (VLBW) or low birth weight (LBW) neonates or < 10 days of age, refer to the Paediatric Red Book, Table 5.1 (p. 607) [or computer program (MNDN) at RAH] for doses.

C. Oral clindamycin/metronidazole has excellent absorption. If intravenous therapy is deemed necessary, prompt switch to the oral formulation is recommended. (See Stepdown Recommendations and Paediatric Dosing Guide). RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Impetigo* Group A Streptococci Mild * Epidemics must be reported to S. aureus Mupirocin 2% or tid topically 7 days Public Health. Fusidic acid 2% 1 tid-qid topically 7 days - Systemic antibiotics Moderate-severe recommended if: Cloxacillin or 250-500mg PO qid 7 days · multiple/extensive/recurrent Cephalexin 250-500mg PO qid 7 days lesions · immunocompromised b-lactam allergy · fever/constitutional symptoms Erythromycin or 250mg PO qid 7 days · valvular heart disease. Clindamycin 150-300mg PO qid 7 days Folliculitis/ S. aureus Hot compresses + - Usually self-limiting. Furunculosis Antiseptic cleanser - Drainage is occasionally Unresponsive to above required. or extensive - Systemic antibiotics (see Mupirocin 2% or tid topically 7 days Carbuncles) recommended if Fusidic acid 2% 1 tid-qid topically 7 days scalp folliculitis. Whirlpool/hot Pseudomonas aeruginosa Hot compresses + - Self-limiting. tub Antiseptic cleanser Recurrent S. aureus Requires eradication of - If > 6 recurrences/year, furunculosis carrier state: consider suppressive therapy Mupirocin 2% bid intranasally 5 days with clindamycin 150mg PO Alternative daily x at least 3 months. Rifampin + 600mg PO daily 10 days TMP/SMX 1 DS tab PO bid Carbuncles S. aureus Mild * Systemic antibiotics Hot compresses + recommended if: Antiseptic cleanser · surrounding cellulitis Moderate-severe* · fever/constitutional Cloxacillin or 250-500mg PO qid 7-10 days symptoms Cephalexin 250-500mg PO qid 7-10 days · located in central area of b-lactam allergy face. Clindamycin 150-300mg PO qid 7-10 days - Drainage is often necessary. 1 Non-formulary in Capital Health Region hospitals; automatic substitution to mupirocin 2%. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue MRSA nasal S. aureus, methicillin-resistant Eradication of carrier - Continue isolation precautions carriage state until minimum of 2 repeat Mupirocin 2% bid intranasally 14 days cultures, taken 2 and 9 days Consider also after completion of therapy, are TMP/SMX + 1 DS tab PO bid 14 days negative and Infection Control Rifampin + 600mg PO daily 14 days has approved. Chlorhexidine 4% full body wash daily 14 days Vesicular lesions - Notify Public Health at 413-7949 (after hours/weekends 413-7991). Chickenpox - For contact prophylaxis recommendations, see Prophylaxis for Contacts of Communicable Diseases. Children Varicella zoster Refer to Paediatric Guidelines Adults - Must initiate therapy within 24h Immuno- Varicella zoster Acyclovir or 800mg PO 5x/day 5 days of rash onset. competent Famciclovir or 500mg PO tid 5 days - May consider treatment started Valacyclovir 1g PO tid 5 days later than 24 hours if new lesions forming and: · pneumonia (treat x 10 days) · pregnancy. Safety of acyclovir in pregnancy not fully established. Potential benefit vs. potential risk to the fetus should be discussed with the patient. Acyclovir has been used at all stages of pregnancy; no adverse effects to the fetus/newborn have been reported to date. Immunocom Varicella zoster Acyclovir or 800mg PO 5x/d 7-10 days -promised Famciclovir or 500mg PO tid 7-10 days Valacyclovir 1g PO tid 7-10 days Severe Acyclovir 10mg/kg IV q8h 7-10 days RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Vesicular lesions (cont’d)

Zoster (Shingles)

Immunocom- Varicella zoster Acyclovir or 800mg PO 5x/day 7 days * Only indicated for patients: petent* Famciclovir** or 500mg PO tid 7 days · ³ 50 years old Valacyclovir 1g PO tid 7 days · with cranial nerve V1 involvement. - Therapy should be started within 72 hours of rash onset. **Only agent proven to decrease duration of postherpetic neuralgia. Immunocom- Varicella zoster Mild-moderate - Therapy should be started promised Acyclovir or 800mg PO 5x/day 7-10 days within 72 hours of rash onset. Famciclovir or 500mg PO tid 7-10 days Valacyclovir 1g PO tid 7-10 days Severe Acyclovir 10mg/kg IV q8h 7-10 days

3 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Vesicular lesions (cont’d)

Mucocutaneous (fever blisters)

Immunocom- petent

Primary Herpes simplex Acyclovir or 400mg PO tid or 7 days - No role for topical acyclovir. 200mg PO 5x/day Famciclovir or 250mg PO tid 7 days 500mg-1g PO bid 7 days Valacyclovir Recurrent Herpes simplex No therapy indicated* - No role for topical acyclovir. * If recurrences are: · severe and · ³ 6 episodes/year can give acyclovir 400mg PO bid as suppressive therapy. Immunocom- Herpes simplex Acyclovir or 400mg PO 5x/day 7-10 days - HIV patients and transplant promised Famciclovir or 250mg PO tid 7-10 days recipients may benefit from Valacyclovir 500mg-1g PO bid 7-10 days suppressive acyclovir therapy 200-400mg PO bid-tid. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Cellulitis Facial Group A Streptococci Mild * Less than 2% of pen-allergic S. aureus Cloxacillin or 500mg PO qid 7-10 days patients are allergic to Cephalexin 500mg PO qid 7-10 days cephalosporins. Avoid b-lactam allergy* cephalosporins if the patient Clindamycin 150-300mg PO qid 7-10 days has a severe allergy (See b- Moderate-severe lactam allergy section). Cloxacillin or 1g IV q6h 10 days Cefazolin 1g IV q8h 10 days b-lactam allergy* ClindamycinC 600mg IV q8h 10 days Extremities Group A Streptococci Mild - Check between toes for S. aureus Cloxacillin or 500mg PO qid 7-10 days fissures due to tinea pedis ® Group B,C,G Streptococci Cephalexin 500mg PO qid 7-10 days common portal of entry. - Groups B, C, and G Strep may b-lactam allergy exhibit tolerance to b-lactams. If fresh/salt water exposure, Clindamycin or 150-300mg PO qid 7-10 days Addition of gentamicin is consider Vibrio/Aeromonas Erythromycin 250mg PO qid 7-10 days recommended in severe spp. infections. Moderate-severe * Alternative for outpatient Cloxacillin or 1g IV q6h 10 days** management of uncomplicated Cefazolin or 1g IV q8h 10 days** cellulitis in patients with Cefazolin + 2g IV daily 10 days** adequate renal function (Clcr > Probenecid* 2g PO daily or 50mL/min). This regimen is 1g PO bid (give 30 based on pharmacokinetic min. prior to data only. Limited clinical cefazolin) evidence. b-lactam allergy **Stepdown to oral agent when: Clindamycin IV/POC 10 days · resolution of systemic 600mg IV q8h**/ symptoms 300mg PO qid · no further progression of cellulitis. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Peri-rectal Polymicrobial: Mild - Incision/drainage necessary for cellulitis/abscess · Anaerobes Amoxicillin-clavulanate 875mg PO bid 10-14 days abscesses. · Enterobacteriaceae Moderate-severe · S. aureus Clindamycin + 300mg PO qid 10-14 days · Group A Streptococci Ciprofloxacin or 500-750mg PO bid Cefazolin + 1g IV q8h 10-14 days Metronidazole IV/POC 500mg IV/PO q12h Breast - Abscess often requires incision and drainage. abscess/mastitis - Antibiotics not recommended for minimal symptoms or prophylaxis.

Post-partum S. aureus Mild - Can continue breast-feeding Cloxacillin or 500mg PO qid 7-10 days with mastitis but not with Cephalexin 500mg PO qid 7-10 days abscess. b-lactam allergy Clindamycin 150-300mg PO qid 7-10 days Moderate-severe Cloxacillin or 1g IV q6h 7-10 days Cefazolin 1g IV q8h 7-10 days Postsurgical S. aureus Cloxacillin or 500mg PO qid 10-14 days - Post radiation it may be b-haemolytic Streptococci Cephalexin 500mg PO qid 10-14 days difficult to differentiate infection (group A,B,C,G) from inflammation. If no b-lactam allergy change following antibiotic Clindamycin 150-300mg PO qid 10-14 days therapy, consider NSAIDs or topical corticosteroids. - If implants, other pathogens (e.g. coagulase negative Staph, atypical mycobacteria) may be involved. Not post- S. aureus Clindamycin or 300mg PO qid 7-10 days partum, not Anaerobes Amoxicillin-clavulanate 875mg PO bid 7-10 days postsurgical RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Animal bites - If animal unknown or escaped, contact Environmental Health (Capital Health 413-7928) or Medical Officer of Health (Capital Health 413-7600) [after hours/weekends 433-3940] re: risk/management of rabies and tetanus. (Rabies prophylaxis not required for rodents or rabbits.) - Irrigation and debridement necessary. - Primary closure of wound(s) NOT recommended if: · puncture wounds · > 12 hours post injury. - Amoxicillin-clavulanate is drug of choice. No clinical data for bid dosing in bite wounds but should be effective based on pharmacokinetics/dynamics. (Alternative dose = 500mg PO tid.) - Cephalexin/cefazolin and clindamycin not effective against Pasteurella spp or Eikenella spp. - Cultures recommended in established infection. Cats Polymicrobial: Prophylaxis* * Prophylaxis is recommended · Pasteurella spp Amoxicillin-clavulanate 875mg PO bid 3-5 days for all significant cat bites · Streptococcus spp because of high rate of · Staphylococcus spp b-lactam allergy infection. Doxycycline 100mg PO daily 3-5 days · Oral anaerobes Treatment * Prolonged therapy is required · CDC-Group EF-4 Amoxicillin-clavulanate 875mg PO bid 7-10 days* if associated osteomyelitis/ septic arthritis. b-lactam allergy Doxycycline 200mg PO first day 7-10 days* or then 100mg PO daily [Clindamycin + 300mg PO qid 7-10 days* Ciprofloxacin] 500mg PO bid

Severe/Limb-threatening Piperacillin-tazobactam 4.5g IV q8h 10-14 days* RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Animal bites (cont’d) Dogs Polymicrobial: Prophylaxis* *Prophylaxis is recommended if: · Pasteurella spp Amoxicillin-clavulanate 875mg PO bid 3-5 days · moderate/severe · Streptococcus spp · crush injury/edema · Staphylococcus spp b-lactam allergy · age > 50 years · Oral anaerobes Doxycycline 100mg PO daily 3-5 days · puncture wounds · Capnocytophaga spp · bone/joint involvement · Eikenella spp · hand or facial injuries · Weeksella spp · splenectomized patients · CDC-Group EF-4 · immunocompromised. Treatment * Prolonged therapy is required Amoxicillin-clavulanate 875mg PO bid 7-10 days* if associated osteomyelitis/ septic arthritis. b-lactam allergy Doxycycline 200mg PO first day 7-10 days* or then 100mg PO daily [Clindamycin + 300mg PO qid 7-10 days* Ciprofloxacin] 500mg PO bid

Severe/Limb-threatening Piperacillin-tazobactam 4.5g IV q8h 10-14 days* RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Human bites - Irrigation and debridement necessary. - Immobilization and wound elevation, if possible, are beneficial. - Risk factors for developing osteomyelitis: · delay in initial treatment · inadequate debridement · initial suturing of wound. - Amoxicillin-clavulanate is drug of choice. No clinical data for bid dosing in bite wounds but should be effective based on pharmacokinetics/dynamics. (Alternative dose = 500mg PO tid.) - Cephalexin/cefazolin and clindamycin not effective against Eikenella spp. - Cultures recommended in established infections. Polymicrobial: Prophylaxis* * Prophylaxis is recommended · Streptococcus spp Amoxicillin-clavulanate 875mg PO bid 3-5 days if: · S. aureus · moderate/severe · Eikenella spp b-lactam allergy · crush injury/edema · Haemophilus spp Doxycycline 100mg PO daily 3-5 days · bone/joint involvement · Oral anaerobes · hand injuries. Treatment * Prolonged therapy is required Amoxicillin-clavulanate 875mg PO bid 7-10 days* if associated osteomyelitis/ septic arthritis. b-lactam allergy Doxycycline 200mg PO first day 7-10 days* or then 100mg PO daily [Clindamycin + 300mg PO qid 7-10 days* Ciprofloxacin] 500mg PO bid

Severe/Limb-threatening Piperacillin-tazobactam 4.5g IV q8h 10-14 days* RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Diabetic foot General Management – Refer to Tables 1 & 2, pages 141-143 or Regional Wound Care Guidelines 1998. infection - Prevention is key - proper foot care is essential. - Debridement of devitalized tissue is essential. Simple cellulitis See Cellulitis Ulcer, drainage, Polymicrobial: Mild - Adjust dosing of antibiotics fistula · S. aureus [TMP/SMX + 2 DS tabs PO bid 14-21 days* according to renal function. b-haemolytic Streptococci Metronidazole] or 500mg PO bid - Stepdown should be guided (group A,B,C,G) Amoxicillin-clavulanate 875mg PO bid 14-21 days* by clinical improvement and · Enterococcus spp or C&S results. · Enterobacteriaceae [Cefazolin + 1-2g IV q8h 14-21 days* * Duration dependent on · Pseudomonas spp Metronidazole IV/POC] 500mg IV/PO q12h clinical picture. · Anaerobes Moderate-severe **If Pseudomonas cultured, Clindamycin + 300-450mg PO qid All regimens: give q6h if renal function Ciprofloxacin 500-750mg PO bid 3-6 weeks allows. Severe/failure of above regimens/limb-threatening Imipenem or 500mg IV q6h If *** See Osteomyelitis, page Piperacillin-tazobactam 4.5g IV q8h** osteomyelitis***, 148. 6-12 weeks RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Pressure/decubit- - Topical antibiotics of no proven efficacy in colonization or infection. us ulcers/ ulcers - Prevention is most important element in management. 2o to PVD - For total management, refer to Tables 1 & 2, pages 141-143 or Regional Wound Care Guidelines 1998. No evidence of Often colonized with Local wound clinical infection polymicrobic flora management. Refer to Regional Wound Care Guidelines 1998 re: · cleansing · debridement · dressing. Evidence of Polymicrobial: Mild - Deep cultures from cleaned clinical infection · b-haemolytic Streptococci Amoxicillin-clavulanate* 875mg PO bid 7-10 days ulcer base recommended. · cellulitis (group A,B,C,G) or * Amoxicillin-clavulanate has no · regional · S. aureus [TMP/SMX** + 1-2 DS tabs PO bid 7-10 days activity against Pseudomonas adenopathy · Enterococcus spp Metronidazole] 500mg PO bid aeruginosa. · extensive · Enterobacteriaceae **TMP/SMX has no activity ulceration · Pseudomonas spp Moderate-severe against b-haemolytic · fever · Anaerobes Clindamycin + 300mg PO qid 14-21 days Streptococci (Group A & B), · osteomyelitis Ciprofloxacin 500-750mg PO bid Enterococci, or (refer to Pseudomonas aeruginosa. osteomyelitis TMP/SMX + metronidazole section) For parenteral regimens offers a reasonable refer to Diabetic foot inexpensive option for mild infection. infections only.

RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Table 1 – Wound Management* Prepared by Ms. Marilyn Albers, Ms. Cheryl Raiwet, Dr. Mark Joffe, and Dr. Keith Bowering for the Regional Wound Care Committee Assessment Clinical - Type of ulcer · Venous ulcer · Arterial ulcer · Neuropathic ulcer · Malignant wounds · Pressure/decubitus ulcer · Surgical wounds - Location - Size (depth, width, length) - Partial thickness/full thickness - Drainage (type, amount, color, odor) - Wound bed (eschar/slough, epithelialization, granulation). See Red/Yellow/Black Classification, Table 2. - Wound margins (undermining, dead space, sinus tracking) - Surrounding tissues (edema, erythema, induration, maceration) - Evidence of localized/systemic infection - demonstrated by a combination of induration, fever, edema, erythema (IFEE), pain, odor. NB: color of the drainage alone (light green, cream or yellow) is not indicative of clinical infection. - age or physiologic age > 80 years Contributing - peripheral vascular disease factors · diastolic pressure < 60 mm Hg - poor nutritional status · inadequate calories/protein/minerals/fluid intake - decreased mobility - incontinence/moisture - impaired mental status - impaired sensory perception - immunosuppression - pressure, friction and shear

* Refer to Capital Health Regional Wound Care Guidelines (RWCG) 1998. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Table 1 – Wound Management (cont’d)* Investigations Laboratory - CBC and differential - Electrolytes - Serum glucose/albumin/creatinine

Microbiology - Blood cultures recommended if febrile - Wound cultures: - superficial cultures of chronic wounds usually not helpful as these wounds are all contaminated/colonized with microorganisms. - culture of curettage material/tissue from cleaned ulcer base recommended. - NB: repeat cultures of wound not recommended unless adverse change in wound Radiography - Diagnostic imaging studies may be required in certain severe wounds (e.g. diabetic foot, peripheral vascular disease, animal bites) to rule out osteomyelitis. - Doppler studies may be indicated to assess circulation in patients with peripheral vascular disease. Management - Prevention is most important element in management. 1. Cleanse with normal saline 2. Use principles of wound healing (DIP-A-MOPI) D – debride necrotic tissue I – identify and treat infection P – pack dead space lightly A – absorb excess exudate M – maintain moist wound surface O – open wound edges P – protect from trauma and infection I – insulate wound bed 3. Dress wound based on DIP-A-MOPI and R/Y/B Classification (Table 2). 4. Consult with other health disciplines for additional management (RWCG 1998 Appendix E & G). Antibiotics - Topical antibiotics of no proven efficacy in colonization or infection. - Antibiotics of limited value if circulation severely compromised. - For specific antibiotic therapy recommendations, see specific wound type (e.g. diabetic foot, pressure/decubitus ulcer, etc.). * Refer to Regional Wound Care Guidelines (RWCG) 1998. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Table 2 – Red/Yellow/Black Classification (RWCG 1998 Appendix B) Prepared by Ms. Marilyn Albers, Ms. Cheryl Raiwet, Dr. Mark Joffe, and Dr. Keith Bowering for the Regional Wound Care Committee RED YELLOW BLACK Classification 50% of wound is red granulated 50% of wound is white/yellow/cream 50% of wound is black necrotic tissue tissue Goal Provide a moist wound environment. Remove the white, cream, or yellow Remove necrotic tissue** Protect it. colored slough. Cleaning Normal Saline Normal Saline Normal Saline Debridement* N/A Mechanical, Surgical, Autolytic, Mechanical, Surgical, Autolytic, Enzymatic Enzymatic Dressing* Scant drainage N/S soaked gauze N/S soaked gauze N/S soaked gauze Hydrocolloid Hydrocolloid Hydrocolloid Hydrogel Hydrogel Hydrogel Impregnated gauze Impregnated gauze Non-adherent gauze Non-adherent gauze Non-adherent gauze Non-adherent dressing Non-adherent dressing Non-adherent dressing Transparent films Transparent films Transparent films Enzymatic debriders + Use occlusive dressings cautiously Hypertonic gauze Hypertonic gauze Foams Moderate-heavy Foams Foams Impregnated gauze drainage Alginates Alginates Alginates Enzymatic debriders Packing* - recommended in wounds with dead space to prevent premature closure of the skin (allows healing from the bottom up) Scant drainage N/S gauze N/S gauze N/S gauze Calcium alginates Calcium alginates Calcium alginates Impregnated gauze strips Impregnated gauze strips Impregnated gauze strips Moderate-heavy Hypertonic gauze Hypertonic gauze Hypertonic gauze drainage * For information on wound product choices, refer to RWCG 1998 Appendix C. ** Debridement of necrotic tissue should only be done if there is adequate circulation for healing, otherwise necrotic tissue can act as a barrier for infection. Sharp debridement should be done by specially trained personnel. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Post-operative wounds Not involving S. aureus Mild GU/GI tract Group A Streptococci Cloxacillin or 500mg PO qid 7-10 days Occasionally: Cephalexin 500mg PO qid 7-10 days · Enterobacteriaceae b-lactam allergy Clindamycin 300mg PO qid 7-10 days

Moderate-severe - Stepdown after 48-72h if Cefazolin or 1g IV q8h 7-10 days clinical improvement. [Clindamycin PO +/- 300mg PO qid 7-10 days Gentamicin] 7mg/kg IV q24h Involving GU/GI S. aureus Mild - Surgical drainage may be tract b-haemolytic Streptococci Amoxicillin-clavulanate 875mg PO bid indicated. (group A,B,C,G) or - Stepdown after 48-72h if Enterococcus spp Cephalexin + 500mg PO qid clinical improvement. Enterobacteriaceae Metronidazole 500mg PO bid - Cephalosporins and Anaerobes All regimens: clindamycin have no activity b-lactam allergy 7-10 days or against Enterococcus spp. Clindamycin PO + 300mg PO qid until patient - Tailor antibiotics to C&S Ciprofloxacin PO 500-750mg PO bid afebrile and results. wound Moderate-severe granulating 1g IV q8h [Cefazolin + 500mg PO bid Metronidazole PO] or 300mg PO qid/ [Clindamycin PO/IV 600mg IV q8h + 7mg/kg IV q24h Gentamicin] RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Post-operative wounds (cont’d) Post-episiotomy S. aureus Mild - Check gram stain for presence b-haemolytic Streptococci Cephalexin 500mg PO qid 5-7 days of anaerobes. (group A,B,C,G) Occasionally: b-lactam allergy · Enterobacteriaceae Clindamycin* 150-300mg PO qid 5-7 days * Clindamycin has no aerobic · Anaerobes gram negative coverage - Moderate-severe correlate with gram stain/ Amoxicillin-clavulanate 875mg PO bid 7-10 days culture. or Clindamycin* 300mg PO qid 7-10 days or [Cefazolin + 1g IV q8h 7-10 days Metronidazole] 500mg PO bid RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA

Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Skin & Soft Tissue Rapidly progres- - Surgical debridement is essential. sive skin and soft - Infectious Diseases consult strongly recommended. tissue infections - Duration of therapy (IV/PO) dependent on clinical picture. Clindamycin + 600mg IV q8h See below - Preoperatively and before Gentamicin + 7mg/kg IV q24h cultures it may be difficult to Penicillin 3-4MU IV q4h differentiate the different types of infections listed below. Necrotizing Group A Streptococci (GAS) Clindamycin + 600mg IV q8h 10-14 days - Invasive GAS is reportable to fasciitis/ Rarely: Penicillin 3-4MU IV q4h the Medical Officer of Health myositis · Group B, C, G (Capital Health 413-7600; after Streptococci hours/weekends 433-3940). Public Health will do contact investigation and follow-up. - Prophylaxis of Invasive Group A Streptococci is recommend- ed by Public Health. See Prophylaxis for Contacts of Communicable Diseases. - Use of IV immune globulin (150mg/kg/d x 5 days) should be considered if streptococcal toxic shock also present. Synergistic nec- Mixed aerobic/anaerobic Imipenem 1g IV q6h 10-14 days rotizing cellulitis organisms Gas gangrene Clostridium perfringens Clindamycin + 600mg IV q8h 10-14 days - Adjunctive hyperbaric oxygen Penicillin 3-4MU IV q4h therapy may be considered. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Bone & Joint Osteomyelitis Hematogenous S. aureus [Cloxacillin +/- 1-2g IV q6h 4-6 weeks - Bone/blood cultures Gentamicin*] or 7mg/kg IV q24h recommended as [Cefazolin +/- 1-2g IV q8h 4-6 weeks occasionally other organisms Gentamicin*] 7mg/kg IV q24h may be involved. * Gentamicin recommended for b-lactam allergy empiric gram negative ClindamycinC +/- 600mg IV q8h 4-6 weeks coverage. Discontinue if S. 7mg/kg IV q24h aureus confirmed. Gentamicin* - Cloxacillin + rifampin 600mg PO daily may be considered in recurrent/refractory S. aureus osteomyelitis. - Stepdown to oral agents if ensure adequate bactericidal serum levels and clinical improvement. (Recommend minimum 2 weeks IV antibiotics.) Intravenous S. aureus [Cloxacillin + 2g IV q6h 6 weeks - Bone/blood cultures drug use Pseudomonas aeruginosa Gentamicin*] or 7mg/kg IV q24h recommended prior to Occasionally: [Cefazolin + 1-2g IV q8h 6 weeks institution of therapy. · Candida spp Gentamicin*] 7mg/kg IV q24h * Gentamicin recommended for empiric gram negative Severe penicillin coverage. Discontinue if S. allergy/anaphylaxis aureus confirmed. Vancomycin + 1g IV q12h 6 weeks - Predilection for SC joint, ribs, Gentamicin* 7mg/kg IV q24h vertebrae, long bones. - Must rule out endocarditis. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Bone & Joint Osteomyelitis (cont’d) Contiguous Vascular Polymicrobial: [Clindamycin + 300mg PO qid minimum 6 - Deep culture recommended insufficiency, · S. aureus Ciprofloxacin] or 500-750mg PO bid weeks to tailor antibiotic regimens. diabetic foot · Streptococcus spp [Cefazolin + 1-2g IV q8h - Stepdown should be guided · Enterobacteriaceae Metronidazole IV/POC] 500mg IV/PO q12h minimum 6 by clinical improvement and · Pseudomonas spp weeks C&S results. May need · Anaerobes Severe/Limb-threatening prolonged therapy with oral Imipenem 500mg IV q6h agents. or - If aminoglycosides are used, 4.5g IV q8h (If minimum 6 recommend: Piperacillin-tazobactam Pseudomonas weeks · extended interval dosing cultured, give q6h if · close monitoring of renal function minimum 6 creatinine and interval allows.) weeks serum aminoglycoside levels. - Adjust dosing of antibiotics

according to renal function. Post-nail Pseudomonas aeruginosa Prophylaxis* * Evidence for this not puncture of foot Occasionally: Ciprofloxacin 750mg PO bid 5 days established but may be · S. aureus considered (within 24h of nail · Bacillus spp puncture). · Anaerobes Treatment - Surgical debridement always Piperacillin-tazobactam 4.5g IV q6h minimum 2 necessary. + weeks (IV + PO) - Culture recommended prior to Tobramycin 7mg/kg IV q24h institution of therapy.

Stepdown to complete Ciprofloxacin 750mg PO bid minimum 2 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA weeks Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Bone & Joint Osteomyelitis (cont’d) Post-operative S. aureus Vancomycin* + 1g IV q12h 6-8 weeks - Bone cultures recommended prosthetic joint S. epidermidis Gentamicin 1.5mg/kg IV q8h prior to institution of therapy. Occasionally: * Tailor antibiotics to C&S · Streptococcus spp results. Vancomycin has slow · Enterobacteriaceae distribution in tissues and · Pseudomonas spp delayed bactericidal activity. It should only be used long term when it is the only agent to which the organism is susceptible. - Best results with: · removal of prosthetic joint · 6-8 weeks of antimicrobial therapy · antimicrobial impregnated beads/cement-role not established but may be beneficial. - If joint cannot be removed recommend: · TMP/SMX + rifampin for Staph infection · prolonged therapy (months). RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Bone & Joint Osteomyelitis (cont’d) Post-operative S. aureus Vancomycin* + 1g IV q12h 6-8 weeks - Sternal debridement and bone sternotomy S. epidermidis Gentamicin 1.5mg/kg IV q8h cultures recommended. Enterobacteriaceae - Tailor antibiotics to C&S Occasionally: results. Vancomycin has slow · Corynebacterium spp distribution in tissues and delayed bactericidal activity. It should only be used long term when it is the only agent to which the organism is susceptible. - If sternal wires cannot be removed recommend: · TMP/SMX + rifampin for Staph infections · prolonged therapy (months). Septic arthritis Adults S. aureus Cloxacillin +/- 1-2g IV q6h 3 weeks - Joint drainage essential. · Native joints Pseudomonas aeruginosa* Gentamicin 1.5mg/kg IV q8h * Tailor antibiotics to C&S · +/- non- Occasionally: or results. penetrating · Candida spp Cefazolin +/- 1-2g IV q8h 3 weeks - For chronic monoarticular trauma Gentamicin 1.5mg/kg IV q8h arthritis consider mycobacterial infection. Gonococcal Neisseria gonorrhoeae Cefotaxime 1g IV q8h 7 days * Stepdown if clinical · < 30 years improvement after 24-48 old Stepdown* hours. · polyarticular Cefixime or 400mg PO bid to complete 7 days pain +/- skin Ciprofloxacin 500mg PO bid to complete 7 days lesions RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Bone & Joint Septic arthritis (cont’d) Rheumatoid S. aureus Cefazolin +/- 1-2g IV q8h 4 weeks - Recommend culture of joint arthritis Streptococcus spp Gentamicin 7mg/kg IV q24h prior to institution of therapy. Enterobacteriaceae b-lactam allergy - Tailor antibiotics to C&S Clindamycin IV/POC + 600mg IV q8h/ 4 weeks results. 300mg PO qid Ciprofloxacin 750mg PO bid Prosthetic joint S. aureus Vancomycin* + 1g IV q12h 6-8 weeks * Tailor antibiotics to C&S S. epidermidis Gentamicin 7mg/kg IV q24h results. Vancomycin has slow, Rare: erratic distribution in tissues · Streptococcus spp and delayed bactericidal · Enterobacteriaceae activity. It should only be used · Pseudomonas spp long term when it is the only agent to which the organism is susceptible. - Best results with: · removal of prosthetic joint · 6-8 weeks of antimicrobial therapy · antimicrobial impregnated beads/cement-role not established but may be beneficial. - If prosthesis cannot be removed recommend: · TMP/SMX + rifampin for Staph infections · prolonged therapy (months). RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Bone & Joint Septic arthritis (cont’d)

Intravenous S. aureus [Cloxacillin + 2g IV q6h 4 weeks - Joint/blood cultures drug use Pseudomonas aeruginosa Gentamicin*] or 7mg/kg IV q24h recommended prior to Occasionally: [Cefazolin + 1-2g IV q8h 4 weeks institution of therapy. · Candida spp Gentamicin*] 7mg/kg IV q24h * Gentamicin recommended for empiric gram negative Severe penicillin allergy/ coverage. Discontinue if S. anaphylaxis aureus confirmed. Vancomycin + 1g IV q12h 4 weeks - Predilection for SC joint, ribs, Gentamicin* 7mg/kg IV q24h vertebrae, long bones. - Must rule out endocarditis. Septic bursitis S. aureus Mild - Aspirate fluid initially and daily. Cloxacillin PO 500mg PO qid 3 weeks - For chronic bursitis consider or mycobacterial infection. Cephalexin 500mg PO qid 3 weeks

Moderate-severe Cloxacillin IV 1-2g IV q6h 3 weeks or Cefazolin 1-2g IV q8h 3 weeks

b-lactam allergy Clindamycin 300mg PO qid 3 weeks RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Pharyngitis - Majority of cases of pharyngitis are of viral etiology and do not require antimicrobial therapy. The following suggests a viral etiology: · conjunctivitis · cough · hoarseness · rhinorrhea. - Group A Streptococcal pharyngitis is most common in children between 5-15 years old. - The role of Mycoplasma pneumoniae and Chlamydia pneumoniae has been suggested but not substantiated. Empiric therapy for these organisms is not recommended. - Occasionally pharyngitis is caused by Group C, G Streptococci and Arcanobacterium haemolyticum. A. haemolyticum causes pharyngitis in young adults (12-30 years old). Many have scarlatiniform rash, most marked on the extremities. Notify laboratory if clinically suspected. - Accurate diagnosis of Group A Strep pharyngitis cannot be made on clinical presentation alone. Throat swab recommended. Rapid antigen detection test for Group A Strep is not recommended (low sensitivity, negative result must be confirmed with culture). - Treat according to C&S results as: · Group A Strep is a self-limited disease (3-4 days) · antimicrobial therapy can be delayed while awaiting throat culture results and still prevent acute rheumatic fever · delay in antibiotic therapy may diminish reinfection rates. - Follow up cultures are not routinely recommended except if: · family history of rheumatic fever · outbreak of rheumatic fever · outbreak of pharyngitis in a closed community · repeat transmission within families (“ping-pong” spread). RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Pharyngitis (cont’d) Acute Group A Streptococci* Penicillin VK 300mg PO tid or 10 days * Resistance: 600mg PO bid** · no in vitro resistance to b-lactam allergy penicillin Erythromycin 250mg PO qid or 10 days · up to 5% macrolide 333mg PO tid resistance. or - TMP/SMX – no activity against Clindamycin 300mg PO tid 10 days Group A Streptococcus. - Quinolones and cephalosporins NOT indicated in pharyngitis – too broad- spectrum, potential to increase resistance. **This is a reasonable dosing alternative. Adult data lacking; extrapolated from paediatric data. Non-responders Group A Streptococci If not used as 1st line - Up to 5% of Group A (after 72 hours Clindamycin 300mg PO tid 10 days Streptococci are resistant to of therapy) or macrolides. or Erythromycin 250mg PO qid or 10 days Early relapse 333mg PO tid (2-7 days post therapy) Late relapse Group A Streptococci Penicillin VK 300mg PO tid or 10 days - Continuous antibiotic prophy- or 600mg PO bid* laxis is not recommended. Recurrent Alternative * This is a reasonable dosing Clindamycin or 300mg PO tid 10 days alternative. Adult data lacking; Erythromycin 250mg PO qid or 10 days extrapolated from paediatric 333mg PO tid data. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Pharyngitis (cont’d) Asymptomatic - Up to 20% of the population may carry Group A Strep asymptomatically. carrier - Chronic carriers are not significant in the spread of Group A Strep and are at little risk of rheumatic fever. * Eradication of asymptomatic carriage is recommended only if high risk: · family history of rheumatic fever · outbreak of rheumatic fever · outbreak of pharyngitis in a closed community · repeat transmission within families · multiple (> 3/year) culture-confirmed episodes of symptomatic pharyngitis. Group A Streptococci No therapy required* **Consider using benzathine pen G (1.2MU IM x 1 dose) if High risk* compliance is questionable. Clindamycin 300mg PO tid 10 days or *** This is a reasonable dosing [Penicillin VK** 300mg PO tid or 10 days alternative. Adult data + 600mg PO bid*** lacking; extrapolated from Rifampin] 300mg PO bid 4 days paediatric data. Gonococcal Neisseria gonorrhoeae* Cefixime or 400mg PO single dose * Notify lab if clinically Ciprofloxacin 500mg PO single dose suspected. Submit Alternative specimen in charcoal Ceftriaxone 125mg IM single dose transport medium. Plus** **All regimens should be Azithromycin or 1g PO single dose followed by empiric treatment Doxycycline 100mg PO bid 7 days for chlamydial infection. Laryngitis Viruses No antibiotic therapy recommended RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Bordetella pertussis Treatment - Notify Public Health at 413- Erythromycin base 500mg PO qid 10 days 7949 (after hours/weekends 413-7991). Alternative - B. pertussis may be a cause Azithromycin 500mg PO first day 5 days of persistent cough (>14 or then 250mg PO days) in adults. daily x 4 days - For contact prophylaxis Clarithromycin 250-500mg PO bid 10 days recommendations, see or Prophylaxis for Contacts of TMP/SMX 1 DS tab PO bid 10 days Communicable Diseases. Public Health will do contact investigation and notification. Rhinitis Viruses No antibiotic therapy - Adults get 3-4 colds/year. Allergies recommended. - Counsel on importance of handwashing in preventing Decongestant* spread of viruses. - Yellow/green nasal discharge is not indicator of bacterial infection. * May alleviate symptoms but will not shorten duration of symptoms. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Otitis Media Acute S. pneumoniae Amoxicillin 500mg PO tid 10 days - Acute otitis media is H. influenzae b-lactam allergy uncommon in adults. Moraxella catarrhalis TMP/SMX 1 DS tab PO bid 10 days - TMP/SMX ~21% S. Group A Streptococci pneumoniae resistance. S. aureus Failure of first line S. pneumoniae Amoxicillin-clavulanate 875mg PO bid 10 days - S. pneumoniae: agents: H. influenzae Alternative · 17.4% penicillin resistance · persistent M. catarrhalis Cefuroxime axetil 500mg PO bid 10 days · 13% macrolide resistance. Group A Streptococci · prolonged b-lactam allergy - For Pen (I) S. pneumoniae S. aureus · recurrent* Azithromycin 500mg PO first day 5 days amoxicillin is most active of or then 250mg PO all oral b-lactam agents. daily x 4 days * For recurrences > 6 weeks Clarithromycin 250-500mg PO bid 10 days apart, see Acute otitis media. Chronic S. aureus Treat according to C&S - Recommend ENT consult for Enterobacteriaceae results. tympanocentesis +/- surgical Pseudomonas aeruginosa intervention. Anaerobes Hospital acquired See Sinusitis - Hospital otitis acquired Invasive otitis P. aeruginosa Surgical debridement + - Most cases occur in externa Piperacillin + 4g IV q6h 6 weeks (IV+PO) diabetics. Tobramycin 7mg/kg IV q24h - CT scan recommended. Stepdown Ciprofloxacin 750mg PO bid Mastoiditis Acute See Otitis media Chronic Polymicrobial: Surgical drainage minimum 2 - Need to rule out concomitant · Anaerobes Treat according to C&S of weeks osteomyelitis. · S. aureus surgical cultures. · Enterobacteriaceae · Pseudomonas spp RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Sinusitis - The benefit of antibiotic therapy in sinusitis is controversial (up to 60% resolve spontaneously). - Most common predisposing factor is viral upper respiratory tract infection (URTI). Up to 10% of sinusitis may be related to dental disease. - Prevention: · limit spread of viral infections by handwashing · avoid environmental tobacco smoke · avoid allergen exposure. - A bacterial etiology is more likely if: · URTI symptoms persist for at least 10 days · URTI symptoms get worse after 5 days · maxillary toothache · purulent nasal discharge · poor response to decongestants. - Nasopharyngeal cultures are not helpful in identifying sinus pathogen(s). - Sinus x-rays are not routinely recommended as they will not differentiate between viral URTI and bacterial sinusitis. - CT scan only recommended for complications of acute sinusitis/chronic sinusitis not responding to therapy/severe presentation where diagnosis suspected. - MRI not recommended due to poor bone definition. - The role of Mycoplasma pneumoniae and Chlamydia pneumoniae in acute sinusitis has been suggested but not substantiated. Empiric therapy for these organisms is not recommended. - Adjunctive therapy with topical/systemic decongestant and/or irrigation with saline solution may be helpful. NB: Antihistamines have no role in the management of acute sinusitis. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Sinusitis (cont’d) Acute S. pneumoniae Amoxicillin* 500mg PO tid 10 days*** * Amoxicillin retains best · symptoms < 4 H. influenzae coverage of all oral b-lactam weeks M. catarrhalis b-lactam allergy agents against S. · < 3 episodes/ Occasionally: TMP/SMX** 1 DS tab PO bid 10 days*** pneumoniae (including year · S. aureus intermediate strains). · Group A Streptococci **TMP/SMX ~21% S. · Anaerobes pneumoniae resistance in Northern/Central Alberta. If b-lactam allergy and previous antimicrobial exposure, use a 2nd line agent (below). ***Studies have demonstrated efficacy with as little as 3 days of therapy. Shorter course may be considered. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Sinusitis (cont’d) Failure of first H. pneumoniae Amoxicillin-clavulanate 875mg PO bid 10 days - Need to consider resistant line agents: M. catarrhalis or organisms, especially · clinical H. influenzae Cefuroxime axetil 500mg PO bid 10 days penicillin-resistant deterioration Occassionally: S. pneumoniae and after 72 h of · S. aureus b-lactam allergy b-lactamase producing antibiotic · Group A Streptococci Azithromycin 500mg PO first day then 5 days H. influenzae. therapy · Anaerobes or 250mg PO daily x 4 days · no Clarithromycin 500mg PO bid 10 days improvement or post therapy Levofloxacin or 500mg PO daily 7-10 days 400mg PO daily 7-10 days Moxifloxacin Acute recurrent S. pneumoniae Amoxicillin 500mg PO tid 10 days - Recommend refer to ENT if · > 4 episodes/ H. influenzae ³ 4 episodes/year. year and M. catarrhalis b-lactam allergy · each episode Occasionally: TMP/SMX 1 DS tab PO bid 10 days ³ 10 days · S. aureus duration and · Group A Streptococci · complete res- · Anaerobes olution between episodes

Chronic Anaerobes Amoxicillin-clavulanate 875mg PO bid 3 weeks* * A single prolonged (3 · symptoms ³ Occasionally: weeks) course of antibiotic 12 weeks · S. aureus b-lactam allergy may be of value in chronic · S. pneumoniae Clindamycin 300-450mg PO qid 3 weeks* sinusitis. · H. influenzae - Repeated courses of · M. catarrhalis antibiotics are not · Group A Streptococci recommended. · Enterobacteriaceae - Refer to ENT if not responding. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Sinusitis (cont’d) Hospital- acquired < 4 days See Sinusitis - Acute hospitalization

³ 4 days - Risk factors: hospitalization · mechanical ventilation · facial fractures · nasal packing · nasogastric tubes · otitis media post head trauma. - Recommend: · ENT consult · Remove nasogastric tube · Semi-recumbent positioning · Sinus aspiration for C&S: Þ tailor antibiotics to C&S results. - If no response to therapy in 7 days, insertion of a drainage catheter should be considered. Enterobacteriaceae Clindamycin IV/POC 600mg IV q8h/ 10 days * If Pseudomonas/ Pseudomonas spp* + 300mg PO qid Acinetobacter cultured, Acinetobacter spp* Ciprofloxacin 500-750mg PO bid recommend combination S. aureus Severe therapy with tobramycin. Yeast** Piperacillin-tazobactam 4.5g IV q6h 10 days **Addition of fluconazole or recommended if yeast seen Imipenem 500mg IV q6h 10 days on gram stain or culture of sinus aspirate. Fungal See Recommended Empiric Therapy of Fungal Infections RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Parapharyngeal Polymicrobial: Surgical drainage + space infections · Streptococcus spp Penicillin + 3-4MU IV q4h 10-14 days · Anaerobes Metronidazole IV/POC 500mg IV/PO q12h · Eikenella corrodens b-lactam allergy Clindamycin IV/POC 600mg IV q8h/ 10-14 days 300mg PO qid Odontogenic See Recommended Empiric Therapy of Dental Infections Bronchitis - Acute bronchitis in adults and children is almost exclusively viral in etiology. - Green/yellow sputum prodcution is indicative of inflammatory reaction and does not necessarily imply bacterial infection. - Prolonged cough (> 3weeks) is not unusual in acute viral bronchitis (45% of patients still coughing at 2 weeks and 25% after 3 weeks). - Pertussis may mimic acute bronchitis and is underdiagnosed. Investigate if persistent cough associated with vomiting. - Mycoplasma pneumoniae and Chlamydia pneumoniae have been implicated but not fully established as pathogens in acute bronchitis. Empiric therapy for these organisms is not recommended. - In most patients the respiratory exam is normal (few patients may have wheezes). Chest x-ray is indicated if there is any suspicion of pneumonia on history or physical exam. - Follow-up not recommended unless: · symptoms worsen or new symptoms develop (dyspnea, persistent fever, vomiting) · coughing > 1 months · symptoms recur > 3 episodes/year. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Bronchitis (cont’d) Acute Viruses No antibiotic therapy * Meta-analyses have shown recommended.* no benefit in patients with acute bronchitis. Management - Corticosteroids (inhaled/oral) · increased humidity are not recommended as · smoking cessation there is insufficient evidence · antitussives – may to support their use. alleviate symptoms - Expectorants are not but will not reduce recommended; good duration of illness hydration more effective. · bronchodilators – should not be used routinely but may have modest benefit for protracted cough. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Bronchitis (cont’d) Acute - Chronic bronchitis - productive cough for at least 3 months/year for at least 2 consecutive years. exacerbation of - Criteria for acute exacerbation of chronic bronchitis: chronic · • sputum volume · • sputum purulence bronchitis (AECB) · • dyspnea. - Approximately 50% of acute exacerbations of chronic bronchitis are viral in etiology. - Antibiotic therapy is only recommended if two or more of above criteria are present. - Adjunctive therapy is essential to management: · smoking cessation · bronchodilators: Þ Ipratropium (AtroventÒ) and short acting B-agonists1 are effective in combination. Þ Long acting B-agonists2 are not currently indicated in the management of AECB but may be useful in chronic COPD. · corticosteroids: Þ Systemic corticosteroids are indicated in most cases (prednisone 0.5-1mg/kg/d for 3-14 days). Þ Inhaled corticosteroids are not indicated in the mangement of AECB but may be useful in chronic COPD. · O2 therapy. - COPD patients should be given influenza vaccine (yearly) and pneumococcal vaccine (every 6 years). - The role of Mycoplasma pneumoniae and Chlamydia pneumoniae in AECB has not been fully established. Empiric therapy for these organisms is not recommended. At least 2 of above Haemophilus spp First line agents - Duration of therapy: criteria and < 4 S. pneumoniae Amoxicillin or 500mg PO tid 7-10 days · preliminary reports exacerbations Moraxella catarrhalis Doxycycline 200mg PO first day 7-10 days indicate that 5 days of /year or then 100mg PO daily therapy may be as TMP/SMX 1 DS tab PO bid 7-10 days effective as 10 days.

Failure of first line agents See below 1. Short acting B-agonists: fenoterol, salbutamol, terbutaline 2. Long acting B-agonists: formoterol. salmeterol RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Bronchitis (cont’d) AECB (cont’d) Role of quinolones: **Ciprofloxacin has suboptimal coverage of S. pneumoniae and should not be used routinely in AECB. Because it retains the best activity against Pseudomonas aeruginosa, ciprofloxacin may have a role in end stage disease with/without bronchiectasis, when there has been documentation of colonization/infection with this organism. ***Levofloxacin and moxifloxacin have excellent coverage for the pathogens involved. However because of their broad spectrum and the potential for increasing resistance in S. pneumoniae, these agents should be reserved for â-lactam allergic patients or patients who have failed first/second line antibiotic therapy. At least 2 of above Haemophilus spp Second line agents * Failure of first line agents: criteria and: S. pneumoniae Cefuroxime axetil 250-500mg PO bid 7-10 days · no improvement in · ³ 4 Moraxella catarrhalis or symptoms after 10 days exacerbations Enterobacteriaceae Amoxicillin-clavulanate 875mg PO bid 7-10 days of antibiotic therapy or /year Pseudomonas spp** · clinical deterioration after b-lactam allergy 72 h of antibiotic therapy. or † 500mg PO first day 5 days The efficacy of 5 day therapy · Failure of first Azithromycin then 250mg PO daily has been shown with line agents* or x 4 days moxifloxacin in AECB. or Clarithromycin 250-500mg PO bid 7-10 days NB: These studies did not · Antibiotics in specifically address failure of or † last 6 weeks 500mg PO daily 5-10 days initial antibiotic therapy. The Levofloxacin*** efficacy of a 5 day course of or 400mg PO daily 5-10 days† antibiotics requires further Moxifloxacin*** study in this patient population. Patients with end stage lung disease and severe bacterial exacerbation, use 10 days. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Community - For complete management of CAP in Capital Health, refer to CAP Pathway. For more information phone 408-5550 (physicians)/ acquired 408-5465 (others). pneumonia (CAP) - S. pneumoniae still most common bacterial pathogen causing community acquired pneumonia: Capital Health · 17.4% resistance to penicillin (16% intermediate, 1.4% high level) · 13% resistance to macrolides · 8% resistance to tetracyclines. - Intracellular pathogens: · Empiric therapy for pneumonia should include coverage for intracellular pathogens such as Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella spp. (Legionella is rare locally but should be considered in patients with travel history to endemic areas.) · Signs and symptoms are often prolonged with C. pneumoniae/M. pneumoniae despite appropriate therapy · C. pneumoniae emerging as a pathogen in elderly/nursing home acquired pneumonia. - Poor outcome risk factors: · respiratory rate > 30/minute · diastolic blood pressure < 60 mmHg, systolic blood pressure < 90 mmHg · acute renal dysfunction · malnourishment or > 5% weight loss in past month (nutritional consult recommended) · functional impairment (occupational therapy and/or physiotherapy consult recommended) · age and comorbid factors are also contributors to outcome. - The following antibiotics are not recommended empirically in adult pneumonia: · amoxicillin - unless proven S. pneumoniae · cephalexin - no activity against Pen I/R S. pneumoniae, Haemophilus spp, M. pneumoniae, or C. pneumoniae · ciprofloxacin - poor activity against S. pneumoniae. - For patients who may require admission to hospital, calculation of Pneumonia Severity of Illness (PSI) Score is recommended. (See Table 3) - The following measures are also recommended: · smoking cessation · annual influenza vaccine · pneumococcal vaccine (every 6 years). - Follow-up chest x-ray recommended at 6 weeks. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Community acquired pneumonia (cont’d) Outpatient Young patients: S. pneumoniae Doxycycline 200mg PO first day 10 days · no comorbid Mycoplasma pneumoniae or then 100mg PO daily factors† Chlamydia pneumoniae Erythromycin 500mg PO qid 10 days Alternative Azithromycin 500mg PO first day 5 days or then 250mg PO daily x 4 days Clarithromycin 250-500mg PO bid 10 days Young patients: S. pneumoniae Doxycycline 200mg PO first day 10 days * Failure of first line agents: · smokers Haemophilus influenzae or then 100mg PO daily · no improvement in · chronic lung Mycoplasma pneumoniae Azithromycin 500mg PO first day 5 days symptoms after disease Chlamydia pneumoniae or then 250mg PO daily completion of antibiotic x 4 days therapy Clarithromycin 250-500mg PO bid 10 days · clinical deterioration after Failure of first line 72 hours of antibiotic agents* 500mg PO daily 10 days therapy. Levofloxacin or 400mg PO daily 10 days Moxifloxacin Older patients: S. pneumoniae No comorbid factors * Pneumonia due to Klebsiella · no comorbid H. influenzae Doxycycline 200mg PO first day 10 days should be treated with factors† S. aureus or then 100mg PO daily combination therapy for a Moraxella catarrhalis Azithromycin 500mg PO first day 5 days minimum of 14 days. Enterobacteriaceae* or then 250mg PO daily Chlamydia pneumoniae x 4 days Clarithromycin 250-500mg PO bid 10 days †Comorbid factors: asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition, hospitalization in past 3 months. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Community acquired pneumonia (cont’d) Outpatient * Pneumonia due to Klebsiella Older patients: S. pneumoniae Levofloxacin or 500mg PO daily 10 days should be treated with · with comorbid H. influenzae Moxifloxacin or 400mg PO daily 10 days combination therapy for a factors† S. aureus [Cefuroxime axetil + 500mg PO bid 10 days minimum of 14 days. Moraxella catarrhalis Erythromycin**] 500mg PO qid **If intolerant to erythromycin, Enterobacteriaceae* use azithromycin or Chlamydia pneumoniae clarithromycin. Hospitalized - For patients who require admission to hospital, calculation of Pneumonia Severity of Illness (PSI) Score is recommended.(Table 3) - Investigations: · CBC with differential, random glucose, electrolytes, creatinine, ALT · Chest x-ray, PA and lateral · Sputum gram stain and C&S for patients with productive cough · Blood cultures · Arterial blood gas on room air, or on baseline O2 if patient receiving chronic oxygen Moderate S. pneumoniae No comorbid factors† * Macrolides have uncertain H. influenzae Doxycycline 200mg PO first day 10-14 days efficacy for pneumococcal S. aureus or then 100mg PO daily bacteremia. Group A Streptococci Azithromycin* 500mg PO first day 5 days Enterobacteriaceae or then 250mg PO daily Chlamydia pneumoniae x 4 days Legionella spp Clarithromycin* 500mg PO bid 10-14 days Comorbid factors† **This agent has 99% Levofloxacin** or 500mg PO daily 10-14 days bioavailability and should be Moxifloxacin*** or 400mg PO daily 10-14 days used orally. 750mg IV q8h 10-14 days ***Non-formulary in Capital [Cefuroxime + 500mg IV/PO first 5 days Health Region hospitals. Azithromycin] day then 250mg PO daily x 4 days †Comorbid factors: asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition, hospitalization in past 3 months. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Community acquired pneumonia (cont’d)

Hospitalized (cont’d)

Severe S. pneumoniae [Cefotaxime + 1g IV q8h 10-14 days - Consider Hantavirus. · PaO2 < 60mmHg H. influenzae Azithromycin] 500mg IV/PO first 5 days - In immunocompromised, also · respiratory rate S. aureus day then 250mg PO consider Pseudomonas, > 30/minute Group A Streptococci daily x 4 days PCP, or TB. · sepsis with end Enterobacteriaceae or organ dysfunc- Chlamydia pneumoniae Levofloxacin IV/POD 500mg IV/PO daily* 10-14 days * This agent has 99% tion Legionella spp bioavailability and should be · extra pulmonary used orally if possible. septic complicat-ions · cavitation · multilobar involvement · PSI risk class V (See Table 3) RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Table 3 - Pneumonia Severity of Illness Scoring System Patient Characteristic Points assigned Demographic factors Age: Males age (in yrs) Females age (in yrs) - 10 Nursing home resident +10 Comorbid illnesses Neoplastic disease +30 Liver disease +20 Congestive +10 Cerebrovascular disease +10 Renal disease +10 Physical examination findings Altered mental status +20 Respiratory rate >30/minute +20 Systolic blood pressure < 90 mmHg +20 Temperature < 35OC or > 40OC +15 Pulse > 125/minute +10 Laboratory findings pH < 7.35 +30 BUN > 10.7 mmol/L or creatinine ³ 120 umol/L +20 Sodium < 130 mmol/L +20 Glucose > 13.9 mmol/L +10 Hematocrit < 30% +10 PO2 < 60 mmHg or O2 sat < 90% +10 Pleural effusion +10 Risk # of Points Mortality (%) Recommendations for Class Site of Care I < 50 yrs, no comorbidity, RR < 24, 0.1 Outpatient normal BP, T £ 38oC, P £ 110 II £ 70 points 0.6 Outpatient III 71- 90 points 2.8 Generally outpatient IV 91 – 130 points 8.2 Inpatient V >130 points 29.2 Inpatient Reprinted from Fine MJ, Auble TE, Yearly DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336: 243-50 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Nursing home - Consider influenza during appropriate season. acquired - Respiratory syncytial virus may cause pneumonia outbreaks in the elderly. pneumonia * Chlamydia pneumoniae is emerging as a pathogen in elderly/nursing home acquired pneumonia. Signs and symptoms may be prolonged. S. pneumoniae Mild-moderate - Consider anti-pseudomonal H. influenzae Levofloxacin** or 500mg PO daily 10-14 days coverage if: S. aureus Moxifloxacin or 400mg PO daily 10-14 days · recent ventilatory support Enterobacteriaceae [Cefuroxime axetil + 500mg PO bid 10-14 days and Chlamydia pneumoniae* Erythromycin***] 500mg PO qid · previous broad-spectrum antibiotics. If aspiration: Severe/ICU **This agent has 99% Oral anaerobes [Cefotaxime† + 1g IV/IM q8h 10-14 days bioavailability and should be Azithromycin IV/PO] 500mg IV/PO first 5 days used orally whenever day then 250mg PO possible. daily x 4 days *** If intolerant to erythromycin, or use azithromycin or D 500mg IV/PO daily** 10-14 days Levofloxacin IV/PO clarithromycin. † If IM route necessary, use ceftriaxone 1g IM daily. Influenza Influenza A Prophylaxis - Vaccination is first line of Amantadine for influenza defense. A only. See page 260. Influenza A Treatment < 64 years old * For influenza A only. Influenza B Amantadine* Ö 100mg PO bid 5 days † For influenza A or or > 65 years old B. 100mg PO daily 5 days ÖEfficacy of these agents Oseltamivir† Ö or 75mg PO bid 5 days documented only if started Zanamivir† Ö 10mg inhaled by 5 days within 48h of symptom onset. mouth bid RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Hospital acquired - Blood cultures recommended. pneumonia - For immunocompromised patients, recommend Infectious Diseases consult. Early onset - See Community Acquired · < 4 days Pneumonia, page 168. hospitalization Late onset - Enterobacteriaceae Cefuroxime +/- 750mg IV q8h 10-14 days * S. aureus coverage is · ³ 4 days Gentamicin 7mg/kg IV q24h suboptimal with these hospitalization or regimens. Tailor antibiotics (For associated Cefotaxime* +/- 1g IV q8h 10-14 days to C&S results. risk factors, see Gentamicin 7mg/kg IV q24h **This agent has 99% below) or bioavailability and should be Levofloxacin IV/POD * 500mg IV/PO daily** 10-14 days used orally if possible. · aspiration See Aspiration pneumonia, page 173. · coma Enterobacteriaceae Cefuroxime +/- 750mg IV q8h 10-14 days * If culture proven S. aureus, · diabetes S. aureus* Gentamicin 7mg/kg IV q24h do not use quinolone · head injury b-lactam allergy monotherapy (risk of rapid Clindamycin IV/PO C 600mg IV q8h/ 10-14 days emergence of resistance). + 300mg PO qid Ciprofloxacin IV/POD 400mg IV q12h/ 500-750mg PO bid · ventilatory Enterobacteriaceae Piperacillin-tazobactam + 4.5g IV q6h 14 days - Tailor antibiotics to C&S support Pseudomonas spp** Tobramycin results. · prior multiple Acinetobacter spp b-lactam allergy 7mg/kg IV q24h * Ciprofloxacin has best antibiotics S. aureus (rare) Clindamycin IV/POC antipseudomonal activity of + 600mg IV q8h/ 14 days all fluoroquinolones. Ciprofloxacin* IV/POD 300mg PO qid **For culture proven P. + 400mg IV q12h/ aeruginosa, recommend two 500-750mg PO bid antipseudomonal agents. Tobramycin 7mg/kg IV q24h RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Aspiration - For immunocompromised patients, recommend Infectious Diseases consult. pneumonia - Suspect aspiration pneumonia if: · predisposing factors: Þ ¯ level of consciousness Þ dysphagia Þ periodontal disease Þ mechanical interference (ET/NG tubes) · insidious onset of symptoms (cough, sputum, fever) · infiltrates in dependent pulmonary segments, especially RLL. - May progress to abscess/empyema within 1-2 weeks; 50% of patients may develop putrid sputum. - Fusobacterium necrophorum more virulent and may be more destructive. Community Oral anaerobes Penicillin + 3MU IV q6h 10-14 days acquired, no Streptococci spp Metronidazole 500mg PO bid comorbid factors† Eikenella corrodens b-lactam allergy Clindamycin IV/POC 600mg IV q8h/ 10-14 days 300mg PO qid Community See Hospital-acquired acquired with aspiration pneumonia below † comorbid factors Hospital acquired Polymicrobial: Amoxicillin-clavulanate 875mg PO bid 10-14 days - If recent ventilatory support · Oral anaerobes or and/or prior multiple · Enterobacteriaceae [Cefuroxime IV/PO 750mg IV q8h/ 10-14 days antibiotics, consider · S. aureus + 500mg PO bid Pseudomonal coverage. · S. pneumoniae Metronidazole IV/POC] 500mg IV/PO q12h · H. influenzae Severe/ICU · Moraxella catarrhalis Clindamycin IV/POC 600mg IV q8h/ 10-14 days + 300mg PO qid Ciprofloxacin IV/POD 400mg IV q12h/ or 500-750mg PO bid C 600mg IV q8h/ 10-14 days Clindamycin IV/PO 300mg PO qid + 1g IV q8h Cefotaxime †Comorbid factors: asthma, lung cancer, COPD, diabetes, alcoholism, chronic renal or liver failure, CHF, chronic corticosteroid use, malnutrition, hospitalization in past 3 months. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Lung abscess Oral anaerobes: Clindamycin IV/POC 600mg IV q8h/ 3-6 weeks - Treat until pulmonary infiltrate · Fusobacterium spp or 300mg PO qid has cleared. · Prevotella spp Penicillin + 3MU IV q6h 3-6 weeks - Consider TB/fungi, especially · Porphyromonas spp Metronidazole 500mg PO bid if cavitation without air fluid · Peptostreptococcus spp level. Eikenella corrodens Streptococci spp Empyema Acute - usually S. pneumoniae Cefuroxime 750mg IV q8h 2-4 weeks - Culture recommended. associated with S. aureus - Tailor antibiotics to C&S pneumonia Group A Streptococci results (If S. pneumoniae I/R, H. influenzae recommend cefotaxime/ ceftriaxone). - Chest tube may be needed. Chronic Oral anaerobes: Cefuroxime + 750mg IV q8h 3-6 weeks - Chest tube drainage · Fusobacterium spp Metronidazole 500mg PO bid recommended. May require · Porphyromonas spp surgical decortication. · Prevotella spp b-lactam allergy - Culture recommended. · Peptostreptococcus spp Clindamycin IV/POC 600mg IV q8h/ 3-6 weeks - Must rule out tuberculosis. Streptococci spp + 300mg PO qid - Tailor antibiotics to C&S 500-750mg PO bid results. Enterobacteriaceae Ciprofloxacin PO RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Pneumocystis carinii pneumonia (PCP) † † Treatment Pneumocystis carinii TMP/SMX 20mg/100mg/kg/d 21 days After 21 days therapy, PCP or PO div tid-qid prophylaxis is indicated in [Trimethoprim 20mg/kg/d PO div 21 days HIV (+) patients (see below). + tid-qid * Check G6PD status in Dapsone*] 100mg PO daily selected patients. or **Watch for dysglycemia and Pentamidine** or 4mg/kg IV daily 21 days pancreatitis. [Clindamycin IV/PO 600mg IV q8h/ 21 days ***Indications for adjunctive + 300-450mg PO qid corticosteroid therapy: Primaquine*] 15mg PO daily · PaO2 < 70mmHg (on room PLUS if indicated*** air) Adjunctive Corticosteroid · D(A-a)O2 > 35mmHg. Prednisone 40mg PO bid 5 days then Prednisone 40mg PO daily 5 days then Prednisone 20mg PO daily 11 days Prophylaxis and - PCP prophylaxis recommended for: 3 9 post-treatment · HIV patients with CD4 < 200 cells/mm (0.2 x 10 /L) suppression · solid organ or bone marrow transplant in past 12 months. Consider for other patients with prolonged high dose corticosteroids/immunosuppression. Pneumocystis carinii TMP/SMX 1 DS tab PO chronic* - TMP/SMX and dapsone also q M,W,F or provide prophylaxis of 1 SS tab PO daily toxoplasmosis. Alternative - TMP/SMX also provides Dapsone or 100mg PO q M,W,F chronic* prophylaxis of some bacterial Pentamidine 4mg/kg IV or aerosol chronic* infections. every 4 weeks * Continue as long as 3 CD4 < 200 cells/mm . RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Respiratory Tuberculosis (TB) Recommend investigation for TB in adults if: · symptoms of: Þ cough > 3 weeks Þ fever/night sweats Þ weight loss and · high risk: Þ foreign-born (Asia, Africa, Latin America) Þ First Nations Þ elderly Þ homeless or · chest x-ray with upper lobe cavity or fibronodular infiltrate. - If suspect TB, place patient in respiratory isolation until sputum AFB smear negative x 3. - If AFB smear/culture positive, initiate therapy and report case to Public Health. - Strongly consider directly observed therapy (DOT) via Public Health. - If history of previous TB treatment or contact with drug-resistant TB, consult TB specialist. M. tuberculosis Isoniazid 5mg/kg PO daily Duration - Monitor for drug toxicity: + (max 300mg/dose) dependent on · baseline CBC with Rifampin 10mg/kg PO daily susceptibility differential + (max 600mg/dose) results, drugs · platelet count Pyrazinamide 30mg/kg PO daily used, adverse · AST + (max 2g/dose) effects, and · urinalysis Ethambutol 20mg/kg PO daily compliance. · serum creatinine + · visual acuity (Snellen 25mg PO daily Pyridoxine* (vitamin B6) chart)/color vision (isochromatic plates). * Give with INH to decrease incidence of peripheral neuropathy. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Gastrointestinal Gastroenteritis Mild-moderate Unknown etiology - most Fluid replacement + cases bismuth subsalicylate +/- antimotility agents Severe* Bacterial: Ciprofloxacin 500mg PO bid 3 days - Culture recommended. · Campylobacter spp - Tailor antibiotics to C&S · Shigella spp Alternative results. · Salmonella spp** TMP/SMX 1 DS tab PO bid 3 days * Treat if: · E. coli O157:H7*** · > 6 diarrheal Occasionally: episodes/day · Aeromonas spp · bloody diarrhea · Pleisiomonas spp · persistent diarrhea. · Vibrio spp - Tailor antibiotics to C&S · Yersinia spp results. Parasitic: **Treatment of enteric See Treatment of Enteric Salmonella infections not Parasitic Infections recommended. Consider only if: · age < 3 months · immunocompromised · hemoglobinopathy · chronic GI tract disease · elderly patients with severe symptoms. ***Treatment of E. coli 0157:H7 not recommended. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Gastrointestinal Travellers’ diarrhea Mild Toxigenic E. coli Fluid replacement + - Self-limiting. Usual duration Campylobacter spp bismuth subsalicylate +/- of diarrhea 3-5 days. Shigella spp antimotility agents. - Persistent diarrhea suggests Salmonella spp giardiasis. See Treatment of Enteric Parasitic Infections. Severe Toxigenic E. coli Ciprofloxacin 500mg PO bid 3 days - Culture recommended. · bloody diarrhea Campylobacter spp - Tailor antibiotics to C&S · fever Shigella spp Alternative results. Salmonella spp* TMP/SMX 1 DS tab PO bid 3 days - Treat if: · > 6 diarrheal episodes/day · bloody diarrhea · persistent diarrhea. * Treatment of enteric Salmonella infections not recommended. Consider only if: · age < 3 months · immunocompromised · hemoglobinopathy · chronic GI tract disease · elderly patients with severe symptoms. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Gastrointestinal Antibiotic-associated - AAD suspected if: · antibiotic therapy in last 2 months (local study indicates incidence of AAD with clindamycin similar to that diarrhea (AAD) with cephalosporins) · onset of diarrhea > 72 hours after hospitalization. - Submit one stool sample for C. difficile toxin (culture not recommended). If negative and still suspect AAD, submit another stool specimen. - Discontinue antibiotics if possible. If not possible, consider changing to lower AAD risk group of antibiotics if appropriate (e.g. aminoglycosides, quinolones, TMP/SMX, tetracyclines, and/or metronidazole). - Do NOT use antidiarrheals, e.g. loperamide (Imodium®), diphenoxylate (Lomotil®). - Vancomycin IV not effective. Metronidazole IV of uncertain efficacy (only use in combination for severe/toxic megacolon). Acute Clostridium difficile Metronidazole 250mg PO qid or 10 days - Unless severe clinical 500mg PO tid 10 days deterioration, should not assume therapeutic failure of metronidazole until minimum of 6 days of therapy complet- ed without symptomatic improvement. Recurrent - Recurrence occurs in 15-20% of patients. Clostridium difficile Metronidazole 250mg PO qid or 10 days * Re-treatment with metronid- 500mg PO tid 10 days azole is recommended as Alternative* majority of recurrences are reinfections (not relapses). Vancomycin** 125mg PO qid 10 days **Vancomycin restricted to: · documented failure or clinical deterioration on metronidazole therapy · documented/impending toxic megacolon · intolerance or side effects on metronidazole therapy. - For multiple relapses, addition of rifampin (300mg PO bid x 10 days) to vancomycin or metronidazole may be beneficial. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Gastrointestinal Antibiotic- associated diarrhea (cont’d) Severe/toxic Clostridium difficile Metronidazole IV + 500mg IV q12h 10 days megacolon Metronidazole PO + 250mg PO/NG qid Vancomycin PO/NG/PR 125mg PO/NG/PR qid Helicobacter - Compliance is essential to achieve expected eradication rates of 85-90% and to decrease development of antimicrobial pylori associated resistance. duodenal - Eradication therapy regimens that include only one antibiotic are NOT recommended (potential to induce resistance). /gastric ulcer - More than one course of treatment is NOT appropriate without further investigation. - Post H. pylori therapy, acid suppression course (H2 - antagonist or proton pump inhibitor [PPI]) NOT recommended for uncomplicated ulcers. If complicated (perforation, hemorrhage, obstruction), recommend acid suppression course x 4-6 weeks following H. pylori eradication regimen. - Efficacy of H. pylori eradication therapy has not been proven in patients with: · gastroesophageal reflux disease (GERD) · non-ulcer dyspepsia · NSAID - induced gastropathy · family history of H. pylori. Helicobacter pylori [Clarithromycin + 500mg PO bid 7 days Amoxicillin + 1g PO bid (PPI or Ranitidine bismuth)] or 500mg PO bid 7 days [Clarithromycin + 500mg PO bid Metronidazole + PPI] or 2 tabs PO qid 7 days * Although a less expensive [Bismuth subsalicylate regimen, compliance is + 250mg PO qid reduced with this regimen due Metronidazole + 500mg PO qid to side effects and multiple drug interactions. Tetracycline + RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA PPI]* RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Gastrointestinal Cholecystitis - Mild cases do not require Acute Enterobacteriaceae Ampicillin + 2g IV q6h 7-10 days*** antimicrobial therapy. Enterococcus spp* Gentamicin +/- 7mg/kg IV q24h * Coverage of anaerobes and Anaerobes* Metronidazole IV/POC 500mg IV/PO q12h Enterococcus is controversial. Recommended if: Alternative · elderly Cefazolin** +/- 1g IV q8h 7-10 days*** · immunocompromised/ Metronidazole IV/POC 500mg IV/PO q12h diabetic/cirrhosis or · bile duct-bowel C 600mg IV q8h/ 7-10 days*** Clindamycin IV/PO ** anastomosis. 300mg PO qid + ** Cefazolin and clindamycin do 7mg/kg IV q24h Gentamicin not cover Enterococcus. *** Short course (3-5 days) may be considered if: · no perforation · no abscess · no cholangitis. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Gastrointestinal Cholangitis - Blood cultures recommended Acute Enterobacteriaceae Ampicillin + 2g IV q6h 10 days (high risk of bacteremia). Enterococcus spp Gentamicin +/- 7mg/kg IV q24h - Coverage of anaerobes is Anaerobes Metronidazole IV/POC 500mg IV/PO q12h controversial but recommended if previous Alternative biliary surgery. Vancomycin + 1g IV q12h 10 days - Pseudomonas aeruginosa Gentamicin +/- 7mg/kg IV q24h potential pathogen it post- Metronidazole IV/POC 500mg IV/PO q12h ERCP. - Drainage of obstructed biliary tree is essential for therapy of cholangitis. Recurrent Enterobacteriaceae Therapy - May be seen following Enterococcus spp See acute cholangitis reconstructive surgery of the Prophylaxis biliary tract. TMP/SMX 1 DS tab PO daily 3-4 months then Alternative re-evaluate Ciprofloxacin 500mg PO daily 0 Perforation/ See 2 peritonitis pericholecystic abscess Pancreatitis - Recent article recommends Acute Non-bacterial Empiric therapy not prophylactic antibiotics in recommended. acute necrotizing pancreatitis however prospective studies show no reduction in mortality. Complicated: Enterobacteriaceae Surgical debridement + - Surgical debridement and · pancreatic Enterococcus spp Ampicillin + 2g IV q6h Based on clinical drainage essential. abscess S. aureus Gentamicin + 7mg/kg IV q24h improvement. - Tailor antibiotics to C&S · infected Coagulase negative Staph Metronidazole IV/POC 500mg IV/PO q12h May require results. pseudocyst Anaerobes Alternative prolonged * If Candida spp isolated on · infected Candida spp* Imipenem or 500mg IV q6h antibiotic therapy. culture, recommend adding necrotic Piperacillin-tazobactam 4.5g IV q8h fluconazole or amphotericin B. pancreas RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Gastrointestinal Liver abscess - Blood cultures recommended (increased risk of bacteremia). - Drainage required (percutaneous where feasible). - Investigation of GI tract recommended. - Most patients will defervesce within 2 weeks of antibiotic therapy and drainage. - Surgical drainage recommended if: · fever persists > 2 weeks on appropriate therapy · biliary obstruction. Bacterial Enterobacteriaceae [Ampicillin + 2g IV q6h Minimum 4 weeks - Enterococcal coverage Anaerobes Gentamicin + 7mg/kg IV q24h or indicated empirically. Enterococcus spp Metronidazole IV/POC] 500mg IV/PO q12h until CT resolution * If E. histolytica has not been Streptococcus anginosus/ or (may be up to 4 ruled out, add metronidazole. milleri group Imipenem* 500mg IV q6h months)** **If clinical improvement/ defervescence consider stepdown, e.g. amoxicillin- clavulanate or (ciprofloxacin + metronidazole). Entamoeba histolytica 750mg PO tid 10 days - Recommend E. histolytica Parasitic Metronidazole serology and chest x-ray. followed by 650mg PO tid 20 days - Check for history of diarrhea. lodoquinol1 - Often do not have high spiking fevers (unlike bacterial liver abscess). 1 Non-formulary in Capital Health Region hospitals.

RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Gastrointestinal Diverticulitis Polymicrobial: Mild-moderate * Coverage of Enterococcus is · Enterobacteriaceae [TMP/SMX + 1 DS tab PO bid 7-10 days** controversial. Only · Anaerobes Metronidazole] 500mg PO bid amoxicillin-clavulanate covers · Enterococcus spp* or Enterococcus. Amoxicillin-clavulanate 875mg PO bid 7-10 days** ** Duration directed by clinical or response. Treat until afebrile [Ciprofloxacin + 500mg PO bid 7-10 days** 3-5 days. Metronidazole] 500mg PO bid

Severe See 2o Peritonitis Appendicitis Acute Enterobacteriaceae Uncomplicated * Complicated: Enterococcus spp Empiric therapy not · gangrene Anaerobes recommended. Refer to · perforation Surgical Prophylaxis. · abscess · peritonitis. Complicated* See 2o Peritonitis RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Gastrointestinal Peritonitis Spontaneous Treatment: bacterial - Blood/peritoneal fluid cultures recommended. O peritonitis (SBP) - Spontaneous bacterial peritonitis is usually monomicrobial. Polymicrobial infections suggest bowel perforation. See 2 peritonitis. - Urinary/intravascular catheterization may increase risk of infection - avoid if possible.

Prophylaxis: - SBP will occur in 5-25% of cirrhotic patients with ascites. Prophylactic antibiotics decrease incidence of initial/recurrent episodes of SBP but have not demonstrated reduction in hospitalization or survival rates. - Long term prophylaxis with antibiotics increases carriage of multiresistant organisms. Recommend screen for VRE upon hospitalization. Enterobacteriaceae Treatment * Recommended duration if Occasionally: Cefotaxime 1g IV q8h 10-14 days* bacteremic. · S. pneumoniae - Shorter duration of therapy (5 · Streptococcus spp days) may be effective if repeat paracentesis (at 48 hours) shows < 0.25 x 109/L PMNS and culture negative. - Aminoglycosides should be avoided in patients with cirrhosis. Prophylaxis High risk patients only: Cirrhosis + ascites +/- previous GI bleed

TMP/SMX 1 DS tab PO daily M-F (5 days/week) * Quinolones are acceptable Alternative alternatives but may select for Ciprofloxacin* 750mg PO q weekly gram positive organisms. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Gastrointestinal Peritonitis (cont’d) - Enterococcal coverage is recommended if: · distal colon surgery · hepatobiliary/pancreatic infection (increased risk of Enterococcal bacteremia) · patients with chronic illness or immunosuppression · previous antibiotic therapy (excluding surgical prophylaxis) · if Enterococcus is a predominant organism in culture. - Duration of therapy: · Uncomplicated: short course (3-5 days) if: Þ gastroduodenal ulcer perforation with surgery within 24 hours Þ penetrating trauma with surgery within 12 hours of injury. · Complicated/established intraabdominal infections: minimum 7 days (IV/PO) or until: Þ afebrile Þ normal WBC/differential Þ no residual fluid collections. Secondary Polymicrobial: Ampicillin + 2g IV q6h Duration of * This regimen does not have peritonitis · Enterobacteriaceae Gentamicin + 7mg/kg IV q24h therapy enterococcal coverage. · abscess · Enterococcus spp Metronidazole IV/POC 500mg IV/PO q12h dependent on - Stepdown to oral agents · bowel · Anaerobes Alternative* clinical picture. when tolerating oral intake perforation · Streptococcus spp Clindamycin IV/POC 600mg IV q8h/ See above. and clinical improvement. · ruptured · Candida spp + 300mg PO qid appendix Gentamicin 7mg/kg IV q24h Documented failure of first line agents Imipenem 500mg IV q6h Alternative Piperacillin-tazobactam 4.5g IV q8h Stepdown 875mg PO bid Amoxicillin-clavulanate or 500-750mg PO bid [Ciprofloxacin + 500mg PO bid Metronidazole]* RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Gastrointestinal Peritonitis (cont’d) Tertiary peritonitis P. aeruginosa Treat according to C&S Continue antibiotic - All abscess collections Coagulase negative Staph results therapy until require drainage. Enterococcus faecium patient: - Persistent peritonitis in Candida spp · afebrile patients with multiple · normal WBC/ organ dysfunction or differential immunosuppression · no residual often does not respond to fluid collect- antibiotic therapy. ions. CAPD peritonitis Coagulase negative Staph Cefazolin IP + 500mg/L load then - If pathogen is S. aureus, S. aureus 125mg/L to each eradicate nasal carriage. Enterobacteriaceae exchange Refer to page 131. Gentamicin IP 2mg/kg load Day 1 - For positive cultures, see then 1mg/kg dose Table 4 following. on Day 2 Alternative Day 1: Vancomycin IP < 40kg - 1g > 40kg - 2g rd +/- to 3 bag x 4-6 h dwell time Day 1 & 2: Gentamicin IP 2mg/kg load Day 1 then 1mg/kg dose on Day 2 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Table 4 - Treatment of Culture - proven CAPD Peritonitis Pathogen Recommended Empiric Therapy Recommended Dose Recommended Duration Culture negative Cefazolin IP +/- 125mg/L to each exchange To complete 14 days; repeat Gentamicin IP 4mg/L to each exchange culture S. aureus, methicillin Cefazolin IP + 125mg/L to each exchange To complete 21 days susceptible Rifampin PO 600mg PO daily S. aureus, methicillin Consult Infectious Diseases resistant Enterococcus spp Ampicillin IP + 125mg/L to each exchange To complete 14 days Gentamicin IP 4mg/L to each exchange Other gram-positive Cefazolin IP 125mg/L to each exchange To complete 14 days organisms Gram-negative organisms Gentamicin IP or 4mg/L to each exchange To complete 14 days (excluding Pseudomonas) adjust according to C&S results Pseudomonas spp [Ciprofloxacin PO or 500mg PO bid To complete 21-28 days Piperacillin IV or 4g IV q12h If no response, remove catheter. Ceftazidime IP]*+ 125mg/L to each exchange Tobramycin IP 6-8mg/L to each exchange * according to C&S results Polymicrobial Cefazolin IP + 125mg/L to each exchange To complete 21 days - suspect bowel perforation Gentamicin IP + 4mg/L to each exchange C Þ consider surgical Metronidazole IV/PO 500mg IV/PO q12h intervention Candida spp Fluconazole PO or IP + 200mg PO or IP daily 4-6 weeks Flucytosine PO** 2g PO load + 1g PO daily Recommend catheter removal. NB: Some non-albicans Candida may be resistant to fluconazole. ** Must be obtained through HPB Special Access Program (Emergency Release). Contact pharmacy for assistance in ordering. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Vulvovaginitis Candidiasis Candida spp Asymptomatic - Treat male partner only if Treatment not necessary Candida balanitis present. Symptomatic Use miconazole 2% or Fluconazole 150mg PO 1 dose clotrimazole 1% cream bid or for 7 days. Clotrimazole - Recurrent candidal 2% cream or 5g intravag hs 3 days vaginitis - consider tablet 200mg intravag hs or 3 days investigation for: or 500mg intravag 1 dose · diabetes Miconazole · HIV infection. ovule 400mg intravag hs 3 days - Fluconazole is not or recommended in Terconazole pregnancy. 5g intravag hs 3 days - Terconazole is not 0.8% cream or 80mg intravag hs 3 days recommended in first ovule trimester of pregnancy. Trichomoniasis T. vaginalis Metronidazole 2g PO 1 dose - Treat all cases and their sexual partners regardless of symptoms.

61 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Vulvovaginitis (cont’d) Bacterial vaginosis Non-inflammatory alteration Asymptomatic of normal vaginal flora: Do NOT treat unless: - Treatment of male sexual · ¯ Lactobacillus spp · pregnant partner not recommended. · • Gardnerella vaginalis · pre-IUD insertion · • Bacteroides spp · pre-gynecologic · • Mobiluncus spp surgery · • Mycoplasma hominis · pre-induced abortion Symptomatic Metronidazole tablet 500mg PO bid or 7 days or 0.75% gel1,2 5g intravag bid 5 days Alternative * Topical clindamycin not Clindamycin recommended in 300mg PO bid 7 days pregnancy (may be capsule or 5g intravag hs 7 days associated with pre-term 2% cream1 delivery). Pregnancy/Lactation 300mg PO bid 7 days **2g dose - High recurrence Clindamycin* or 2g PO** 1 dose rate - not best option. Metronidazole 1 Non-formulary in Capital Health Region hospitals. 2 Nidagel® NOT Metrogel®

62 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Cervicitis Chlamydial* Chlamydia trachomatis Azithromycin or 1g PO 1 dose * Must rule out gonorrhea or Doxycycline 100mg PO bid 7 days treat it empirically. - Test, and treat if Pregnancy/Lactation necessary, all recent (4-6 Azithromycin 1g PO 1 dose weeks) sexual contacts. or **Erythromycin estolate is Erythromycin base (not 500mg PO qid 7 days contraindicated in estolate)** pregnancy as it may cause intrahepatic cholestasis. Gonococcal* Neisseria gonorrhoeae Cefixime or 400mg PO 1 dose * All patients should also be Ciprofloxacin 500mg PO 1 dose treated for chlamydial infection (see above). Alternative - Test, and treat if Ceftriaxone 250mg IM 1 dose necessary, all recent (4-6 weeks) sexual contacts. - Ciprofloxacin is not recommended in pregnancy. Nonchlamydial/ Azithromycin or 1g PO 1 dose - Doxycycline is not nongonococcal Doxycycline 100mg PO bid 7 days recommended in pregnancy. Alternative Erythromycin base 500mg PO qid 7 days

63 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Urethritis (male) Chlamydial* Chlamydia trachomatis Azithromycin or 1g PO 1 dose * Must rule out gonorrhea or Doxycycline 100mg PO bid 7 days treat it empirically. Alternative - Test, and treat if Erythromycin base 500mg PO qid 7 days necessary, all recent (4-6 weeks) sexual contacts. Gonococcal* Neisseria gonorrhoeae Cefixime or 400mg PO 1 dose * All patients should also be Ciprofloxacin 500mg PO 1 dose treated for chlamydial Alternative infection (see above). Ceftriaxone 250mg IM 1 dose - Test, and treat if necessary, all recent (4-6 weeks) sexual contacts. Nonchlamydial/ Azithromycin or 1g PO 1 dose nongonococcal Doxycycline 100mg PO bid 7 days Alternative Erythromycin base 500mg PO qid 7 days Epididymo-orchitis* Sexually Chlamydia trachomatis Cefixime + 800mg PO 1 dose * Important to rule out transmitted- usually Neisseria gonorrhoeae Doxycycline 100mg PO bid 10 days torsion of testis (surgical age < 35 years Alternative emergency). Doxycycline + 100mg PO bid 10 days - Combination therapy for [Ciprofloxacin or 500mg PO 1 dose both gonorrhea and Ceftriaxone] 250mg IM 1 dose chlamydia recommended. Non-sexually Enterobacteriaceae Ciprofloxacin 500mg PO bid 10 days - Risk factors: transmitted Alternative · age > 35 years TMP/SMX 1 DS tab PO bid 10 days · recent urinary tract Severe/hospitalized instrumentation Ampicillin + 1-2g IV q6h 10 days · anatomical Gentamicin 7mg/kg IV q24h abnormalities.

64 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Pelvic inflammatory disease

Mild-moderate N. gonorrhoeae [Cefixime or 800mg PO 1 dose - Test, and treat if C. trachomatis Ceftriaxone] + 250mg IM 1 dose necessary, all recent (4-6 Enterobacteriaceae Doxycycline +/- 100mg PO bid 14 days weeks) sexual contacts. Anaerobes Metronidazole* 500mg PO bid 14 days - If patient has IUD, remove Streptococcus spp soon after therapy is Haemophilus spp Alternative initiated. Mycoplasma hominis? Ofloxacin1 +/- 400mg PO bid 14 days * Add metronidazole for Metronidazole* 500mg PO bid 14 days women at higher risk of anaerobic infection: · adnexal mass/tubo- ovarian abscess · peritonitis · females > 25 years old · presence of IUD · previous history of PID. 1 Non-formulary in Capital Health Region hospitals.

65 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Pelvic inflammatory disease (cont’d)

Moderate-severe - Hospitalization should be considered when: · not responding to therapy (72 hours) · unable to tolerate oral medications or noncompliant · pregnant · immunocompromised (e.g. HIV) · adnexal mass/tubo-ovarian abscess · need for laparoscopy to clarify diagnosis. N. gonorrhoeae Cefoxitin + 2g IV q8h Until 48 hours after C. trachomatis Doxycycline 100mg IV/PO bid clinical Enterobacteriaceae improvement then Anaerobes stepdown Streptococcus spp Alternative Haemophilus spp Clindamycin + 600mg IV q8h Until 48 hours after Mycoplasma hominis? Gentamicin 7mg/kg IV q24h clinical improvement then stepdown Stepdown Cefixime + 400mg PO bid To complete at Doxycycline +/- 100mg PO bid least 14 days *Add metronidazole for Metronidazole* 500mg PO bid women at higher risk of anaerobic infection: · adnexal mass/tubo- ovarian abscess · peritonitis · females > 25 years old · presence of IUD · previous history of PID.

66 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Pelvic inflammatory disease (cont’d)

Pregnancy N. gonorrhoeae Clindamycin + 600mg IV q8h Until 48 hours after - Hospitalization should be C. trachomatis Gentamicin 1.5mg/kg IV q8h clinical considered for all pregnant Enterobacteriaceae improvement then patients with PID. Anaerobes stepdown. Streptococcus spp Alternative Haemophilus spp Cefoxitin + 2g IV q8h Until 48 hours after Mycoplasma hominis? Erythromycin base 250mg PO qid clinical improvement then stepdown. Stepdown *Add clindamycin for Erythromycin +/- 250mg PO qid To complete at women at higher risk of Clindamycin* 300mg PO tid least 14 days anaerobic infection: Plus · adnexal mass/tubo- If gonorrhea documented ovarian abscess Cefixime 400mg PO bid To complete at · peritonitis least 14 days · females > 25 years old · presence of IUD · previous history of PID.

67 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Endometritis Postpartum Early (< 2 days) Anaerobes Cefoxitin + 2g IV q8h Until 48 hours after - Usually after caesarean b-haemolytic Streptococci Doxycycline 100mg IV/PO bid clinical section. Enterobacteriaceae improvement then Chlamydia trachomatis stepdown. Mycoplasma hominis Alternative Clindamycin + 600mg IV q8h Until 48 hours after Gentamicin 7mg/kg IV q24h clinical improvement then stepdown. Stepdown Doxycycline + 100mg PO bid To complete at Metronidazole 500mg PO bid least 14 days or Clindamycin alone 450mg PO qid To complete at least 14 days Late (2 days - 6 Chlamydia trachomatis Doxycycline 100mg PO bid 14 days - Usually after vaginal weeks) Mycoplasma hominis delivery. Septic pelvic vein Polymicrobial: Cefotaxime + 1g IV q8h 4-6 weeks - Check for pulmonary thrombophlebitis · Anaerobes Metronidazole IV/POC 500mg IV/PO q12h emboli. (postpartum, post · Viridans Group - Heparin therapy pelvic surgery, post Streptococci Alternative recommended along with abortion) · b-haemolytic Imipenem 500mg IV q6h 4-6 weeks antibiotics. Streptococci · Enterobacteriaceae

68 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Post-episiotomy S. aureus Mild - Check gram stain for b-haemolytic Streptococci Cephalexin 500mg PO qid 5-7 days presence of anaerobes. (group A,B,C,G) b-lactam allergy * Clindamycin has no Occasionally: Clindamycin* 150-300mg PO qid 5-7 days aerobic gram negative · Enterobacteriaceae Moderate-severe coverage - correlate with · Anaerobes Amoxicillin-clavulanate 875mg PO bid 7-10 days gram stain/culture. or Clindamycin* or 300mg PO qid 7-10 days [Cefazolin + 1g IV q8h 7-10 days 500mg PO bid Metronidazole] Labial abscess S. aureus Amoxicillin-clavulanate 875mg PO bid 7-10 days b-haemolytic Streptococci or (group A,B,C,G) Cephalexin + 500mg PO qid 7-10 days Enterobacteriaceae Metronidazole 500mg PO bid Anaerobes b-lactam allergy Clindamycin + 300mg PO qid 7-10 days Ciprofloxacin 500mg PO bid Prostatitis Acute Enterobacteriaceae Mild-moderate Ciprofloxacin or 500mg PO bid 2-4 weeks - In men with recurrent UTI Norfloxacin1 or 400mg PO bid 2-4 weeks due to the same organism, TMP/SMX 1 DS tab PO bid 2-4 weeks the prostate may be the Severe source. Ampicillin + 1-2g IV q6h Stepdown to oral Gentamicin 7mg/kg IV q24h agents when clinical improvement to complete 2-4 weeks 1 Non-formulary in Capital Health Region hospitals; automatic substitution to ciprofloxacin.

69 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Prostatitis (cont’d) Chronic Enterobacteriaceae Ciprofloxacin or 500mg PO bid 12 weeks - If no response in 4-6 S. aureus Norfloxacin1 or 400mg PO bid 12 weeks weeks, consult urologist. Enterococcus spp TMP/SMX or 1 DS tab PO bid 12 weeks Occasionally infected Pseudomonas aeruginosa Trimethoprim 100mg PO bid 12 weeks prostatic calculi. Proctitis N. gonorrhoeae See Urethritis C. trachomatis Herpes simplex virus (HSV) Primary episode - No role for topical Acyclovir or 400mg PO tid or 5-7 days acyclovir. Famciclovir or 250mg PO tid 5-7 days Valacyclovir 500mg-1g PO bid 5-7 days Recurrent See Genital Herpes - recurrent Treponema pallidum Benzathine penicillin G 2.4MU IM 1 dose Genital - For all patients presenting with genital ulcers, consider HIV testing. ulcers/lesions - Genital ulcers/lesions increase transmission and acquisition of HIV. Herpes NB: Therapy ideally should Primary episode Herpes simplex II Acyclovir or 400mg PO tid 5-7 days* be initiated within 72 Herpes simplex I Famciclovir or 250mg PO tid 5-7 days* hours of onset of Valacyclovir 500mg - 1g PO bid 5-7 days* symptoms. - No role for topical Severe**/hospitalized acyclovir. Acyclovir 5mg/kg IV q8h Switch to oral * Recent data indicates that therapy ASAP to 5 days may be sufficient. complete 10 days **Severe herpes infection: therapy. · disseminated · pneumonitis · hepatitis · meningitis/encephalitis · sacral radiculitis. 1 Non-formulary in Capital Health Region hospitals; automatic substitution to ciprofloxacin.

70 RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Genital ulcers/lesions (cont’d) Herpes (cont’d) Recurrent Herpes simplex II No therapy* * For patients who have Herpes simplex I occasional mild recurrences. Episodic - For patients with frequent Famciclovir or 125mg PO bid 5 days moderate to severe Valacyclovir 500mg PO bid 5 days recurrences with prodrome. Must have: · drug on hand Alternative 400mg PO tid 5 days · compliant patient Acyclovir · initiation of therapy within hours of prodromal symptoms (maximum 24 hours). No proven efficacy if started after 24 hours. Suppressive - For patients who: Acyclovir 400mg PO bid 6-12 months · have frequent (³ 6 Famciclovir or 250mg PO bid 6-12 months episodes/year) moderate to severe Valacyclovir 250-500mg PO bid 6-12 months or recurrences. 500mg PO daily · may be useful in couples where one is HSV(+) and other HSV(-). - If symptom free for 6-12 months, reassess rate of recurrences and need for continuing suppressive therapy. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Genital ulcers/lesions (cont’d) Herpes (cont’d) Pregnancy - Early pregnancy: · no data that acyclovir will prevent congenital herpes (rare event). · Infectious Diseases consult recommended. - Late pregnancy: · Primary episode ® 50% risk of transmission to infant. · Recurrent ® maximum 4% risk to infant. · HSV infection in infant has 50% mortality. - If active lesions at time of labour, perform a caesarean section. Primary episode Herpes simplex II Acyclovir 5mg/kg IV q8h Switch to oral - Safety of acyclovir in Herpes simplex I or therapy ASAP pregnancy not fully established. Potential 400mg PO tid 5-7 days benefit vs. potential risk to the fetus should be discussed with the patient. Acyclovir has been used at all stages of pregnancy; no adverse effects to the fetus/newborn have been reported to date. Recurrent Herpes simplex II - Suppressive therapy with Herpes simplex I acyclovir during the third trimester to prevent recurrence at time of delivery and decrease risk of viral shedding is currently being studied. - I.D. consult recommended. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Genital ulcers/lesions (cont’d) Syphilis Treponema pallidum Benzathine Pen G 2.4MU IM 1 dose - All sexual contacts of · Primary b-lactam allergy early syphilis should be · Secondary Doxycycline 100mg PO bid 14 days tested and treated. · Latent < 1 year Alternative in b-lactam - All HIV patients with early duration (early) allergic pregnant patients syphilis should receive Desensitization* then benzathine Pen G 2.4MU Benzathine Pen G 2.4MU IM 1 dose IM weekly x 3 weeks. or * Contact pharmacy for Erythromycin base 500mg PO qid 14 days desensitization protocol. · Latent > 1 year Treponema pallidum Benzathine Pen G 2.4MU IM weekly 3 weeks - Consider lumbar puncture duration (late) b-lactam allergy to exclude asymptomatic · Cardiovascular Doxycycline 100mg PO bid 28 days neurosyphilis.

· Neurosyphilis Treponema pallidum Penicillin G 3-4 MU IV q4h 10-14 days - If severe allergy/ anaphylaxis to penicillin consider: · desensitization (contact pharmacy for protocol) · Infectious Diseases consult. Azithromycin 1g PO 1 dose - Must rule out herpes Alternative simplex and syphilis. Ciprofloxacin or 500mg PO bid 3 days Ceftriaxone or 250mg IM 1 dose Erythromycin base 500mg PO qid 7 days RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Genital ulcers/lesions (cont’d) Genital Warts - Refer to specialist for: ·large/extensive warts ·resistant lesions ·vaginal/meatal warts. - Recommend HIV testing/counselling. - Increased risk of progression to neoplasia if smoker or HIV infection. - No eradication therapy available. - Therapy may reduce lesion size but no evidence this alters risk of transmission. Condyloma Human Papilloma Virus Podofilox 0.5% solution Apply to warts (not 3 days (4 days off) - Self application. acuminata or contiguous skin) bid May repeat 3 day - Contraindicated in: cycle up to 7 times · pregnancy Imiquimod 5% cream* · cervical, meatal Apply to warts 3 Up to 16 weeks vaginal, or anal warts. times/week, wash off * Greater efficacy in women 6-10 hours later than men. Dermatitis is the most common adverse event. Alternative - Must be applied by a Podophyllin resin 25% Apply to warts (not May repeat weekly physician. contiguous skin), 1-2 times - Contraindicated in: wash off 1-4 hours · pregnancy or later · cervical or anal warts.

Bi or tri chloracetic Apply to warts (not - Must be applied by a acid 50-80% contiguous skin) physician. weekly Other options · Cryotherapy · Electrocautery · Laser therapy RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Genital Scabies Sarcoptes scabiei Permethrin 5% cream Apply, wash off after May be repeated - Wash clothes and 8-14 hours in 7 days bedding. - Examine and treat sexual Alternative partners. Lindane* 1% cream or Apply, wash off after May be repeated - Consider treatment of lotion 8 hours in 7 days entire household. - Pruritus may persist for several weeks. Retreat after 1 week if no clinical improvement. * Potential neurotoxicity/aplastic anemia. Not recommended in pregnancy/lactation or children < 2 years. Pubic Lice Phthirus pubis Permethrin 1% cream Apply, wash off after May be repeated * Potential rinse 10 minutes in 7 days neurotoxicity/aplastic anemia. Not Alternative recommended in Lindane* 1% shampoo Apply, wash off after May be repeated pregnancy/lactation or 4 minutes in 7 days children < 2 years. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Urinary Tract Asymptomatic Bacteriuria

Adult males/females No therapy - Routine screening · community recommended* except cultures not · hospitalized as noted below. recommended. * Only treat symptomatic · institutionalized episodes of UTI in these · long term patient populations. catheterization

Prior to: E. coli Ciprofloxacin 500mg PO single dose - Pre procedure cultures · urologic/ Other Enterobacteriaceae or should be taken. gynecologic Enterococcus spp* TMP/SMX** 1 DS tab PO single dose - Treat according to C&S instrumentation/ or results. surgery [Gentamicin +/- 1.5mg/kg IV single dose * If C&S results unavailable, · surgery involving Ampicillin] 1g IV single dose enterococcal coverage is recommended for high- prosthetic risk patients: material · elderly/institutionalized · catheter removal · catheterized in patients · obstruction and/or catheterized for anatomical abnormality > 48 hours post of GU tract surgery involving · diabetes. prosthetic **TMP/SMX has no activity material against Enterococcus spp. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Urinary Tract Asymptomatic Bacteriuria (cont’d)

Pregnancy - Screening for bacteriuria recommended at 12-16 weeks. - Pre/post treatment urine cultures recommended. - Repeat urine culture monthly for remainder of pregnancy. E. coli Nitrofurantoin* or 50-100mg PO qid 3 days - Tailor antibiotic to C&S Other Enterobacteriaceae Cephalexin or 250mg PO qid 3 days results. Group B Streptococci Amoxicillin 500mg PO tid 3 days * Nitrofurantoin should be avoided near term (36-42 S. saprophyticus Alternative 1DS tab PO bid 3 days weeks) due to potential for TMP/SMX** haemolytic anemia in the or newborn. 100mg PO bid 3 days Trimethoprim** **TMP/SMX, trimethoprim should not be used in last six weeks of pregnancy due to potential for jaundice, haemolytic anemia and kernicterus in newborn. Diabetes (Type I & II) E. coli Treat according to C&S - Post treatment urine with glycosuria Other Enterobacteriaceae results with most narrow cultures recommended. Group B Streptococci spectrum agent(s). - There are no data to Enterococcus spp support this practice, however treatment of asymptomatic bacteriuria may prevent ascending infections which may complicate renal nephropathy. - Optimal control of diabetes is best prevention. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Urinary Tract Asymptomatic Bacteriuria (cont’d) Cirrhosis Enterobacteriaceae Treat according to C&S - Post treatment urine results with most narrow cultures recommended. spectrum agent(s). - Treatment of asymptom- atic bacteriuria is controversial - may ¯ incidence of spontaneous bacterial peritonitis. - Avoid urinary catheterization if possible. Renal Transplants Stent removal E. coli Ciprofloxacin or 250mg PO bid 14 days after stent - Obtain 48 hour pre stent Other Enterobacteriaceae Treat according to C&S removal removal urine culture. Enterococcus spp results. S. aureus Start treatment prior to Coagulase negative Staph Corynebacterium spp stent removal. First year post E. coli Treat according to C&S 14 days - Pre/post treatment urine transplant Other Enterobacteriaceae results. cultures recommended. Enterococcus spp - Common urinary contaminants (see p. 326) should not be considered uropathogens unless stent or other prosthetic material in situ. Repeat culture recommended. > 1 year post E. coli - Treatment may not be transplant Other Enterobacteriaceae necessary unless: Enterococcus spp · pregnant · prior to urologic manipulation · anatomical abnormality. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Urinary Tract Cystitis - In symptomatic premenopausal women, screening for pyuria (dipstick or microscopy) is highly sensitive and the preferred diagnostic technique. - If urine cultures indicated, ensure proper urine collection: · cleansing prior to collection of midstream urine (MSU) · MSU sample should be collected no sooner than 2 hours after last voiding · dipslide should be dipped into a voided urine sample immediately and no later than 30 minutes after collection · urine submitted in sterile container (e.g. cystoscopy) should be refrigerated and transported on ice. - 108 cfu/L - significant indication of urinary tract infection 107 cfu/L - significant with signs/symptoms. Lab will work up 1 or 2 organisms at this colony count if relevant diagnosis. 106 cfu/L - low colony count - may be significant in females with pyuria/dysuria syndrome, males, or children. Lab will work up if pure uropathogen and history provided. ³ 3 organisms - mixed - probable contamination. Lab will work up if a uropathogen > 80% predominant.

- E. coli resistance: · amoxicillin 73% · cephalexin 68% · TMP/SMX 16%

- Amoxicillin/cephalexin no longer empiric first line agents except in: · pregnancy (limited options) · known susceptibility to these agents. Longer therapy (5-7 days) recommended. - Cephalothin (not cefazolin) correlates with cephalexin susceptibility of E. coli. - Antifungal prophylaxis in women receiving antibiotic therapy is NOT routinely recommended. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Urinary Tract Cystitis (cont’d) Females Young sexually E. coli TMP/SMX or 1 DS tab PO bid 3 days - Screen for pyuria. active, first episode S. saprophyticus Trimethoprim 100mg PO bid 3 days Routine pre/post Other Enterobacteriaceae treatment urine cultures Alternative are not recommended Ciprofloxacin 100-250mg PO bid 3 days when presenting with or pyuria and typical Norfloxacin1 400mg PO bid 3 days symptoms of cystitis/ or adequate response to Nitrofurantoin* 50-100mg PO qid 5-7 days therapy. * Nitrofurantoin - inexpensive regimen but may be less effective in eradicating pathogen from vagina). Longer therapy (5-7 days) is recommended. Recurrent cystitis Early - E. coli TMP/SMX 1 DS tab bid 7 days - Pre/post treatment urine < 1 month S. saprophyticus or cultures recommended. following therapy Other Enterobacteriaceae Trimethoprim 100mg PO bid 7 days - > 90% of recurrences are for UTI due to reinfection (differ- Alternative ent strain or species) Ciprofloxacin 100-250mg PO bid 7 days usually after 2-4 weeks. or - Relapse (same organism) Norfloxacin1 400mg PO bid 7 days usually occurs within 2 weeks after completion of therapy. Urologic investigation may be indicated. 1 Non-formulary in Capital Health Region hospitals; automatic substitution to ciprofloxacin. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Urinary Tract Cystitis (cont’d) Females (cont’d) Recurrent cystitis (cont’d) Frequent - ³ 3 episodes/year · related to E. coli Peri-coital prophylaxis* * Therapy may be taken S. saprophyticus TMP/SMX 1 SS tab PO just before or after coitus. coitus Other Enterobacteriaceae or pericoitus* Nitrofurantoin 50-100mg PO pericoitus* · unrelated to E. coli Continuous prophylaxis coitus S. saprophyticus TMP/SMX 1 SS tab PO qhs or 6 months Other Enterobacteriaceae or 3x/week Trimethoprim 100mg PO qhs 6 months OR Patient initiated therapy - Self-treatment based on Same regimens as for symptoms. recurrent cystitis - - Patients should have drug Early on hand. Males - Pre/post treatment urine cultures recommended. - UTI in men may be associated with functional or anatomic abnormality of the urinary tract. - Urologic work-up recommended in males with recurrent or complicated infections and all young boys. First episode E. coli TMP/SMX* or 1 DS tab PO bid 7 day * TMP/SMX has no activity Other Enterobacteriaceae Ciprofloxacin or 250mg PO bid 7 days against Enterococcus spp. Enterococcus spp Norfloxacin1 400mg PO bid 7 days Recurrent E. coli TMP/SMX* 1 DS tab PO bid 6 weeks - Urologic work-up Other Enterobacteriaceae or recommended. Need to Enterococcus spp Ciprofloxacin 250-500mg PO bid 6 weeks rule out chronic bacterial or prostatitis. Norfloxacin1 400mg PO bid 6 weeks * TMP/SMX has no activity against Enterococcus spp. 1 Non-formulary in Capital Health Region hospitals; automatic substitutition to ciprofloxacin. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Urinary Tract Complicated UTI

Complicating factors: Enterobacteriaceae TMP/SMX** 1 DS tab PO bid 7 days - Pre/post treatment urine · diabetes Enterococcus spp or cultures recommended. · symptoms > 7 Group B Streptococci* Trimethoprim 100mg PO bid 7 days * Diabetics are days predisposed to UTI with · > 55 years old Alternative Group B Streptococci. (females) Ciprofloxacin 250mg PO bid 7 days **TMP/SMX has no activity or against: Norfloxacin1 400mg PO bid 7 days · Enterococci spp · Group B Streptococci. - Intravaginal estriol administration has been reported to prevent recurrent UTIs in postmenopausal women. Abnormality of Enterobacteriaceae Ciprofloxacin 500mg PO bid 10-14 days - Pre/post treatment urine urinary tract: Pseudomonas spp cultures recommended. · anatomical Enterococcus spp Alternative - Because of potential for · functional Corynebacterium Ampicillin + 1g IV q6h 10-14 days resistant organisms, it · metabolic urealyticum Gentamicin 7mg/kg IV q24h is important to modify empiric therapy to most narrow spectrum option based on C&S results. 1 Non-formulary in Capital Health Region hospitals; automatic substitution to ciprofloxacin. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Urinary Tract Complicated UTI (cont’d) Pregnancy - Pre/post treatment urine cultures recommended followed by monthly follow-up cultures during remainder of pregnancy. E. coli Nitrofurantoin* 50-100mg PO qid 7 days * Nitrofurantoin should be Other Enterobacteriaceae or avoided near term (36-42 Group B Streptococci Cephalexin 250mg PO qid 7 days weeks) due to potential for S. saprophyticus or haemolytic anemia in the Amoxicillin 500mg PO tid 7 days newborn. **TMP/SMX, trimethoprim Alternative should not be used in last TMP/SMX** 1 DS tab PO bid 7 days six weeks of pregnancy or due to potential for Trimethoprim** 100mg PO bid 7 days jaundice, haemolytic anemia and kernicterus in newborn. - Quinolones are not recommended in pregnancy. Chronic - Optimal hydration essential in these patients. catheterization **Fever in this population does not necessarily imply UTI. - Because of increased risk of resistant organisms, do not treat unless evidence of systemic infection and modify empiric therapy to most narrow spectrum option based on C&S results. Enterobacteriaceae Asymptomatic - Infections may be Enterococcus spp None polymicrobial. Pseudomonas spp Symptomatic** Candida spp* Ciprofloxacin 500mg PO bid 10-14 days * See Recommended or ***Amoxicillin-clavulanate Empiric Therapy of Amoxicillin- 875mg PO bid 10-14 days has no activity against Fungal Infections. clavulanate*** Pseudomonas. Fungal See Recommended Empiric Therapy of Fungal Infections. Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Therapy DoseB Duration Urinary Tract Complicated UTI (cont’d)

Renal transplants Early Enterobacteriaceae Treat according to - Pre/post treatment urine Enterococcus spp recent (< 1 month) urine cultures, as well as blood C&S results cultures, recommended. or - Symptoms may be non- Ciprofloxacin 500mg PO bid 14 days* specific: nausea, May need longer vomiting, malaise, fever, therapy if increased creatinine. bacteremic. - Adjust dosing of Alternative antibiotics according to Cefotaxime 1g IV q12h 14 days* renal function. May need longer - Stepdown to most narrow therapy if spectrum oral agent bacteremic. when patient afebrile for 24-48 hours. * In early transplants if stent in place, treat for 14 days after stent removal. Prophylaxis Recurrent UTI pre E. coli TMP/SMX 1 SS tab PO hs * Patients will be on this transplant or Other Enterobacteriaceae MWF* regimen for PCP > 3 UTI/year post Enterococcus spp Alternative prophylaxis for six months transplant Ciprofloxacin 250mg PO hs MWF post transplant. or **Do not use if creatinine Nitrofurantoin** 100mg PO hs clearance < 60mL/min. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Urinary Tract Pyelonephritis Uncomplicated E. coli TMP/SMX 1 DS tab PO bid 14 days - Pretreatment urine Enterobacteriaceae or cultures recommended. S. saprophyticus Ciprofloxacin 500mg PO bid 14 days** * Stepdown to oral agent(s) or as soon as tolerated. Gentamicin* 7mg/kg IV q24h 14 days **Recent evidence suggests 7 days of ciprofloxacin may be sufficient. This requires further study. Complicated · elderly E. coli Ciprofloxacin 500mg PO bid 14 days - Pre/post treatment urine · catheterized Other Enterobacteriaceae cultures recommended. · spinal cord injury Pseudomonas spp Alternative - Urologic investigation · obstruction Enterococcus spp Amoxicillin-clavulanate 875mg PO bid 14 days recommended if recurrent · diabetes Group B Streptococci or or symptoms > 72 hours. Gentamicin + 7mg/kg IV q24h 14 days - Amoxicillin-clavulanate Ampicillin 1g IV q6h does not cover Pseudomonas. - If enterococcal bacteremia, use ampicillin + gentamicin. · pregnancy E. coli Cefotaxime 1g IV q8h 14 days - Pre/post treatment urine Other Enterobacteriaceae cultures recommended Group B Streptococci Alternative followed by monthly Gentamicin + 1.5 - 2mg/kg IV q8h 14 days follow-up cultures during Ampicillin 1g IV q6h remainder of pregnancy. - Tailor antibiotics to C&S results. - Stepdown to oral agent(s) as soon as tolerated. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Central Nervous System Meningitis - Lumbar puncture recommended prior to antibiotic therapy except if: · S&S of focal neurological deficit · papilledema · uncorrected coagulopathy · GCS < 11 · hemodynamically unstable. NB: Do not delay antibiotics if LP cannot be performed expediently. - Blood culture recommended. - Directigen of CSF not recommended. - Patients with severe b-lactam allergy, use chloramphenicol +/- vancomycin +/- gentamicin. - For prophylaxis of H. influenzae and N. meningitidis, refer to Prophylaxis for Contacts of Communicable Diseases. Recommendations for the Addition of Vancomycin to Cefotaxime in Meningitis in the Capital Health Region - S. pneumoniae resistance in Northern/Central Alberta: · Penicillin 17.4% ~ Intermediate 16% ~ High level 1.4% · Cefotaxime/Ceftriaxone < 1% - Addition of vancomycin to cefotaxime may be considered if: · severely ill patients requiring ICU admission · patients who received multiple courses of b-lactam antibiotics in the last year (i.e. recurrent otitis media/sinusitis) · patients with recent travel outside of Canada · S. pneumoniae suspected/confirmed on CSF gram stain. - NB: Vancomycin has slow distribution and poor CSF penetration. It should be given AFTER the first dose of cefotaxime and continued only if C&S results indicate cefotaxime resistant S. pneumoniae. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Central Nervous System Meningitis (cont’d)

< 18 years old Refer to Paediatric Guidelines 18-50 years old S. pneumoniae Cefotaxime 2g IV q6h 10 days · immunocom- N. meningitidis petent H. influenzae

Adult > 50 years S. pneumoniae Cefotaxime + 2g IV q6h S. pneumoniae, - Cephalosporins have no · immunocompro- Listeria monocytogenes Ampicillin 2g IV q4h N. meningitidis - activity against Listeria. mised (including N. meningitidis 10 days - HIV individuals - need to HIV) Enterobacteriaceae rule out: · alcoholism L. monocytogenes, · Cryptococcosis · debilitating illness Enterobacteriaceae · M. tuberculosis - 21 days · Syphilis · Toxoplasmosis. Post trauma or post S. pneumoniae* Cloxacillin + 2g IV q4h 10-14 days * Especially if CSF leak. operative S. aureus Ceftazidime 2g IV q8h **Recommended regimen if Enterobacteriaceae external ventricular drain Pseudomonas spp Alternative** (EVD). Vancomycin + 1g IV q12h 10-14 days Ceftazidime* 2g IV q8h Shunt (meningitis/ S. epidermidis Vancomycin + 1g IV q12h 14 days after shunt - Shunt removal should be ventriculitis) S. aureus Cefotaxime 2g IV q6h removal done ASAP. Enterobacteriaceae - Tailor antibiotics to C&S Propionobacterium spp ³ 21 days if results. Corynebacterium spp Enterobacteria- Enterococcus spp ceae RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Central Nervous System Brain Abscess

Contiguous 2o to - Surgical drainage often necessary if: sinusitis/otitis · lesions > 3cm (usually single · gas present in abscess abscess) · risk of herniation or rupture into ventricles · no improvement with medical therapy. Polymicrobial: Cefotaxime 2g IV q6h 6 weeks*** * This regimen · Viridans Group + recommended if: Streptococci Metronidazole IV/POC* 500mg IV/PO q8h** · S&S of meningitis · Microaerophilic · history of recurrent Streptococci Alternative otitis/sinusitis · Anaerobes: Penicillin + 3-4MU IV q4h 6 weeks*** · MIC of Viridans Group Peptostreptococcus spp Metronidazole IV/POC 500mg IV/PO q8h** Streptococci ³ Bacteroides spp 0.1mg/mL. Prevotella spp Temporal lobe† † Pseudomonas spp and Porphyromonas spp Ceftazidime + 2g IV q8h ***If surgically Enterobacteriaceae may Fusobacterium spp Metronidazole IV/POC 500mg IV/PO q8h** excised, 3 weeks be pathogens in temporal lobe abscess. **Automatic substitution policy of IV q8h ® q12h therefore indicate “No substitution”. Hematogenous 2o to Viridans Group Streptococci Cloxacillin + 2g IV q4h 6 weeks - Blood cultures must be endocarditis S. aureus Cefotaxime 2g IV q6h taken. (usually multiple abscesses) RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Central Nervous System Brain Abscess (cont’d)

Post trauma S. aureus Cloxacillin + 2g IV q4h 6 weeks * Use ceftazidime in place Post neurosurgery Enterobacteriaceae Cefotaxime* 2g IV q6h of cefotaxime if increased Pseudomonas spp or risk of Pseudomonas: Cloxacillin + 2g IV q4h 6 weeks · prolonged ventilatory Ceftazidime* 2g IV q8h support Alternative · prolonged Vancomycin + 1g IV q12h 6 weeks hospitalization 3rd generation as above · previous broad Cephalosporin* spectrum antibiotics · burns. HIV Toxoplasma gondii Pyrimethamine + 200mg PO loading at least 3-6 weeks * In sulfa-allergic patients, dose then 50-75mg use clindamycin instead PO daily of sulfadiazine or can try Folinic acid + 10mg PO daily desensitization. [Clindamycin IV/POC 600-900mg IV q6h/ or 300-450mg PO qid Sulfadiazine1]* 4-8g/day PO

then suppressive therapy for life 50mg PO daily lifetime Pyrimethamine + 10mg PO daily Folinic acid + 1-1.5g PO q6h Sulfadiazine1 1 Not commercially available in Canada. Contact pharmacy for assistance in ordering. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Central Nervous System Epidural abscess S. aureus (60-90%) Cloxacillin + 2g IV q4h 4 weeks - Usually requires emergent Rare: Gentamicin 7mg/kg IV q24h If osteomyelitis, 8 surgical intervention. · Streptococci weeks - Treat according to C&S · Enterobacteriaceae results. · Pseudomonass - Very little data on epidural penetration of antibiotics. Several case reports of success with cefazolin +/- gentamicin (however CSF penetration of antibiotic may be important especially in first few days due to risk of infection extending into dural sac). - IVDU - increased risk of Pseudomonas; recomm- end adding ceftazidime. Subdural empyema Polymicrobial: Cefotaxime + 2g IV q6h 6 weeks - Condition usually requires · Viridans Group Metronidazole IV/POC 500mg IV/PO q8h* emergent surgical Streptococci or drainage. · Microaerophilic Penicillin + 3-4MU IV q4h 6 weeks - If associated Streptococci Metronidazole IV/POC 500mg IV/PO q8h* osteomyelitis, need to · Anaerobes: cover S. aureus (add Peptostreptococcus * Automatic cloxacillin). spp substitution policy of Bacteroides fragilis IV q8h ® q12h Prevotella/Porphyr- therefore indicate omonas spp “No substitution”. Fusobacterium spp RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Central Nervous System Encephalitis Enteroviruses Acyclovir 10mg/kg IV q8h 10 days * Herpes simplex is most Herpes simplex virus* common cause of Arboviruses sporadic fatal encephalitis Rabies and is one of the few Post infectious: treatable causes. · mumps - Infectious Diseases · measles consult recommended. · rubella - CSF should be sent for · influenza HSV PCR. Contact · varicella Provincial Lab. Mycoplasma spp Bartonella (Cat Scratch disease) RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Vascular Pericarditis Viral: Purulent - Recommend urgent · usually Enterovirus Cloxacillin + 2g IV q4h 6 weeks consult for drainage if Mycoplasma spp Gentamicin 1.5mg/kg IV q8h bacterial etiology S. aureus suspected. Occasionally: - Tailor antibiotics to C&S · b-haemolytic results. Streptococci · Enterobacteriaceae · S. pneumoniae · M. tuberculosis Endocarditis - Diagnosis includes: · multiple positive blood cultures · murmur · definite emboli · vegetations on echocardiogram. - Blood cultures: · draw maximum 2 sets/day (set = 2 aerobic/1 anaerobic bottle) · adults – 8-10mL of blood/bottle · consult microbiology laboratory if unusual/fastidious organism suspected. - For positive cultures, refer to Table 5 (following). Native valve Viridans Group Streptococci Subacute (> 1 month Culture negative - * Extended interval (non-IVDU) S. aureus symptoms) 6 weeks aminoglycoside dosing Enterococcus spp Ampicillin + 2g IV q4h not recommended. HACEK organisms Gentamicin* 1mg/kg IV q8h Desired gentamicin peak Acute (< 1 month Culture positive - = 3-4mg/L. symptoms) see Table 5 Only need to continue Ampicillin + 2g IV q4h following gentamicin for 6 weeks if Cloxacillin + 2g IV q4h Endocarditis Enterococcus or selected Gentamicin* 1mg/kg IV q8h HACEK organism. Penicillin-allergy Vancomycin + 1g IV q12h 1mg/kg IV q8h Gentamicin* HACEK = Haemophilus aprophilus/H. parainfluenzae, Actinobacillus actinomycetemcomitans, , Eikenella corrodens, Kingella spp. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Vascular Endocarditis (cont’d)

Intravenous Drug S. aureus Cloxacillin + 2g IV q4h 2 weeks* * Treat for 4-6 weeks if: Users (right-sided) Gentamicin 1mg/kg IV q8h 2 weeks · metastatic infection · left side involved. Alternative/MRSA** ** In Northern/Central Vancomycin** + 1g IV q12h 2 weeks* Alberta, prevalence of Gentamicin 1mg/kg IV q8h 2 weeks MRSA ~ 7% (most institutionally acquired). Empiric vancomycin not routinely recommended at time of publication. Prosthetic valve · early (< 8 weeks) Coagulase negative Staph Vancomycin + 1g IV q12h 6 weeks - Recommend urgent Occasionally: Gentamicin + 1mg/kg IV q8h 2 weeks surgical consult. · S. aureus Rifampin 300mg PO bid 6 weeks · Corynebacterium spp · late (> 8 weeks) Viridans Group Streptococci Vancomycin + 1g IV q12h 6 weeks* * Tailor antibiotics to C&S Coagulase negative Staph Gentamicin + 1mg/kg IV q8h results. S. aureus Rifampin 300mg PO bid Enterococcus spp Rarely: · Propionibacterium spp · S. bovis RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Table 5 - Treatment of Culture - proven Endocarditis Pathogen Recommended Empiric Recommended DoseB Recommended Comments Therapy Duration Viridans Group Streptococci Pen MIC £ 0.1mg/mL* Penicillin + 3MU IV q4h 2 weeks * Alternative in b-lactam allergic patients: Gentamicin** or 1mg/kg IV q8h 2 weeks vancomycin +/- gentamicin. Penicillin alone or 3MU IV q4h 4 weeks **Do not use extended interval Ceftriaxone + 1g IV daily 2 weeks aminoglycoside dosing. Desired Gentamicin** 1mg/kg IV q8h 2 weeks gentamicin peak = 3-4mg/L. Pen MIC > 0.1 - £ 0.5mg/mL* Penicillin + 3MU IV q4h 4 weeks - For pen MIC > 0.1mg/mL, check MIC to Gentamicin** or 1mg/kg IV q8h 2 weeks ceftriaxone (reported by micro lab). Ceftriaxone + 1g IV daily 4 weeks Gentamicin 1mg/kg IV q8h 2 weeks Pen MIC ³ 1.0mg/mL* Ceftriaxone + 1g IV daily 4-6 weeks - If cefotaxime/ceftriaxone I or R, consult Gentamicin** 1mg/kg IV q8h 4-6 weeks Infectious Diseases. If symptoms > 3 months, recommend 6 weeks of therapy Enterococcus spp * Do not use extended interval Amp S, Gent synergy S Ampicillin + 2g IV q4h 4-6 weeks aminoglycoside dosing. Desired Gentamicin* 1mg/kg IV q8h 4-6 weeks gentamicin peak = 3-4mg//L. Amp S, Gent synergy R Ampicillin 3g IV q4h 8-12 weeks

Amp R, Gent synergy S Vancomycin + 1g IV q12h 4-6 weeks Gentamicin* 1mg/kg IV q8h 4-6 weeks Vancomycin resistant Consult Infectious Diseases RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Table 5 - Treatment of Culture - proven Endocarditis (cont’d) Pathogen Recommended Empiric Recommended DoseB Recommended Comments Therapy Duration S. aureus (right-sided) Cloxacillin sensitive Cloxacillin + 2g IV q4h 2 weeks* - Do not use extended interval Gentamicin 1mg/kg IV q8h 2 weeks aminoglycoside dosing. Desired gentamicin peak = 3-4mg/L. Cloxacillin resistant Vancomycin + 1g IV q12h 2 weeks* * Treat for 4-6 weeks if: Gentamicin 1mg/kg IV q8h 2 weeks · metastatic infection · left side involved. - involvement - rule out septic pulmonary emboli. S. aureus (left-sided) Cloxacillin sensitive Cloxacillin +/- 2g IV q4h 4-6 weeks - Do not use extended interval Gentamicin or 1mg/kg IV q8h 3-5 days aminoglycoside dosing. Desired gentamicin peak = 3-4mg/L. Cefazolin +/- 2g IV q8h 4-6 weeks Gentamicin 1mg/kg IV q8h 3-5 days Cloxacillin resistant Vancomycin +/- 1g IV q12h 4-6 weeks - Consult Infectious Diseases. Rifampin* 600mg PO daily 4-6 weeks - Increased incidence of recurrence. * Consider adding rifampin if not responding or if suppurative complications. HACEK organisms Ceftriaxone or 1g IV daily 4 weeks * Eikenella - no evidence that gentamicin [Ampicillin +/- 2g IV q4h 4 weeks has synergistic activity. Gentamicin*] 1.5mg/kg IV q8h 4 weeks - Cardiobacterium - addition of gentamicin recommended. - For other HACEK organisms, addition of gentamicin for synergy should be considered (controversial). Enterobacteriaceae Ceftriaxone + 1g IV daily minimum of 6 weeks - Consult Infectious Diseases. Gentamicin 1.5-2mg/lg IV q8h minimum of 6 weeks - Valve replacement often necessary depending on organism. Pseudomonas aeruginosa Piperacillin + 3g IV q4h minimum of 6 weeks - Consult Infectious Diseases. Tobramycin 2mg/kg IV q8h minimum of 6 weeks - Valve replacement recommended if left sided involvement. Fungal Consult Infectious Diseases HACEK = Haemophilus aprophilus/H. parainfluenzae, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella spp. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Sepsis Community-acquired Intraabdominal See Peritonitis, pages 185- source 187. Intravenous drug See Endocarditis, page 221. - Must rule out endocarditis. users - Check CXR to rule out septic pulmonary emboli. Pelvic source See Pelvic inflammatory disease, pages 194-195. Respiratory source See Community acquired pneumonia, page 168-169. Splenectomized S. pneumoniae Cefotaxime 1g IV q8h 2 weeks - These individuals should be vaccinated with pneumococcal vaccine. Whether adults have increased risk of infection from other encapsulated organisms (H. influenzae, N. meningitidis) is controversial. Urosepsis See Pyelonephritis, p. 213.

Septic shock - source S. pneumoniae Cefotaxime* + 2g IV q6h** Duration - Blood cultures unknown N. meningitidis Gentamicin +/- 7mg/kg IV q24h dependent on recommended prior to (see above for sepsis Enterobacteriaceae Ampicillin*** 2g IV q4h source of infection empiric antibiotic therapy. due to known/ S. aureus * If S. aureus strongly suspected, add suspected sources) cloxacillin. **Use at higher dose until CNS infection ruled out. ***In immunocompromised patients/elderly, recommend empiric ampicillin to cover for RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Listeria spp. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Sepsis Hospital acquired Respiratory source See Hospital acquired pneumonia, page 172-173. Intraabdominal See Peritonitis, pages 185- source 187.

Pelvic source See Endometritis or Septic vein thrombophlebitis, page 196.

Line-related S. aureus Cefazolin +/- 1-2g IV q8h Duration depend- - Remove line if possible. Coagulase negative Staph Gentamicin 1mg/kg IV q8h ent on: - For CNS, line removal is (CNS) · ability to often sufficient - may not b-lactam allergy remove line need antibiotic therapy. Vancomycin +/- 1g IV q12h · organism - Avoid treatment in Gentamicin 1mg/kg IV q8h involved (i.e. response to single S. aureus - positive blood culture minimum 2 for CNS. Repeat culture weeks). recommended. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Sepsis Hospital acquired (cont’d)

Immunocompro- S. aureus Vancomycin + 1g IV q12h Duration - Assess patient for line mised with Coagulase negative Staph Gentamicin 7mg/kg IV q24h dependent on: removal. tunnel/exit site (CNS) · type of line - Blood cultures must be infections Corynebacterium jeikeium · ability to taken prior to empiric Leuconostoc spp* remove line therapy. Pediococcus spp* · state of immun- - Avoid continued empiric Enterobacteriaceae osuppression use of vancomycin in Pseudomonas spp · organism patients whose cultures Yeast (see Recommended involved are negative for b-lactam Empiric Therapy of Fungal resistant gram-positive Infections) organisms. * Leuconostoc/Pediococcus spp are resistant to vancomycin and 3rd gen- eration cephalosporins. Hyperalimentation S. aureus See Line-related sepsis. Coagulase negative Staph Candida spp See Recommended Empiric Therapy of Fungal Infections for Candida spp. Candidemia See Recommended Empiric Therapy of Fungal Infections. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseB Duration Febrile neutropenia Recommendations for the Use of Vancomycin in Febrile Neutropenia - Empiric vancomycin should not be used routinely in febrile neutropenics. - Vancomycin therapy should be considered empirically in: · clinically obvious central venous catheter-related infections (tunnel infection) · patients with positive blood culture for gram-positive organisms not yet identified · known colonization with MRSA or Pen-R S. pneumoniae. - Vancomycin therapy should be discontinued on day 3-5 if cultures negative for b-lactam resistant gram-positive organisms. Coagulase negative Staph Piperacillin + 3g IV q4h If neutrophil count - Locally: 9 S. aureus Tobramycin* 1.5-2mg/kg IV q8h > 0.5x10 /L – · • gram-positive Enterococcus spp or 7 days minimum infections Viridans Group Streptococci 7mg/kg IV q24h · infrequent Corynebacterium spp Alternative If neutrophil count Pseudomonas 9 Bacillus spp Ceftazidime +/- 2g IV q8h < 0.5x10 /L - infections. Stomatococcus spp Tobramycin* 1.5-2mg/kg IV q8h 2 weeks minimum * These regimens provide b-haemolytic Streptococci or suboptimal coverage of S. pneumoniae 7mg/kg IV q24h Consider S. aureus. Rhodococcus spp ICU admission stepdown to oral - Ceftazidime monotherapy: 500mg IV q6h agent if: Enterobacteriaceae Imipenem + · has inferior gram- Pseudomonas spp 1.5-2mg/kg IV q8h · non-septic Tobramycin positive (Streptococci, Burkholderia spp or presentation Enterococci) activity Anaerobes 7mg/kg IV q24h (no chills, compared to hypotension or piperacillin Antifungal therapy Rarely other organisms may fluid · may promote should be considered in cause infections in these resuscitation) antimicrobial patients who remain individuals. · patient stable resistance febrile and neutropenic · culture at day 4-7 despite · may not be optimal in negative adequate antibiotic patients with · mucositis coverage. Fungal blood profound/prolonged resolving cultures recommended. neutropenia. · neutrophils > 9 - Ciprofloxacin prophylaxis 0.1x10 /L. may increase likelihood of gram-positive infections. RECOMMENDED EMPIRIC THERAPY OF SELECTED INFECTIONS IN ADULT PATIENTSA

FOOTNOTES:

A. These are empiric antibiotic recommendations based on local susceptibility patterns, Capital Health hospitals’ antimicrobial formulary, and need to restrict and rationalize antibiotic use. Antibiotics listed for each condition are not all inclusive, nor are they all approved by HPB for the listed indication. Choice of empiric antibiotic therapy should be based on the patient’s age, allergies, co-morbidities, and clinical condition, as well as cost and convenience of the dosage regimen. Empiric antibiotic therapy should be modified to more narrow spectrum antibiotic(s) according to culture and susceptibility (C&S) results.

B. Usual adult dose in patients with normal renal and hepatic function.

C. Oral clindamycin/metronidazole have excellent absorption. If intravenous therapy is deemed necessary, prompt switch to the oral formulation is recommended. (See Stepdown Recommendations)

D. Oral quinolones have excellent absorption and bioavailability. With equivalent doses, the serum concentration attained with oral quinolones is comparable to that of the IV formulation. Therefore, unless the patient is strictly NPO, use oral quinolones. (See Stepdown Recommendations) RECOMMENDED EMPIRIC THERAPY OF SELECTED OPHTHALMIC INFECTIONS Prepared by Dr. E. Blondel-Hill and Ms. R. Muzyka Reviewed by Dr. G. Drummond, Dr. M. Greve, Dr. R. Johnson, Dr. J. Leong-Sit, and Dr. L. Uniat, Ophthalmologists, Capital Health

Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseA Duration Blepharitis - Bilateral inflammation of eyelid margin with irritation, burning, and itching. - Dry scales can be seen on the lashes of the upper and lower lids. Lids may become thick and irregular. S. aureus Warm compresses + - Infectious etiology suspected but S. epidermidis Wash off debris, then apply not proven. Moraxella lacunata Ophthalmic Ointment - Often associated with seborrhea. P. acnes Bacitracin-Polymyxin B or qhs 6-8 weeks - Difficult to eradicate. Corynebacterium spp Erythromycin 0.5% qhs 6-8 weeks - Eyelid hygiene is key to therapy. - Patients with associated rosacea may benefit from doxycycline 100mg PO bid x 3-4 weeks. Hordeolum (sty) - Pain, redness, and tenderness of the eyelid margin followed by an area of induration. External S. aureus Hot compresses 10-15 min tid Until a yellowish - Self-limiting condition; antibiotics (adjacent to or qid point is formed that not necessary. eyelash follicles) ruptures and drains - Often associated with blepharitis. Internal S. aureus Hot compresses 10-15 min tid - Rarely drains spontaneously. (on conjunctival or qid - Recurrence is common. side of lid) If cellulitis is present: - Often associated with blepharitis. Cloxacillin or 500mg PO qid 7 days Cephalexin 500mg PO qid 7 days Chalazion - Sterile, nontender, chronic granulomatous inflammation of the meibomian gland. - At onset may be indistinguishable from a sty. Resolves after a few days, leaving a painless, slowly growing round mass in the lid. - Most chalazia disappear after a few months; incision and curettage may be indicated if there is no resolution after 6-8 weeks. Hot compresses 10-15 min tid 6-8 weeks or until or qid resolved RECOMMENDED EMPIRIC THERAPY OF SELECTED OPHTHALMIC INFECTIONS

Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseA Duration Canaliculitis - Nasal conjunctival redness, swollen and pouting punctum, and a mucopurulent discharge with itching, tearing, and irritation. - Digital pressure over the punctum results in a greenish-yellow exudate often followed by yellowish concretions. A. israelii Remove granules + - Gram stain of the exudate confirms Ophthalmic Solution diagnosis. Penicillin G 100,000U/mLB qid 1 week - Surgical drainage may be ophthalmic solution necessary if curettage fails. + - Definitive treatment is surgical; Erythromycin 500mg PO qid 10 days antibiotics may play a 2o role. Dacryocystitis - Unilateral inflammation of lacrimal sac due to obstruction of the flow of tears from the sac. Acute S. pneumoniae Infants - Collect exudate from lacrimal S. aureus Massage lacrimal sac punctum for C&S. H. influenzae - Infants: S. pyogenes Adults · 50% resolve spontaneously by P. aeruginosa Warm compresses + 12-18 months. Cloxacillin or 500mg PO qid 7 days · If chronic consider probing (after Cephalexin 500mg PO qid 7 days 1 year of age). - Adults (usually > 40 years): · Usually requires systemic therapy. · Chronic or recurrent cases usually require dacryocystorhinostomy. Conjunctivitis Viral - Unilateral with 30-50% of cases spreading to the other eye. (pink eye) - Clear watery discharge, mild foreign-body sensation, burning, red eyelid, preauricular lymphadenopathy and follicular reaction. - Onset of photophobia and ocular pain after 10-14 days in adults suggests corneal involvement (rare). - Prevent transmission by counseling on handwashing and avoiding personal contact. Virus viable on dry surfaces for ³ 2 weeks. Adenovirus Cold compresses ± - Typically lasts 2 to 4 weeks; highly Decongestants ± contagious for the first 2 weeks. Lubricants - Topical corticosteroids are not recommended. RECOMMENDED EMPIRIC THERAPY OF SELECTED OPHTHALMIC INFECTIONS

Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseA Duration Conjunctivitis (cont’d) Bacterial (cont’d) Hyperacute - Usually unilateral with a fulminant onset (< 24 hours) - Copious purulent discharge, conjunctival hyperemia, redness, and irritation. Preauricular lymphadenopathy commonly seen. - Corneal perforation can occur in up to 10% of cases. Refer to an ophthalmologist promptly. N. gonorrhoeae Ceftriaxone or 1g IM 1 dose - Obtain gram stain and culture of N. meningitidis Ciprofloxacin 500mg PO 1 dose conjunctival scrapings. + - Frequent association with Doxycycline or 100mg PO bid 7 days chlamydial disease (up to 33%). Azithromycin 1g PO 1 dose - Consider adjunctive topical antibiotic therapy. Acute - Usually begins unilaterally with involvement of the second eye within 24 to 48 hours. - Moderate purulent discharge, conjunctival hyperemia, and eyelid swelling/redness. Preauricular lymphadenopathy usually absent. - Cultures are not recommended unless infection is not resolving with standard therapy. S. pneumoniae Ophthalmic Solution (adults) - Often self-limiting. H. influenzae Gramicidin-Polymyxin B or qid 7-10 days - Oral antibiotics not indicated. C S. aureus Gentamicin 0.3% qid 7-10 days - Topical corticosteroids not Group A Strepto- Ophthalmic Ointment (infants/ recommended. cocci children) Moraxella spp Bacitracin-Polymyxin B or qid 7-10 days Proteus spp Erythromycin 0.5% qid 7-10 days

Chronic - Redness, irritation, lid excoriation, scant mucopurulent discharge, or morning crusting for > 4 weeks. Staphylococcus spp Ophthalmic Solution - Eyelid hygiene is important. Moraxella spp Gramicidin-Polymyxin B or qid 7-10 days - If persists for > 10 days, do not Enterobacteriaceae Ophthalmic Ointment repeat treatment. Look for 2o Bacitracin-Polymyxin B or qid 7-10 days causes such as chronic Erythromycin 0.5% qid 7-10 days nasolacrimal obstruction or chronic blepharitis. RECOMMENDED EMPIRIC THERAPY OF SELECTED OPHTHALMIC INFECTIONS

Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseA Duration Conjunctivitis (cont’d) Newborn N. gonorrhoeae Prophylaxis - Hyperpurulent conjunctivitis that Erythromycin 0.3% ophthalmic both eyes once only appears 2 to 4 days after birth. ointment - If severe, irrigate eye hourly with Treatment normal saline until discharge Cefotaxime 200mg/kg/d IV div 7 days eliminated. q6h - The mother and her sexual partner(s) should also be treated. C. trachomatis Prophylaxis - Hyperpurulent conjunctivitis that Erythromycin 0.3% ophthalmic both eyes once only appears 3 to 10 days after birth. ointment - The mother and her sexual Treatment partner(s) should also be Erythromycin 40mg/kg/d PO/IV 14 days treated. div q6h Adult Inclusion - Onset usually 1-2 weeks after inoculation. - Usually unilateral with mild discomfort, minimal conjunctival injection and no exudate. C. trachomatis Doxycycline 100mg PO bid 2-3 weeks - Can remain undetected for a long time. Alternative - Sexual partner(s) should also be Erythromycin or 250mg PO qid 2-3 weeks treated. Azithromycin 1g PO 1 dose RECOMMENDED EMPIRIC THERAPY OF SELECTED OPHTHALMIC INFECTIONS

Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseA Duration Keratitis - A serious and potentially sight-threatening infection of the cornea (ocular pain, photophobia, conjunctival injection, tearing, decreased vision, foreign body sensation, corneal infiltrate or opacity and purulent discharge). - Refer to an ophthalmologist promptly. Viral Herpes simplex Ophthalmic Solution - Debridement recommended. Trifluridine 1% q1h, 9x/day 10-14 days - Addition of oral acyclovir is or (up to 21 days) controversial. Ophthalmic Ointment - Topical corticosteroids are Acyclovir 3% (ER) 5x/day 7-10 days restricted to specific clinical presentations. Consult an ophthalmologist. - 30-50% rate of recurrence within 2 years. Varicella zoster Acyclovir 800mg PO 5x/day 10 days - Therapy ideally should be or initiated within 72 hours of onset Famciclovir 500mg PO tid 10 days of skin lesions. or - Skin lesions on tip of nose Valacyclovir 1g PO tid 10 days generally result in corneal involvement. Bacterial · Contact Lens P. aeruginosa Ophthalmic Solutions - Rapid onset of symptoms. B User Staphylococcus spp Tobramycin 15mg/mL +/- q15-60min, around 3-4 weeks - Ciprofloxacin 0.3% solution may Streptococcus spp Piperacillin 6mg/mLB the clock for 24-72 (dependent on form a white precipitate on the B. cereus or hours, then slowly clinical picture) cornea. Enterobacteriaceae Ciprofloxacin 0.3% (alone) reduce frequency. Moraxella spp P. acnes · Non-Contact Staphylococcus spp Ophthalmic SolutionsB - Risk factors: Lens User Streptococcus spp Cefazolin 33mg/mL + · diabetes B. cereus [Gentamicin 15mg/mL or q15-60min, around 3-4 weeks · immunosuppression Enterobacteriaceae Tobramycin 15mg/mL] the clock for 24-72 (dependent on · dry cornea. B Moraxella spp Alternative hours, then slowly clinical picture) - Quinolones may not provide P. acnes Vancomycin 50mg/mL + reduce frequency. optimal staph and strep Ceftazidime 50mg/mL coverage. RECOMMENDED EMPIRIC THERAPY OF SELECTED OPHTHALMIC INFECTIONS

Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseA Duration Keratitis (cont’d) Fungal Aspergillus spp Ophthalmic Solutions - Risk factors: B Fusarium spp Amphotericin B 0.1% or q2-3h, then slowly up to 6 weeks · trauma due to vegetation Candida spp Natamycin 5% (ER) reduce frequency. · chronic topical steroid use. - Very resistant to topical therapy; debridement usually required. May need corneal transplant. - Topical/oral corticosteroids are contraindicated. - Consider adjunctive systemic antifungal therapy. Protozoan Acanthamoeba spp Ophthalmic Solutions - Risk factors: Propamidine 0.1% (ER) + q1h while awake Dependent on · trauma Neomycin-gramicidin- clinical picture · soft contact lens use polymyxin B (overnight use increases or risk). Polyhexamethylene biguanide - Severe pain is a predominant B 0.02% (alone) symptom. - Consult microbiology for diagnosis. RECOMMENDED EMPIRIC THERAPY OF SELECTED OPHTHALMIC INFECTIONS

Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseA Duration Endophthalmitis - Inflammation of the vitreous is an urgent and severe ocular infection (ocular pain, decreased vision, headache, photophobia, hazy cornea, eyelid swelling, conjunctival injection, decreased red reflex and hypopyon). - Refer to an ophthalmologist immediately. - Anterior chamber tap and vitreous biopsy for culture should be performed prior to initiating therapy. - Intravitreal administration of antimicrobials is essential (intravitreal ophthalmic preparations are not commercially available; manufactured by pharmacy). Post-Surgical Acute S. epidermidis Ophthalmic PreparationsB - Fulminant onset 2-7 days S. aureus Vancomycin 1mg/0.1mL + 0.1mL intravitreally Dependent on postoperatively. Streptococcus spp Ceftazidime 2.25mg/0.1mL 0.1mL intravitreally clinical picture - Vitrectomy may be required. Pseudomonas spp B-lactam AllergyB - IV antibiotics usually not needed Vancomycin 1mg/0.1mL + 0.1mL intravitreally Dependent on unless infection is outside globe. [Gentamicin 0.2mg/0.1mLD or 0.1mL intravitreally clinical picture - Intravitreal dexamethasone Amikacin 0.4 mg/0.1mLD] 0.1mL intravitreally 0.4mg/0.1mL may be beneficial. Chronic P. acnes Ophthalmic PreparationB - Low grade infection occurring S. epidermidis Vancomycin 1mg/0.1mL 0.1mL intravitreally Dependent on 1 month to 1 year post-op. Fungi (see next page) clinical picture

Post-Trauma B. cereus Ophthalmic PreparationsB - Fulminant onset 2-7 days S. epidermidis Vancomycin 1mg/0.1mL + 0.1mL intravitreally Dependent on following penetrating trauma. Enterobacteriaceae Ceftazidime 2.25mg/0.1mL 0.1mL intravitreally clinical picture - Vitrectomy may be required. Pseudomonas spp B-lactam AllergyB - Consider adjunctive systemic Anaerobes Vancomycin 1mg/0.1mL + 0.1mL intravitreally Dependent on antibiotics. D Fungi (see next page) [Gentamicin 0.2mg/0.1mL or 0.1mL intravitreally clinical picture - Intravitreal dexamethasone Amikacin 0.4 mg/0.1mLD] 0.1mL intravitreally 0.4mg/0.1mL may be beneficial. RECOMMENDED EMPIRIC THERAPY OF SELECTED OPHTHALMIC INFECTIONS

Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseA Duration Endophthalmitis (cont’d) Hematogenous Streptococcus spp Ophthalmic PreparationsB - Insidious onset. N. meningitidis Vancomycin 1mg/0.1mL + 0.1mL intravitreally Dependent on - Risk factors: S. aureus Ceftazidime 2.25mg/0.1mL 0.1mL intravitreally clinical picture · endocarditis B B. cereus* B-lactam Allergy · immunosuppression Candida spp* (see Vancomycin 1mg/0.1mL + 0.1mL intravitreally Dependent on · *chronic IV drug abuser below) [Gentamicin 0.2mg/0.1mLD or 0.1mL intravitreally clinical picture D · TPN. Amikacin 0.4 mg/0.1mL ] 0.1mL intravitreally - Blood cultures should be taken. plus - Vitrectomy may be required. Systemic Antibiotics - IV antibiotics required for Cefotaxime/Ceftriaxone 2g IV q6h/2g IV 6 weeks, systemic infection (tailor + q12h dependent on antibiotics according to C&S Vancomycin 1g IV q12h culture results results). Fungal Candida spp Ophthalmic PreparationB - Etiologies include: Aspergillus spp Amphotericin B 5mcg/0.1mL 0.1mL intravitreally Dependent on · chronic post-surgical Fusarium spp clinical picture · penetrating ocular trauma due to vegetation · hematogenous. - Vitrectomy may be required. - Systemic antifungal therapy recommended if hematogenous source. RECOMMENDED EMPIRIC THERAPY OF SELECTED OPHTHALMIC INFECTIONS

Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseA Duration Periorbital - Marked hyperemia and edema of eyelids and facial subcutaneous tissues. Cellulitis - No impairment of eye movement, vision or pupillary response. 2o to paranasal S. aureus Mild/Afebrile - Stepdown to oral agents when sinusitis Group A Streptococci Amoxicillin-clavulanate Paediatric clinically improved. S. pneumoniae 40 mg/kg/d PO div tid 7-10 days - Consider otolaryngology H. influenzae or Adult consult. 875 mg PO bid 7-10 days Cefuroxime axetil Paediatric 40 mg/kg/d PO div bid 7-10 days Adult 500 mg PO bid 7-10 days Moderate/Severe Cefuroxime Paediatric 100-150 mg/kg/d IV div 7-10 days q8h Adult 750mg IV q8h 7-10 days 2o to skin S. aureus Clindamycin PO/IV Paediatric - Types of trauma include: trauma Group A Streptococci 30-40mg/kg/d PO div 7-10 days · puncture wounds Anaerobes qid/40mg/kg/d IV div · lacerations q8h · insect bites Adult · animal bites. 300mg PO qid/ 600mg 7-10 days IV q8h or Amoxicillin-clavulanate Paediatric 40mg/kg/d PO div tid 7-10 days Adult 875mg PO bid 7-10 days RECOMMENDED EMPIRIC THERAPY OF SELECTED OPHTHALMIC INFECTIONS

Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseA Duration Periorbital Cellulitis (cont’d) 2o to S. pneumoniae Paediatric - Blood cultures recommended. bacteremia H. influenzae Cefotaxime 200mg/kg/d IV div q6h 7-10 days Adult Cefotaxime 1g IV q8h 7-10 days Orbital Cellulitis - Initial soft tissue swelling, redness, and increased warmth of the eyelids. - Progresses to impairment of extraocular motility, globe proptosis, ocular pain, diplopia and/or decreased vision. - Consult Ophthalmology, Otolaryngology and Infectious Diseases. - Obtain urgent CT scan of orbit and sinuses and blood cultures. - Complications include visual loss from optic neuropathy, cavernous sinus thrombosis, and meningitis. 2o to S. aureus Paediatric** * Anaerobes are more prominent paranasal S. pneumoniae Cloxacillin + 200mg/kg/d IV div q6h 10-14 days pathogens in adults. sinusitis H. influenzae Cefotaxime +/- 200mg/kg/d IV div q6h **Stepdown to oral therapy when Anaerobes* Metronidazole 30mg/kg/d IV div q12h clinically appropriate. Adult** Cloxacillin + 2g IV q6h 10-14 days Cefotaxime + 2g IV q6h Metronidazole 500mg IV q12h RECOMMENDED EMPIRIC THERAPY OF SELECTED OPHTHALMIC INFECTIONS Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy DoseA Duration Orbital Cellulitis (cont’d) 2o to immuno- Mucor spp Amphotericin B 0.8mg/kg IV daily; if 3g total dose * For bacterial causes, see suppression Rhizopus spp tolerated increase up above. Substitute ceftazidime Bacterial* to 1.5mg/kg/d for cefotaxime/ceftriaxone. - Risk factors: · diabetic ketoacidosis · neutropenia. - Surgical debridement necessary. - Treat underlying condition. - Consult ophthalmologist re: need for intravitreal antifungal. 2o to trauma S. aureus Paediatric - Tailor antibiotic therapy to C&S Group A Streptococci Vancomycin + 60mg/kg/d IV div q6h 10-14 days results. Bacillus spp Cefotaxime + 200mg/kg/d IV div q6h Anaerobes Metronidazole PO/IV 30mg/kg/d PO/IV div q12h Adult Vancomycin + 1g IV q12h 10-14 days Cefotaxime + 2g IV q6h Metronidazole PO/IV 500mg PO/IV q12h

FOOTNOTES: ER = Emergency Release A. Usual adult dose in patients with normal renal and hepatic function unless otherwise noted. B. Not commercially available, manufactured by Pharmacy. C. Ocular toxicity may occur with prolonged use of aminoglycoside ophthalmic solutions (> 7-10 days). D. Retinal toxicity related to intravitreal use of aminoglycosides (gentamicin > amikacin). RECOMMENDED EMPIRIC THERAPY OF FUNGAL INFECTIONS Prepared by Dr. E. Blondel-Hill and Ms. S. Fryters Reviewed by Dr. S. Shafran, Director, Adult Infectious Diseases and Dr. A. Krol, Division of Dermatology and Cutaneous Sciences

Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Dose1 Duration Non-hair bearing Trichophyton spp Topical therapy with one - Oral therapy is effective, but skin Epidermophyton spp of: topical therapy is preferred. Tinea pedis* Microsporum spp Ciclopirox 1% Apply bid 2-4 weeks * Tinea pedis prone to Tinea cruris Clotrimazole 1% Apply bid 2-4 weeks recurrence; prolonged therapy Tinea manuum Ketoconazole 2% Apply daily 2-4 weeks (4-6 weeks) recommended. Tinea facei Miconazole 2% Apply bid 2-4 weeks Tinea corporis Naftifine 1% Apply daily - bid 2-4 weeks Terbinafine 1% Apply daily - bid 2-4 weeks Tolnaftate 1% Apply bid 2-4 weeks * 4-6 weeks for T. pedis Hair bearing skin Trichophyton spp Adult - Topical therapy not Tinea capitis Microsporum spp Terbinafine* 250mg PO daily 2-4 weeks recommended. Tinea barbae Itraconazole 100mg PO bid 4-8 weeks - For severe inflammatory Alternative disease (kerion), adjunctive Fluconazole 150mg PO weekly 4-8 weeks prednisone is sometimes used. Griseofulvin 250mg PO daily 6-12 weeks * Poor response with M. canis. Paediatrics Continue therapy for 6-8 Terbinafine* < 20kg weeks. 62.5mg PO daily 2-4 weeks 20-40kg or 125mg PO daily 2-4 weeks > 40kg 250mg PO daily 2-4 weeks

Griseofulvin 15-20mg/kg/d PO in 6-12 weeks divided doses RECOMMENDED EMPIRIC THERAPY OF FUNGAL INFECTIONS Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Dose1 Duration Tinea versicolor Malassezia furfur Topical: - Oral therapy recommended for: (Pityriasis (Pityrosporum orbiculare) Clotrimazole 1% Apply bid 7 days · extensive involvement versicolor) Ketoconazole 2% Apply daily 7 days · recurrent infections Miconazole 2% Apply bid 7 days · failure of topical agents. Selenium sulfide 2.5% Apply daily 7 days - Oral terbinafine (Lamisil®) is Terbinafine 1% Apply daily - bid 7 days not effective. Oral Itraconazole or 200mg PO daily 7 days Ketoconazole 200mg PO daily 7 days Onychomycosis Trichophyton spp Terbinafine 250mg PO daily 6 weeks (fingers) - Terbinafine is more effective (Tinea unguium) 12 weeks (toes) than either itraconazole or oral griseofulvin. Sporotrichosis · lympho- Sporothrix schenckii Itraconazole 200mg PO daily 6 months cutaneous · extra- Sporothrix schenckii - Refer to Infectious Diseases; cutaneous need for prolonged therapy. Candida Vaginal Candida albicans Asymptomatic candidiasis Occasionally non-albicans Treatment not spp necessary Symptomatic Fluconazole* or 150mg PO 1 dose * Fluconazole is not Clotrimazole recommended in pregnancy. 2% cream or 5g intravag hs 3 days - Fluconazole may be less tablet 200mg intravag hs or 3 days effective for non-albicans spp. 500mg intravag 1 dose or Econazole ovule or 150mg intravag hs 3 days Miconazole or 400mg intravag hs 3 days Terconazole 0.8% cream or 5g intravag hs 3 days ovule 80mg intravag hs 3 days RECOMMENDED EMPIRIC THERAPY OF FUNGAL INFECTIONS Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Dose1 Duration Candida (cont’d) Vaginal candidiasis Recurrent Candida albicans Fluconazole 50mg q M,W,F or 6 months* - Screen for HIV. Occasionally non-albicans 150mg q 7 days * Reassess for need to continue spp prophylaxis at 6 months. - Fluconazole is not recommended in pregnancy. Oral Candida albicans Nystatin susp or 500,000 U (5mL) qid 7-10 days - Screen for HIV unless: candidiasis Occasionally non-albicans Clotrimazole vag insert 100mg PO daily 7-10 days · infant (thrush) spp used orally · known immunodeficiency Alternative 7-10 days /immunosuppression Fluconazole 50mg PO daily · recent use of inhaled steroids. - For immunosuppressed Infants patients, fluconazole is Nystatin 100,000 U (1mL) qid 7-10 days recommended. Maintenance therapy may be necessary (e.g. 50mg M,W,F). Candiduria Candida spp Fluconazole* 200mg PO first day, 5 days - Need to treat asymptomatic then 100mg PO daily Candiduria not established. Alternative - Usually associated with foreign Amphotericin B 50mg/1000mL H2O at 1-2 days body in urinary tract. bladder irrigation 42mL/h - In chronic catheterization: or · consider therapy if 2 Amphotericin B 0.3mg/kg IV 1 dose repeated isolation of Candida spp (may indicate upper renal tract infection) · remove catheter if possible. * Fluconazole may not be effective against C. krusei or C. glabrata. RECOMMENDED EMPIRIC THERAPY OF FUNGAL INFECTIONS Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Dose1 Duration Candida (cont’d) Esophageal Candida albicans Fluconazole 100mg PO daily* 14 days - Always indicative of immuno- candidiasis Occasionally non-albicans suppression. spp * Suspension available. Invasive - Remove central venous and/or peritoneal dialysis catheters if possible. candidiasis - Discontinue broad spectrum antibiotics if possible. - Serial blood cultures (minimum daily x 3) to ensure sterilization. - Fundoscopic examination should be considered. - Increased mortality in elderly and ICU patients. - For positive Candida spp cultures: · C. krusei, C. glabrata - usually resistant to fluconazole · C. lusitaniae, C. guilliermondi - usually resistant to amphotericin B. Candida albicans Fluconazole 800mg IV loading minimum 14 days * Usually associated with Candida tropicalis* dose then after last positive prosthetic device, especially Candida parapsilosis* or 400-800mg IV/PO blood culture central venous catheters. Candida glabrata daily - Amphotericin B recommended Candida krusei Amphotericin B2 0.5-1mg/kg/d IV minimum 14 days empirically if: after last positive · hemodynamically blood culture unstable · neutropenic (ANC < 0.5 x 109/L) · suspect non-albicans Candida spp. Invasive Aspergillus fumigatus Amphotericin B2 1-1.5mg/kg/d IV prolonged - Infectious Diseases consult Aspergillosis Aspergillus flavus recommended. Other Aspergillus spp - Itraconazole (200mg PO bid) may be useful as a stepdown oral agent. RECOMMENDED EMPIRIC THERAPY OF FUNGAL INFECTIONS Infection Usual Pathogens Recommended Empiric Recommended Recommended Comments Therapy Dose1 Duration Fungal sinusitis Aspergillus spp Immunocompetent - In immunocompetent host, Rhizopus spp Antifungal therapy not fungi in sinuses may be Mucor spp routinely recommended associated with nasal polyposis Immunocompromised and do not routinely require Amphotericin B2 0.8-1.5mg/kg/d Total dose 2.5g antifungal therapy. (up to 3g for - In immunocompromised Mucor spp) patients/diabetic ketoacidosis, a fungal infection may present as a cellulitis that may rapidly progress and be fatal. Surgical debridement is necessary. Endemic Cryptococcus spp - Infectious Diseases consult mycoses Histoplasma spp strongly recommended. Blastomyces spp * Therapy/dose/duration Coccidioides spp dependent on clinical picture. 1. Unless otherwise indicated, usual adult dose in patients with normal renal and hepatic function. 2. Amphotericin B IV Test doses and incremental dosing are no longer recommended for the following reasons: a. hypersensitivity reactions and anaphylaxis are rare b. fever and chills associated with amphotericin B administration are not dose- or time-dependent c. commercial formulation now in use is of high purity d. causes unnecessary delays in patient receiving therapeutic dose.

The routine use of premedication (e.g. acetaminophen + diphenhydramine +/- corticosteroid +/- meperidine) is also no longer recommended prior to the initial dose of amphotericin B IV but may be administered promptly if an adverse reaction does occur, and then as pretreatment with subsequent amphotericin B doses. TREATMENT OF ENTERIC PARASITIC INFECTIONS Developed by Dr. S. Houston, Dr. E. Blondel-Hill, and Ms. S. Fryters Reviewed by Dr. S. Shafran, Director, Adult Infectious Diseases

Parasite Symptoms Recommended Recommended Recommended Comments Drug Dose Duration · This section includes the most common intestinal parasites (acquired locally or abroad) along with recommended therapy. · Ova and parasite exam recommended if diarrhea > 4 days duration. · Collect one sample initially. Use SAF fixative transport system. Multiple (3) stool samples on alternate days (collected within 10 days) indicated if: Þ chronic, persistent or relapsing diarrhea Þ illness in person with recent travel history or immigration from endemic areas Þ food handler Þ suspected helminthic infection. · Post treatment ova and parasite exam indicated for: Þ food handlers Þ institutionalized/long term care patients Þ post treatment amebiasis. HELMINTHS Trematodes

Clonorchis/ · usually Praziquantel 25mg/kg PO tid 1 day · Acquired from Opisthorchis asymptomatic or undercooked fish from 1 (liver fluke) · can cause Albendazole 400mg PO daily 7 days Southeast Asia. recurrent biliary symptoms/ cholan- giocarcinoma 1 Must be obtained through HPB Special Access Program (Emergency Release). Contact pharmacy for assistance in ordering. TREATMENT OF ENTERIC PARASITIC INFECTIONS

Parasite Symptoms Recommended Recommended Recommended Comments Drug Dose Duration HELMINTHS Nematodes Ascaris · usually Mebendazole 100mg PO bid 3 days · May cause eosinophilia. lumbricoides asymptomatic · Common in developing (roundworm) · not usually a countries. cause of diarrhea · May be acquired in Alberta– transmission via soil. · Worm migration may result in serious sequelae. Enterobius · perianal pruritus Adult & Paediatric · Most common human vermicularis Mebendazole 100mg PO Repeat in 2 parasite. (pinworm) weeks · Common in children and (2 doses total) household contacts.

Trichuris · diarrhea may Mebendazole 100mg PO bid 3 days · Acquired mostly in trichiura occur with heavy tropical regions. (whipworm) infections

Strongyloides · usually Ivermectin1 200mg/kg PO daily 2 days · Acquired mostly in stercoralis asymptomatic tropical regions. · may cause Alternative · May develop hyper- diarrhea +/- Albendazole1 400mg PO daily 3 days infection syndrome in eosinophilia immunocompromised patient. Infectious Diseases consult recommended. 1 Must be obtained through HPB Special Access Program (Emergency Release). Contact pharmacy for assistance in ordering. TREATMENT OF ENTERIC PARASITIC INFECTIONS

Parasite Symptoms Recommended Recommended Recommended Comments Drug Dose Duration HELMINTHS Nematodes (cont’d) Ancylostoma · usually Mebendazole 100mg PO bid 3 days · Acquired mostly in duodenale, asmptomatic tropical regions. Necator · does not cause · Intestinal blood loss may americanus diarrhea occur with heavy (hookworm) infections. Cestodes

Diphylloboth- · usually Praziquantel 5-10mg/kg PO 1 dose · Acquired from rium latum asymptomatic undercooked fresh water (fish tapeworm) fish, including salmon (North Canada). Taenia · usually Praziquantel 5-10mg/kg PO 1 dose saginatum asymptomatic (beef tapeworm)

Taenia solium · usually Praziquantel 5-10mg/kg PO 1 dose · May be transmitted to (pork tapeworm) asymptomatic others causing cysticercosis (treatment is albendazole). TREATMENT OF ENTERIC PARASITIC INFECTIONS

Parasite Symptoms Recommended Recommended Recommended Comments Drug Dose Duration PROTOZOA Blastocystis · diarrhea Asymptomatic · Potential pathogen. hominis · abdominal pain None · Treatment recommended and cramping Symptomatic Adult if symptomatic and other · nausea Metronidazole 750mg PO tid 10 days causes (infectious/non- Paediatric infectious) of diarrhea or 35-50mg/kg/d PO div 10 days have been excluded. tid · Little data available on Iodoquinol Adult optimal therapy. 650mg PO tid 20 days Paediatric 40mg/kg/d PO div tid1 20 days (max 650mg/dose) Chilomastix · usually None · Non-pathogenic. mesnilii asymptomatic · Found in persons exposed to poor sanitary conditions. Cryptosporidium · nausea No established · Self-limiting diarrhea (+/- 2 parvum · anorexia therapy weeks) in immunocompet- · weight loss ent patient. · watery diarrhea · Chronic diarrhea in · abdominal immunocompromised cramping patient (e.g. HIV). Cyclospora · nausea TMP/SMX 1 DS tab PO bid 7 days · Symptoms last an cayetanensis · anorexia average of 7 weeks · weight loss HIV patients (longer in immuno- · watery diarrhea TMP/SMX 1 DS tab PO qid 10 days compromised patient). · abdominal · Outbreaks linked to cramping ingestion of berries. 1 Available as 210 and 650mg tablets TREATMENT OF ENTERIC PARASITIC INFECTIONS

Parasite Symptoms Recommended Recommended Recommended Comments Drug Dose Duration PROTOZOA Dientamoeba · diarrhea Asymptomatic · Potential pathogen. fragilis (intermittent) None · Increased incidence of · abdominal pain Symptomatic Adult coinfection with pinworm. · nausea Iodoquinol 650mg PO tid 20 days Paediatric · anorexia 1 · fatigue or 40mg/kg/d PO div tid 20 days · weight loss (max 650mg/dose) Adult Tetracycline 500mg PO qid 10 days Paediatric, > 8 years old only or 40mg/kg/d PO div 10 days qid (max 2g/day) Adult & Paediatric 2 25-30mg/kg/d PO div 7 days Paromomycin tid Endolimax nana · usually None · Non-pathogenic. asymptomatic · Found in persons exposed to poor sanitary conditions. Entamoeba coli · usually None · Non-pathogenic. asymptomatic · Found in persons exposed to poor sanitary conditions. Entamoeba dispar · usually None · Non-pathogenic. asymptomatic · Microscopically indistinguishable from E. histolytica. 1 Available as 210 and 650mg tablets 2 Available as 250mg capsules TREATMENT OF ENTERIC PARASITIC INFECTIONS Parasite Symptoms Recommended Recommended Recommended Comments Drug Dose Duration PROTOZOA Entamoeba · diarrhea Metronidazole 750mg PO tid 10 days · May be asymptomatic histolytica · followed by cyst passer. (Amebiasis) · liver abscess Iodoquinol 650mg PO tid 20 days (to eradicate luminal cysts) Giardia lamblia · nausea Adult · May cause chronic · anorexia Metronidazole* 250mg PO tid or 5 days diarrhea and mal- · watery, foul 2g PO hs 3 days absorption. smelling diarrhea or Paediatric · May be asymptomatic. · abdominal pain 15mg/kg/d PO div tid 5 days * Can be used in 1 and distention Paromomycin** Adult & Paediatric pregnancy. 25-35mg/kg/d PO div 7 days ** Not absorbed; may be tid useful for treatment in pregnancy. Iodamoeba None · Non-pathogenic. buetschlii · Found in patients exposed to poor sanitary conditions. 1 Available as 250mg capsules RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS

A,B,C,D A,B,C,D SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS GENERAL Gastric surgery Gastroduodenal · Enterobacteriaceae · cefazolin 1g IV x 1 dose Cephalosporin allergy: Gastric resection · Gram positive cocci · gentamicin 1.5mg/kg IV + Gastroplasty clindamycin 600mg IV x 1 dose high risk only: decreased gastric acidity or motility, morbid obesity, gastric ulcer or malignancy, hemorrhage PEG Biliary tract surgery High risk: > 60 yrs old, · Enterobacteriaceae · cefazolin 1g IV x 1 dose Cephalosporin allergy: biliary obstruction, common · Enterococcus spp · gentamicin 1.5mg/kg IV + bile duct stones, acute · Clostridium spp clindamycin 600mg IV x 1 dose cholecystitis, previous biliary surgery, non-functioning gallbladder ERCP if biliary obstruction

Low risk OPTIONAL: · cefazolin 1g IV x 1 dose RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS

A,B,C,D A,B,C,D SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS GENERAL Bowel surgery Elective colorectal surgery · Enterobacteriaceae · cefazolin 1g IV + metronidazole Cephalosporin allergy: · Anaerobes 500mg IV x 1 dose · gentamicin 1.5mg/kg IV + or clindamycin 600mg IV x 1 dose · cefazolin 1g IV x 1 dose + erythromycin 1g PO + metronidazole 500mg PO at 1300h, 1400h & 2300h the day before surgery (after bowel prep) Appendectomy · Enterobacteriaceae No perforation, gangrene, peritonitis, Cephalosporin allergy: Emergency bowel surgery · Anaerobes or abscess: · gentamicin 1.5mg/kg IV + Bowel obstruction · cefazolin 1g IV + metronidazole clindamycin 600mg IV x 1 dose Fistulas/Discontinuous 500mg IV x 1 dose bowel segments Perforation, gangrene, peritonitis, or abscess (see perforated viscus below) Perforated viscus · Enterobacteriaceae · ampicillin 2g IV q6h + gentamicin Cephalosporin allergy: Institute treatment rather · Anaerobes 7mg/kg/day IV + metronidazole · gentamicin 7mg/kg/day IV + than prophylaxis · Enterococcus spp 500mg IV/PO q12h x at least 5 days clindamycin 600mg IV q8h x at (considered contaminated) least 5 days Herniorrhaphy · S. aureus · Prophylaxis not routinely indicated · S. epidermidis OPTIONAL for mesh insertion and/or · Streptococcus spp morbid obesity: Cephalosporin allergy: · cefazolin 1g IV x 1 dose · clindamycin 600mg IV x 1 dose Mastectomy/lumpectomy · S. aureus · Prophylaxis not routinely indicated · b-haemolytic Prophylaxis may be considered in Streptococci morbidly obese (> 150% IBW) Cephalosporin allergy: patients: · clindamycin 600mg IV x 1 dose · cefazolin 2g IV x 1 dose RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS

A,B,C,D A,B,C,D SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS OBSTETRICAL/GYNECOLOGICAL Abortion · Enterobacteriaceae 1st trimester: Cephalosporin allergy: · Anaerobes · doxycycline 100mg PO 1h pre-op + · gentamicin 1.5mg/kg IV + · Group B Streptococci 200mg PO ½ hour post-op clindamycin 600mg IV x 1 dose · Enterococcus spp or · cefazolin 1g IV x 1 dose All 2nd trimester: · cefazolin 1g IV x 1 dose Caesarean section · Enterobacteriaceae · cefazolin 1g IV x 1 dose after Cephalosporin allergy: high risk only: active labor, · Anaerobes clamping cord · gentamicin 1.5mg/kg IV + rupture of membranes > 6h · Group B Streptococci clindamycin 600mg IV after · Enterococcus spp clamping cord Hysterectomy · Enterobacteriaceae · cefazolin 1g IV +/- metronidazole Cephalosporin allergy: abdominal · Anaerobes 500mg IV x 1 dose · gentamicin 1.5mg/kg IV + vaginal · Group B Streptococci clindamycin 600mg IV x 1 dose · Enterococcus spp UROLOGY Retroperitoneal surgery Adrenalectomy · S. aureus · cefazolin 1g IV x 1 dose Cephalosporin allergy: Nephrectomy · Streptococcus spp · clindamycin 600mg IV x 1 dose

Ileal conduit · Enterobacteriaceae · cefazolin 1g IV + metronidazole Cephalosporin allergy: · Anaerobes 500mg IV x 1 dose · gentamicin 1.5mg/kg IV + clindamycin 600mg x 1 dose RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS

A,B,C,D A,B,C,D SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS UROLOGY Prostatectomy · Enterobacteriaceae Oral regimens: (give 1-2 h pre-op) transurethral or peritoneal · Pseudomonas spp · co-trimoxazole 1 DS tablet PO - negative urine culture · Enterococcus spp or · ciprofloxacin 500mg PO Positive urine culture - institute treatment rather Parenteral regimen: Cephalosporin allergy: than prophylaxis · cefazolin 1g IV x 1 dose · gentamicin 1.5mg/kg IV x 1 dose Urethral dilatation · Prophylaxis not routinely indicated

Vasectomy · Prophylaxis not routinely indicated

CARDIAC Open heart surgery Adults Prosthetic valve · S. aureus · cefazolin 1g IV pre-op + 1g IV q8h x Cephalosporin allergy: Coronary artery bypass · S. epidermidis 24h post-op · vancomycin 1g IV pre-op + 1g IV Other open heart surgery · Corynebacterium spp q12h x 24h post-op · Enterobacteriaceae · If patient hospitalized > 3 days pre-op, add gentamicin 1.5mg/kg IV pre-op + 1.5mg/kg IV q8-12h x 24h post-op RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS

A,B,C,D A,B,C,D SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS CARDIAC Open heart surgery (cont’d) Paediatrics Prosthetic valve · S. aureus Cephalosporin allergy: Congenital repairs · S. epidermidis Pre-op: Pre-op: · Corynebacterium spp · cefazolin 30mg/kg (max 1g) IV · vancomycin 20mg/kg (max 1g) IV · Enterobacteriaceae Post-op: Post-op: Closed sternum Closed sternum · cefazolin 30mg/kg (max 1g) IV q8h · vancomycin 20mg/kg (max 1g) x 2 doses post-op IV q12h x 1 dose post-op Open sternum, skin closed Open sternum, skin closed · cefazolin 30mg/kg (max 1g) IV q8h · vancomycin 20mg/kg (max 1g) x 2 doses post-op + cefazolin IV q12h x 1 dose post-op + 30mg/kg IV pre- & 8h post-closure vancomycin 20mg/kg IV pre- & 12h post-closure Open sternum, skin open (with patch) Open sternum, skin open (with or patch) or Sternum opened in PICU, skin open or Sternum opened in PICU, skin open closed or closed · cefazolin 30mg/kg (max 1g) IV q8h · vancomycin 20mg/kg (max 1g) + gentamicin 2.5mg/kg IV q12h x IV q12h + gentamicin 2.5mg/kg 48h post-op + same regimen pre- & IV q12h x 48h post-op + same 8h post-closure regimen pre- & 12h post-closure Pacemaker implant · S. aureus · cefazolin 1g IV x 1 dose Cephalosporin allergy: · S. epidermidis · clindamycin 300mg PO x 1 dose (give 1 h pre-op) or · clindamycin 600mg IV x 1 dose Cardiac catheterization · Prophylaxis not routinely indicated RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS

A,B,C,D A,B,C,D SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS THORACIC Esophageal resection · S. aureus Pre-op: Cephalosporin allergy: · S. epidermidis · cefazolin 1g IV + metronidazole Pre-op: · Streptococcus spp 500mg IV · gentamicin 1.5mg/kg IV + · Enterobacteriaceae clindamycin 600mg IV · Oral anaerobes Post-op: Post-op: · cefazolin 1g IV q8h + · gentamicin 1.5mg/kg IV q8-12h + metronidazole 500mg IV q12h x clindamycin 600mg IV q8h x maximum of 48h maximum of 48h Pneumonectomy · S. aureus Pre-op: Cephalosporin allergy: · S. epidermidis · cefazolin 1g IV Pre-op: · Streptococcus spp or · gentamicin 1.5mg/kg IV + · Enterobacteriaceae · cefuroxime 750mg IV clindamycin 600mg IV · Oral anaerobes Post-op: Post-op: · cefazolin 1g IV q8h until chest · gentamicin 1.5mg/kg IV q8-12h + tubes removed or maximum of 48h clindamycin 600mg IV q8h until or chest tubes removed or · cefuroxime 750mg IV q8h until maximum of 48h chest tubes removed or maximum of 48h Lobectomy · S. aureus Pre-op: Cephalosporin allergy: complete or partial · S. epidermidis · cefazolin 1g IV Pre-op: · Streptococcus spp · clindamycin 600mg IV +/- · Enterobacteriaceae gentamicin 1.5mg/kg IV · Oral anaerobes Post-op (OPTIONAL): Post-op (OPTIONAL): · cefazolin 1g IV q8h x 2-3 doses · clindamycin 600mg IV q8h +/- gentamicin 1.5mg/kg IV q8-12h x 2-3 doses RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS

A,B,C,D A,B,C,D SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS VASCULAR Arterial surgery involving · S. aureus · cefazolin 1g IV x 1 dose Cephalosporin allergy: the abdominal aorta, a · S. epidermidis · clindamycin 600mg IV x 1 dose prosthesis, or a groin · Enterobacteriaceae or incision · vancomycin 1g IV x 1 dose Carotid endarterectomy · S. aureus · Prophylaxis not routinely indicated · S. epidermidis If prosthetic material: Cephalosporin allergy: · cefazolin 1g IV x 1 dose · clindamycin 600mg IV x 1 dose or · vancomycin 1g IV x 1 dose PLASTICS Reconstructive surgery Tissue flaps · S. aureus · cefazolin 1g IV x 1 dose Cephalosporin allergy: Reduction mammoplasty · Streptococcus spp · clindamycin 600mg IV x 1 dose Panniculectomy Reconstructive limb surgery with possible contamination · S. aureus · cefazolin 1g IV q8h + gentamicin Cephalosporin allergy: · Streptococcus spp 7mg/kg/day IV x at least 7 days · gentamicin 7mg/kg/day IV + Institute treatment rather · Enterobacteriaceae · if heavily soiled add metronidazole clindamycin 600mg IV q8h x at than prophylaxis · Anaerobes 500mg IV/PO q12h to above least 7 days regimen RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS

A,B,C,D A,B,C,D SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS ORTHOPEDIC Joint replacement · S. aureus · cefazolin 1g IV pre-op +/- 1g IV q8h Cephalosporin allergy: Fractures with internal · S. epidermidis x 2 doses post-op · clindamycin 600mg IV pre-op +/- fixation (nails, plates, wires) 600mg IV q8h x 2 doses post-op or · vancomycin 1g IV pre-op +/- 1g IV q12h x 2 doses post-op Fractures, complex (open) · S. aureus · cefazolin 1g IV q8h + gentamicin Cephalosporin allergy: considered contaminated · S. epidermidis 7mg/kg/day IV x at least 7 days · gentamicin 7mg/kg/day IV + · Enterobacteriaceae · If heavily soiled add metronidazole clindamycin 600mg IV q8h x at Institute treatment rather 500mg IV/PO q12h to above least 7 days than prophylaxis regimen or · vancomycin 1g IV q12h + gentamicin 7mg/kg/day IV x at least 7 days Amputation of lower limb · S. aureus · cefazolin 1g IV + metronidazole Cephalosporin allergy: · S. epidermidis 500mg IV x 1 dose · gentamicin 1.5mg/kg IV + · Enterobacteriaceae clindamycin 600mg IV x 1 dose · Clostridium spp SPINAL SURGERY Laminectomy · S. aureus Spinal fusion, prolonged surgery, Cephalosporin allergy: Microdiscectomy · S. epidermidis insertion of prosthetic material: · clindamycin 600mg IV x 1 dose Spinal fusion · cefazolin 1g IV x 1 dose or · vancomycin 1g IV x 1 dose RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS

A,B,C,D A,B,C,D SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS NEUROSURGERY Craniotomy · S. aureus · cefazolin 1g IV x 1 dose Cephalosporin allergy: high risk only: re-exploration, · S. epidermidis · clindamycin 600mg IV x 1 dose microsurgery or · vancomycin 1g IV x 1 dose Cerebrospinal fluid shunting · S. aureus · cefazolin 1g IV x 1 dose Cephalosporin allergy: operations · S. epidermidis · vancomycin 1g IV x 1 dose External ventricular drain · S. aureus · cefazolin 1g IV x 1 dose pre- Cephalosporin allergy: (EVD) · S. epidermidis insertion + cefazolin 1g IV x 1 dose · vancomycin 1g IV x 1 dose pre- Intracranial pressure (ICP) pre-removal insertion + vancomycin 1g IV x 1 monitor dose pre-removal OPHTHALMOLOGY Cataract extraction · S. aureus Eye drops pre-op: Corneal transplant · S. epidermidis · gentamicin Retinal detachment · Streptococcus spp or Vitrectomy · Enterobacteriaceae · tobramycin Dacryocystorhinostomy · Pseudomonas spp or Eyelid Surgery · polymyxin B - gramicidin Cephalosporin allergy: Enucleation Subconjunctival injection at end of Subconjunctival injection at end of procedure: procedure: · cefazolin 100mg · gentamicin 20mg x 1 dose or · tobramycin 20mg x 1 dose RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS

A,B,C,D A,B,C,D SURGERY COMMON PATHOGENS REGIMEN(S) OF CHOICE ALTERNATIVE REGIMENS HEAD AND NECK Oropharyngeal surgery incision through oral or · S. aureus Cephalosporin allergy: pharyngeal mucosa · Streptococcus spp · cefazolin 1g IV x 1 dose · clindamycin 600mg IV x 1 dose · Oral anaerobes For specific recommendations, refer to Dental section, Antimicrobial Prophylaxis in Dentistry. Tonsillectomy · Prophylaxis not routinely indicated Adenoidectomy Rhinoplasty

A. Postoperative doses are not routinely indicated. If the surgery is contaminated, please indicate the postoperative antibiotic orders are for treatment. B. Recommended adult doses for patients with normal weight and renal function. Refer to dosing guidelines for more information. For adult patients with total body weight > 100kg, use cefazolin 2g IV. For paediatric doses, see Paediatric Dosing Guide. C. When gentamicin is ordered in combination for prophylaxis, give gentamicin first (administer over 30 minutes just prior to procedure). When vancomycin is ordered, administer over at least 60 minutes just prior to procedure. D. Intraoperative dosing is not routinely indicated unless it is a prolonged surgical procedure e.g. cefazolin q4h intraoperatively vancomycin q12h intraoperatively ANTIMICROBIAL PROPHYLAXIS FOR THE PREVENTION OF BACTERIAL ENDOCARDITIS

ENDOCARDITIS PROPHYLAXIS RECOMMENDED ENDOCARDITIS PROPHYLAXIS NOT RECOMMENDED Cardiac Conditions Cardiac Conditions

High risk: Negligible risk: Prosthetic cardiac valves (including bioprosthetic and homograft Previous coronary artery bypass graft surgery valves) prolapse without valve regurgitation1 Previous bacterial endocarditis (even in absence of heart disease) Physiologic, functional or innocent heart murmurs Complex cyanotic congenital cardiac defects Cardiac pacemaker/defibrillator Surgically constructed systemic pulmonary shunts or conduits Isolated secundum atrial septal defect (ASD) Moderate risk: Surgical repair of ASD, VSD, or PDA without residua beyond 6 mos. Most other congenital cardiac defects Previous RHD* or Kawasaki disease without valve dysfunction Acquired valve dysfunction [e.g. rheumatic heart disease (RHD)*] Hypertrophic with valve regurgitation &/or thickened leaflets

Dental or Surgical Procedures Dental or Surgical Procedures

Dental/oral2: Procedures which cause gingival or mucosal bleeding Dental/oral: Procedures not likely to cause gingival bleeding (fillings (including professional cleaning). above gum line, adjustment of orthodontic appliances, injection of Resp. tract: Tonsillectomy and/or adenoidectomy. Surgical intraoral anaesthetics, shedding of primary teeth) procedures that involve respiratory mucosa. Bronchoscopy with rigid Resp tract: Tympanostomy tube insertion. Endotracheal intubation. bronchoscope. Bronchoscopy with flexible scope +/- biopsy4. GI3: Sclerotherapy for esophageal varices. Esophageal dilatation. GI: TEE4. Endoscopy +/- biopsy4. ERCP with biliary obstruction. Biliary tract surgery. Surgical GU: C-section. Vaginal hysterectomy or uncomplicated vaginal procedures that involve intestinal mucosa. delivery4. If no infection: urethral catheterization, uterine D&C, GU: Cystoscopy. Urethral dilatation. Prostatic surgery. In presence of therapeutic abortion, sterilization procedures, insertion/removal of IUD. infection: any GU procedure (NB: attempt to treat infection prior to Other: Cardiac catheterization. Implantation of cardiac pacemakers, procedure). defibrillators, stents. Incision/biopsy of surgically scrubbed skin. Circumcision.

* Patients who have had rheumatic fever but do not have evidence of RHD, do NOT need prophylaxis. 1. Males > 45 yrs with MVP, without a consistent systolic murmur, may warrant prophylaxis. 2. Prophylaxis recommended for patients with high and moderate risk cardiac conditions listed in left-hand box above. 3. Prophylaxis recommended for patients with high risk cardiac conditions; optional for patients with moderate risk cardiac conditions. 4. Prophylaxis optional for patients with high risk cardiac conditions. ANTIMICROBIAL PROPHYLAXIS FOR THE PREVENTION OF BACTERIAL ENDOCARDITIS

SITUATION DRUG DOSE (ADULTS1)/ SITUATION DRUG DOSE (ADULTS1)/ ROUTE/DURATION ROUTE/DURATION

Dental, Oral, Respiratory Tract, Esophageal Procedures Genitourinary/Gastrointestinal (excluding Esophageal) Procedures

Standard Amoxicillin 2g PO 1h before High risk Ampicillin + 2g IV/IM + Gentamicin 1.5mg/kg IV/IM (max. No oral intake Ampicillin 2g IV/IM £ 30 min before 120mg) £ 30 min before then 6h later: then 6h later: Pen-allergic Clindamycin 300mg2 PO 1h before Ampicillin or 1g IV/IM or Amoxicillin 1g PO or High risk, Vancomycin + 1g IV over 1-2 h + Azithromycin3 500mg PO 1 h before Pen-allergic Gentamicin 1.5mg/kg IV/IM (max. 120mg) £ 30 min before or Moderate risk Amoxicillin 2g PO 1h before Clarithromycin3 500mg PO 1 h before or Ampicillin 2g IV/IM £ 30 min before Pen-allergic, Clindamycin 300-600mg IV £ 30 min no oral intake before Moderate risk, Vancomycin 1g IV over 1-2 h £ 30 min or pen-allergic before

Cefazolin4 1g IV/IM £ 30 min before 1. Paediatric doses: amoxicillin/ampicillin 50mg/kg (pre-procedure), 25mg/kg (post-procedure); clindamycin 20mg/kg; azithromycin/clarithromycin 15mg/kg; cefazolin 25mg/kg; gentamicin 2mg/kg; vancomycin 20mg/kg. Total paediatric dose should not exceed adult dose. 2. Clindamycin doses of 600mg are not needed. A dose of 300mg achieves adequate serum levels and is better tolerated. 3. Azithromycin and clarithromycin offer no microbiological advantage over erythromycin but are better tolerated. Activity of all macrolides against Viridans Group Streptococci may not be optimal. 4. Cephalosporins should not be used in patients with severe/immediate-type (e.g. urticaria/angioedema, anaphylaxis) penicillin allergy. Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277:1794-1801. BLOOD/BODY FLUID EXPOSURE

Exposure - percutaneous, mucosal (eyes, nose, mouth, vagina, rectum), or non-intact skin exposure to: · blood · body fluids (vaginal secretions, semen, CSF, synovial/pleural/ peritoneal/pericardial/amniotic fluids) · other fluids containing visible blood NB: · Urine, feces, vomitus, tears and respiratory secretions are not considered infectious unless contaminated with blood. · Saliva - a potential risk for HBV transmission only, unless contaminated with blood · Vaginal/seminal fluids – very low risk for HCV transmission, unless contaminated with blood

Immediate Management - 1. Encourage bleeding of cut/puncture wounds and cleanse with soap and water, followed by isopropyl alcohol (70%) swab. 2. Splashes to mucous membranes (eyes, nose, mouth) should be flushed with water ASAP for 10 minutes. 3. Remove contaminated clothing. 4. Report accident as soon as possible. See Table 1

NB: Counseling is an essential component of blood/body fluid exposure management.

Table 1 - Significant Blood/Body Fluid Exposure

Contact After Hours 0830 - 2200h 2200 - 0830h Community Needlestick Response Team Regional Public Health 480-6598 (beeper) 433-3940 (answering service) 0800 - 1600h Monday - Friday 1600h - 0800h Monday-Friday Occupational Health & Safety Saturday and Sunday UAH 407-6968 RAH 477-4175 Emergency Department Hospital GNCHHC 450-7311 Leave voice mail message with MCHHC 930-5806 Occupational Health & Safety. SCHHC 460-6320 Glenrose 471-7919 EG Site 482-8311 BLOOD/BODY FLUID EXPOSURE

Risk of Infection

HIV percutaneous High risk: exposure 0.3% · deep injury · visible blood in device · source mucous Þ early stage of HIV membrane 0.1% Þ end stage AIDS · large volume Hepatitis B 10-30% Hepatitis B vaccination strongly recommended for all health care workers. Hepatitis C 3% Most common blood-borne virus.

Hepatitis B Follow-up Protocol

RECIPIENT* Anti-HBsAg Anti-HBsAg Anti-HBsAg positive negative, negative previously (not immunized) positive HBsAg No intervention · Vaccine booster · HBIG** & Hepatitis positive · Hepatitis B B vaccination series serology 1 · Hepatitis B serology month after at 3 and 6 months booster HBsAg No intervention · Vaccine booster · Hepatitis B negative · Hepatitis B vaccination series S serology 1 · Hepatitis B serology O month after (post vaccine U booster series) R HBsAg No intervention · Vaccine booster · Hepatitis B C status · Hepatitis B vaccination series E unknown/ serology 1 · Hepatitis B serology low risk month after at 3 and 6 months booster HBsAg No intervention · Vaccine booster · HBIG & Hepatitis B status · Hepatitis B vaccination series unknown/ serology 1 · Hepatitis B serology high month after at 3 and 6 months risk*** booster * If recipient has tested HBsAg positive in last 2 years - no need to retest. ** Hepatitis B immune globulin - obtain from Canadian Blood Services BLOOD/BODY FLUID EXPOSURE *** High risk: high risk sexual behaviour (homosexual men, sexual partner who is an injection drug user [IDU], multiple sexual partners), other STDs, sexual or blood contact with a known case of HBV, IDU, tattoos/body piercing, persons from endemic areas (e.g. SE Asia, Subsaharan Africa)

HIV Follow-up Protocol

SOURCE RECIPIENT All cases Do base line HIV serology. If source HIV negative Repeat HIV serology in 6 months If source HIV status unknown and low Repeat HIV serology in 3 and 6 months risk If source HIV status unknown and If negative, retest at 6 weeks, 3 and 6 high risk* months. Prophylaxis If source HIV positive If negative, retest at 6 weeks, 3 and 6 months. Anti-retroviral prophylaxis - see next page. Consult Infectious Diseases Specialist to assess need for: · 2 drug (standard) prophylaxis or · 3 drug (high risk) prophylaxis. * High risk: high risk sexual behaviour (homosexual men, sexual partner who is an injection drug user [IDU], multiple sexual partners), other STDs, sexual or blood contact with a known case of HIV, IDU, tattoos/body piercing

Hepatitis C Follow-up Protocol

SOURCE RECIPIENT All cases Do base line hepatitis C serology If source hepatitis C negative Repeat hepatitis C serology in 6 months If source hepatitis C status unknown Repeat hepatitis C serology in 3 and 6 months If source hepatitis C positive or Repeat hepatitis C serology in 3 and 6 hepatitis C status unknown and high months. Refer to Infectious Disease risk* Specialist. Offer counselling. * High risk: IDU, receipt of blood or blood products before 1990 or blood-derived coagulation products after 1985, dialysis, tattoos/body piercing, sexual or blood contact with a known case of HCV, high risk sexual behavior (homosexual men, sexual partner who is an injection drug user [IDU], multiple sexual partners) BLOOD/BODY FLUID EXPOSURE Anti-retroviral Prophylaxis

- Prophylaxis should be started as soon as possible (within 1-2 hours) after exposure (to a maximum of 96 hours). - Short term supply of antiretroviral agents (2 or 3 drug regimens) available from Pharmacy (after hours - through Emergency department) within Capital Health region. Further therapy given depending on: · HIV status of source patient · risk factors of source patient · type of exposure.

SOURCE - KNOWN HIV Consult Infectious Diseases specialist to assess if give: Standard Prophylaxis · 2 drugs: Zidovudine (AZT) 200mg PO tid x 28 days Lamivudine (3TC) 150mg PO bid x 28 days OR High Risk Prophylaxis Þ source is HIV patient in early/acute infection or end-stage AIDS Þ large volume exposure from HIV positive patient · 3 drugs: Zidovudine (AZT) 200mg PO tid x 28 days Lamivudine (3TC) 150mg PO bid x 28 days Indinavir 800mg PO tid x 28 days

SOURCE KNOWN - HIV SEROLOGY PENDING

· If source patient high risk (see HIV follow-up protocol), give standard prophylaxis pending serology results. Þ If HIV negative, discontinue prophylaxis. Þ If HIV positive, consult Infectious Diseases.

SOURCE UNKNOWN

· Anti-retroviral prophylaxis not recommended. SEXUAL ASSAULT - Adults Developed by Dr. Barb Romanowski Reviewed by Dr. Bonnie Abel, Medical Director, SARTE

SARTE (Sexual Assault Response Team Edmonton) is available to provide assistance – 445-3359.

Tests recommended in sexual assault: · vaginal wet mount for Trichomonas vaginalis · vaginal gram stain, pH/amine odour/whiff test · cultures* from appropriate sites (urethra, endocervix, rectum, pharynx) for: Þ Neisseria gonorrhoeae Þ Chlamydia trachomatis * non-culture diagnostic tests (e.g. EIA, Gen-Probe) are not recommended in sexual assault cases NB: All above tests should ideally be performed a minimum of 72 hours post assault (< 72 hours may indicate pre-assault infection or false negative) · serology (baseline): Þ syphilis (RPR and MHA-TP)* Þ HIV* Þ Hepatitis B

Prophylaxis - sexual assault: · indication for prophylaxis must be individualized · prophylaxis indicated if: Þ assailant infected Þ prophylaxis requested by victim Þ victim unlikely to return for follow-up Þ victim has symptoms/signs of infection

Organism Prophylaxis/Treatment Neisseria gonorrhoeae Ciprofloxacin 500mg PO x 1 dose or Cefixime 400mg PO x 1 dose PLUS Chlamydia trachomatis Azithromycin 1g PO x 1 dose +/- Trichomonas vaginalis Metronidazole 2g PO x 1 dose Hepatitis B Hepatitis B immunoglobulin + Hepatitis B vaccine at 0, 2, 6 months (alternative = 0, 1, 4 months) HIV If assailant known to be HIV positive: · offer HIV post exposure prophylaxis · consult Infectious Diseases. * Follow up syphilis and HIV serology at 2, 6, 12 and 24 weeks post assault. IMMUNIZATION RECOMMENDATIONS

Alberta Vaccination Schedule (Infants/Children) Age Vaccine 2 months DaPTP, Hib 4 months DaPTP, Hib 6 months DaPTP, Hib 12 months MMR (1st dose) 18 months DaPTP, Hib 4-6 years DaPTP, MMR (2nd dose) Grade 5 Hepatitis B (3 doses) 14-16 years Td (and every 10 years thereafter, i.e. at age 25, 35, etc.) DaPTP = Diphtheria, acellular Pertussis, Tetanus, MMR = Measles, Mumps, Rubella Polio (Inactivated) Td = Tetanus, Diphtheria Hib = Haemophilus influenzae type B Adapted from Can J Infect Dis 1999;10(1):14.

Pneumococcal Vaccine

Strongly Recommended - high risk*:

· asplenia (traumatic/surgical/congenital) · splenic dysfunction · sickle-cell disease NB: Where possible give vaccine 10-14 days prior to splenectomy or at beginning of chemotherapy for Hodgkin’s disease * Vaccine failures may occur in this group - advise counseling (re: fulminant pneumococcal sepsis and need to seek early medical advice with fever).

Recommended:

· all persons ³ 65 years old · all residents of long term care facilities · patients with chronic cardiovascular/pulmonary disease, cirrhosis, alcoholism, chronic renal disease, diabetes mellitus, HIV infection, and other conditions associated with immunosuppression, chronic cerebrospinal fluid leak

NB: Vaccine may be administered simultaneously with influenza vaccine (separate injection site)

Not recommended:

· children < 2 years of age · asthma (as the single underlying condition) · otitis media (as the single underlying condition) Adapted from: 1. Canadian Immunization Guide – Health Canada, 5th edition, 1998. 2. Communication from Disease Control and Prevention – Alberta Health, October 1998. IMMUNIZATION RECOMMENDATIONS

Meningococcal Vaccine

In Capital Health, due to increased incidence of meningococcal disease in 1999-2000, immunization recommended for persons 2-24 years old. General recommendations include: · asplenic patients (See Functional/Anatomical Asplenia below) · individuals travelling* to: Þ sub-Saharan Sahel region (“meningitis belt”) of Africa Þ Saudia Arabia Þ other regions depending on current epidemic activity*. * Consult Travel Clinic (requires individual assessment). Dose: 0.5 mL SC (booster at 5 years)

- Vaccine coverage includes serogroups A, C, Y, W-135. In Capital Health, most meningococcal cases due to serogroup C. - Vaccine offers > 90% protection in individuals 2 years of age and older. - The vaccine takes 10-14 days to become effective. - Protection for serogroup C disease lasts ~5 years in individuals 2 years of age and older. - Pregnancy and breastfeeding are NOT contraindications to meningococcal immunization. Not recommended: · children < 2 years of age Adapted from: 1. Canadian Immunization Guide – Health Canada, 5th edition, 1998. 2. Communication from Capital Health Regional Public Health, February 14, 2000.

Functional/Anatomical Asplenia

Highly recommendeda:

· Influenza vaccine annually during peak season [0.5 mL IM] · Haemophilus vaccine [0.5 mL IM]b · Pneumococcal vaccine (booster at 3-6 years, depending on age at revaccination) [0.5 mL IM/SC] b

Recommendeda,c: · Meningococcal vaccine (booster every 5 years) [0.5 mL SC] b a. Vaccine failures may occur in this group – advise counselling (re: fulminant sepsis and need to seek early medical advice with fever). b. Where possible give vaccines 10 – 14 days prior to splenectomy or beginning of chemotherapy for Hodgkin’s disease. c. The need for meningococcal vaccine in this patient population is controversial. However, given the increased incidence of meningococcal disease in the Capital Health region in 1999-2000, this vaccine is currently recommended, in addition to the other three listed. In children up to 5 years old and patients within 1 year after asplenia, penicillin prophylaxis is recommended. Decision to continue prophylaxis beyond this time frame should involve Infectious Diseases specialist. Adapted from: 1. Capital Health Regional Public Health Communicable Disease Corner 1997(Aug); 7: 3 2. Canadian Immunization Guide – Health Canada, 5th edition, 1998. IMMUNIZATION RECOMMENDATIONS 3. Infectious Diseases and Immunization Committee, Canadian Paediatric Society. Prevention and therapy of bacterial infections for children with asplenia or hyposplenia. Paed Child Health 1999;4:417- 21.

Influenza Vaccine

Vaccine should be given annually to: High risk:

· adults and children with chronic cardiac or pulmonary disorders (bronchopulmonary dysplasia, cystic fibrosis, asthma) or with chronic conditions [diabetes and other metabolic diseases, cancer, immunodeficiency (including HIV), immunosuppression (including renal transplants), renal disease, anemia, hemoglobinopathy] · residents of nursing homes or long term care facilities · people ³ 65 years of age · children and adolescents (6 mo - 18 yrs) with conditions treated with long term acetylsalicylic acid · people at high risk of influenza complications traveling to foreign destinations where influenza is likely to be circulating People capable of transmitting influenza to those at high risk:

· health care workers and other personnel who have continuous, direct care contact with people in high risk groups (above) · household contacts (including children) of people at high risk who cannot be immunized or are immunosuppressed or elderly/frail Others:

· people who provide essential community services and other adults who wish to reduce their chances of acquiring infection and consequently missing work · pregnant women in high risk groups (vaccine is considered safe for pregnant women, regardless of stage of pregnancy)

Protection begins 2 weeks post vaccination and lasts up to 6 months (may be less in the elderly). Adapted from Canada Communicable Diseases Report 2000;26(ACS-2):1-15.

Hepatitis A Vaccine

Recommended: · long term or frequent travellers to endemic regions · residents of communities with high endemic rates or recurrent outbreaks of Hepatitis A · persons planning to live for prolonged periods in developing countries · members of the armed forces, emergency relief organization workers, and others likely to be posted abroad at short notice to areas with high rates of Hepatitis A infections · residents and staff of institutions for mentally handicapped · personnel working with Hepatitis A virus · zoo-keepers, veterinarians, and researchers who handle non-human primates · patients with hemophilia A or B who receive plasma derived clotting factors · patients with underlying chronic liver disease (e.g. Hepatitis B or C) May be considered: · high risk for infection (homosexual men, illicit drug use) · inmates of correctional facilities where there is an ongoing problem with Hepatitis A infections not responsive to other control measures IMMUNIZATION RECOMMENDATIONS Adapted from: 1. Canada Communicable Diseases Report 1994; 20: 133-143. 2. MMWR 1999;48(RR12):1-37.

Varicella Vaccine

The National Advisory Committee on Immunization (NACI) recommends primary vaccination of healthy persons > 12 months who are susceptible to the disease, especially:

· health care workers · individuals in close contact with pregnant women · household contacts of immunocompromised individuals · child care workers · primary and secondary school teachers.

Þ It is estimated that the vaccine offers 70 - 90% protection against varicella of any severity and 95% protection against severe varicella for at least 7 - 10 years post-vaccination.

A comprehensive varicella vaccination program will be implemented by Public Health in 2001. Call Health Link (408-5465) for details.

Dose: · 12 months - 12 years 1 x 0.5mL dose

· ³ 13 years 2 x 0.5mL doses at least 28 days apart

NB: Should not be given within: Þ 14 days preceding administration of immunoglobulins or blood products Þ 4 weeks of receipt of another live vaccine. Not recommended in:

· children < 12 months of age · persons with hypersensitivity to any component of the vaccine including gelatin and neomycin (contact dermatitis to neomycin is NOT a contraindication) · immunocompromised patients - vaccine may be beneficial in select cases. Consult Infectious Diseases specialist. · pregnant patients - avoid pregnancy for 1 month post-vaccination · persons with blood dyscrasias · persons with active untreated tuberculosis.

Critical issues that require more study include:

Þ duration of vaccine-induced immunity Þ long term impact of vaccine on varicella and herpes zoster (shingles) Þ coverage levels required to prevent emergence of/transmission to susceptible cohorts in older populations. Adapted from: 1. Canada Communicable Disease Report 1999; 25: 1-16. 2. Capital Health Regional Public Health Communicable Disease Corner 1999(May);3:1. 3. Infectious Diseases and Immunization Committee. Varicella vaccine: summary of a Canadian consensus conference. Can J Infect Dis 1999;10:331-2. PROPHYLAXIS FOR CONTACTS OF COMMUNICABLE DISEASES INVASIVE DISEASE

Neisseria meningiditis* - Prophylaxis recommended for: · household contacts, including those frequently eating or sleeping in same dwelling · child care facility or nursery school contacts · individuals in contact with index case’s nasopharyngeal secretions (i.e. kissing, sharing food or beverages) within last 7 days · medical personnel if mouth-to-mouth resuscitation, intubation, or nasotracheal suctioning before antibiotics begun · index case unless treated with cefotaxime/ceftriaxone.

Recommended Prophylaxis Children Adults Rifampin 1 month 10mg/kg PO bid x 2 days (max 600mg) Ceftriaxone > 1 month – 12 years 125mg IM single dose 250mg IM single dose > 12 years 250mg IM single dose Ciprofloxacin 500mg PO single dose

Haemophilus influenzae type B* - Prophylaxis recommended for: · household contacts if: · ³ 1 child £ 4 years incompletely vaccinated or · any child < 12 mos or · immunocompromised child(ren) regardless of vaccination status Þ prophylax all household contacts except pregnant women · child care facility or nursery school contacts if: · ³ 2 cases within 60 days in facility and incompletely vaccinated children attend or · 1 case in facility and incompletely vaccinated children £ 2 years attend Þ prophylax children and personnel (except if pregnant) · index case if any of above scenarios AND treated with ampicillin or chloramphenicol; not needed if treated with cefotaxime/ceftriaxone. - Unvaccinated or incompletely vaccinated children should also receive a dose of vaccine and be scheduled for completion of the recommended age-specific immunization schedule (See Immunization Recommendations).

Recommended Prophylaxis Children Adults Rifampin 1 month 20mg/kg PO daily x 4 days (max 600mg) * Reportable to the Medical Officer of Health (Capital Health 413-7600; after hours/weekends 433-3940). Public Health will do contact investigation, follow-up, and prophylaxis. PROPHYLAXIS FOR CONTACTS OF COMMUNICABLE DISEASES INVASIVE DISEASE (cont’d)

Group A Streptococcal (GAS) Disease*

Chemoprophylaxis recommended for household/close contacts** of patients with the following:

· Streptococcal Toxic Shock Syndrome

· necrotizing fasciitis/myositis/soft tissue necrosis

· death directly attributable to invasive GAS within 7 days of diagnosis

· GAS pneumonia

**household contacts: all contacts living in the same household as the case patient within 7 days of patient becoming ill

close contacts: persons who share sleeping arrangements and/or persons who have had direct mucous membrane contact with oral/nasal secretions within 7 days of patient becoming ill

Recommended Prophylaxis Children Adults

Cephalexin 25-30mg/kg/day x 10 days 250mg PO qid x 10 days (max 500mg/dose) or 500mg PO bid x 10 days

Pen VK 25-30mg/kg/day x 10 days 300mg PO qid x 10 days (max 500mg/dose)

Erythromycin 25-30mg/kg/day x 10 days 250mg PO qid x 10 days (estolate) (base) (max 500mg/dose) * Reportable to the Medical Officer of Health (Capital Health 413-7600; after hours/weekends 433-3940). Public Health will do contact investigation and follow-up.

Adapted from: 1. Alberta Advisory Committee on Communicable Disease Control, 1996. 2. Capital Health Regional Public Health Communicable Disease Corner 1999(Aug);3: 8. PROPHYLAXIS FOR CONTACTS OF COMMUNICABLE DISEASES INFLUENZA A

· Amantadine is 70-90% effective in preventing Influenza A (not effective against Influenza B).

· Amantadine prophylaxis indicated: Þ for control of Influenza A outbreaks among high risk residents of institutions Þ as an adjunct to late vaccination of people at high risk Þ as sole agent for prophylaxis during an influenza outbreak in high risk individuals where vaccination cannot be given Þ as a supplement to vaccination in high risk individuals with impaired immune response to the vaccine Þ for unvaccinated persons who provide hands on patient care for high risk individuals during an outbreak.

· Duration of amantadine prophylaxis should be 8 days from last infectious case OR 14 days total, whichever comes first.

NB: Amantadine prophylaxis should not replace annual influenza vaccination in groups where vaccination is recommended.

Recommended Amantadine Dosage by Age and Renal Status

Age Dosage No recognized renal disease 1-9 yearsA 5mg/kg divided once or twice daily, total daily dose <150mg 10-64 years 200mg divided once or twice dailyB ³ 65 years 100mg once dailyC Recognized renal disease Creatinine clearance Dosage (mL/min/1.73m2) 10-64 years old > 65 years old ³ 80mL/min 100mg twice daily 100mg once daily 60-79mL/min Alternating daily doses of Alternating daily doses of 200mg and 100mg 100mg and 50mg 40-59mL/min 100mg once daily 100mg every 2 days 30-39mL/min 200mg twice weekly 100mg twice weekly 20-29mL/min 100mg three times/week 50mg three times/week 10-19mL/min Alternating weekly doses of Alternating weekly doses 200mg and 100mg of 100mg and 50mg A Use in children < 1 year of age has not been evaluated adequately. B Dosage reduction to 100mg/day is recommended for people with a seizure disorder as they may be at risk for more frequent seizures with the higher dosage. C The reduced dosage is recommended to minimize the risk of toxic effects, as renal function generally declines with age and side effects have been reported more frequently in the elderly. Calculation of estimated creatinine clearance: (140 – age) x IBW* (kg) * If ABW < IBW, use ABW. Females Clcr (mL/min) = Scr (mmol/L) Males Clcr (mL/min) = Clcr (female) x 1.2 Adapted from Canada Communicable Diseases Report 2000;26(ACS-2):1-15. PROPHYLAXIS FOR CONTACTS OF COMMUNICABLE DISEASES

PERTUSSIS (Whooping Cough) - Adults are important reservoirs of B. pertussis (By 12 years post-immunization there is no demonstrable protection against pertussis).

- Prophylaxis should be given to the following significant contacts: · all household/child care contacts regardless of age or immunization status · all exposed daycare staff who work in the infant room · all significant contacts under 12 months of age · all unimmunized persons who have significant contact.

- Prophylaxis is of benefit only if started within 14 days from first contact with primary case. In high-risk exposure settings (i.e. household), prophylaxis may be considered for up to 21 days from first contact with primary case.

- Public Health will do contact investigation and notification.

Recommended Prophylaxis Children Adults

Erythromycin 40mg/kg/d PO div qid x 10 days 500mg PO qid x 10 days (estolate) (base) (max 1g/day) Alternatives:

Azithromycin 10mg/kg PO first day then 500mg PO first day then 5mg/kg PO daily x 4 days 250mg PO daily x 4 days

Clarithromycin 15mg/kg/d PO div bid x 10 days 250-500mg PO bid x 10 days

TMP/SMX 8mg TMP/kg/d PO div bid x 10 1 DS tab PO bid x 10 days days PROPHYLAXIS FOR CONTACTS OF COMMUNICABLE DISEASES

VARICELLA ZOSTER

Immune globulin provides passive immunization against Varicella Zoster virus

Indication:

In the following individuals who have been exposed to an active case of chicken pox or have had skin to skin contact with a case of zoster lesions (shingles): · immunocompromised individuals · susceptible pregnant women (Varicella IgG negative) · newborn infants whose mother developed chicken pox within 5 days before delivery or within 48 hours after delivery · hospitalized premature infants (< 28 weeks gestation or £ 1000 grams) regardless of maternal history. - Varicella is reportable to Public Health (413-7949; after hours/weekends 413-7991).

- If VZIG is indicated, it should be given ASAP (maximum 96 hours after exposure). Public Health can assist with arrangements. NB: · Susceptible health care workers should contact Occupational Health if exposed to chicken pox. · Healthy susceptible individuals should contact physician if exposed. Þ Acyclovir can reduce severity of symptoms if started promptly (within 24h of rash). Þ There is some evidence that varicella vaccine may be effective as post-exposure prophylaxis if given within 3-5 days of exposure. This may be an option in healthy individuals however, at present, Public Health still recommends VZIG as primary prophylaxis for high risk contacts as described above. Adapted from: 1. Capital Health Regional Public Health Communicable Disease Corner 1997(Sep);8: 2-3. 2. Estrada B. What’s new in varicella vaccine? Infect Med 2000;17:150. TRAVEL MEDICINE RECOMMENDATIONS Prepared by Dr. S. Houston, Dr. E. Blondel-Hill, and Ms. S. Fryters Reviewed by Dr. S. Shafran, Director, Adult Infectious Diseases

DISEASE INDICATIONS PREVENTION - This section has been included for general information only and is not meant to replace the expert advice provided by Regional Travel Clinics. - High risk travellers or those with complex itineraries should seek advice from a Travel Clinic 6-8 weeks prior to departure. - High risk travellers are those travelling to developing countries who are: Þ staying in rural areas Þ living in local conditions Þ staying for long periods of time. - Capital Health Travellers’ Health Service: 10320 - 100 Street Edmonton, AB T5J 0R3 (780) 413-5745 - Fever (up to 1 year) post-travel to the tropics is Malaria until proven otherwise. Recommend: Þ urgent blood smears for malaria Þ blood cultures. - Ensure routine immunizations (e.g. diphtheria, pertussis, tetanus, polio, measles, mumps, rubella, H. influenzae type B, hepatitis B +/- influenza and pneumococcal) are up to date. - Immunocompromised or pregnant patients generally should not receive live virus vaccines. - Websites of interest: www.cdc.gov/travel/index.htm www.hc-sc.gc.ca/hpb/lcdc/osh/prof_e.html TRAVEL MEDICINE RECOMMENDATIONS

DISEASE INDICATIONS PREVENTION DISEASES ASSOCIATED WITH INSECT VECTORS (cont’d) Malaria - Dependent on: - Mosquito avoidance measures very · itinerary important: · country of travel · permethrin impregnated bed net (can be · destination within country. obtained at T.R.I.P.S 1-800-880-8747) · repellent with 30-35% DEET (use only - All travellers to malaria endemic areas require low concentrations in children). advise based on individualized assessment of above. Consult Travel Clinic. All regimens should be started 1-2 weeks prior to travel and continued for 4 weeks post travel.

Chloroquine resistant areas: Mefloquine 250mg PO qweekly Alternative: Doxycycline 100mg PO daily

Chloroquine sensitive areas: Chloroquine phosphate 500mg PO qweekly

Mefloquine resistant areas: Doxycycline 100mg PO daily TRAVEL MEDICINE RECOMMENDATIONS

DISEASE INDICATIONS PREVENTION DISEASES ASSOCIATED WITH INSECT VECTORS Japanese Encephalitis - Travellers staying > 1 month in rural areas of: - 3 dose inactivated vaccine (> 1 year of age) · Southeast Asia given over 2-4 weeks (90% effective). · Indian subcontinent - If needed, booster can be given 3 years later. - Consult Travel Clinic. Yellow Fever - Vaccine is legal requirement in many - Live vaccine (> 9 months old): countries. Consult Travel Clinic. · only available at designated centres - Recommended for travellers to endemic areas · 10 year protection. of: · tropical South America · sub-Saharan Africa DISEASES ASSOCIATED WITH ENVIRONMENTAL/ANIMAL CONTACTS Tetanus - Increased risk in low income, developing - All adults should have Td booster every 10 Diphtheria countries, especially new states of former years (5 years if contaminated wound). Soviet Union. - If never vaccinated, give primary series. Rabies - Selected high risk travellers staying > 1 month - 3 dose IM or intradermal* vaccine given over in: 3-4 weeks. · parts of Mexico * Intradermal vaccination is effective and less · India costly. · Nepal - Pre-exposure vaccination removes the need · Thailand for post-exposure rabies immunoglobulin · Philippines and shortens the course of vaccination if · Vietnam exposure does occur. - Potential risk in all developing countries. - Consult Travel Clinic. Td = Tetanus, Diphtheria TRAVEL MEDICINE RECOMMENDATIONS

DISEASE INDICATIONS PREVENTION DISEASES ASSOCIATED WITH CONTAMINATED FOOD AND WATER Hepatitis A - Travel outside: - Food/water precautions · U.S. and Canada - Hepatitis A vaccine: · Western Europe · inactivated vaccine · Japan · adults and children (2-18 years of age): · Australia 1 dose + booster (6-12 months later) · New Zealand · > 10 years protection - Vaccination not routinely recommended due to - Food/water precautions - low risk of acquiring cholera. - Oral cholera vaccine is not routinely recomm- - Consider if travel/work in: ended for travellers even to endemic areas. · crowded/impoverished areas · refugee camps. Typhoid Fever - Travel to: - Food/water precautions - Salmonella typhi · certain parts South America - Vaccine (50-80% protection) · Africa · 3 dose live oral vaccine (Vivotif Berna/L®) · Indian subcontinent (including Nepal) Þ sachets (³ 3 years of age) Þ capsules (³ 5 years of age) Polio - Travel to: - Food/water precautions · sub-Saharan Africa - Single dose lifetime booster with IPV · Southeast Asia OR · Indian subcontinent If never vaccinated, give primary series of IPV. Travellers’ diarrhea - Most common illness of travel. - Food/water precautions - Risk to all travellers out of Western - Prophylaxis not recommended. For treatment industrialized countries. of diarrheal episodes, see Empiric Therapy Recommendations. IPV = Inactivated polio vaccine TRAVEL MEDICINE RECOMMENDATIONS

DISEASE INDICATIONS PREVENTION DISEASES ASSOCIATED WITH PERSON TO PERSON TRANSMISSION Hepatitis B - Travel to any developing country if: - 3 dose vaccine given over 3-6 months. · healthcare worker - Routine immunization recommended (in · stay > 6 months Alberta - grade 5 students). · sexual activity - Consistent latex condom use. · children in low income areas. Measles - Travel to developing countries. - Single booster if born after 1956 and haven’t received primary (2 dose) series of measles vaccine. (Persons born in 1956 and prior are considered immune to measles.) Meningococcal - Travel to: - Meningococcal vaccine (A, C, Y, W-135) disease · sub-Saharan Sahel region of Africa - Booster at 3-5 years · Saudi Arabia · other regions depending on current epidemic activity* * Consult Travel Clinic. Tuberculosis - High risk in most developing countries: - Consider BCG vaccine. · stay > 3 months NB: Tuberculin test recommended prior to · health care worker. travel and 3 months after return. Sexually transmitted - Sexual activity. - Abstinence safest diseases OR · HIV/HPV/HSV Consistent latex condom use. · N. gonorrheae (often multidrug resistant) · Chancroid · Syphilis · Hepatitis B · C. trachomatis INFECTION PREVENTION AND CONTROL Reviewed by NAPIC (Northern Alberta Practitioners in Infection Control) and Dr. Mark Joffe

USE OF UNIVERSAL/STANDARD/ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR ALL PATIENTS. HANDWASHING IS THE SINGLE MOST IMPORTANT STEP IN PREVENTING THE TRANSMISSION OF INFECTION. Handwashing is recommended: · for visibly soiled hands · before/after each patient contact · after contact with body fluids/blood/mucous membranes/non-intact skin · after contact with soiled or contaminated inanimate objects · after removing gloves · prior to placement and/or handling of invasive devices (e.g. intravascular lines/urinary catheters) Antiseptic/Antimicrobial Soaps · NOT RECOMMENDED FOR USE IN GENERAL PATIENT CARE AND NON- CLINICAL AREAS · Recommended in the following situations: Þ in areas where there are patients who are immunosuppressed or at high risk of infection (e.g. neonatal/paediatric/adult intensive care, burn units, dialysis units, transplant units) Þ where invasive procedures are performed (e.g. operating rooms, delivery rooms) Þ in patient rooms where antibiotic resistant organisms have been identified · Waterless handwashing agents (alcohol-based handrubs) are acceptable alternatives where handwashing facilities are inadequate/inaccessible Appropriate barriers (gloves, gowns, masks, and eye protection) must be worn if dealing with, or anticipate exposure to, blood/body fluids: Gloves · are to be worn as an adjunct to handwashing. Gloves do not replace handwashing. · should never be washed and reused · are worn to prevent gross soiling of hands with blood and body fluids and excretions · must always be changed between each patient contact · hands must be washed following glove removal Gowns · are worn to protect clothing and exposed skin from soiling/contamination · should be used only once · should be fluid-resistant if exposure to significant amounts of blood or body fluids is anticipated Masks · should be worn if anticipate splashing or aerosolization of blood/body fluids · should be removed, handled by ties or elastics, and discarded following use Eye Protection · should be worn to protect eyes from splashes or aerosols of blood or body fluids · should protect from the sides as well as the front INFECTION PREVENTION AND CONTROL PRECAUTIONS Duration of Infective Mode of Precautions* Organism Precautions Material Transmission Single Room Gloves Gowns Mask Colonization and/ · In Capital Health, reported or infection with: by microbiology lab to Regional Public Health for Methicillin - Body fluids Direct contact Acute care: If in direct contact If direct If nasal surveillance. resistant or or Yes with colonized or contact with carrier · Consult Infection Control/ S. aureus (MRSA) secretions droplet infected body patient or Infectious Diseases containing Long term fluids/secretions if in contact regarding treatment and organism Handwashing at all with Vancomycin - care: decolonization procedures. times when leaving respiratory resistant Assess each · Continue precautions until situation patient room secretions at least 2 consecutive S. aureus (VRSA) individually cultures taken 48 hours following completion of therapy and 1 week apart are negative. Always consult Infection Control prior to discontinuation of precautions. · Recommend culture both nares/bilateral groin and any open wound. Rescreen weekly (acute care)/monthly (long term care) and if patient becomes septic or if clinical status deteriorates. NB: Other multiresistant organisms may be transmitted nosocomially. Consultation with Infection Control is recommended. * Use of disposable dishes is not recommended to prevent transmission of antibiotic-resistant organisms. INFECTION PREVENTION AND CONTROL PRECAUTIONS Duration of Infective Mode of Precautions* Organism Precautions Material Transmission Single Room Gloves Gowns Mask Colonization and/ · In Capital Health, reported or infection with: by microbiology lab to Regional Public Health for Vancomycin - Body fluids Direct contact Yes If in direct contact If direct No surveillance. · Consult resistant or with colonized or contact with Infection Control/ Infectious Enterococci secretions infected body patient Diseases regarding containing fluids/secretions (VRE) treatment +/- decolonization organism procedures. Handwashing at · Continue precautions for all times when duration of stay in facility or leaving patient until 3 consecutive cultures room taken 48 hours following completion of therapy and 1 Inanimate objects week apart are negative. from patient room Always consult with often harbor Infection Control prior to organisms discontinuation of precautions. · Recommend culture stool/rectum, wounds, urinary catheter/colostomy sites. Rescreen weekly (acute care)/monthly (long term care) and if patient becomes septic or if clinical status deteriorates. NB: Other multiresistant organisms may be transmitted nosocomially. Consultation with Infection Control is recommended. * Use of disposable dishes is not recommended to prevent transmission of antibiotic-resistant organisms. INFECTION PREVENTION AND CONTROL SCREENING FOR MRSA/VRE

Routine screening for methicillin-resistant Staphylococcus aureus (MRSA)* and vancomycin-resistant Enterococcus (VRE)** recommended: · on admission if previous hospitalization within the last 12 months to a health care facility outside of Alberta · on admission if previous hospitalization to a health care facility where MRSA/VRE has been documented in last 6 months · on admission if patient previously known to be MRSA/VRE positive · on admission if patient receiving long term antibiotic therapy · roommate of documented cases of MRSA/VRE Þ if secondary cases found, more extensive screening of patient care unit is recommended

NB: Health care workers are not routinely screened unless a MRSA/VRE outbreak is ongoing – consultation with Infection Control/Occupational Health recommended.

* MRSA screening: · nasal (one swab for both nostrils) and groin (one swab for bilateral groin area) Þ place swab in clear transport medium Þ indicate “MRSA Screen only” on requisition

**VRE screening: · stool specimen (sterile container) or · rectal swab - 1cm through anal sphincter Þ place swab in clear transport medium · indicate “VRE Screen only” on requisition

DECOLONIZATION FOR MRSA

· Decolonization may be considered for patients who are colonized but not infected with MRSA · Infectious Diseases consultation strongly recommended · Decolonization must include all components of local and systemic therapy for 14 consecutive days to be maximally effective in eradicating MRSA colonization. · Decolonization includes: Þ local therapy: · topical application of mupirocin 2% cream to nares bid and · total body bath with chlorhexidine gluconate 4% daily AND Þ systemic therapy: · two oral antibiotics based on susceptibility testing (to reduce emergence of resistance) NB: During decolonization, patient must be closely monitored for skin integrity and side effects of antibiotics. Post-decolonization screening of previously positive body sites recommended to determine effectiveness of therapy. HANDWASHING

Handwashing is the single most important way to stop the spread of infections. Up to 80% of common infections are spread by hands.

Antibacterial soap

· Promotes antimicrobial resistance. · Proper handwashing with regular soap and water can remove germs very effectively. · There is no need to use antibacterial soaps in the home, school or workplace. · Antibacterial soap should be reserved for hospital settings (e.g. surgeons who are preparing for surgery).

When to Wash Your Hands

· Before meals · Before feeding children, including breastfeeding · Before and after preparing food, especially raw meat, poultry or fish · After using the toilet/helping a child use the toilet/changing diapers · After blowing your nose, coughing or sneezing · Before and after being with someone who is sick · Before and after treating a wound · Before inserting or removing contacts · After playing with toys shared with other children · After handling animals/pets or their waste

How to Wash Your Hands

· Use soap and warm water Water alone does not get rid of germs. · Rub hands together for 20 seconds (or sing Twinkle Twinkle Little Star) Pay particular attention to the fingertips and under the fingernails. Up to 95% of germs may be found under the fingernails. · Rinse hands for 10 seconds · Dry hands completely Use a clean, dry towel if possible. Note: Care must be taken, especially in public places, to not recontaminate hands by touching dirty surfaces. After washing your hands in public washrooms, use paper towels to turn off the taps and open the door. ANTIMICROBIAL PROPHYLAXIS IN DENTISTRY

Prepared by Antibiotics in Dentistry Working Group, Capital Health Reviewed by Division of Oral Surgery, Capital Health

The following categories of patients require antimicrobial prophylaxis for dental procedures/surgery:

I. Patients at risk of bacterial endocarditis (see Table 1 and 1a)

II. Immunocompromised patients

Table 2. PROPHYLAXIS RECOMMENDED FOR DENTAL PROCEDURES IN FOLLOWING IMMUNOCOMPROMISED PATIENTS Cause Example Drugs corticosteroids immunosuppressants cytotoxic agents Malignant disease leukemia Hodgkin’s disease other haematologic malignancies Metabolic poorly controlled diabetes mellitus hemodialysis patients (not chronic ambulatory peritoneal dialysis) Others radiotherapy/osteoradionecrosis of head & neck transplant patients neutrophil count < 1 x 109/L patients with an indwelling intravascular catheter NB: Patients with AIDS/HIV or autoimmune disorders that do not meet one of the above criteria do NOT require prophylaxis.

Table 2a. RECOMMENDED ANTIBIOTIC REGIMENS Antibiotic Adult Dose Paediatric Dose amoxicillin 2g PO x 1 dose 50mg/kg (max 2g) PO x 1h before 1 dose 1h before b-lactam allergy clindamycin 300mg PO x 1 20mg/kg (max 300mg) dose 1h before PO x 1 dose 1h before

III. Patients with orthopedic joint prostheses (see Table 3)

IV. High risk dental surgical procedures (see Table 4) ANTIMICROBIAL PROPHYLAXIS IN DENTISTRY

Table 1. PROPHYLAXIS OF BACTERIAL ENDOCARDITIS: CARDIAC CONDITIONS & DENTAL PROCEDURES ENDOCARDITIS PROPHYLAXIS RECOMMENDED ENDOCARDITIS PROPHYLAXIS NOT RECOMMENDED

Cardiac Conditions Cardiac Conditions

High risk: Negligible risk: Prosthetic cardiac valves (including bioprosthetic and homograft Previous coronary artery bypass graft surgery valves) Mitral valve prolapse without valve regurgitation1 Previous bacterial endocarditis (even in absence of heart disease) Physiologic, functional or innocent heart murmurs Complex cyanotic congenital cardiac defects Cardiac pacemaker/defibrillator Surgically constructed systemic pulmonary shunts or conduits Isolated secundum atrial septal defect (ASD) Moderate risk: Surgical repair of ASD, VSD, or PDA without residua beyond 6 Most other congenital cardiac defects mos. Acquired valve dysfunction [e.g. rheumatic heart disease (RHD)*] Previous RHD* or Kawasaki disease without valve dysfunction Hypertrophic cardiomyopathy Mitral valve prolapse with valve regurgitation &/or thickened leaflets

Dental/Oral2 Procedures Dental/Oral Procedures

Procedures known to cause gingival or mucosal bleeding Procedures not likely to cause gingival bleeding, such as fillings (including professional cleaning) above the gum line or adjustment of orthodontic appliances Incision & drainage of infected tissue Injection of local intraoral anaesthetics, except intraligamentary Surgical procedures that involve intestinal3 or respiratory mucosa injections) Shedding of primary teeth

* Patients who have had rheumatic fever but do not have evidence of RHD, do NOT need prophylaxis. 1. Males > 45 yrs with MVP, without a consistent systolic murmur, may warrant prophylaxis. 2. Prophylaxis recommended for patients with high and moderate risk cardiac conditions listed in left-hand box above. 3. Prophylaxis recommended for patients with high risk cardiac conditions; optional for patients with moderate risk cardiac conditions. ANTIMICROBIAL PROPHYLAXIS IN DENTISTRY Table 1a. PROPHYLAXIS OF BACTERIAL ENDOCARDITIS: RECOMMENDED ANTIBIOTIC REGIMENS

SITUATION DRUG ADULT DOSE/ PAEDIATRIC DOSE1/ ROUTE/DURATION ROUTE/DURATION

Dental and Oral Procedures

Standard Amoxicillin 2g PO 1h before 50mg/kg PO 1h before

No oral intake Ampicillin 2g IV/IM £ 30 min before 50mg/kg IV/IM £ 30 min before

Pen-allergic Clindamycin 300mg2 IV/PO 1h before 20mg/kg IV/PO 1h before or Azithromycin3 500mg 1 h before 15mg/kg PO 1 h before or Clarithromycin3 500mg 1 h before 15mg/kg PO 1 h before Pen-allergic, Clindamycin 300mg IV £ 30 min before 20mg/kg IV £ 30 min before no oral intake or Cefazolin4 1g IV/IM £ 30 min before 25mg/kg IV/IM £ 30 min before For high risk patients (Table 1) with poor oral hygiene, consider rinsing with chlorhexidine mouthwash for 1 minute prior to dental procedure AFTER systemic antibiotic (since oral irrigation itself can induce bacteremia). NB: Prolonged use of chlorhexidine prior to, or following, the dental procedure is NOT recommended as it may result in selection of antimicrobial resistant oral bacteria. The use of chlorhexidine for non high risk patients is NOT recommended. 1. Total paediatric dose should not exceed adult dose. 2. Clindamycin doses of 600mg are not needed. A dose of 300mg achieves adequate serum levels and is better tolerated. 3. Azithromycin and clarithromycin offer no microbiological advantage over erythromycin but are better tolerated. Activity of all macrolides against Viridans Group Streptococci may not be optimal. 4. Cephalosporins should not be used in patients with severe/immediate-type (e.g. urticaria/angioedema, anaphylaxis) penicillin allergy. Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277:1794-1801. ANTIMICROBIAL PROPHYLAXIS IN DENTISTRY Table 3. PROPHYLAXIS OF DENTAL PROCEDURES IN PATIENTS WITH PROSTHETIC JOINTS

· Long term antibiotic prophylaxis in patients with prosthetic joints is NOT recommended. · Routine prophylaxis of dental procedures in patients with prosthetic joints is NOT recommended as: · there are inadequate data to support its use · dental procedure-induced bacteremias are a very rare (< 0.05%) cause of prosthetic joint infections · major professional associations (ADA, AAOM, AAOS, BSAC) recommend against routine prophylaxis · risks (adverse/allergic reactions, antimicrobial resistance) and costs of antibiotic prophylaxis are greater than any benefit.

Prophylaxis may be considered for the following high risk cases:

· Re-operated joints · Loose prostheses · Joint replacement procedure < 1 year previous · Previous joint infection

NOTE: Prophylaxis is NOT required for fixed prostheses, such as screws, plates, and pins.

Table 3a. RECOMMENDED ANTIBIOTIC REGIMEN Antibiotic Adult Dose Paediatric Dose clindamycin 300mg PO x 1 20mg/kg (max 300mg) dose 1h before PO x 1 dose 1h before For above high risk patients with poor oral hygiene, consider rinsing with chlorhexidine mouthwash for 1 minute immediately prior to dental procedure. NB: Prolonged use of chlorhexidine prior to, or following, the dental procedure is NOT recommended as it may result in selection of antimicrobial resistant oral bacteria. ANTIMICROBIAL PROPHYLAXIS IN DENTISTRY Table 4. RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN DENTISTRY SURGERY/PROCEDURE ADULT DOSE/ PAEDIATRIC DOSE1/ COMMENTS ROUTE/DURATION ROUTE/DURATION NB: For high risk groups (patients at risk of bacterial endocarditis, immunosuppressed patients or patients at risk of prosthetic joint infection), refer to Tables 1-3 respectively for prophylaxis recommendations.

- The following recommendations for prophylaxis are for patients not belonging to high risk groups.

- Antibiotic prophylaxis should always be given pre-operatively.

- The value of post-operative antibiotic doses has not been well validated in dental surgery but may be of benefit in certain invasive/complicated procedures.

- Established infections require treatment NOT prophylaxis. Refer to Recommended Empiric Therapy of Selected Dental Infections.

DENTOALVEOLAR SURGERY (tooth extraction, cystectomies, alveoplasty, apical surgery) Simple/minimally invasive NO surgical prophylaxis NO surgical prophylaxis oral surgical procedures indicated indicated Alveolar (Dry socket) NO surgical prophylaxis NO surgical prophylaxis osteitis indicated indicated Complicated oral surgical · amoxicillin 2g PO x 1 dose · amoxicillin 50mg/kg PO x 1 procedures 1h pre-op dose 1h pre-op (e.g. difficult third molar or or extraction) · penicillin G 2MU IV < 30 min · penicillin G 200,00U IV < 30 pre-op min pre-op b-lactam allergy: b-lactam allergy: · clindamycin 300mg PO x 1 · clindamycin 20mg/kg PO x 1 dose 1h pre-op dose 1h pre-op or or · clindamycin 300-600mg IV < · clindamycin 20mg/kg IV < 30 30 min pre-op min pre-op 1. Total paediatric dose should not exceed adult dose. ANTIMICROBIAL PROPHYLAXIS IN DENTISTRY Table 4. RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN DENTISTRY SURGERY/PROCEDURE ADULT DOSE/ PAEDIATRIC DOSE1/ COMMENTS ROUTE/DURATION ROUTE/DURATION ENDOSSEOUS IMPLANTS

Endosseous implants · amoxicillin 2g PO 1h pre-op · amoxicillin 50mg/kg 1h pre-op * The value of prolonged + amoxicillin 500mg PO q8h + amoxicillin 50mg/kg PO q8h postoperative antibiotic use has x 3 days post-op* x 3 days post-op* not been proven. + + · chlorhexidine mouthwash† · chlorhexidine mouthwash† **Prolonged use of chlorhexidine b-lactam allergy: b-lactam allergy: prior to, or following, the dental · clindamycin 300mg PO 1h · clindamycin 20mg/kg PO 1h procedure is NOT recommended pre-op + clindamycin 300mg pre-op + clindamycin as it may result in selection of PO q6h x 3 days post-op* 20mg/kg PO q6h x 3 days antimicrobial resistant oral + post-op* bacteria. · chlorhexidine mouthwash† + · chlorhexidine mouthwash† † rinse with chlorhexidine mouthwash for 1 minute † rinse with chlorhexidine immediately prior to dental mouthwash for 1 minute procedure** immediately prior to dental procedure** 1. Total paediatric dose should not exceed adult dose. ANTIMICROBIAL PROPHYLAXIS IN DENTISTRY Table 4. RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN DENTISTRY SURGERY/PROCEDURE ADULT DOSE/ PAEDIATRIC DOSE1/ COMMENTS ROUTE/DURATION ROUTE/DURATION PERIODONTAL SURGERY

Gingivectomy NO surgical prophylaxis NO surgical prophylaxis indicated indicated Replaced flaps Surgical prophylaxis not Surgical prophylaxis not * Use of antimicrobial prophylaxis Apically positioned flaps routinely indicated* routinely indicated* in these procedures is Osseous surgery (no implants) controversial. A single pre- operative dose of antibiotic may be indicated in some cases depending on extent of surgery, anatomical location, and oral hygiene of patient. Regenerative techniques · amoxicillin 2g PO x 1 dose · amoxicillin 50mg/kg PO x 1 - A short course of chlorhexidine 1h pre-op dose 1h pre-op post-op is recommended. + + * Prolonged use of chlorhexidine · chlorhexidine mouthwash† · chlorhexidine mouthwash† prior to, or following, the dental b-lactam allergy: b-lactam allergy: procedure is NOT recommended · clindamycin 300mg PO x 1 · clindamycin 20mg/kg PO x 1 as it may result in selection of dose 1h pre-op dose 1h pre-op antimicrobial resistant oral + + bacteria. · chlorhexidine mouthwash† · chlorhexidine mouthwash† - Some experts advocate † † tetracycline antibiotic use for their rinse with chlorhexidine rinse with chlorhexidine antiinflammatory properties. mouthwash for 1 minute mouthwash for 1 minute immediately prior to dental immediately prior to dental procedure* procedure* ENDODONTICS Conservative endodontic NO surgical prophylaxis NO surgical prophylaxis procedures indicated indicated e.g. root canal therapy 1. Total paediatric dose should not exceed adult dose. ANTIMICROBIAL PROPHYLAXIS IN DENTISTRY Table 4. RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN DENTISTRY SURGERY/PROCEDURE ADULT DOSE/ PAEDIATRIC DOSE1/ COMMENTS ROUTE/DURATION ROUTE/DURATION MAXILLOFACIAL SURGERY

Orthognathic surgery · penicillin G 2MU IV < 30 min · penicillin G 200,00U IV < 30 - If extraoral incisions, use pre-op + penicillin VK 300- min pre-op + penicillin VK clindamycin (added S. aureus 600mg PO qid x 7 days post- 40mg/kg/d PO div qid x 7 coverage). op days post-op - Consider chlorhexidine b-lactam allergy: b-lactam allergy: mouthwash x 7 days. · clindamycin 300-600mg IV < · clindamycin 20mg/kg IV < 30 30 min pre-op + clindamycin min pre-op + clindamycin 300mg PO qid x 7 days post- 20mg/kg PO qid x 7 days op post-op Major bone grafting

· intraoral · penicillin G 2MU IV < 30 min · penicillin G 200,00U IV < 30 pre-op + penicillin VK 300- min pre-op + penicillin VK 600mg PO qid x 3-7 days 40mg/kg/d PO div qid x 3-7 post-op days post-op Alternative: Alternative: · clindamycin 300-600mg < 30 · clindamycin 20mg/kg IV < 30 min IV pre-op + clindamycin min pre-op + clindamycin 300mg PO qid x 3-7 days 20mg/kg PO qid x 3-7 days post-op · extraoral · clindamycin 300-600mg IV < · clindamycin 20mg/kg IV < 30 30 min pre-op + clindamycin min pre-op + clindamycin 300-600mg IV x 1 dose post- 20mg/kg IV x 1 dose post-op op Alternative: Alternative: · cefazolin 1g IV < 30 min pre- · cefazolin 25mg/kg IV < 30 op + cefazolin 1g IV x 1 dose min pre-op + cefazolin post-op 25mg/kg IV x 1 dose post-op 1. Total paediatric dose should not exceed adult dose. ANTIMICROBIAL PROPHYLAXIS IN DENTISTRY Table 4. RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN DENTISTRY SURGERY/PROCEDURE ADULT DOSE/ PAEDIATRIC DOSE1/ COMMENTS ROUTE/DURATION ROUTE/DURATION MAXILLOFACIAL SURGERY

Temporomandibular joint surgery

· intraoral · penicillin G 2MU IV < 30 min · penicillin G 200,00U IV < 30 pre-op + penicillin VK 300- min pre-op + penicillin VK 600mg PO qid x 3-7 days 40mg/kg/d PO div qid x 3-7 post-op days post-op Alternative: Alternative: · clindamycin 300-600mg < 30 · clindamycin 20mg/kg IV < 30 min IV pre-op + clindamycin min pre-op + clindamycin 300mg PO qid x 3-7 days 20mg/kg PO qid x 3-7 days post-op · extraoral · cefazolin 1g IV < 30 min pre- · cefazolin 25mg/kg IV < 30 op min pre-op Alternative: Alternative: · clindamycin 300-600mg IV < · clindamycin 20mg/kg IV < 30 30 min pre-op min pre-op 1. Total paediatric dose should not exceed adult dose. ANTIMICROBIAL PROPHYLAXIS IN DENTISTRY Table 4. RECOMMENDED DRUG REGIMENS FOR SURGICAL PROPHYLAXIS IN DENTISTRY SURGERY/PROCEDURE ADULT DOSE/ PAEDIATRIC DOSE1/ COMMENTS ROUTE/DURATION ROUTE/DURATION FACIAL TRAUMA

Facial trauma

· open reduction · penicillin G 2MU IV < 30 min · penicillin G 200,00U IV < 30 - If extraoral incisions, use pre-op + penicillin VK 300- min pre-op + penicillin VK clindamycin (added S. aureus 600mg PO qid x 7 days post- 40mg/kg/d PO div qid x 7 coverage). op if prosthetic material days post-op if prosthetic - Consider chlorexidine mouthwash placed material placed x 7 days. b-lactam allergy: b-lactam allergy: · clindamycin 300-600mg IV < · clindamycin 20mg/kg IV < 30 30 min pre-op + clindamycin min pre-op + clindamycin 300mg PO qid x 7 days post- 20mg/kg PO qid x 7 days op if prosthetic material post-op if prosthetic material placed placed · closed reduction · penicillin G 2MU IV < 30 min · penicillin G 200,000U IV < 30 pre-op min pre-op b-lactam allergy: b-lactam allergy: · clindamycin 300-600mg IV < · clindamycin 20mg/kg IV < 30 30 min pre-op min pre-op ORTHODONTICS

Orthodontic adjustments NO surgical prophylaxis NO surgical prophylaxis indicated indicated

Subgingival band NO surgical prophylaxis NO surgical prophylaxis placement indicated indicated 1. Total paediatric dose should not exceed adult dose. RECOMMENDED EMPIRIC THERAPY OF SELECTED DENTAL INFECTIONSA

Prepared by Ms. M. Mehta and Dr. E. Blondel-Hill in collaboration with the Antibiotics in Dentistry Working Group, Capital Health Reviewed by Division of Oral Surgery, Capital Health

Table 1. SPECTRUM OF ACTIVITY OF ANTIMICROBIAL AGENTS AGAINST SELECTED ORAL MICROORGANISMS Anaerobic Viridans Gram Actinobacillus Capnocyto- Eikenella Actinomyces Group Comments negative spp phaga spp corrodens spp Streptococci bacilli - Use penicillin V as it results in higher Penicillin +/- +/- +/- + + + plasma levels than penicillin G. - Achieves higher serum concentrations Amoxicillin +/- +/- +/- + + + than oral penicillin; recommended in prophylaxis of dental infections. Amoxicillin- - BID dosing now recommended. clavulanate +/- + +/- + + + - Alternative in dental infections. - Not recommended in prophylaxis/ Oral treatment of dental infections. Cephalosporins* - - +/- - - + - >90% of Viridans Group Streptococci are resistant to cephalexin. - Poor activity against most dental Erythromycin +/- - - - - + pathogens. - Offer no microbiological advantage Azithromycin/ over erythromycin in the treatment of Clarithromycin +/- - - - - + dental infections. - Not recommended in prophylaxis/ Ciprofloxacin/ treatment of dental infections (no Levofloxacin +/- - + + + - anaerobic coverage). - Alternative in the prophylaxis/treatment Clindamycin + +/- - + - + of dental infections. - No aerobic coverage; use as an Metronidazole - + - - - - adjunct to penicillin. Doxycycline/ - Anti-inflammatory properties may have Tetracycline +/- - + + + + role in odontogenic infections. * Includes agents such as cephalexin, cefixime, cefuroxime axetil, cefprozil. RECOMMENDED EMPIRIC THERAPY OF SELECTED DENTAL INFECTIONSA

Table 2. MICROORGANISMS ASSOCIATED WITH DENTAL INFECTIONS* Aerobic Gram Positive Cocci · Viridans Group Streptococci § Streptococcus milleri group § Streptococcus mutans group Aerobic Gram Positive Bacilli · Rothia dentocariosa

Aerobic Gram Negative Coccobacilli · Actinobacillus spp · Campylobacter spp · Capnocytophaga spp · Eikenella spp Anaerobic Gram Positive · Actinomyces spp · Peptostreptococcus spp · Eubacterium spp Anaerobic Gram Negative Bacilli · Porphyromonas spp · Fusobacterium spp · Prevotella spp · Bacteroides spp Spirochetes · Treponema spp * Aerobic Gram Negative Bacilli and Staphylococcus aureus rarely cause dental infections. They may be the causative agents in patients with serious underlying disease. RECOMMENDED EMPIRIC THERAPY OF SELECTED DENTAL INFECTIONSA Infection Recommended Empiric Recommended Adult Comments Therapy DoseB/Duration - Most dental infections are polymicrobial (aerobic & anaerobic bacteria). Normal oral flora consists of >500 bacterial species. - The etiology of dental infections is multifactorial. Organisms that are part of the normal flora of the mouth (see Table 2) may be associated with dental infections. - Local antibiotic therapy (+/- local delivery systems) is not routinely recommended as it offers no advantage over conventional mechanical debridement. - The routine use of mouthwashes/rinses for infection control/occupational risk exposure is not recommended. - NB: Prolonged use of chlorhexidine is NOT recommended as it may result in selection of antimicrobial resistant oral bacteria. - For treatment of fungal/yeast infections of the oral cavity, refer to Recommended Empiric Therapy of Fungal Infections.

Odontogenic Root caries 1. Repair all carious * High risk: lesions. · > 3 root caries in last 3 years 2. Patient education and · recent full mouth oral hygiene instruction. reconstruction 3. Optimize the use of · severe periodontal disease fluorides. · extensive gingival recession 4. Institute dietary changes. · xerostomia

Unresponsive to above High Risk Patients* Rinse with 15 mL PO for 30 Chlorhexidine gluconate **There is some evidence of benefit in root caries, but not seconds bid (after in enamel caries. 0.12% mouthwash** toothbrushing) x 3 weeks then reevaluate RECOMMENDED EMPIRIC THERAPY OF SELECTED DENTAL INFECTIONSA Infection Recommended Empiric Recommended Adult Comments Therapy DoseB/Duration Odontogenic Endodontic Abscesses First line therapy - Antibiotics are NOT recommended without drainage (dentoalveolar, Surgical drainage & and debridement. periapical) debridement If unable to achieve optimal drainage Penicillin VK +/- 300-600mg PO qid x 7 days Metronidazole* 500mg PO bid x 7 days * Addition of metronidazole recommended if signs of b-lactam allergy fascial space infection or systemic symptoms develop. Clindamycin 150-300mg PO qid x 7 days Dry socket - Pain management essential. rd (fibrinolytic alveolitis) The benefit of antimicrobial - Post extraction complication (usually of mandibular 3 therapy has not been molar). established and is not - An infectious etiology has been proposed but not recommended. substantiated. Periodontal Gingivitis - Inflammation of the soft tissues around teeth without loss of periodontal support. Acute Immunocompetent Herpes simplex I Primary Acyclovir 400mg PO tid or 200mg PO 5x/day x 7 days Famciclovir 250mg PO tid x 7 days Valacyclovir 500mg-1g PO bid x 7 days Recurrent No therapy indicated Immunocompromised* * If immunocompromised, medical consultation advised. Acyclovir 400mg PO 5x/day x 7-10 days HIV patients and transplant recipients may benefit from 250mg PO tid x 7-10 days suppressive acyclovir therapy 200-400mg PO bid-tid. Famciclovir 500mg-1g PO bid x 7-10 days Valacyclovir RECOMMENDED EMPIRIC THERAPY OF SELECTED DENTAL INFECTIONSA Infection Recommended Empiric Recommended/Adult Comments Therapy DoseB/Duration Periodontal Gingivitis (cont’d) Chronic First line therapy - In refractory cases, evaluation of systemic factors Personal plaque/calculus recommended: control and professional · diabetes debridement essential · pregnancy · viral infection Patient education and oral · endocrine dysfunction hygiene instruction · vitamin deficiency/malnutrition · reduced host defences (eg. HIV, blood dyscrasias, Correction of plaque medication +/or radiation therapy induced) retentive factors* · xerostomia · smoking. Unresponsive to above, add - In refractory cases, desquamative gingivitis should be Rinse with 15 mL PO for 30 Chlorhexidine gluconate differentially diagnosed from mucocutaneous disorders seconds bid (after such as: 0.12% mouthwash toothbrushing) x 3 weeks then · lichen planus reevaluate · pemphigus Antibiotics not · cicatrical pemphigoid recommended · squamous cell carcinoma.

* e.g. overcontoured crowns, open margins, caries, etc. Acute necrotizing First line therapy - Frequently seen in HIV patients. ulcerative gingivitis Personal plaque/calculus (ANUG or “trench control and professional - Oxygenating agents such as hydrogen peroxide or mouth”) debridement essential sodium perborate (Amosan®) may be used as adjunctive therapy. Systemic symptoms* +/- unresponsive to above *NB: Antibiotic use should be reserved for patients Penicillin VK 300-600mg PO qid x 7 days showing systemic signs and symptoms. b-lactam allergy 150-300mg PO qid x 7 days Clindamycin RECOMMENDED EMPIRIC THERAPY OF SELECTED DENTAL INFECTIONSA Infection Recommended Empiric Recommended/Adult Comments Therapy DoseB/Duration Periodontal Pericoronitis - Painful infection developing around impacted/partially erupted teeth. Antibiotics not routinely recommended - Pain management essential.

Mild-Moderate/Localized - Consider removal of the offending tooth. Personal plaque/calculus control and professional debridement essential Systemic symptoms* +/- unresponsive to above *NB: Antibiotic use should be reserved for patients showing systemic signs and symptoms. Penicillin VK +/- 300-600mg PO qid x 7days Metronidazole 500mg PO bid x 7 days b-lactam allergy Clindamycin 150-300mg PO qid x 7 days Periodontitis - Inflammation of the gingiva & adjacent attachment apparatus associated with loss of attachment due to destruction of the periodontal ligament & loss of adjacent supporting bone. Early onset First line therapy - May involve host defense abnormalities. (< 35 years): Personal plaque/calculus · prepubertal control and professional - Associated with severe & rapid periodontal destruction. · juvenile debridement essential · rapidly - Actinobacillus actinomycetemcomitans plays a prominent role. progressive Consider referral to a Prepubertal - Rare condition that usually affects deciduous teeth. periodontal specialist - Neutropenia observed. Juvenile - Age of onset between 10-20 years. Rapidly Progressive - Age of onset between 20-30 years. RECOMMENDED EMPIRIC THERAPY OF SELECTED DENTAL INFECTIONSA Infection Recommended Empiric Recommended Adult Comments Therapy DoseB/ Duration Periodontal Periodontitis (cont’d) Adult Chronic First line therapy - Therapeutic response may be adversely affected by: Personal plaque/calculus 1. Underlying systemic conditions (e.g. diabetes control and professional mellitus, Crohn’s disease etc.) debridement essential 2. Reduced host defenses (eg. HIV, blood dyscrasias, medication +/or radiation therapy induced, etc.) Antibiotics not recommended 3. Smoking (increases the risk of poor response to treatment 5 fold).

Refractory First line therapy - Progressive destruction of periodontal attachment Personal plaque/calculus despite diligent mechanical treatment. control and professional debridement essential - If not responding, consider referral.

Unresponsive to above Tetracycline* or 250mg PO qid x 7 days * Some experts advocate tetracycline antibiotics for their Doxycycline* 100mg PO bid x 7days anti-inflammatory properties.

Alternative - Since Actinobacillus may be found in up to 1/3 of cases, 300-600mg PO qid x 7days Penicillin VK +/- clindamycin not optimal. 500mg PO bid x 7 days Metronidazole RECOMMENDED EMPIRIC THERAPY OF SELECTED DENTAL INFECTIONSA Infection Recommended Empiric Recommended Adult Comments Therapy DoseB/Duration Periodontal Periodontal abscess First line therapy Personal plaque/calculus - If recurrent, consider referral or extraction. control and professional debridement essential - Surgical drainage of both the pocket and the pulp chamber must be considered when there is a combined Systemic symptoms +/- periodontal-endodontic lesion. unresponsive to above* * The role of antibiotics in the treatment of periodontal Paediatric abscess is not established. Penicillin VK +/- 40mg/kg/d PO div tid or qid x 7 days 15-30mg/kg/d PO div bid x 7 Metronidazole days b-lactam allergy 40mg/kg/d PO div qid x 7 Clindamycin days

Adult 300-600mg PO qid x 7 days Penicillin VK +/- 500mg PO bid x 7 days Metronidazole b-lactam allergy 150-300mg PO qid x 7 days Clindamycin or 250mg PO qid x 7days ** Some experts advocate tetracycline antibiotics for their Tetracycline** or 100mg PO bid x 7 days anti-inflammatory properties (controversial). Doxycycline** RECOMMENDED EMPIRIC THERAPY OF SELECTED DENTAL INFECTIONSA Infection Recommended Empiric Recommended Adult Comments Therapy DoseB/Duration Periodontal Post-operative First line therapy peri-implantitis Personal plaque/calculus control and professional debridement essential

Severe/Abscess* * If implant mechanically unstable, or extensive abscess First line therapy + develops, removal of implant recommended. Penicillin VK +/- 300-600mg PO qid x 7 days Metronidazole 500mg PO bid x 7 days b-lactam allergy 150-300mg PO qid x 7 days Clindamycin

Adjunctive Therapy Rinse with 15 mL PO for 30 Chlorhexidine gluconate seconds bid (after 0.12% mouthwash toothbrushing) x 3 weeks RECOMMENDED EMPIRIC THERAPY OF SELECTED DENTAL INFECTIONSA Infection Recommended Empiric Recommended Adult Comments Therapy DoseB/Duration Oral Fascial space First line therapy - May require immediate hospitalization and maintenance infections Surgical drainage essential of the airway.

Paediatric Penicillin 150,000-250,000u/kg/d IV q6h + x 10 days Metronidazole 30mg/kg/d IV div q12h x 10 days b-lactam allergy Clindamycin 40mg/kg/d IV div q8h x 10 days

Adult 2 MU IV q4-6h x 10 days Penicillin + 500 mg IV q12h x 10 days Metronidazole b-lactam allergy 600 mg IV q8h x 10 days Clindamycin

A. These are empiric antibiotic recommendations based on local susceptibility patterns, Capital Health hospitals’ antimicrobial formulary, and need to restrict and rationalize antibiotic use. Antibiotics listed for each condition are not all inclusive, nor are they all approved by HPB for the listed indication. Choice of empiric antibiotic therapy should be based on the patient’s age, allergies, co-morbidities, and clinical condition, as well as cost and convenience of the dosage regimen. Empiric antibiotic therapy should be modified to narrower spectrum antibiotic(s) according to culture and susceptibility (C&S) results. B. Usual adult dose in patients with normal renal and hepatic function. ANTIMICROBIALS IN PREGNANCY Prepared by Ms. Rita Muzyka, B.Sc.Pharm Reviewed by Dr. S. Shafran, Director, Adult Infectious Diseases

DRUG RISK COMMENTS FACTOR* ANTIBACTERIAL AGENTS b-Lactams Penicillins B Considered safe. Penicillins & BLI B No human data suggesting toxic effects. Cephalosporins B Considered safe. Imipenem B No human data on use in the 1st trimester, however 3 references consider it to be safe during the perinatal period. Animal studies have not shown teratogenic effects or fetal malformations. Meropenem B No human data. Animal studies have not revealed impaired fertility or harm to the fetus. Aminoglycosides Fetal VIII cranial nerve toxicity resulting in hearing loss has occurred with some Amikacin C aminoglycosides (i.e. streptomycin). Ototoxicity due to in utero exposure, however, Gentamicin has not been reported with these agents. Tobramycin Streptomycin D Not recommended in pregnancy. Associated with congenital deafness with prolonged use for tuberculosis. Macrolides Azithromycin B Limited human data. No fetal malformations have been reported in animal studies. Clarithromycin C No congenital anomalies reported in human infants. Teratogenic in animals at high doses. Erythromycin B Considered safe. Estolate salt associated with increased incidence of cholestatic jaundice in mother, but not in the fetus or infant. ANTIMICROBIALS IN PREGNANCY

DRUG RISK COMMENTS FACTOR* ANTIBACTERIAL AGENTS (cont’d) Quinolones Ciprofloxacin C Therapeutic doses used during human pregnancy are unlikely to pose a substantial teratogenic risk, however ciprofloxacin should not be considered a first line agent. Animal studies have shown an association with permanent arthropathy. Levofloxacin C Limited human data. Animal studies have not shown teratogenic effects. Norfloxacin C Therapeutic doses used during human pregnancy are unlikely to pose a substantial teratogenic risk, however norfloxacin should not be considered a first line agent. Ofloxacin C Use during human gestation does not appear to be associated with an increased risk of major congenital malformations. High doses in rats have produced minor skeletal variations in the offspring. Others Chloramphenicol C Use with caution in final stage of pregnancy. May be associated with gray baby syndrome. Clindamycin B Considered safe. Metronidazole B In two recent meta-analyses, no relationship was found between birth defects and use of metronidazole in human pregnancy. Mutagenic in bacteria and carcinogenic in rodents. Nitrofurantoin B Considered safe but use with caution near term due to potential for hemolytic anemia in the newborn. Manufacturer recommends avoiding during labour and delivery. Sulfonamides B Considered safe in humans, however jaundice, hemolytic anemia, and kernicterus (D if near term) may occur in the newborn if given near term. Teratogenic in some species. Tetracyclines D Not recommended in pregnancy. Associated with abnormal development of fetal teeth and bone, congenital defects, and maternal liver toxicity. ANTIMICROBIALS IN PREGNANCY

DRUG RISK COMMENTS FACTOR* ANTIBACTERIAL AGENTS (cont’d) Others (cont’d) Trimethoprim C Although case reports and controlled trials have not demonstrated an increase in fetal abnormalities; it is a folate antagonist so it should be used with caution. Vancomycin C No cases of congenital defects recorded in humans. ANTIFUNGAL AGENTS Amphotericin B B No reports linking use during various stages of pregnancy with congenital defects. Fluconazole C Teratogenic effects in humans may be dose dependent. Congenital anomalies reported in infants with maternal dose of 400-800 mg/day (n=4), however a short course of £ 150 mg/day has not been associated with an increased incidence of congenital defects. High doses in rats produced teratogenic and embryotoxic effects. Flucytosine C Women treated in 2nd and 3rd trimesters resulted in no defects in the newborns (n=3). Embryotoxic and teratogenic in some animal species; use in pregnant humans not studied. Itraconazole C Cases of malformations in human infants have been reported (n=14). Dose-related increase in toxicity and teratogenicity found in animal studies. Ketoconazole C Doses > 400 mg/day impair testosterone and cortisol synthesis; may affect development of male fetus. Embryotoxic and teratogenic in rats in high doses. Terbinafine B Limited human data. Animal studies reveal no evidence of fetal harm. Vaginal Products Clotrimazole B Considered safe in all trimesters. Miconazole C Considered safe in all trimesters. Nystatin B Considered safe in all trimesters. Systemic absorption after topical or mucosal application is negligible. Terconazole C Considered safe in all trimesters. ANTIMICROBIALS IN PREGNANCY

DRUG RISK COMMENTS FACTOR* ANTIPARASITIC AGENTS Chloroquine C Doses used for malaria prophylaxis and treatment are considered safe during pregnancy. Mebendazole C Use after first trimester not associated with a significant increase in major congenital defects in humans. Embryotoxic and teratogenic in rats. Mefloquine C Safe after 16 weeks gestation. Pentamidine C Limited human data. Animal studies have not resulted in a significant increase in congenital abnormalities, however embryotoxicity has occurred. Praziquantel B Limited human data. No teratogenic effects in animal studies. Primaquine C May cause hemolytic anemia in a human fetus with G6PD deficiency. If possible, withhold drug until after delivery. Pyrimethamine C Considered safe. Folic acid (5 mg/day) supplementation should be given to prevent folate deficiency. Quinine D Not recommended in pregnancy. Large doses used during early stages of human pregnancy have resulted in a number of malformations. ANTIMYCOBACTERIAL AGENTS Dapsone C Use during human pregnancy does not appear to present a major risk to the fetus. Ethambutol B Considered safe. Isoniazid C Considered safe. Pyrazinamide C Recommended if resistant tuberculosis is suspected, however the effects to the fetus are not known. Rifampin C Although animal studies have revealed teratogenic and embryotoxic effects, it is not a proven teratogen in humans and could be used with isoniazid and ethambutol if necessary. Streptomycin D Not recommended in pregnancy. Associated with congenital deafness with prolonged use for tuberculosis. ANTIMICROBIALS IN PREGNANCY

DRUG RISK COMMENTS FACTOR* ANTIVIRAL AGENTS Acyclovir B Used during all stages of pregnancy; no adverse events in the fetus or newborn have been reported. Has also been used in neonates. Amantadine C Limited human data. Embryotoxic and teratogenic in some animals at high doses. Delavirdine C No human data. Teratogenic in rats. Didanosine B Human case reports involving prenatal exposure to didanosine alone or in combination with other antiretrovirals resulted in 1 infant with a birth defect (n=16). Animal studies have not produced teratogenic effects or fetal toxicity. Efavirenz C No human data. Teratogenic effects have been seen following standard doses in non-human primates. Famciclovir B No human data. Animal studies have not shown any embryotoxic or teratogenic effects. Foscarnet C No human data. Animal studies have resulted in skeletal anomalies or variations in the newborn. Ganciclovir C No human data. Animal studies have demonstrated embryotoxic and teratogenic effects as well as infertility. Indinavir C No birth defects have been reported in human case reports. Animal studies have not demonstrated a high potential to produce fetal development toxicity. Lamivudine C Human case reports involving prenatal exposure to lamivudine alone or in combination with other antiretrovirals resulted in 1 infant with a birth defect (n=46). Animal studies using high doses have demonstrated no evidence of harm to the fetus. Nelfinavir B Animal studies showed no apparent effect on pregnancy, fertility, or reproduction. Nevirapine C Teratogenic effects have not been observed in animal studies. Has been used in neonates. Ritonavir B Limited human data. Animal studies showed no apparent effect on pregnancy, ANTIMICROBIALS IN PREGNANCY fertility, or reproduction. ANTIMICROBIALS IN PREGNANCY

DRUG RISK COMMENTS FACTOR* ANTIVIRAL AGENTS (cont’d) Saquinavir B Human case reports involving prenatal exposure to saquinavir alone or in combination with other antiretrovirals resulted in 1 infant with a birth defect (n=22). Animal trials have resulted in no reproductive, teratogenic, or developmental effects in the fetus. Stavudine C Human case reports involving prenatal exposure to stavudine alone or in combination with other antiretrovirals resulted in 1 infant with a birth defect (n=6). Animal studies using high doses have not resulted in birth defects. Valacyclovir B No human data. Animal studies have not resulted in an increased incidence of adverse pregnancy outcomes. Zalcitabine C No birth defects have been reported in human case reports (n=28). Animal studies have demonstrated toxic and teratogenic effects at high doses. Zidovudine C Exposure during various stages of pregnancy did not result in an increased risk of adverse pregnancy outcomes when compared with the expected proportion in the general population. As well, it appears to be effective for the reduction of maternal- fetal transmission of HIV-1 infection. * Risk Factor Legend: A. Controlled studies in women fail to demonstrate a risk to the fetus. B. Animal studies have not revealed toxicity but there are no adequate human studies, or animal studies have shown toxicity that was not confirmed in human studies. C. Animal studies have revealed toxicity and there are no adequate human studies, or studies in humans and animals are not available, however potential benefit may justify the potential risk to the fetus. D. Positive evidence of human fetal risk exists, but the benefits from use in pregnant women may be acceptable despite the risk. X. Human and/or animal studies have shown a risk to the fetus, and risks outweigh benefits. Contraindicated in pregnancy. Abbreviations: BLI = b-lactamase inhibitor, G6PD = glucose-6-phosphate dehydrogenase ANTIMICROBIALS IN LACTATION Prepared by Ms. Rita Muzyka, B.Sc.Pharm Reviewed by Dr. S. Gross, Director, Edmonton Breastfeeding Clinic and Dr. S. Shafran, Director, Adult Infectious Diseases

In the vast majority of cases, lactating women on antibiotic therapy do NOT need to interrupt breastfeeding. In almost all cases where antibiotics are clinically indicated, the benefits of breastfeeding outweigh the risks, where present, of antibiotic exposure.

DRUG RISK COMMENTS FACTOR* ANTIBACTERIAL AGENTS b-Lactams Penicillins a Excreted in human milk; possible allergic sensitization or disruption of the GI flora. Penicillins & BLI a Small amount excreted in human milk. Cephalosporins a Excreted in human milk; possible allergic sensitization or disruption of the GI flora. Imipenem ? Excreted in human milk, but poor oral absorption. Meropenem ? No human data on excretion in milk, but poor oral absorption. Aminoglycosides a Small amount excreted in human milk; poor systemic absorption by infant. Macrolides Azithromycin ? Excreted in human milk. Clarithromycin a <1% of maternal dose excreted in human milk. No adverse effects reported in nursing infants. Erythromycin a Excreted in human milk. No adverse effects reported in nursing infants. Quinolones Ciprofloxacin a 2% of maternal dose is excreted in human milk. No adverse effects reported in nursing infants. Levofloxacin ? No human data on excretion in milk. Norfloxacin b Not detected in human milk following maternal administration of a single 200 mg dose. Ofloxacin a 2% of maternal dose is excreted in human milk. No adverse effects reported in nursing infants. ANTIMICROBIALS IN LACTATION

DRUG RISK COMMENTS FACTOR* ANTIBACTERIAL AGENTS (cont’d) Others Chloramphenicol b Excreted in human milk; possible bone marrow suppression. Clindamycin a Small amount excreted in human milk. Metronidazole a One case of excessive diarrhea reported in a nursing infant, however no adverse effects were reported in a study using a maternal dose of 400 mg tid. Observe infant for stool changes. Nitrofurantoin a Insignificant amount excreted in human milk. Infants with G6PD deficiency may develop hemolytic anemia. Sulfonamides a Use with caution in premature infants and infants with G6PD deficiency or jaundice. Tetracyclines a Excreted in human milk; poor systemic absorption by nursing infant. Trimethoprim a Small amount excreted in human milk. No adverse effects reported in the nursing infant. Vancomycin a Excreted in human milk; poor systemic absorption by nursing infant. No adverse effects reported in nursing infants. ANTIFUNGAL AGENTS Amphotericin B b No human data on excretion in milk, although has been used in neonates. Fluconazole a Approximately 10% of maternal dose excreted in human milk. Risk to nursing infant is unknown, however has been used safely in neonates. Flucytosine b No human data on excretion in milk, although has been used in neonates. Itraconazole ? Excreted in human milk. Potential effects to the nursing infant are not known. Ketoconazole a <1% of maternal dose is excreted in human milk. No adverse effects reported in nursing infants. Terbinafine ? Oral formulation is excreted in human milk. Potential effects to the nursing infant are not known. With the cream and spray, the small amount absorbed through the skin is unlikely to affect the nursing infant. ANTIMICROBIALS IN LACTATION

DRUG RISK COMMENTS FACTOR* ANTIPARASITIC AGENTS Chloroquine a Although the amount excreted in human milk is not considered to be harmful to the nursing infant, it is insufficient to provide adequate protection against malaria. Mebendazole a Only 2-10% of oral dose is absorbed; negligible amount excreted in human milk. Mefloquine b Only 3-4% of maternal dose is excreted in human milk. No adverse effects have been reported in nursing infants, however with continued maternal use drug accumulation may occur (plasma half-life = 10-21 days). Pentamidine ? No human data on excretion in milk, however systemic concentrations achieved via aerosol are low thus milk levels are probably nil. IV therapy probably safe as poor oral absorption. Praziquantel b Excreted in human milk. Primaquine ? No human data on excretion in milk Pyrimethamine a Excreted in human milk. Quinine a Excreted in human milk. ANTIMYCOBACTERIAL AGENTS Dapsone a Significant amount excreted in human milk; nursing infant may be at risk of developing hemolytic anemia. Ethambutol a Insignificant amount excreted in human milk. Isoniazid a Excreted in human milk. Potential for hepatotoxicity may exist. Pyrazinamide ? Excreted in human milk. Rifampin a Insignificant amount excreted in human milk. Streptomycin a Excreted in human milk; poor systemic absorption by infant. ANTIVIRAL AGENTS Acyclovir a Significant amount excreted in human milk; poor systemic absorption by infant. Amantadine b Small amount excreted in human milk. No adverse effects reported in nursing infants. ANTIMICROBIALS IN LACTATION

DRUG RISK COMMENTS FACTOR* ANTIVIRAL AGENTS (cont’d) Antiretrovirals ? Centers for Disease Control and Prevention recommend that HIV-infected women in developed countries NOT breast-feed in order to avoid post-natal transmission of HIV to the infant. Famciclovir ? No human data on excretion in milk. Significant amount excreted in rat milk. Foscarnet ? No human data on excretion in milk. Significant amount excreted in rat milk. Ganciclovir ? No human data on excretion in milk. Valacyclovir a No human data on excretion in milk, however it is rapidly and almost completely converted to acyclovir, which is considered to be safe in breast feeding.

* Risk Factor Legend: a = Considered safe for nursing infants when therapeutic dosages are administered to the mother. b = Caution indicated, however benefits may outweigh the risks. x = Usually contraindicated; either avoid medication during nursing or nursing should be withheld if the medication is necessary. ? = Unknown; information is lacking regarding excretion in breast milk and/or effect on nursing infant. Abbreviations: BLI = b-lactamase inhibitor, G6PD = glucose-6-phosphate dehydrogenase EXPOSURE TO SELECTED* COMMUNICABLE DISEASES DURING PREGNANCY Reviewed by Dr. J. Galbraith, Medical Microbiology & Infectious Diseases, Director, Microbiology, DKML and Dr. S. Shafran, Director, Adult Infectious Diseases

Infectious Agent Potential Effect on Rate of Perinatal Maternal Screening Prevention Fetus Transmission The best way to prevent many of these infections is to maintain careful handwashing practices and keep all adult immunizations up to date. Cytomegalovirus · Congenital Syndrome† Maternal infection: - Routine screening not - Handwashing (especially (CMV) especially: · primary – 15% (primary recommended. when changing diapers). Primary Þ Hearing loss infection associated with or Þ Hepatosplenomegaly more severe fetal Reactivated Þ Jaundice infection) Þ Microcephaly · reactivated – 5% · up to 2.3% of all live births are affected by intrauterine CMV infections. Hepatitis B · Hepatitis · 10-20% (if HBeAg positive - - Routine HBsAg (performed - HBIG (Hepatitis B immune st · Cirrhosis and/or liver 90%) in 1 trimester). globulin) and HBV vaccine cancer (as an adult) · Transmission usually at should be given to baby at time of delivery birth. - If non-immune mother exposed in pregnancy give HBIG and HBV vaccine. Hepatitis C · Hepatitis · 6% - Screening HCV-Ab - Avoid high risk behavior · Cirrhosis and/or liver · Increased risk of recommended in high risk (e.g. IVDU) cancer (as an adult) transmission if mother co- pregnant patients: - Currently no post exposure infected with HIV. Þ intravenous drug users prophylaxis available. Þ blood transfusion before 1992 Þ undiagnosed hepatitis. *NB: This list is not all inclusive. There are other infections, including syphilis, enteroviruses, lymphocytic choriomeningitis virus, Coxiella burnetti, and tuberculosis, which may be associated with congenital infection. Consult with Infectious Diseases recommended. EXPOSURE TO SELECTED* COMMUNICABLE DISEASES DURING PREGNANCY

Infectious Agent Potential Effect on Rate of Perinatal Maternal Screening Prevention Fetus Transmission Herpes Simplex Primary Primary · Transmission occurs at time - Consult Virology lab in - Consult Infectious or · Fetal loss of delivery in 90-95% of event of suspected primary Diseases for treatment of Recurrent · Congenital Syndrome† cases. infection in pregnancy. primary infection. Vaginal delivery: Primary and Recurrent · primary – 41% - Inspect for lesions at time - If lesions present at time of · Mucocutaneous lesions · recurrent – 4% of delivery (maternal delivery, recommend · Disseminated disease · Neonatal HSV infection shedding can occur in the caesarean section. · Encephalitis affects 1/5000 births (half of absence of lesions). - Daily suppressive oral these related to primary acyclovir can be infection). considered in late third trimester. Human · AIDS (progression - 25% (rate reduced to 8% in - Routine HIV antibody - Avoid high risk behavior. st Immunodeficiency during childhood) one study of women treated (performed in 1 trimester). - For documented HIV Virus (HIV) with zidovudine and less - Repeat in 3rd trimester if exposure in pregnancy, than 3% with suppressive high risk for HIV. consult Infectious triple antiretroviral therapy) Diseases. - majority of infants infected - If HIV positive, consult in 3rd trimester or at time of Infectious Diseases (re: delivery. antenatal/perinatal - transmission may also antiretroviral therapy). occur with breastfeeding. - Avoid breastfeeding. Parvovirus B19 · Fetal loss · 17-33% - Routine screening not - Droplet precautions. (Fifth disease) · Hydrops · Maternal infection: recommended. - If mother Parvovirus IgM · Anemia Þ < 20 weeks gestation – - If maternal exposure or positive, consult Maternal/ · Congestive heart failure 17% risk of fetal loss suspect infection, contact Fetal specialist. Þ > 20 weeks gestation – Virology lab re: Parvovirus 6% risk of fetal loss IgG and IgM. EXPOSURE TO SELECTED* COMMUNICABLE DISEASES DURING PREGNANCY

Infectious Agent Potential Effect on Rate of Perinatal Maternal Screening Prevention Fetus Transmission Rubella · Fetal loss · 67-85% - 1st trimester - Routine Rubella IgG - Vaccination before or after st · Congenital Syndrome† (infection in 1st trimester performed in 1 trimester. pregnancy (not during). especially: associated with more - If maternal rubella - In acute infection – droplet Þ Hearing loss severe fetal infection) suspected, perform Rubella precautions. nd rd Þ Congenital heart · 25-35% - 2 and 3 trimester IgM. - In neonatal infection failure acquired congenitally, use Þ Cataracts contact precautions. Þ Thrombocytopenia/ Purpura Toxoplasma gondii · Fetal loss · 1st trimester – 10-25% - Routine screening not - Wash hands: · Congenital Syndrome† (increased risk for severe recommended. · before eating especially: perinatal infection) - If maternal exposure or · after handling raw meat nd Þ Chorioretinitis · 2 trimester – 30-54% suspect infection, contact · after contact with rd Þ Hydrocephales · 3 trimester – 60-65% lab re: Toxo-plasma soil/cat feces. Þ Intracerebral IgG/IgM/IgA. - Unless known to be calcification immune to Toxo, pregnant woman should avoid: · eating raw or rare beef, pork, or lamb · contact with cats of unknown feeding history · cleaning litter boxes. - If mother Toxo IgM positive, consult Infectious Diseases re: possible amniocentesis and treatment to reduce likelihood of transmission to fetus. EXPOSURE TO SELECTED* COMMUNICABLE DISEASES DURING PREGNANCY

Infectious Agent Potential Effect on Rate of Perinatal Maternal Screening Prevention Fetus Transmission Varicella Zoster Primary infection Primary · 5-7% of pregnancies - Routine screening generally - Non-immune women or · Congenital Syndrome† complicated by VZV not recommended. should be vaccinated especially: infection. - If pregnant woman (with no before or after pregnancy Perinatal period Þ Limb hypoplasia · 2% risk of congenital history of previous chicken (not during). Þ Ocular abnormalities varicella infection if mother pox) is exposed, perform - Non-immune women Þ CNS abnormalities develops varicella within STAT Varicella IgG. exposed during pregnancy · Dermatomal scarring first 20 weeks of pregnancy. - If suspect primary infection, should receive VZIG · 20-40% risk of neonatal contact Virology lab re: VZV (within 96 hours of Perinatal period varicella infection if mother testing: exposure). · Chicken pox develops varicella in · DFA of lesions - best - If pregnant woman or +/- peripartum period. test neonate develops · Encephalitis or varicella, consult Infectious · serology (IgG and IgM). Diseases. - Exposed neonate should receive VZIG prophylaxis. † Congenital Syndrome – One or more of the following: jaundice, hepatosplenomegaly, microcephaly, CNS abnormalities, ocular abnormalities, thrombocytopenia/purpura, hemolytic anemia, intracerebral calcifications, hearing loss, intrauterine growth retardation, prematurity. INTRAPARTUM ANTIMICROBIAL PROPHYLAXIS

· At 35-37 weeks, obtain single swab from lower vagina and anorectum.

· Give intrapartum prophylactic antibiotics* upon commencement of labour if: Þ culture positive for GBS or Þ patient has one or more of the following risk factors: - previous baby with invasive GBS disease - GBS bacteriuria during present pregnancy - delivery at < 37 weeks gestation - premature rupture of membranes at < 37 weeks gestation - prolonged rupture of membranes (³18h) - intrapartum fever (³ 37.50C).

* If patient receiving treatment for amnionitis with antibiotics active against GBS (ampicillin, penicillin, clindamycin, erythromycin) additional prophylactic antibiotics are not needed.

Antimicrobial Regimen Dose & Duration Comments Penicillin* 5MU IV then * Penicillin preferred because: 2.5MU IV q4h until delivery · narrow spectrum or · less likely to select resistant organisms. Ampicillin 2g IV then 1g IV q4h until delivery - Ampicillin + gentamicin recommended if chorioamnionitis suspected. b-lactam allergy ** Q6h dosing is to accommodate Clindamycin 600mg IV q6h** until delivery local newborn caremap. or Pharmacokinetically, clindamycin Erythromycin 500mg IV q6h until delivery should be given q8h. PERINATAL HIV PROTOCOL Developed by the University of Alberta Department of Medicine, Division of Infectious Diseases, and the Capital Health Regional Women’s Health Program, in consultation with Child Health/ Newborn Medicine Division

Antiretroviral Prophylaxis Antiretroviral Regimens Clinical Scenario Mother Neonate HIV-infected pregnant · Give IV zidovudine* (ZDV) during · Give oral ZDV* for six weeks woman in labour who labour and delivery, regardless of postpartum. has received antepartum ART regimen. combination AND antiretroviral therapy · The mother should continue her (ART) during the current antepartum ART regimen pregnancy and is throughout labour wherever thought to have been possible. compliant with treatment or known to NB: Caesarean section is not have had a good viral recommended for the purpose of load response reducing HIV transmission to the neonate. HIV-infected pregnant · Give IV ZDV* during labour and · Give oral ZDV* for six weeks woman: delivery. postpartum. · who has had no AND AND ART during the · Give nevirapine in a single dose · Give nevirapine1 2mg/kg PO in a current pregnancy of 200mg PO immediately if the single dose within 72 hours of OR woman presents in labour. delivery. · in whom compliance with NB: Consider caesarean section for ART is thought to the purpose of reducing HIV have been poor transmission to the neonate if not in (especially if active labour and the membranes documented by a are intact. high viral load) Infant born to HIV- · Give oral ZDV* for six weeks infected mother who postpartum. has received no ART +/- during pregnancy or · Nevirapine1 2mg/kg PO in a single intrapartum dose should be considered. 1 Suspension available through the Special Access Program [Boehringer Ingelheim (905) 631-4759].

* Zidovudine Regimen Time of Administration Zidovudine (ZDV) Regimen Intrapartum (mother) IV ZDV 2mg/kg (current body weight) over 1 hour, followed by a continuous infusion of 1mg/kg/hour until delivery (i.e. cord is clamped). Postpartum (neonate) Full term (>/= 34 weeks) ZDV syrup 2mg/kg/dose q6h x 6 weeks, beginning as soon as possible (within 8-12 hours) after birth. NB: IV dosage for infants who cannot tolerate oral intake is 1.5mg/kg/dose q6h Premature (< 34 weeks) ZDV 1.5mg/kg/dose q12h PO or IV x 2 weeks then 2mg/kg q8h PO or IV x 4 weeks, beginning as soon as possible (within 8-12 hours) after birth. Revision 6, September 2000 GUIDE TO GRAM STAIN INTERPRETATION

This is meant to be a general guide only. l The organism list for each bacterial morphology type is not all inclusive. l Bacterial morphology may be altered by antibiotic therapy, and some transport/culture media. l Clinical correlation is essential when choosing empiric therapy.

Bacterial Morphology Probable Organisms GRAM POSITIVE · Cocci in clusters/clumps Staphylococcus spp Micrococcus spp Pediococcus spp Aerococcus spp · Cocci in pair/chains Streptococcus spp Gemella spp Enterococcus spp Peptostreptococcus spp · Bacilli (small) non spore forming Listeria spp Corynebacterium spp Erysipelothrix spp Propionibacterium spp Lactobacillus spp Actinomyces spp Other anaerobic bacilli · Bacilli (large) +/- spores Clostridium spp Bacillus spp · Bacilli branching/beaded/ Nocardia spp filamentous Actinomyces spp Streptomyces spp GRAM NEGATIVE · Bacilli Enterobacteriaceae Pseudomonas spp Other nonfermentative bacilli · Coccobacilli/pleomorphic bacilli Haemophilus spp HACEK* group Pasteurella spp Brucella spp Bacteroides spp Other anaerobic bacilli · Diplococci Neisseria spp Moraxella catarrhalis Acinetobacter spp · Fusiform Fusobacterium spp Capnocytophaga spp · Curved Campylobacter spp GUIDE TO GRAM STAIN INTERPRETATION * HACEK = Haemophilus aprophilus/H. parainfluenzae, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella spp. COMMENSAL AND PATHOGENIC ORGANISMS FOR SPECIFIC BODY SITES

RESPIRATORY TRACT

Normal Oropharyngeal Flora* May be part of normal flora but may be potential pathogens in lower respiratory tract** Viridans group Streptococci Streptococcus pneumoniae Non haemolytic Streptococci Haemophilus influenzae/parainfluenzae Coagulase negative Staphylococci Moraxella catarrhalis Anaerobes (Prevotella spp, Porphyromonas Staphylococcus aureus spp, Fusobacterium spp) b-haemolytic Streptococci Neisseria spp Enterobacteriaceae Corynebacterium spp Pseudomonas and non-fermentative bacilli Micrococcus spp Neisseria meningitidis Stomatococcus spp Candida spp Lactobacillus spp Corynebacterium pseudodiphteriticum Enterococcus spp Pasteurella spp Bacillus spp * Some of these organisms may be involved in polymicrobial infections (aspiration pneumonia, bronchiectasis) ** Quality of sputum is assessed microscopically. Only adequate specimens are cultured. Potential pathogens are reported when ³ normal flora or if predominant organism seen on gram stain. COMMENSAL AND PATHOGENIC ORGANISMS FOR SPECIFIC BODY SITES

EYES

Normal Flora Potential Pathogens Coagulase negative Staphylococci Haemophilus influenzae Viridans group Streptococci Streptococcus pneumoniae Non-haemolytic Streptococci Staphylococcus aureus Corynebacterium spp Moraxella spp Neisseria spp (except N. gonorrhoeae) b-haemolytic Streptococci Peptostreptococcus spp Neisseria gonorrhoeae Propionibacterium spp Pseudomonas aeruginosa* Acinetobacter spp Enterobacteriaceae* * These organisms may cause keratitis (trauma or contact lens related), rather than conjunctivitis.

EARS

Normal Flora Potential Pathogens Coagulase negative Staphylococci Streptococcus pneumoniae Viridans group Streptococci Moraxella catarrhalis Non-haemolytic Streptococci Haemophilus influenzae Corynebacterium spp Staphylococcus aureus Neisseria spp b-haemolytic Streptococci Bacillus spp Pseudomonas aeruginosa* Peptostreptococcus spp Enterobacteriaceae* Propionibacterium spp Other gram negative bacilli* Anaerobes** * These organisms may be colonizers of external canal. Correlation with gram stain and clinical presentation recommended. **May be involved in chronic otitis media but not acute otitis media. COMMENSAL AND PATHOGENIC ORGANISMS FOR SPECIFIC BODY SITES

URINARY TRACT*

Common Contaminants Potential Pathogens Lactobacillus spp Enterobacteriaceae Viridans group Streptococci Staphylococcus saprophyticus Non-haemolytic Streptococci Enterococcus spp Neisseria spp b-haemolytic Streptococci (group A&B) Corynebacterium spp Pseudomonas spp Coagulase negative Staph (other than S. saprophyticus) Other non-fermentative bacilli Gardnerella vaginalis** Streptococcus bovis Anaerobes Staphylococcus aureus Oligella spp** Candida spp Haemophilus influenzae Corynebacterium urealyticum Aerococcus urinae Streptococcus pneumoniae * Work-up/reporting of urine samples based on colony count/clinical information/number and type of organisms: ** Occasionally may cause urinary tract infections. 108 cfu/L - significant indication of urinary tract infection 107 cfu/L - significant with signs/symptoms. Lab will work up 1 or 2 organisms at this colony count if relevant diagnosis. 106 cfu/L - low colony count - may be significant in females with pyuria/dysuria syndrome. Lab will work up if pure uropathogen and history provided. ³ 3 organisms - mixed-probable contamination. Lab will work up if a uropathogen > 80% predominant. COMMENSAL AND PATHOGENIC ORGANISMS FOR SPECIFIC BODY SITES

GENITAL TRACT

Normal Flora Potential Pathogens Lactobacillus spp Pathogen: Viridans group Streptococci N. gonorrhoeae - cervicitis Non-haemolytic Streptococci Chlamydia trachomatis - cervicitis Enterococcus spp Herpes simplex Coagulase negative Staphylococci Trichomonas vaginalis - vaginitis Gardnerella vaginalis Potential Pathogens*: Corynebacterium spp Candida spp b-haemolytic Streptococci (group B,C,G) b-haemolytic Streptococci (group A) Enterobacteriaceae Staphylococcus aureus Anaerobes Actinomyces spp (IUD) Candida spp Neisseria meningitidis Pasteurella spp Pseudomonas aeruginosa Pregnancy**: b-haemolytic Streptococci (group B) Listeria monocytogenes Haemophilus influenzae * Other organisms may be involved post surgical/post abortion/post partum. ** Potential for disease in fetus/newborn. COMMENSAL AND PATHOGENIC ORGANISMS FOR SPECIFIC BODY SITES

SKIN/SOFT TISSUE

Potential Pathogens Normal Skin Flora Superficial/ Superficial Deep Skin¬ Wounds (< 2 cm)• Wounds(> 2cm)® Coagulase negative Staph Staphylococcus aureus Staphylococcus aureus Staphylococcus aureus Viridans group Streptococci b-haemolytic Streptococci b-haemolytic Streptococci b-haemolytic Streptococci Non-haemolytic Streptococci (group A,B,C,G) (group A,B,C,G) (group A,B,C,G) Corynebacterium spp Pseudomonas aeruginosa Enterobacteriaceae Enterobacteriaceae Bacillus spp Candida spp Pasteurella multocida Pseudomonas & other non- Acinetobacter spp Dermatophytes Pseudomonas & other non- fermentative bacilli Candida spp fermentative bacilli Pasteurella multocida Peptostreptococcus spp Mycobacterium spp Enterococcus spp Propionibacterium spp Haemophilus spp Candida spp Moraxella spp Nocardia spp Streptococcus milleri group Bacillus anthracis Eikenella corrodens Erysipelothrix rhusiopathiae Anaerobes Bacillus cereus Corynebacterium spp S. lugdunensis/S. schleiferi Other coagulase negative Staph Erysipelothrix rhusiopathiae Capnocytophaga spp Vibrio spp Actinomyces spp Nocardia spp Fungal pathogens Mycobacterium spp Bacillus anthracis ¬ Superficial/skin: rash/abrasion/impetigo/folliculitis/balanitis/boils/acne • Superficial wounds (< 2 cm in depth): wounds/incisions/ulcers/sebaceous cysts/catheter site/cellulitis/abscesses COMMENSAL AND PATHOGENIC ORGANISMS FOR SPECIFIC BODY SITES ® Deep wounds (> 2 cm in depth): wounds/incisions/ulcers/abscesses EMPIRIC THERAPY OF SPECIFIC ORGANISMS

* Empiric therapy recommendations for specific organisms are based on published microbiologic/clinical data, and local susceptibility patterns. Antibiotics listed for each organism are not all inclusive. Empiric antibiotic therapy should be modified to more narrow spectrum antibiotic(s) according to susceptibility results.

AEROBIC GRAM POSITIVE COCCI

ORGANISM EMPIRIC THERAPY* COMMENTS Abiotrophia spp Penicillin + Gentamicin · Part of normal flora of oropharynx. (nutritionally variant Streptococci) · May cause native/prosthetic valve endocarditis, bacteremia, and ocular infections. · Penicillin tolerance and resistance have been reported. Aerococcus spp Ampicillin +/- Gentamicin · May cause urinary tract infections, bacteremia, and endocarditis. · Often resistant to TMP/SMX. Alloiococcus otitidis Amoxicillin · May have role in chronic otitis media. Enterococcus faecalis Ampicillin + Gentamicin · Part of normal flora of GI tract and female GU tract. (if gentamicin synergy S) · Cause of urinary tract infections and nosocomial infections. · Ampicillin preferred (2-4 times lower MIC than penicillin). · High incidence of gentamicin synergy resistance. · Increased ciprofloxacin resistance noted in urinary isolates. · Cephalosporins and TMP/SMX have no activity against E. faecalis. Enterococcus faecium Vancomycin + Gentamicin · Part of normal flora of GI tract. (if gentamicin synergy S) · Cause of urinary tract infections and nosocomial infections. · Almost all isolates resistant to ampicillin. · Marked increase in vancomycin resistance in last year. · Increased ciprofloxacin resistance noted in urinary isolates. · Cephalosporins and TMP/SMX have no activity against E. faecium. Enterococcus gallinarum Ampicillin · Inherent low level resistance to vancomycin. Enterococcus casseliflavus · Low level pathogenicity; do not have infection control implications of vancomycin resistant E. faecium or E. faecalis.

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AEROBIC GRAM POSITIVE COCCI (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Gemella spp Penicillin +/- Gentamicin · Normal flora of the respiratory and GI tracts. · May cause endocarditis, CNS, bone & joint, and respiratory tract infections. · In serious infections, addition of gentamicin recommended. Helcococcus spp Penicillin +/- Gentamicin · May be associated with wound infections, especially in patients with peripheral vascular disease or diabetes. · Often present with co-pathogens. Lactococcus spp Penicillin +/- Gentamicin · Part of normal flora of GI tract. · Rarely associated with endocarditis, wound/urinary and eye infections. · Low level pathogen. Leuconostoc spp Penicillin +/- Gentamicin · May cause bacteremia, meningitis, peritonitis, and line-related infections in immunocompromised patients. · Infections often polymicrobial in patients with previous antibiotic therapy. · Resistant to vancomycin. · Decreased susceptibility to cephalosporins (especially 3rd generation). · In serious infections, addition of gentamicin recommended. Micrococcus spp Cloxacillin · Part of normal skin flora (low level pathogen). · Rare cause of various infections, including line-related, in immunocompromised patients. · Some strains exhibit cloxacillin/cephalosporin resistance. Pediococcus spp Penicillin +/- Gentamicin · May cause bacteremia, visceral abscesses, or line-related infections in immunocompromised/debilitated patients. · Resistant to vancomycin. · Decreased susceptibility to cephalosporins (especially 3rd generation). · In serious infections, addition of gentamicin recommended.

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AEROBIC GRAM POSITIVE COCCI (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Staphylococcus aureus Cloxacillin or · If erythromycin R/clindamycin S, use clindamycin with caution as st 1 generation cephalosporin resistance may develop during prolonged therapy. · Cause of skin/bone/joint/wound/line-related infections, bacteremia, septicemia, endocarditis, and pneumonia. MRSA suspected MRSA: (nosocomial infection and · Increased incidence of MRSA in Capital Health (7%) previous antibiotic therapy) · Several outbreaks in hospitals and long term care. Vancomycin · Most isolates represent colonization rather than infection. · MRSA isolates are resistant to all penicillins and cephalosporins. Staphylococcus lugdunensis Vancomycin · Associated with wound/prosthetic device infections and endocarditis. · Often resistant to cloxacillin. Staphylococcus spp – Coagulase Vancomycin · Normal skin flora. negative · Infections usually associated with intravenous catheter/foreign material/implants or prosthetic joints. Staphylococcus saprophyticus Ciprofloxacin · Cause of urinary tract infections in sexually active young females (15-55 or years old). May cause UTI in males, commonly in association with Cephalexin indwelling catheter/obstruction. or · Susceptibility to TMP/SMX variable. Nitrofurantoin Staphylococcus schleiferi Vancomycin · Associated with wound/prosthetic device infections and endocarditis. · May be transmitted by pets. Stomatococcus spp Ampicillin +/- Gentamicin · Part of normal oropharyngeal flora. · Has been associated with septicemia, endocarditis, catheter related sepsis, meningitis, and peritonitis, usually in immunocompromised/ debilitated patients. · In serious infections, addition of gentamicin recommended.

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AEROBIC GRAM POSITIVE COCCI (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Streptococcus agalactiae Ampicillin +/- Gentamicin · May cause neonatal infections (sepsis, meningitis, pneumonia), maternal (Group B Strep) fever and postpartum infections. · May cause skin/soft tissue/bone infections, and bacteremia in adults, especially in diabetics. · Resistant to TMP/SMX. · May exhibit tolerance – in serious infections addition of gentamicin should be considered. Streptococcus bovis Ampicillin · Associated with bacteremia, endocarditis (native & prosthetic valve), meningitis, and rarely urinary tract infections. · Strong association between S. bovis bacteremia and malignancy of the colon. Streptococcus Penicillin +/- Gentamicin · Part of normal flora of the oropharynx and GI tract. (Group C & G) · May cause skin/soft tissue infections, pharyngitis, endocarditis, septicemia, meningitis, pneumonia, and bone & joint infections. · May exhibit tolerance - in serious infections addition of gentamicin should be considered. Streptococcus iniae Penicillin · Associated with wound infections and bacteremia in patients with history of handling fish.

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AEROBIC GRAM POSITIVE COCCI (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Streptococcus pneumoniae Otitis Media · Cause of pneumonia, sepsis, meningitis, otitis media, and sinusitis. Amoxicillin · Resistance (Northern/Central Alberta): Meningitis Penicillin – 20% Cefotaxime Intermediate 16% +/- High level 4% (in Capital Health proper 1.4% high level resistance) Vancomycin TMP/SMX – 21% Erythromycin – 13% Refer to Recommended Tetracycline – 8% Empiric Therapy Section. Clindamycin – 5% Cefuroxime – 10% Cefotaxime/Ceftriaxone – 1%

Activity of various b-lactam agents against Pen-I S. pneumoniae Amoxicillin > Cefuroxime > Cefprozil > Cefixime+ > Cefaclor+ > Cephalexin+

+ +Due to • MIC, these agents should not be used if S. pneumoniae resistance is suspected. NB: Pen-R isolates are resistant to all oral cephalosporins.

Streptocococcus pyogenes Pharyngitis/Cellulitis · Cause of pharyngitis, skin/soft tissue infections, pneumonia, septicemia, (Group A Strep) Penicillin and toxic shock-like syndrome. or · Resistant to TMP/SMX. Erythromycin · ~5% resistance to macrolides. Necrotizing fasciitis/Septic shock Penicillin + Clindamycin Viridans Group Streptococcus (VGS) Penicillin +/- Gentamicin · Part of normal flora of oropharynx and GI/GU tracts. - S. milleri group (If MIC 0.25-2.0 mg/mL, add · May cause bacteremia and endocarditis. - S. mutans gentamicin) · S. milleri group (especially S. anginosus) – involved in deep abscesses, - S. salivarius commonly with anaerobes. - S. sanguis group Severe infection · S. mutans - dental caries. - S. mitis Cefotaxime · Increasing resistance to penicillin and clindamycin.

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GRAM POSITIVE BACILLI

ORGANISM EMPIRIC THERAPY* COMMENTS Arcanobacterium haemolyticum Erythromycin · Associated with pharyngitis in young adults (with/without a rash). · Rare cause of bacteremia, osteomyelitis, skin/soft tissue infections, and brain abscesses. · Resistant to TMP/SMX. Bacillus cereus Vancomycin · Cause of bacteremia, endocarditis, brain abscess, and pneumonia in or predisposed individuals (especially IVDU/malignancy/alcoholism). Imipenem · May cause severe ocular or wound infections following trauma. · Resistant to penicillins and cephalosporins. Bacillus spp (other) Penicillin · Low level pathogen (usually represent environmental contaminants). · May cause infections in immunocompromised patients. Brevibacterium spp Tetracycline · Low level pathogen. or · May cause bacteremia, meningitis, and osteomyelitis. Vancomycin · Usually resistant to penicillin. Corynebacterium amycolatum Vancomycin · May cause wound/foreign body/respiratory and urinary tract infections. or · Often exhibits multiple resistance to penicillins, cephalosporins, Tetracycline clindamycin, and ciprofloxacin. Corynebacterium diphtheriae Penicillin · Cause of diphtheria (skin, pharyngeal). · Culture performed by special request only. Prophylaxis · Diphtheria antitoxin mainstay of therapy. Erythromycin · Antimicrobial therapy of secondary importance for patient but useful in prophylaxis of contacts. Corynebacterium glucuronicum Penicillin · Normal GU flora but has been associated with GU infections in males (prostatitis/urethritis). Corynebacterium CDC Group G Vancomycin or · May cause wound/bone/joint/ocular infections, and endocarditis. Penicillin · Often exhibit multiple resistance. Corynebacterium jeikeium Vancomycin · Colonizes skin of hospitalized patients. · May cause foreign device/wound/bone infections, endocarditis, meningitis. Corynebacterium minutissimum Erythromycin · Part of normal skin flora. · Association with erythrasma is questionable.

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GRAM POSITIVE BACILLI (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Corynebacterium propinquum Penicillin · Rare association with endocarditis and pneumonia. Corynebacterium pseudodiphtheriticum Penicillin +/- Gentamicin · Cause of respiratory tract infections, especially in ventilated/ICU patients. · May also cause foreign device/wound infections and endocarditis. · In serious infections, addition of gentamicin recommended. Corynebacterium pseudotuberculosis Penicillin · Cause of suppurative granulomatous lymphadenitis. · Usually in patients exposed to animals or who drank unpasteurized milk. Corynebacterium striatum Penicillin · Part of normal flora of skin and nose. · Rare cause of nosocomial infections (especially catheter/prosthetic material related infections). Corynebacterium urealyticum Ciprofloxacin · Often skin colonizer of hospitalized patients. · Associated with urinary tract infections in immunocompromised patients, elderly males with recent hospitalization/urologic manipulation, and patients with history of struvite stones or encrusted cystitis. · May cause bacteremia, bone and soft tissue infections. · Usually exhibit multiple resistance (treat according to susceptibility results). Corynebacterium spp (other) Penicillin · Part of normal skin flora. · Low level pathogen. Erysipelothrix spp Penicillin · Cause of erysipeloid following contact with infected animals. · Bacteremia and endocarditis may occur, especially in immunocompromised patients. · Resistant to vancomycin, TMP/SMX, and aminoglycosides. Gardnerella vaginalis Bacteremia · Part of normal vaginal and anorectal flora. Ampicillin · Associated with: Bacterial vaginosis · bacterial vaginosis (non-inflammatory alteration of normal flora) Metronidazole Þ preterm labour/chorioamnionitis/infections in newborns Urinary tract infections Þ post partum bacteremia Amoxicillin · urinary tract infections (male and female).

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GRAM POSITIVE BACILLI (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Lactobacillus spp Penicillin +/- Gentamicin · Part of normal flora of oral cavity, GI/GU tracts. · May cause infections (bacteremia, endocarditis) in immunocompromised patients. · In serious infections, addition of gentamicin recommended. Listeria monocytogenes Ampicillin + Gentamicin · Cause of meningitis, brain abscess, and bacteremia in immunocompromised or debilitated patients. b-lactam allergy · Cause of perinatal infections (maternal fever/neonatal sepsis +/- TMP/SMX meningitis). · Resistant to cephalosporins and quinolones. · May exhibit tolerance. In serious infections, addition of TMP/SMX or gentamicin recommended. · Prolonged therapy (3 weeks) recommended. Nocardia spp TMP/SMX + · Cause of acute or chronic wounds/abscesses at various body sites nd 2 agent (e.g. ceftriaxone or (skin/soft tissue, lung, CNS). imipenem) · Combination therapy recommended (according to susceptibility results). (based on susceptibility · Susceptibility is species dependent. results) Oerskovia spp Vancomycin · Opportunistic pathogen. or · May cause infections in immunocompromised patients or those with Penicillin prosthetic materials. Rhodococcus equi Erythromycin + Rifampin · Cause of granulomatous pneumonia, lymphadenitis, CNS infections, and wounds/abscesses in immunocompromised patients (especially HIV). · Prolonged therapy recommended (2-6 months). Rothia spp Penicillin +/- Gentamicin · Part of normal oropharyngeal flora. · Implicated in dental caries and periodontal disease. · May cause endocarditis or pneumonia in immunocompromised patients. · In serious infections, addition of gentamicin recommended. · Clinical failures described with vancomycin.

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GRAM NEGATIVE COCCI

ORGANISM EMPIRIC THERAPY* COMMENTS Neisseria gonorrhoeae Cefixime · Cause of sexually transmitted infections (genitourinary, anorectal, or pharyngeal, conjunctival).and disseminated infections (arthritis, Ciprofloxacin bacteremia). or · Resistance to penicillin is widespread. Ceftriaxone · Resistance to ciprofloxacin is slowly emerging in Canada. Neisseria meningitidis Cefotaxime · May be present in nasopharynx of asymptomatic carriers. or · May cause septicemia, meningitis, and occasionally pneumonia, Ceftriaxone conjunctivitis, endophthalmitis, cervicitis/urethritis, septic arthritis. · In Alberta, decreased susceptibility to penicillin noted in some strains. Neisseria spp (other) Penicillin · Part of normal oropharyngeal flora. · Low level pathogen. · May cause infections in predisposed individuals (endocarditis, pneumonia, empyema).

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GRAM NEGATIVE BACILLI – Enterobacteriaceae

ORGANISM EMPIRIC THERAPY* COMMENTS Cedecea spp Ciprofloxacin · Opportunistic pathogen. or · May cause infections (bacteremia, pneumonia) in immunocompromised/ TMP/SMX debilitated individuals. Citrobacter amalonaticus Ciprofloxacin · Found in water, soil, food, and GI tract of humans & animals. Citrobacter freundii complex or · Associated with nosocomial infections (urinary tract, respiratory tract, Gentamicin wounds, bone, skin/soft tissue, peritoneum, meninges, and bloodstream) or and endocarditis. TMP/SMX · These organisms may produce inducible b-lactamases. Therapy with penicillins or cephalosporins not recommended as clinical failures may occur despite in vitro susceptibility. NB: b-lactam - b-lactamase inhibitor combinations not more effective and not recommended. · In serious infections (especially immunocompromised/debilitated patients), combination therapy should be considered. C. koseri (C. diversus) TMP/SMX · Rare cause of neonatal meningitis/brain abscess. or · May cause urinary tract/wound infections, and bacteremia. Ciprofloxacin · More susceptible to b-lactams than other Citrobacter species.

CNS infection Cefotaxime +/- Gentamicin

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GRAM NEGATIVE BACILLI - Enterobacteriaceae (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Edwardsiella spp Ampicillin · Found in cold blooded animals. or · Associated with salmonella-like gastroenteritis, bacteremia, abscesses, TMP/SMX meningitis, or skin/soft tissue infections following aquatic accidents. Enterobacter spp Ciprofloxacin · Cause of nosocomial infections (bacteremia, pneumonia, urinary tract, or wound, bone & joint, CNS) usually in immunocompromised/debilitated Gentamicin patients. or · Previous antimicrobial therapy (especially cephalosporins) risk factor for TMP/SMX Enterobacter infections. · These organisms may produce inducible b-lactamases. Therapy with penicillins or cephalosporins not recommended as clinical failures may occur despite in vitro susceptibility. NB: b-lactam - b-lactamase inhibitor combinations not more effective and not recommended. · In serious infections (especially immunocompromised/debilitated patients), consider combination therapy. Escherichia coli Urinary tract infection · Most common cause of urinary tract infections. Ciprofloxacin or · Cause of nosocomial infections (pneumonia, urinary tract, wounds, Gentamicin or bacteremia). May cause neonatal meningitis. TMP/SMX · Local susceptibility: Other cefazolin* – 93% Cefazolin or cephalexin* – 32% Gentamicin ampicillin – 27% Bacteremia/Severe infections TMP/SMX – 84% Gentamicin or *NB: Cefazolin susceptibility does not predict cephalexin/cephalothin Cefotaxime or susceptibility Ciprofloxacin Hafnia spp TMP/SMX · Cause of opportunistic infections (bacteremia, meningitis, or respiratory/urinary/wound infections). Ciprofloxacin · Some isolates produce inducible b-lactamases. or Gentamicin

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GRAM NEGATIVE BACILLI – Enterobacteriaceae (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Klebsiella spp Urinary tract infection · Cause of community and nosocomial infections (pneumonia, UTI, TMP/SMX bacteremia, skin and soft tissue). or · Resistant to ampicillin. Ciprofloxacin · In serious infection (bacteremia, necrotizing pneumonia, Other endocarditis, neutropenia), recommend combination of b-lactam and Cefazolin +/- Gentamicin* an aminoglycoside. · Extended spectrum b-lactamase production still rare locally. Morganella spp TMP/SMX · Cause of nosocomial urinary tract infections in chronically ill patients or (appears to persist for less time than Providencia spp). Ciprofloxacin · May cause a variety of infections in debilitated patients. or · May produce inducible b-lactamases. Gentamicin · Most strains resistant to nitrofurantoin. Pantoea agglomerans Ciprofloxacin · May be part of transient skin flora after antibiotic therapy. or · Nosocomial infections often indicate exogenous source of infection. TMP/SMX Proteus mirabilis TMP/SMX · Cause of community and nosocomial urinary tract infections, usually in or chronically catheterized patients (P. mirabilis is indicative of upper urinary Ciprofloxacin tract involvement). or · May also cause post-op infections, skin/soft tissue infections. Gentamicin · Resistant to nitrofurantoin. NB: Although generally susceptible to b-lactams, non b-lactam antibiotics appear more efficacious in treatment of urinary tract infections. Proteus vulgaris/penneri TMP/SMX · Cause of nosocomial infections, especially urinary tract. or · May produce inducible b-lactamases – therapy with cephalosporins not Ciprofloxacin recommended. or · Most strains resistant to nitrofurantoin. Gentamicin

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GRAM NEGATIVE BACILLI – Enterobacteriaceae (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Providencia spp Urinary tract infection · Cause of urinary tract infections in chronically catheterized patients. TMP/SMX · May cause nosocomial infections in debilitated patients who have received prior antibiotics. · May produce inducible b-lactamases. · Often exhibit multiple resistance (increasing resistance to ciprofloxacin ~50%). · P. stuartii more resistant than P. rettgeri. Salmonella spp Diarrheal illness* · Ubiquitous in animals. Ciprofloxacin · Acquired by ingestion of contaminated food/water: or Þ ½ of cases related to contaminated poultry TMP/SMX Þ exposure to reptiles also risk factor. · Common cause of intestinal infections. Other · May also cause bacteremia, intravascular infections, endocarditis, urinary Ciprofloxacin tract infections, skin/soft tissue infections, and osteomyelitis. or · Treatment for diarrheal illness recommended only in patients who Ceftriaxone** are: Þ < 6 months old Þ > 65 years old Þ immunosuppressed. · Monotherapy with aminoglycosides should not be used (poor intracellular penetration). **Ceftriaxone recommended over cefotaxime in severe infections.

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GRAM NEGATIVE BACILLI – Enterobacteriaceae (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Serratia spp TMP/SMX · Cause of nosocomial infections (pneumonia, bacteremia, wound and or urinary tract infections). Gentamicin · May also cause endocarditis, especially in drug addicts. · May produce inducible b-lactamases. Therapy with penicillins or Severe infection cephalosporins not recommended as clinical failures may occur despite in Imipenem vitro susceptibility. NB: b-lactam - b-lactamase inhibitor combinations not more effective and not recommended. · Locally ~20% resistance to ciprofloxacin. Check susceptibility report. · In serious infections, especially immunocompromised and debilitated patients, consider combination therapy. · Increased resistance noted in long term care. Shigella spp Adults · Cause of bloody & non-bloody diarrhea. Ciprofloxacin · Problem with increasing antimicrobial resistance (ampicillin, Children TMP/SMX). Cefixime · Cefixime may be useful in children. or TMP/SMX* Yersinia enterolitica Ciprofloxacin · Cause of enterocolitis, especially in children (may be difficult to or differentiate from acute appendicitis). TMP/SMX · May cause septicemia in patients with chronic illness.

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GRAM NEGATIVE BACILLI – Non-Enterobacteriaceae – Fermentative

ORGANISM EMPIRIC THERAPY* COMMENTS Aeromonas spp Diarrhea · Found in water sources (fresh/sea). Treatment not recommended · Associated with gastroenteritis (often self-limited). unless symptoms severe or · May cause skin/soft tissue infections and sepsis (infections more severe prolonged in immunocompromised patients). Severe diarrhea/Other · Resistant to ampicillin and 1st/2nd cephalosporins. infections TMP/SMX or Ciprofloxacin Pasteurella multocida Animal bite · Part of normal oral flora of dogs and cats. Amoxicillin-clavulanate · Associated with bite wounds, osteomyelitis, bacteremia, meningitis, and or pneumonia. Doxycycline · Usually resistant to 1st generation cephalosporins, erythromycin, and Other clindamycin. Penicillin Diarrhea · Found in the environment (soil/water). Treatment not recommended · Associated with gastroenteritis (often self-limited) – more severe in unless symptoms severe or immunocompromised individuals. prolonged. · Extraintestinal infections (septicemia, meningitis) are rare. Severe diarrhea/Other · Resistant to ampicillin and 1st/2nd generation cephalosporins. infections TMP/SMX or Ciprofloxacin Vibrio spp Diarrhea · Found in water sources (fresh/salt). Treatment not recommended · May cause gastroenteritis, wound/eye/ear infections, and septicemias unless symptoms severe or (usually following contact with, or ingestion of, contaminated water). prolonged · Diarrheal illness usually self-limited, except for Vibrio cholerae. Severe diarrhea/Other infections Ciprofloxacin or TMP/SMX or Tetracycline

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GRAM NEGATIVE BACILLI – Non-Enterobacteriaceae – Non-Fermentative

ORGANISM EMPIRIC THERAPY* COMMENTS Achromobacter spp Ciprofloxacin · Found in water sources. or · Opportunistic/low level pathogen. TMP/SMX · Rare cause of nosocomial infections related to contaminated water. Acinetobacter spp TMP/SMX · Part of normal flora of the skin, conjunctiva, pharynx, urethra, and vagina. or · May cause nosocomial infections (pneumonia, bacteremia, meningitis, Ciprofloxacin wound, and urinary tract infections). or · Often exhibit multiple resistance. In serious infection, combination Imipenem therapy (based on susceptibility results) is recommended. Agrobacterium spp Ciprofloxacin · A plant pathogen. or · May cause infections in immunocompromised patients (especially with TMP/SMX indwelling devices). Alcaligenes spp Ciprofloxacin · Colonizers of the skin, ear, and GI tract. or · Often colonize respiratory/GI tract of hospitalized patients. TMP/SMX · Contamination of hospital environments, equipment, or fluids may result in nosocomial infections. · Resistant to aminoglycosides. Bergeyella spp Animal bite · Part of oral/nasal flora of dogs. Amoxicillin-clavulanate · Associated with bite wounds, septicemia, and meningitis (following Other dog/cat bite or exposure). Ampicillin · Resistant to aminoglycosides. Brevundimonas spp Ciprofloxacin · Low level pathogen. or · Rare cause of opportunistic infections. TMP/SMX

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GRAM NEGATIVE BACILLI – Non-Enterobacteriaceae – Non-Fermentative (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Burkholderia cepacia Ciprofloxacin · Plant pathogen. or · Pathogen in patients with cystic fibrosis or chronic granulomatous TMP/SMX disease. or · May cause nosocomial infections (organisms can survive in water and Ceftazidime disinfectant solutions) and opportunistic infections in or immunocompromised/debilitated individuals. Meropenem · Resistant to aminoglycosides. · Usually exhibits multiple resistance (clinical correlation of this not certain). · Role of combination therapy has not been established. Chryseobacterium indologenes Doxycycline · Found in environmental/water sources. or · Rare cause of nosocomial infections (pneumonia, bacteremia) Ciprofloxacin · Exhibits multiple resistance (aminoglycosides, b-lactams, vancomycin). Chryseobacterium meningosepticum Doxycycline · Found in environmental/water sources. or · May colonize respiratory tract of neonates and adults in intensive care. TMP/SMX · Rare cause of nosocomial infections in immunocompromised patients. or · Associated with meningitis in premature and newborn infants. Ciprofloxacin · Exhibits multiple resistance (b-lactams, aminoglycosides, vancomycin). NB: Rifampin has good activity and can be used in combination with Meningitis another agent. Vancomycin +/- Rifampin Comamonas spp Ciprofloxacin · Found in environmental sources. or · Low level pathogen, rarely associated with bacteremia, endocarditis, Ceftazidime ocular infections. · Often exhibits multiple resistance.

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GRAM NEGATIVE BACILLI – Non-Enterobacteriaceae – Non-Fermentative (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Flavobacterium spp Ciprofloxacin · Found in environmental/water/food sources. or · Rare cause of nosocomial infections. TMP/SMX · Resistant to aminoglycosides and most b-lactams (occasionally susceptible to ceftazidime). Methylobacterium spp TMP/SMX · Found in environmental sources. or · Low level pathogen. Quinolones · Rare cause of nosocomial infections. Moraxella catarrhalis TMP/SMX · Potential pathogen in acute exacerbation of chronic bronchitis, sinusitis, or otitis media, pneumonia, conjunctivitis. Doxycycline · Resistant to amoxicillin and 1st generation cephalosporins. · Susceptible to amoxicillin-clavulanate, macrolides, and quinolones. Moraxella spp Ampicillin · May colonize human skin and mucous membranes. · May cause conjunctivitis (M. lacunata), meningitis, endocarditis, and septic arthritis. · Usually susceptible to TMP/SMX, macrolides, and quinolones. Myroides odoratum Doxycycline · Low level pathogen. or · Rare opportunistic pathogen in immunocompromised patients. Ciprofloxacin +/- Rifampin · Multiple resistance (b-lactams, aminoglycosides). Ochrobactrum spp Ciprofloxacin · Found in environmental/water sources. or · Rare cause of nosocomial infections (catheter related bacteremias). TMP/SMX Oligella spp Ampicillin · O. urethralis may be part of the endogenous flora of the urethra. - O. urethralis or · O. ureolytica is probably more pathogenic and may be involved in urinary - O. ureolytica Ciprofloxacin tract infections, bacteremias, and wound infections.

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GRAM NEGATIVE BACILLI – Non-Enterobacteriaceae – Non-Fermentative (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Pseudomonas aeruginosa Piperacillin + Tobramycin · Found in water, soil, vegetation. May colonize skin and GI tract. · Opportunistic pathogen in predisposed patients (cystic fibrosis, b-lactam allergy haematologic malignancy, neutropenia, burns, IVDU, mechanical Ciprofloxacin +/- Tobramycin ventilation). · Causes various infections in these patients: skin & soft tissue, CNS infection/meningitis pneumonia, urinary tract, otitis externa, endocarditis, bone & joint, eye. Ceftazidime or Meropenem · Combination therapy recommended for non-urinary infections. + · Resistant to TMP/SMX. Tobramycin · Ciprofloxacin has best anti-pseudomonal activity of all quinolones. Pseudomonas spp (other than P. Piperacillin +/- Tobramycin · Opportunistic pathogen – may cause nosocomial infections. aeruginosa) · Variable susceptibility to TMP/SMX. Urinary tract · Role of combination therapy with aminoglycoside not well established but Ciprofloxacin may be prudent in severe infections. Ralstonia pickettii TMP/SMX · Found in environmental source. or · Rare cause of nosocomial infections. Ciprofloxacin · Resistant to aminoglycosides. Roseomonas spp Ciprofloxacin · Rare cause of infection (bacteremia, wounds, abscesses) in or immunocompromised patients. TMP/SMX · Infections associated with intravascular devices difficult to treat unless foreign material removed. Shewanella spp Ciprofloxacin · Found in environmental/food sources. or · Rare opportunistic pathogen in predisposed individuals (hepatobiliary TMP/SMX disease). ·Usually resistant to penicillin and cephalosporins. Sphingobacterium spp Ciprofloxacin · Low level pathogen. or · Rare cause of nosocomial infections in immunocompromised patients. TMP/SMX · Resistant to aminoglycosides. or Tetracycline

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GRAM NEGATIVE BACILLI – Non-Enterobacteriaceae – Non-Fermentative (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Sphingomonas spp Ciprofloxacin · Found in environmental/water sources. or · Rare cause of nosocomial infections. TMP/SMX or Tetracycline Stenotrophomonas maltophilia TMP/SMX · Colonizer in patients who have received broad spectrum antibiotics or (especially carbapenems). It is important to differentiate colonization Doxycycline from infection. · Opportunistic pathogen (respiratory tract, bacteremia, urinary and wound infections) in predisposed (malignancy, ICU, previous antibiotics, immunosuppression) patients. · Multiple resistance to cephalosporins, quinolones, and aminoglycosides. · In serious infections, combination therapy (according to susceptibility report) is recommended. NB: Very high incidence of ticarcillin-clavulanate resistance locally. Weeksella spp Ampicillin · Recovered from urogenital tract of women. or · Pathogenic role not established. Ciprofloxacin · Resistant to aminoglycosides.

GRAM NEGATIVE COCCOBACILLI

ORGANISM EMPIRIC THERAPY* COMMENTS Actinobacillus spp Cefotaxime · Part of normal oropharyngeal flora. · Cause of periodontal disease. · May cause bacteremia, endocarditis, and soft tissue abscesses (often in association with Actinomyces spp). · Ampicillin susceptibility variable.

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GRAM NEGATIVE COCCOBACILLI (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Arcobacter spp Ampicillin · Associated with diarrheal illnesses, bacteremia, and peritonitis in “aerotolerant Campylobacters” or immunocompromised patients. Ciprofloxacin · Many strains exhibit resistance to 1st generation cephalosporins. Bordetella bronchoseptica Ceftazidime · Normal flora of the respiratory tract of some animals. or · Associated with chronic respiratory tract infections in Tetracycline immunocompromised patients. · Resistant to narrow spectrum penicillins/cephalosporins. · Quinolones and TMP/SMX may be effective, however considerable resistance reported to these agents. Bordetella pertussis/parapertussis Erythromycin · Cause of whooping cough (pertussis). or · Adults are important reservoirs of pertussis. TMP/SMX · Prophylaxis should be given to close contacts (within 14 days of first contact). Brucella spp Adult · Zoonotic disease transmitted to humans. Doxycycline + · I.D. consult recommended. Rifampin Paediatrics (< 8 years) TMP/SMX + Gentamicin · TMP/SMX + rifampin – alternative in paediatrics. Campylobacter coli Erythromycin · Cause of gastroenteritis (including travelers diarrhea). or · Rare cause of bacteremia. Ciprofloxacin · Antibiotic therapy indicated if bloody stools, high fever, prolonged symptoms (> 1 week), pregnancy, immunocompromised or relapse. · Antibiotics started on 2nd/3rd day of illness do not have impact on duration of symptoms. Campylobacter fetus Cefotaxime + Gentamicin · May cause perinatal infections or infections in immunocompromised patients (bacteremia, CNS or vascular infection). · in serious infections, combination therapy recommended. · Prolonged therapy recommended (increased risk of relapse).

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GRAM NEGATIVE COCCOBACILLI (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Campylobacter upsaliensis Ciprofloxacin · Associated with diarrheal illness in immunocompromised patients. or · Increased resistance to erythromycin. Amoxicillin-clavulanate Campylobacter hyointestinalis Erythromycin · Associated with diarrhea and/or proctitis (especially in homosexual men). Campylobacter lari Erythromycin · Associated with gastroenteritis in immunocompromised patients. or · Increased resistance to quinolones. Clindamycin Campylobacter spp (other) Erythromycin · Associated with gastroenteritis (including travelers diarrhea). or · Have been implicated in proctitis, neonatal sepsis, meningitis, and Ciprofloxacin infections of prosthetic material. or Cefotaxime Capnocytophaga spp Ciprofloxacin · Normal oropharyngeal flora of humans. - C. gingivalis or · Implicated as pathogens in periodontal disease. - C. ochracea Clindamycin · Associated with infections in immunocompromised patients. - C. sputigena or · Resistant to TMP/SMX and aminoglycosides. - C. haemolytica Cefotaxime · b-lactamase producing strains described. Capnocytophaga spp (canine) (DF-2) Animal bites · Cause of wound infections and septicemia (in association with dog - C. canimorsus Amoxicillin-clavulanate bites/exposure). Debilitated patients at increased risk. Infections often - C. cynodegmi Other life-threatening in immunocompromised individuals (especially Ciprofloxacin splenectomized). or · Resistant to aminoglycosides. Cefotaxime · b-lactamase producing strains described. Cardiobacterium spp Cefotaxime · Normal oropharyngeal flora. · Associated with endocarditis (especially prosthetic valve). · Role of synergistic gentamicin therapy is controversial. CDC Group DF-3 TMP/SMX or · Rare cause of GI infection, bacteremia or abscesses in Doxycycline or immunocompromised patients. Clindamycin · Resistant to penicillins, cephalosporins, and ciprofloxacin.

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GRAM NEGATIVE COCCOBACILLI (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS CDC Group EF-4 Animal bites · Part of normal oral flora of cats and dogs. Amoxicillin-clavulanate · May cause wound infections following cat/dog bites. Other · Usually susceptible to penicillins, TMP/SMX, and quinolones. Ampicillin or Ciprofloxacin Eikenella corrodens Bite wounds · Part of normal oropharyngeal flora. Amoxicillin-clavulanate · Associated with polymicrobial infections (wounds following human bite, Other odontogenic infections, necrotizing pneumonia, lung abscess, Ampicillin endocarditis). or · Resistant to aminoglycosides, 1st generation cephalosporins, Ciprofloxacin metronidazole, clindamycin, and erythromycin. or Doxycycline Haemophilus aprophilus/ Ampicillin +/- Gentamicin* · Normal oropharyngeal flora. paraphrophilus Serious infection · May cause bacteremia, endocarditis or other infections in Cefotaxime immunocompromised patients. * Role of synergistic gentamicin therapy is controversial. Haemophilus ducreyi Azithromycin · Cause of chancroid (ulcerative genital lesion). or Ciprofloxacin or Ceftriaxone

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GRAM NEGATIVE COCCOBACILLI (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Haemophilus influenzae TMP/SMX · May be commensal of human upper respiratory tract. or · Cause of otitis media, sinusitis, and lower respiratory tract infections. Cefuroxime/Cefixime · May cause invasive disease (meningitis, bacteremia, epiglottitis, and or neonatal-maternal sepsis) Doxycycline · May cause localized infection (cellulitis, osteomyelitis, septic arthritis, and genitourinary infections). Meningitis/bacteremia · Resistance (Northern/Central Alberta): - ampicillin ~16% Cefotaxime TMP-SMX 22%. · Resistant to 1st generation cephalosporins and erythromycin. Newer macrolides have enhanced activity but not adequate for serious Haemophilus infections. · Also susceptible to amoxicillin-clavulanate and quinolones. · Recently several cases of invasive infections with nontypeable Haemophilus strains noted in the Capital Health Region. Haemophilus parainfluenzae Ampicillin · Potential pathogen in acute exacerbation of chronic bronchitis, or pneumonia. TMP/SMX · May cause infections similar to H. influenzae. · May cause endocarditis, abscesses, and genitourinary infections. Serious infection · Resistance (Northern/Central Alberta): - ampicillin 26% Cefotaxime TMP/SMX 9%. Kingella spp Ampicillin · Part of normal oropharyngeal flora. or · Opportunistic pathogen, especially in children. Cefotaxime · May cause septicemia, endocarditis, septic arthritis, osteomyelitis, meningitis, endophthalmitis, and pneumonia. · Role of synergistic gentamicin therapy is controversial. · Resistant to clindamycin. Suttonella spp Ampicillin · Rare human pathogen (endocarditis, ocular infections).

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ANAEROBES – Gram Positive

ORGANISM EMPIRIC THERAPY* COMMENTS Actinomyces spp Penicillin · Part of normal flora of oropharynx, GI/GU tract. or · Causative agents of actinomycosis (cervicofacial/thoracic/ Clindamycin abdominopelvic/cerebral). · Cause of chronic wounds/abscesses and draining sinus tracts. · Cause of IUD related pelvic infection. · Often associated with polymicrobial infections (Actinobacillus spp, Eikenella spp, anaerobes, Streptococci spp, Capnocytophaga spp). Bifidobacterium spp Clindamycin · Part of normal flora of oropharynx/GI tract. or · Implicated in polymicrobial infections – pathologic significance uncertain. Metronidazole* * Metronidazole resistance has been described. Clostridium difficile Metronidazole · Ubiquitous in nature [soil, water, animals, intestine of healthy infants (only 3% of adults)]. · May colonize up to 30% of hospitalized patients. · Cause of antibiotic associated diarrhea/pseudomembranous colitis. Clostridium perfringens Penicillin · Part of normal flora of GI tract. or · Cause of gas gangrene, mixed synergistic anaerobic cellulitis, Metronidazole gangrenous cholecystitis, and food poisoning (toxin mediated). · Up to 25% resistance to clindamycin. Clostridium septicum Penicillin · Cause of gas gangrene. or · Bacteremia often indicative of underlying malignancy. Metronidazole or Clindamycin Clostridium ramosum Metronidazole · Associated with gas gangrene, intraabdominal infections especially following trauma. · Some strains resistant to penicillin and/or clindamycin.

25 EMPIRIC THERAPY OF SPECIFIC ORGANISMS

ANAEROBES – Gram Positive (cont’d)

ORGANISM EMPIRIC THERAPY* COMMENTS Clostridium spp (others) Penicillin · May cause gas gangrene or be involved in polymicrobial infections (e.g. or intrabdominal). Metronidazole · Increased incidence of clindamycin resistance. · Certain species produce b-lactamases. · Some resistance to metronidazole reported. Eubacterium spp Penicillin or · Associated with polymicrobial infections – pathologic significance Clindamycin or uncertain Metronidazole* * Metronidazole resistance has been described. Peptostreptococcus spp Penicillin · Part of normal flora of mucous membranes and skin. · May cause wound infections, abscesses, and bacteremia. · Some strains resistant to clindamycin and/or metronidazole. Propionibacterium spp Penicillin · Part of normal flora of mucous membranes and skin. or · Often represents contamination but has been implicated in prosthetic Clindamycin material infections (endocarditis, CNS shunts). · Resistant to metronidazole. · Associated with acne vulgaris (P. acnes) and lacrimal canniculitis (P. propionicum).

ANAEROBIC GRAM NEGATIVE COCCI

ORGANISM EMPIRIC THERAPY* COMMENTS Veillonella spp Metronidazole · Part of normal oropharyngeal flora. or · May be involved in polymicrobial infections. Clindamycin

26 EMPIRIC THERAPY OF SPECIFIC ORGANISMS

ANAEROBIC GRAM NEGATIVE BACILLI

ORGANISM EMPIRIC THERAPY* COMMENTS Bacteroides fragilis group Metronidazole · Part of normal flora of GI tract and female GU tract. · Associated with polymicrobial infections, abscesses of GI/GU tract, skin & soft tissue infections. · As single pathogen may cause bacteremia, endocarditis, meningitis, septic arthritis, and osteomyelitis. · >90% are b-lactamase producers. · ~30% clindamycin resistance locally. Fusobacterium spp Metronidazole · Part of normal flora of GI/GU/respiratory tract. · Associated with anaerobic pleuropulmonary infections (aspiration pneumonia, lung abscess, necrotizing pneumonia, empyema), brain abscess, chronic sinusitis, and iver abscess/intraabdominal infections. · Increased incidence of clindamycin resistance (~15%). · Penicillin resistance up to 40% (b-lactamase production). Porphyromonas spp Metronidazole · Part of normal flora of oropharynx GI/GU tracts. or · Associated with odontogenic/periodontal infections. Clindamycin · Increased incidence of b-lactamase production (up to 30%). · Increased incidence of clindamycin resistance. Prevotella spp Metronidazole · Part of normal flora of oropharynx, GI/GU tracts. or · Associated with head & neck infections, anaerobic pleuropulmonary Clindamycin infections. · Increased incidence of b-lactamase production (up to 30%). · Increased incidence of clindamycin resistance.

27 ANTIBIOGRAM JULY 1, 1999 – JUNE 30, 2000 % SUSCEPTIBLE Site: RAH † syn Penicillin Cefazolin # Isolates TMP/SMX Gent Imipenem Ampicillin Cloxacillin Piperacillin Cefotaxime (urine only) Gentamicin Cefuroxime Ceftazidime Cephalexin/ Tobramycin Cephalothin Tetracycline Vancomycin Clindamycin Ciprofloxacin Erythromycin Nitrofurantoin GRAM POSITIVE E. faecalis 158 98 98 49 E. faecalis (urine) 757 99 56 100 100 65 E. faecium (all isolates) 324 2 76* 35 S. aureus 1731 12 90* 90* 90* 73 99 100 Staph (Coag Neg) 445 12 33 33 33 50 50 100 S. pneumoniae** 200 84 >99 94 82 91 85 100 GRAM NEGATIVE Enterobacteriaceae: C. freundii complex 51 (-) (-) (-) (90) 93 96 93 100 E. aerogenes 45 (-) (-) (-) (79) 84 76 25 98 E. cloacae 240 (-) (-) (-) (84) 91 90 58 100 E. coli 2010 24 28 92 >99 85 97 96 96 K. oxytoca 122 0 39 45 97 98 98 88 99 K. pneumoniae 423 0 84 96 100 98 98 53 99 M. morganii 71 (-) (-) (-) (97) 97 100 13 97 P. mirabilis 196 73 89 95 100 87 98 0 93 S. marcescens 155 (-) (-) (-) (96) 88 86 0 94 Other: A. baumanii 36 79 100 75 83 H. influenzae 256 90 100 100 76 P. aeruginosa 594 86 85 93 75 80 98 S. maltophilia 108 66 100 † Percentage of organisms where synergistic bactericidal activity with gentamicin is attainable. ( ) These organisms may produce inducible b-lactamases. Use of b-lactams may result in clinical failure despite in vitro susceptibility. * These numbers include surveillance as well as clinical isolates. Most isolates represent colonization rather than infection. ** S. pneumoniae resistance–16% intermediate level, 0% high level ANTIBIOGRAM JULY 1, 1999 – JUNE 30, 2000 % SUSCEPTIBLE Site: RAH (ICU, CCU)** † syn Penicillin Cefazolin # Isolates TMP/SMX Gent Imipenem Ampicillin Cloxacillin Piperacillin Cefotaxime (urine only) Gentamicin Cefuroxime Ceftazidime Cephalexin/ Tobramycin Cephalothin Tetracycline Vancomycin Clindamycin Ciprofloxacin Erythromycin Nitrofurantoin GRAM POSITIVE E. faecalis 58 98 99 33 E. faecium 65 3 86* 31 Enterococcus spp (urine) 49 94 47 100 100 47 S. aureus 234 10 93* 93* 93* 80 97 100 Staph (Coag Neg) 182 12 27 27 27 44 43 100 S. pneumoniae 52 79 100 88 75 81 81 100 GRAM NEGATIVE Enterobacteriaceae: E. cloacae 47 (-) (-) (-) 73 81 77 75 100 E. coli 148 21 23 88 99 85 97 98 95 K. pneumoniae 63 0 81 94 100 100 97 40 100 M. morganii 23 (-) (-) (-) 100 100 100 0 100 S. marcescens 67 (-) (-) (-) 93 89 88 0 95 Other: H. influenzae 82 88 99 100 77 P. aeruginosa 97 87 86 92 68 80 99 S. maltophilia 60 62 100 † Percentage of organisms where synergistic bactericidal activity with gentamicin is attainable. ( ) These organisms may produce inducible b-lactamases. Use of b-lactams may result in clinical failure despite in vitro susceptibility. * These numbers include surveillance as well as clinical isolates. Most isolates represent colonization rather than infection. ** Selected organisms from RAH intensive care/coronary care units. See composite RAH antibiogram for other organisms. ANTIBIOGRAM JULY 1, 1999 – JUNE 30, 2000 % SUSCEPTIBLE Site: Capital Health – Long Term Care** † syn Penicillin Cefazolin # Isolates TMP/SMX Gent Imipenem Ampicillin Cloxacillin Piperacillin Cefotaxime (urine only) Gentamicin Cefuroxime Ceftazidime Cephalexin/ Tobramycin Cephalothin Tetracycline Vancomycin Clindamycin Ciprofloxacin Erythromycin Nitrofurantoin GRAM POSITIVE E. faecalis 20 100 100 55 E. faecalis (urine) 364 99 29 99 100 45 E. faecium (all isolates) 57 2 65* 28 S. aureus 960 17 84* 84* 84* 62 95 100 Staph (Coag Neg) 19 11 42 42 42 33 33 100 S. pneumoniae*** 12 92 100 100 100 100 75 100 GRAM NEGATIVE Enterobacteriaceae: C. freundii complex 24 (-) (-) (-) (94) 79 96 100 100 E. cloacae 30 (-) (-) (-) (83) 87 83 35 100 E. coli 632 23 28 87 >99 74 93 92 96 K. oxytoca 33 0 21 33 97 97 94 88 100 K. pneumoniae 162 0 75 94 98 86 92 56 100 M. morganii 35 (-) (-) (-) (100) 91 100 10 97 P. mirabilis 359 79 91 95 (100) 85 91 0 98 P. stuartii 38 (-) (-) (-) (100) 84 50 0 95 S. marcescens 92 (-) (-) (-) (92) 75 60 0 74 Other: H. influenzae 14 71 100 100 71 P. aeruginosa 376 91 92 86 72 89 99 † Percentage of organisms where synergistic bactericidal activity with gentamicin is attainable. ( ) These organisms may produce inducible b-lactamases. Use of b-lactams may result in clinical failure despite in vitro susceptibility. * These numbers include surveillance as well as clinical isolates. Most isolates represent colonization rather than infection. ** Includes all long term care facilities serviced by Dynacare Kasper Medical Laboratories. *** S. pneumoniae resistance - 8% intermediate level, 0% high level ANTIBIOGRAM JULY 1, 1999 – JUNE 30, 2000 % SUSCEPTIBLE Site: Capital Health – Community Hospitals** † syn Penicillin Cefazolin # Isolates TMP/SMX Gent Imipenem Ampicillin Cloxacillin Piperacillin Cefotaxime (urine only) Gentamicin Cefuroxime Ceftazidime Cephalexin/ Tobramycin Cephalothin Tetracycline Vancomycin Clindamycin Ciprofloxacin Erythromycin Nitrofurantoin GRAM POSITIVE E. faecalis 54 100 100 49 E. faecalis (urine) 881 100 48 100 100 58 E. faecium (all isolates) 98 6 88* 35 S. aureus 1015 18 91* 91* 91* 76 98 100 Staph (Coag Neg) 116 15 46 46 46 72 59 100 S. pneumoniae*** 104 84 100 90 84 89 76 100 GRAM NEGATIVE Enterobacteriaceae: C. freundii complex 66 (-) (-) (-) (92) 77 91 99 97 E. aerogenes 17 (-) (-) (-) (100) 100 100 64 100 E. cloacae 94 (-) (-) (-) (91) 91 95 48 98 E. coli 1875 26 31 92 >99 84 98 96 97 K. oxytoca 86 0 55 59 100 94 98 87 98 K. pneumoniae 312 0 78 95 100 95 98 43 100 M. morganii 37 (-) (-) (-) (100) 89 100 10 95 P. mirabilis 167 78 89 98 100 84 98 0 95 S. marcescens 59 (-) (-) (-) (97) 98 88 0 98 Other: C. jejuni 24 88 92 H. influenzae 83 80 99 99 73 P. aeruginosa 360 89 88 89 81 Stenotrophomonas 39 51 97 † Percentage of organisms where synergistic bactericidal activity with gentamicin is attainable. ( ) These organisms may produce inducible b-lactamases. Use of b-lactams may result in clinical failure despite in vitro susceptibility. * These numbers include surveillance as well as clinical isolates. Most isolates represent colonization rather than infection. All VRE cases occurred at the Glenrose Hospital. ** Glenrose, Sturgeon, Misericordia, Edmonton General, and Northeast Centre *** S. pneumoniae resistance - 14% intermediate level, 2% high level ANTIBIOGRAM JULY 1, 1999 – JUNE 30, 2000 % SUSCEPTIBLE Site: Capital Health Community (Region 10) † syn Penicillin Cefazolin # Isolates TMP/SMX Gent Imipenem Ampicillin Cloxacillin Piperacillin Cefotaxime (urine only) Gentamicin Cefuroxime Ceftazidime Cephalexin/ Tobramycin Cephalothin Tetracycline Vancomycin Clindamycin Ciprofloxacin Erythromycin Nitrofurantoin GRAM POSITIVE E. faecalis 62 100 100 74 E. faecalis (urine) 2421 100 69 99 100 77 E. faecium (all isolates) 96 1 74* 35 S. aureus 3450 15 94* 94* 94* 85 97 100 Staph (Coag Neg) 73 18 51 51 51 80 62 100 Staph saprophyticus 178 83 90 100 100 S. pneumoniae** 172 82 99 96 90 94 80 100 GRAM NEGATIVE Enterobacteriaceae: C. freundii complex 138 (-) (-) (-) (96) 77 92 93 97 E. aerogenes 104 (-) (-) (-) (96) 99 97 42 100 E. cloacae 227 (-) (-) (-) (91) 88 96 43 100 E. coli 9912 27 31 94 >99 84 98 95 97 K. oxytoca 210 0 44 55 98 95 99 83 99 K. pneumoniae 1048 0 82 96 100 93 97 55 100 M. morganii 150 (-) (-) (-) (100) 89 99 10 96 P. mirabilis 1007 75 90 96 100 83 96 0 95 S. marcescens 167 (-) (-) (-) (93) 84 74 0 83 Other: C. jejuni 117 97 83 H. influenzae 221 87 100 100 76 P. aeruginosa 1019 93 93 90 78 87 98 S. maltophilia 56 55 100 † Percentage of organisms where synergistic bactericidal activity with gentamicin is attainable. ( ) These organisms may produce inducible b-lactamases. Use of b-lactams may result in clinical failure despite in vitro susceptibility. * These numbers include surveillance as well as clinical isolates. Most isolates represent colonization rather than infection. ** S. pneumoniae resistance-16% intermediate level, 1% high level ANTIBIOGRAM JULY 1, 1999 – JUNE 30, 2000 % SUSCEPTIBLE Site: Fort MacMurray † syn Penicillin Cefazolin # Isolates TMP/SMX Gent Imipenem Ampicillin Cloxacillin Piperacillin Cefotaxime (urine only) Gentamicin Cefuroxime Ceftazidime Cephalexin/ Tobramycin Cephalothin Tetracycline Vancomycin Clindamycin Ciprofloxacin Erythromycin Nitrofurantoin GRAM POSITIVE E. faecalis 144 100 100 59 E. faecium 4 25 75* 100

Enterococcus spp (urine) 71 100 82 97 100 97 S. aureus 357 8 96* 96* 96* 90 97 100 S. pneumoniae** 108 86 99 97 91 97 83 100 GRAM NEGATIVE Enterobacteriaceae: E. cloacae 28 (-) (-) (-) (82) 100 96 58 96 E. coli 598 39 43 95 100 89 98 97 98 K. oxytoca 36 0 0 35 94 100 83 100 100 K. pneumoniae 52 0 31 98 100 94 98 78 98 P. mirabilis 28 89 93 93 100 85 100 0 100 Other: C. jejuni 7 100 86 H. influenzae 104 79 100 100 87 P. aeruginosa 93 86 91 98 64 74 99 † Percentage of organisms where synergistic bactericidal activity with gentamicin is attainable. ( ) These organisms may produce inducible b-lactamases. Use of b-lactams may result in clinical failure despite in vitro susceptibility. * These numbers include surveillance as well as clinical isolates. Most isolates represent colonization rather than infection. ** S. pneumoniae resistance - 7% intermediate level, 2% high level ANTIBIOGRAM JULY 1, 1999 – JUNE 30, 2000 % SUSCEPTIBLE Site: UAH † syn Penicillin Cefazolin # Isolates Imipenem TMP/SMX Gent Ampicillin Cloxacillin Piperacillin Cefotaxime (urine only) Gentamicin Cefuroxime Cephalexin/ Ceftazidime Tobramycin Cephalothin Tetracycline Vancomycin Clindamycin Erythromycin Ciprofloxacin Nitrofurantoin

GRAM POSITIVE Enterococcus spp (all) 1322 82 99 62 S. aureus 1362 12 95 95 95 92 89 100 Staph (Coag Neg) 549 9 28 28 28 54 53 100 S. pneumoniae** 295 85 97 89 69*** 55*** 100 GRAM NEGATIVE Enterobacteriaceae: C. freundii complex 94 (-) (-) (-) (74) 88 91 97 99 E. aerogenes 66 (-) (-) (-) (72) 100 95 44 100 E. cloacae 258 (-) (-) (-) (84) 95 95 51 99 E. coli 1979 60 86 93 92 81 95 97 96 Klebsiella spp 641 0 81 89 97 93 95 69 98 M. morganii 52 (-) (-) (-) (95) 90 98 23 100 P. mirabilis 151 82 96 98 100 83 97 0 92 S. marcescens 126 (-) (-) (-) (97) 97 92 0 97 Other: A. baumanii 58 88 100 88 89 A. lwoffi 17 94 100 94 94 B. cepacia 55 40 9 27 11 H. influenzae 369 83 99 100 81 P. aeruginosa (total) 1180 87 81 85 68 74 92 Pseudomonas spp (CF)* 377 90 89 81 76 64 88 S. maltophilia 132 25 98 † Percentage of organisms where synergistic bactericidal activity with gentamicin is attainable. ( ) These organisms may produce inducible b-lactamases. Use of b-lactams may result in clinical failure despite in vitro susceptibility. * CF = Cystic fibrosis. Includes P. aeruginosa and P. fluorescens ** S. pneumoniae resistance - 12% intermediate level, 3% high level *** Decreased susceptibility compared to other sites as isolates tested are from sterile body sites only. ANTIBIOGRAM JULY 1, 1999 – JUNE 30, 2000 % SUSCEPTIBLE Site: UAH-ICU (3C3, 3C4)* † syn Penicillin Cefazolin # Isolates TMP/SMX Gent Imipenem Ampicillin Cloxacillin Piperacillin Cefotaxime (urine only) Gentamicin Cefuroxime Ceftazidime Cephalexin/ Tobramycin Cephalothin Tetracycline Vancomycin Clindamycin Ciprofloxacin Erythromycin Nitrofurantoin GRAM POSITIVE Enterococcus spp 69 65 100 97 45 S. aureus 69 18 94 94 94 90 97 100 Staph (Coag Neg) 104 5 14 14 14 32 38 100 S. pneumoniae 10 84 100 100 90 50 GRAM NEGATIVE Enterobacteriaceae: E. aerogenes 11 (-) (-) (-) (64) 100 100 91 27 100 100 E. cloacae 22 (-) (-) (-) (78) 100 100 95 41 100 100 E. coli 66 52 79 88 97 100 70 82 98 94 98 K. pneumoniae 57 0 76 88 100 100 95 93 67 98 99 Other: Acinetobacter spp 10 80 100 100 100 90 P. aeruginosa 64 76 74 61 80 97 S. maltophilia 37 97

† Percentage of organisms where synergistic bactericidal activity with gentamicin is attainable. ( ) These organisms may produce inducible b-lactamases. Use of b-lactams may result in clinical failure despite in vitro susceptibility. * Selected organisms from UAH intensive care units. See composite UAH antibiogram for other organisms. ANTIBIOGRAM JULY 1, 1999 – JUNE 30, 2000 % SUSCEPTIBLE Site: UAH-ICU (3C2-Burn unit)* † syn Penicillin Cefazolin # Isolates TMP/SMX Gent Imipenem Ampicillin Cloxacillin Piperacillin Cefotaxime (urine only) Gentamicin Cefuroxime Ceftazidime Cephalexin/ Tobramycin Cephalothin Tetracycline Vancomycin Clindamycin Ciprofloxacin Erythromycin Nitrofurantoin GRAM POSITIVE Enterococcus spp 25 88 100 96 64 S. aureus 35 13 95 95 95 91 100 100 Staph (Coag Neg) 20 5 35 35 35 40 50 100 S. pneumoniae 2 100 - - - - GRAM NEGATIVE Enterobacteriaceae: E. cloacae 24 (-) (-) (-) (100) 100 92 96 25 100 100 E. coli 16 44 88 100 100 100 81 94 100 88 100 K. pneumoniae 21 0 76 100 100 100 81 90 33 100 100 Other: Acinetobacter spp 13 60 100 100 77 62 P. aeruginosa 48 73 61 46 56 90 S. maltophilia 5 80

† Percentage of organisms where synergistic bactericidal activity with gentamicin is attainable. ( ) These organisms may produce inducible b-lactamases. Use of b-lactams may result in clinical failure despite in vitro susceptibility. * Selected organisms from UAH burn unit. See composite UAH antibiogram for other organisms. ANTIBIOGRAM JULY 1, 1999 – JUNE 30, 2000 % SUSCEPTIBLE Site: Grey Nuns † syn Penicillin Cefazolin # Isolates TMP/SMX Gent Imipenem Ampicillin Cloxacillin Piperacillin Cefotaxime (urine only) Gentamicin Cefuroxime Ceftazidime Cephalexin/ Tobramycin Cephalothin Tetracycline Vancomycin Clindamycin Ciprofloxacin Erythromycin Nitrofurantoin GRAM POSITIVE E. faecalis 37 100 100 54 E. faecalis (urine) 286 100 61 99 100 68 E. faecium (all isolates) 42 17 98 44 S. aureus 472 13 88* 88* 88* 74 99 100 Staph (Coag Neg) 77 13 49 49 49 62 50 100 S. pneumoniae** 80 77 100 98 90 82 100 GRAM NEGATIVE Enterobacteriaceae: C. freundii complex 25 (-) (-) (-) (80) 96 80 99 96 E. aerogenes 27 (-) (-) (-) (73) 93 81 46 100 E. cloacae 52 (-) (-) (-) (86) 100 100 52 100 E. coli 770 25 28 91 100 84 97 95 96 K. oxytoca 52 0 50 56 98 100 98 73 100 K. pneumoniae 115 0 88 96 100 97 98 43 100 M. morganii 25 (-) (-) (-) (96) 96 100 20 100 P. mirabilis 71 77 92 97 100 92 99 0 94 S. marcescens 42 (-) (-) (-) (88) 81 79 0 83 Other: C. jejuni 10 100 100 H. influenzae 65 77 98 100 66 P. aeruginosa 200 84 83 88 72 68 95 S. maltophilia 16 56 100 † Percentage of organisms where synergistic bactericidal activity with gentamicin is attainable. ( ) These organisms may produce inducible b-lactamases. Use of b-lactams may result in clinical failure despite in vitro susceptibility. * These numbers include surveillance as well as clinical isolates. Most isolates represent colonization rather than infection. ** S. pneumoniae resistance - 18% intermediate level, 5% high level ANTIBIOGRAM JULY 1, 1999 – JUNE 30, 2000 % SUSCEPTIBLE Site: Peace River Region † syn Penicillin Cefazolin # Isolates TMP/SMX Gent Imipenem Ampicillin Cloxacillin Piperacillin Cefotaxime (urine only) Gentamicin Cefuroxime Ceftazidime Cephalexin/ Tobramycin Cephalothin Tetracycline Vancomycin Clindamycin Ciprofloxacin Erythromycin Nitrofurantoin GRAM POSITIVE E. faecalis 127 100 99 77

E. faecalis (urine) 31 100 55 97 100 70

E. faecium (all isolates) 17 18 91 38 S. aureus 188 10 99 99 99 96 97 100 Staph saprophyticus 17 65 100 100 100 S. pneumoniae* 29 69 97 95 88 92 75 100 GRAM NEGATIVE Enterobacteriaceae: C. freundii complex 16 (-) (-) (-) (94) 94 100 100 100 E. cloacae 21 (-) (-) (-) (62) 100 100 33 100 E. coli 532 43 48 96 100 87 99 99 98 K. oxytoca 17 0 31 56 100 100 100 100 100 K. pneumoniae 50 0 82 98 100 92 98 36 100 P. mirabilis 33 85 94 97 100 91 100 0 100 Other: H. influenzae 25 80 96 100 72 P. aeruginosa 57 84 84 87 77 86 100

† Percentage of organisms where synergistic bactericidal activity with gentamicin is attainable. ( ) These organisms may produce inducible b-lactamases. Use of b-lactams may result in clinical failure despite in vitro susceptibility. * S. pneumoniae resistance - 21% intermediate level, 3% high level REFERENCES GENERAL 1. Blondel-Hill E, Nigrin J. Antimicrobial Susceptibility Manual. 2nd ed. Dynacare Kasper Medical Laboratories. 2001. 2. Gattis WA. A selected review of antimicrobial concentrations within tissues of the bone, eye, and lung. Antimicrobics Infect Dis Newslett 1994;13:75-86. 3. Gilbert DN, Moellering RC, Sande MA, eds. The Sanford guide to antimicrobial therapy 2000. Hyde Park, VT:Antimicrobial Therapy, Inc.; 2000. 4. Gorbach SL, Mensa J, Gatell JM. 1999 pocket book of antimicrobial therapy & prevention. Baltimore, Maryland: Williams & Wilkins; 1999. 5. Lovgren M, Talbot JA. Antimicrobial-resistant Streptococcus pneumoniae. Can J Infect Dis 1999;10(suppl A):27-9A. 6. 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Drugs Ther Perspect 1999;13:10-3. 3. Bourlond A, Lachapelle JM, Aussems J, et al. Double-blind comparison of itraconazole with griseofulvin in the treatment of tinea corporis and tinea cruris. Int J Dermatol 1989;28:410-2. 4. Brautigam M, Nolting S, Schopf RE, et al. German randomized double-blind multicentre comparison of terbinafine and itraconazole for the treatment of toenail tinea infection. Br J Dermatol 1996;134(suppl 46):18-21. 5. Chapman SW, Bradsher RW, Campbell, Jr GD, et al. Practice guidelines for the management of patients with blastomycosis. Clin Infect Dis 2000; 30: 679-83. 6. Crissey JT. Common dermatophyte infections. Postgrad Med 1998;103:191-205. 7. De Backer M, De Keyser P, De Vroey P, et al. A 12-week treatment for dermatophyte toe onychomycosis: terbinafine 250mg/day vs. itraconazole 200mg/day – a double blind comparative trial. Br J Dermatol 1996;134(suppl 46):16-7. 8. Delescluse J. Itraconazole in tinea versicolor: a review. J Am Acad Dermatol 1990;23:551-4. 9. Denning DW. Invasive aspergillosis. Clin Infect Dis 1998;26:781-805. 10. Dragos V, Lunder M. Lack of efficacy of 6 week treatment with oral terbinafine for tinea capitis due to Microsporum canis in children. Pediatr Dermatol 1997;14:46- 8. 11. Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for superficial mycotic infections of the skin: tinea corporis, tinea cruris, tinea faciei, tinea manuum, and tinea pedis. J Am Acad Dermatol 1996;34:282-6. 12. Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for superficial mycotic infections of the skin: pityriasis (tinea) versicolor. J Am Acad Dermatol 1996;34:287-9. 13. Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for superficial mycotic infections of the skin: tinea capitis and tinea barbae. J Am Acad Dermatol 1996;34:290-4. 14. Edwards JEJ, Bodey GP, Bowden RA, et al. International conference for the development of a consensus on the management and prevention of severe candidal infections. Clin Infect Dis 1997;25:43-59. 15. Filho ST, Cuce LC, Foss NT. Efficacy, safety and tolerability of terbinafine for tinea capitis in children: Brazilian multicentric study with daily oral tablets for 1,2, and 4 weeks. J Eur Acad Dermatol Venereol 1998;11:141-6. 16. Galgiani JN, Ampel NM, Catanzaro A, et al. Practice guidelines for the treatment of coccidioidomycosis. Clin Infect Dis 2000; 30: 658-61. 17. Griswold M, Briceland L, Stein D. Is amphotericin B test dosing needed? Ann Pharmacother 1998; 32: 475-77. 18. Gruseck E, Splanemann V, Bleck O, et al. Oral terbinafine in tinea capitis in children. Mycoses 1996;39:237-40. 19. Gupta AK, Einarson TR, Summerbell RC, et al. An overview of topical antifungal therapy in dermatomycoses. Drugs 1998;55:645-74. 20. Hernanz A, Gomez SL, Lastra FG, et al. A comparative double-blind study of terbinafine (Lamisil) and griseofulvin in tinea corporis and tinea cruris. Clin Exp Dermatol 1990;15:210-6. 21. Hickman JG. A double-blind, randomized, placebo-controlled evaluation of short-term treatment with oral itraconazole in patients with tinea versicolor. J Am Acad Dermatol 1996;34:785-7. 22. Hofmann H, Brautigam M, Weidinger G, et al. Treatment of toenail onychomycosis: a randomized, double-blind study with terbinafine and griseofulvin. Arch Dermatol 1995;131:919-22. 23. Kauffman CA, Hajjeh R, Chapman SW. Practice guidelines for the management of patients with sporotrichosis. Clin Infect Dis 2000; 30:684-7. 24. Lachapelle JM, DeDoncker P, Tennstedt D, et al. Itraconazole compared with griseofulvin in the treatment of tinea corporis/cruris and tinea pedis/manus: an interpretation of the clinical results of all completed double-blind studies with respect to the pharmacokinetic profile. Dermatology 1992;184:45-50. 25. Legendre R, Esola-Macre J. Itraconazole in the treatment of tinea capitis. J Am Acad Dermatol 1990;23:559-60. 26. Lewis RE, Klepser ME. The changing face of nosocomial candidemia: epidemiology, resistance, and drug therapy. Am J Health-Syst Pharm 1999;56:525-36. 27. Restrepo A, Robledo J, Gomez I, et al. Itraconazole therapy in lymphangitic and cutaneous sporotrichosis. Arch Dermatol 1986;122:413-7. 28. Rex JH, Walsh TH, Sobel JD, et al. Practice guidelines for the treatment of candidiasis. Clin Infect Dis 2000; 30: 662-78. REFERENCES 29. Saag MS, Graybill RJ, Larsen RA, et al. Practice guidelines for the management of cryptococcal disease. Clin Infect Dis 2000; 30: 710-8. 30. Sharkey-Mathis PK, Kauffman CA, Graybill JR, et al. Treatment of sporotrichosis with itraconazole. Am J Med 1993;95:279-85. 31. Sheehan DJ, Hitchcock CA, Sibley CM. Current and emerging azole antifungal agents. Clin Microbiol Rev 1999;12:40-79. 32. Sobel JD. 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ASHP Commission on Therapeutics. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm 1999; 56: 1839-88. 3. Bauer T, Vennits B, Holm B, et al. Antibiotic prophylaxis in acute nonperforated appendicitis. Ann Surg 1989; 209: 307-11. 4. Bergamini TM, Polk HC. The importance of tissue antibiotic activity in the prevention of operative wound infection. J Antimicrob Chemother 1989; 23: 301-13. 5. Bohnen JMA. Antimicrobial prophylaxis in general surgery. Can J Surg 1991; 34: 548-50. 6. Burke JF. Timing antibiotics to prevent infection. Drug Therapy 1976; Feb: 209-19. 7. Clinical and economic considerations in antimicrobial surgical prophylaxis. Drugs and Therapy Perspectives 1993; 2: 12-14. 8. Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. Clin Infect Dis 1994; 18: 422-7. 9. Dellinger EP. Antibiotic prophylaxis in trauma: penetrating abdominal injuries and open fractures. 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Hopkins CC. Antibiotic prophylaxis in clean surgery: peripheral vascular surgery, noncardiovascular thoracic surgery, herniorrhaphy and mastectomy. Rev Infect Dis 1991; 13(suppl 10): S869-73. 18. Kernodle DS, Kaiser AB. Postoperative infections and antimicrobial prophylaxis. In: Mandell GL, Bennett JE, Dolin R, et al, eds. Principles and practice of infectious diseases. 4th ed. New York: Churchill Livingstone Inc; 1995: 2742-56. 19. Lau WY, Chu KW, Poon GP, et al. Prophylactic antibiotics in elective colorectal surgery. Br J Surg 1988; 75: 782-5. 20. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Am J Infect Control 1999; 27: 97-134. 21. Matsen JM. The frequency of bacterial pathogens in infections potentially preventable by antimicrobial prophylaxis. Scand J Infect Dis Suppl 1990; 70: 9-17. REFERENCES 22. Nichols RL, Smith JW, Garcia RY, et al. 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Antimicrobial prophylaxis in elective colorectal surgery and appendicitis. Scand J Infect Dis 1990; 70: 36-44. 31. Tan E, Hart LL. Metronidazole/neomycin as preoperative bowel preparation. Ann Pharmacother 1993; 27: 1064-6. 32. Waddell TK, Rotstein OD. Antimicrobial prophylaxis in surgery. Can Med Assoc J 1994; 151: 925-31. 33. Winslow RE, Dean RE, Harley JW. Acute nonperforating appendicitis. Arch Surg 1983; 118: 651-5. Obstetrical/Gynecological Surgery 1. Campillo F, Rubio JM. Comparative study of single-dose cefotaxime and multiple doses of cefoxitin and cefazolin as prophylaxis in gynecologic surgery. Am J Surg 1992; 4A(suppl): 12S-5S. 2. Carlson C, Duff P. Antibiotic prophylaxis for cesarean delivery: is an extended-spectrum agent necessary? Obstet Gynecol 1990; 76: 343-6. 3. Crombleholme WR. Use of prophylactic antibiotics in obstetrics and gynecology. Clin Obstet Gynecol 1988; 31: 466-72. 4. Currier JS, Tosteson TD, Platt R. Cefazolin compared with cefoxitin for cesarean section prophylaxis: the use of a two-stage study design. J Clin Epidemiol 1993; 46: 625-30. 5. Faro S. Antibiotic prophylaxis. Obstet Gynecol Clin North Am 1989; 16: 279-89. 6. Gjonnaess H. Antimicrobial prophylaxis in gynaecological and obstetric surgery. Scand J Infect Dis Suppl 1990; 70: 52-67. 7. Hager WD, Rapp RP, Billeter M, et al. Choice of antibiotic in nonelective cesarean section. Antimicrob Agents Chemother 1991; 35: 1782-4. 8. Hemsell DL, Bawdon RE, Hemsell PG, et al. Single-dose cephalosporin for prevention of major pelvic infection after vaginal hysterectomy: cefazolin versus cefoxitin versus cefotaxime. Am J Obstet Gynecol 1987; 156: 1201-5. 9. Hemsell DL, Johnson ER, Hemsell PG, Nobles BJ, et al. Cefazolin is inferior to cefotetan as single-dose prophylaxis for women undergoing elective total abdominal hysterectomy. Clin Infect Dis 1995; 20: 677-84. 10. Hemsell DL. 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Doern G, Vautour R, Gaudet M, et al. Clinical impact of rapid In vitro susceptibility testing and bacterial identification. J Clin Microbiol 1994; 32: 1757-62. 11. Finegold SM. Overview of clinically important anaerobes. Clin Infect Dis 1995; 20(suppl 2): S205-7. 12. Finegold SM. Susceptibility testing, resistance, and resistance mechanisms. Clin Infect Dis 1997; 25(suppl 2): s251-3. 13. Finegold SM, Jousimies-Somer H. Recently described clinically important anaerobic bacteria: medical aspects. Clin Infect Dis 1997; 25(suppl 2): S88-93. 14. Follath F, Costa E, et al. Clinical consequences of development of resistance to third generation cephalosporins. Eur J Clin Microbiol 1987; 6: 446-50. 15. Frieden TR, Mangi RJ. Inappropriate use of oral ciprofloxacin. JAMA 1990; 264: 1438-40. 16. Gold HS, Moellering RC. Antimicrobial drug resistance. Drug Ther 1996; 335: 1445-53. 17. Gorbach SL, Barza M, Blacklow NR, et al. Antimicrobial susceptibility testing: special needs for fastidious organisms and difficult to detect resistance mechanisms. Clin Infect Dis 2000; 30: 799-808. 18. Handwerger S, Tomasz A. Antibiotic tolerance among clinical isolates of bacteria. Rev Infect Dis 1985; 7: 368-86. 19. Hecht DW. Resistance trends in anaerobic bacteria. Clin Microbiol Newslett 2000; 22: 41-4. 20. Hindler J, Thrupp L. Interpretive guidelines for antimicrobial susceptibility test results: what do they mean? Clin Microbiol Newslett 1989; 11: 129-34. 21. Huovinen P, Sundstrom L, Gote S, et al. Trimethoprim and sulfonamide resistance. Antimicrob Agents Chemother 1995; 39: 279-89. 22. Jenkins SG. Antimicrobial susceptibility tests for b-lactam/b-lactamase inhibitors: predictors of clinical efficacy? Clin Microbiol Newslett 1992; 14: 89-96. 23. Koneman EW, Allen SD, Janda WM, et al. Color atlas and textbook of diagnostic microbiology. 5th ed. Philadelphia: J.B. Lippincott Company; 1997. 24. Leegaard TM, Caugant DA, Freholm LO, et al. Apparent differences in antimicrobial susceptibility as a consequence of national guidelines. European Society of Clinical Microbiology & Infectious Diseases. Clinical Microbiol Infect; 6: 290-3. 25. Livermore DM. Beta-lactamases in laboratory and clinical resistance. Clinical Microbiol Rev 1995; 8: 557-84. 26. Livermore D. Carbapenemases: the next generation of beta-lactamases? Am Soc Microbiol Newslett 1993; 59: 129-35. 27. Livermore D. Mechanisms of resistance to beta-lactam antibiotics. Sc J Infect Dis. 1991; 78: 716. 28. Mandell GL, Bennett JE, and Dolin R, eds. Mandell, Douglas and Bennett’s principles & practice of infectious diseases. 5th ed. New York: Churchill Livingstone Inc.;2000. 29. Moosdeen F. The evolution of resistance to cephalosporins. Clin Infect Dis 1997; 24: 487-93. 30. Murray PR. Clinical predictive value of in vitro susceptibility tests. Clin Microbiol Newslett 1990; 12: 44-5. 31. Murray PR, Baron EJ, Pfaller MA, et al. Manual of clinical microbiology - American Society of Microbiology, 7th Edition, 1999. 32. NCCLS. Methods for antimicrobial susceptibility testing of anaerobic bacteria: approved standard, 4th Edition, M11-A4 1977; 17:22. 33. NCCLS. Performance standards for antimicrobial susceptibility testing, Eighth Informational Supplement, M100-S8 1998; 18:1. 34. Nichols RL, et al. Wound and intraabdominal infections: microbiological considerations and approaches to treatment. Clin Infect Dis 1993; 16(suppl 4): 266-72. 35. Report of the Comité de l’Antibiogramme de la Société Française de Microbiologie. CMI 1996; 2(suppl 1): S1-49. 36. Sanders C, Sanders WE. Emergence of resistance during therapy with the newer beta-lactam antibiotics: Role of inducible beta-lactamases and implications for the future. Rev Infect Dis 1983; 5: 639-48. 37. Sanders C. Beta-lactamases of gram-negative bacteria: new challenges for new drugs. Clin Infect Dis 1992; 14: 1089-99. 38. Thornsberry C, et al. Susceptibility testing of fastidious and unusual pathogens. Antimicrobic Newslett 1987; 4: 47-56. 39. Tuomanen E, et al. Antibiotic tolerance among clinical isolates of bacteria. Antimicrob Agents Chemother 1986; 30: 521-7. 40. Wexler HM. Susceptibility testing of anaerobic bacteria: myth, magic, or method? Clin Microbiol Rev 1991; 4: 470-84. 41. Wiedemann B, Kliebe C, Kresken M. The epidemiology of beta-lactamases. J Antimicrob Chemother 1989; 24(suppl B): 1-22. 42. Yu VL, Merigan TC, Barriere SL, eds. Antimicrobial therapy and vaccines. Baltimore, Maryland: Williams & Wilkins; 1999. INDEX

A Azithromycin, 5 Abscess B Brain, 122, 216-217 Bacillus spp, 334 Breast, 135 Bacterial Vaginosis, 190 Epidural, 218 Bacteriuria, asymptomatic, 116, 204-206 Intraabdominal, 112-114, 185-187 Bacteroides fragilis group, 355 Labial, 197 Bergeyella spp, 344 Liver, 183 b-lactam allergy, 69-70 Lung, 107, 174 Bifidobacterium spp, 353 Odontogenic, 300 Bites, Animal, 76-77, 136-137 Pancreatic, 182 Bites, Human, 78, 138 Periodontal, 304 Blastocystis hominis, 248 Peri-rectal, 75, 135 Blepharitis, 229 Abiotrophia spp, 329 Blood/Body Fluid Exposure Prophylaxis, 263- Achromobacter spp, 344 266 Acinetobacter spp, 344 Bone Infections, 83-84, 147-150 Actinobacillus spp, 297, 348 Bordetella spp, 349 Actinomyces spp, 297, 353 Brain Abscess, 122, 216-217 Acute bronchitis, 96, 162-163 CSF Penetration of Antimicrobials, 65-68 Acyclovir IV/PO, 1 Breast abscess, 135 Adenitis, acute cervical, 102 Brevibacterium spp, 334 Aerococcus spp, 329 Brevundimonas spp, 344 Aeromonas spp, 343 Bronchitis Agrobacterium spp, 344 Acute, 96, 162-163 Alcaligenes spp, 344 Exacerbation of Chronic, 164-165 Allergy, b-lactam, 69-70 Bronchiolitis, 96 Alloiococcus otitidis, 329 Brucella spp, 349 Amebiasis, 250 Burkholderia cepacia, 345 Amikacin, 2 Bursitis, septic, 85, 152 Aminoglycosides Conventional, dosing/monitoring, 45-47 C Extended interval, dosing/monitoring, 41-44 Campylobacter spp, 349-350 Amoxicillin-clavulanate, 3 Canaliculitis, 230 Amphotericin B, 244 Candidemia, 243 Amphotericin B, Lipid-complexed, 4 Candidiasis, 241-243 Anaphylaxis, 69-70 Esophageal, 243 Ancylostoma duodenale, 247 Invasive, 243 Animal bites, 76-77, 136-137 Oral, 242 Antibiotic associated diarrhea, 110-111, 179- Vaginal, 241 180 Candiduria, 242 Appendicitis, 111, 184 CAPD Peritonitis, 114, 187-188 Arcanobacterium haemolyticum, 334 Treatment of Culture-proven, 188 Arcobacter spp, 349 Capnocytophaga spp, 297, 350 Arthritis, septic, 85, 150-152 Carbuncles, 71, 130 Gonococcal, 85, 150 Cardiac Infections, 123, 220-223 Intravenous Drug Use, 152 Endocarditis, 123, 220-223 Prosthetic Joint, 151 Pericarditis, 123, 220 Rheumatoid, 151 Surgical Prophylaxis, 254-255 Ascaris lumbricoides, 246 Cardiobacterium spp, 350 Aspergillosis Catheterization, chronic indwelling, 118, 211 Invasive, 243 CDC Group DF-3, 350 Sinusitis, 244 CDC Group EF-4, 351 Aspiration Pneumonia, 106-107, 173 Cedecea spp, 338 Asplenia, 269 Cefaclor, 6 Automatic Therapeutic Substitutions, 57-59 Cefazolin, 7

Bold numbers indicate empiric therapy recommendations for ADULT patients. INDEX

Cefixime, 8 Bacterial, 231 Cefotaxime, 9 Chlamydial, 232 Cefprozil, 10 Gonococcal, 232 Ceftazidime, 11 Newborn, 232 Ceftriaxone, 9 Viral, 230 Cefuroxime axetil, 12 Corynebacterium spp, 334-335 Cefuroxime IV, 13 Croup, 95 Cellulitis, 74-75, 134-135 Cryptosporidium parvum, 248 Bites CSF Penetration of Antimicrobials, 65-68 Animal, 76-77, 136-137 Cyclospora cayetanensis, 248 Human, 78, 138 Cystic Fibrosis exacerbation, 102 Burn, 80 Cystitis, 116-117, 207-209 Diabetic, 139 Cytomegalovirus, Exposure in Pregnancy, 317 Extremities, 75, 134 D Facial, 75, 134 Omphalitis, 74 Dacryocystitis, 230 Orbital, 238-239 Decubitus ulcers, 140 Periorbital, 237-238 Dental Infections, 297-306 Peri-rectal, 75, 135 Dental Prophylaxis, 287-296 Post-operative, 80-81, 135, 144-145 Dermatophytes, 240-241 Rapidly progressive, 82, 146 Diabetic Central Nervous System Infections, 119-122, Cellulitis, 139 214-219 Foot infection, 139 Cephalexin, 14 Osteomyelitis, 148 Cervicitis, 191 Ulcer, 139 Chlamydial, 191 Diarrhea Gonococcal, 191 Antibiotic-associated, 110-111, 179-180 Cestodes, 247 Bacterial, 108, 177 Chalazion, 229 Parasitic, 244-250 Chancroid, 201 Travellers’, 109, 178, 280 Chickenpox, Viral, 108, 177 See Varicella Dientamoeba fragilis, 249 Chilomastix mesnilii, 248 Diphtheria, Travel Medicine Cholangitis, 182 Recommendations, 279 Cholecystitis, 181 Diphyllobothrium latum, 247 Cholera, Travel Medicine Recommendations, Diverticulitis, 184 280 Dosing Chryseobacterium spp, 345 Adult, 35-37 Ciprofloxacin IV, 15 Aminoglycosides, 41-47 Ciprofloxacin PO, 16 Hepatic Impairment, 54-56 Citrobacter spp, 338 Paediatric, 38-40 Clarithromycin, 17 Renal Impairment, 52-53 Clindamycin IV, 18 Vancomycin, 48-49 Clindamycin PO, 19 E Clonorchis, 245 Clostridium difficile diarrhea, 110-111, 179-180 Ears, Commensal/Pathogenic Flora, 325 Clostridium spp, 353-354 Edwardsiella spp, 339 Comamonas spp, 345 Eikenella corrodens, 297, 351 Community acquired Pneumonia, 104-105, Empyema 166-171 Lung, 107, 174 Pathway, 166 Subdural, 218 Severity Index Scoring System, 171 Encephalitis, 122, 219 Complicated UTI, 210-212 Japanese, Travel Medicine Condyloma acuminata, 202 Recommendations, 279 Endocarditis, 123, 220-223 Conjunctivitis, 230-232 Intravenous Drug Use, 221 Bold numbers indicate empiric therapy recommendations for ADULT patients. INDEX

Native valve, 123, 220 Gangrene Prophylaxis Clostridial (Gas), 82, 146 Dental, 288-289 Mixed syngergistic, 82, 146 General, 261-262 Streptococcal, 82, 146 Prosthetic valve, 123, 221 Gardnerella vaginalis, 335 Treatment of culture-proven, 222-223 Gas gangrene, Endolimax nana, 249 See Gangrene Endometritis, 196 Gastroenteritis, 108, 177 Endophthalmitis, 235-236 Gastrointestinal Fungal, 236 Infections, 108-114, 177-188 Hematogenous, 236 Surgical Prophylaxis, 251-252 Post-Surgical, 235 Gemella spp, 330 Post-Trauma, 235 Genital ulcers/lesions, 198-202 Entamoeba coli, 249 Chancroid, 201 Entamoeba dispar, 249 Genital warts, 202 Entamoeba histolytica, 250 Herpes, 198-200 Enterobacter spp, 339 Syphilis, 201 Enterobacteriaceae, 338-342 Genital Tract Enterobius vermicularis, 246 Commensal/Pathogenic Flora, 327 Enterococcus spp, 329 Infections, 115, 189-203 VRE, isolation, 284 Genital Warts, 202 VRE, screening, 285 Gentamicin, Enterocolitis, necrotizing, 111 See Aminoglycosides Epidermophyton, 240 Giardia lamblia, 250 Epididymo-orchitis, 192 Gingivitis, 300-301 Epidural Abscess, 218 Gram Stain Interpretation, 323 Epiglottitis, 95 H Erysipelothrix spp, 335 Escherichia coli, 339 Haemophilus influenzae, 352 Eubacterium spp, 354 Prophylaxis, 272 Eyes, Commensal/Pathogenic Flora, 325 Haemophilus spp, 351-352 Hafnia spp, 339 F Handwashing, 282, 286 Fasciitis, necrotizing, 82, 146 Head and Neck, Surgical Prophylaxis, 260 Febrile neutropenia, 127-129, 227 Helcococcus spp, 330 Pneumonia, 128 Helicobacter pylori, 180 Flavobacterium spp, 346 Helminths, 245-247 Flora, Commensal/Pathogenic, 324-328 Hepatic Impairment, Adult Dosing, 54-56 Fluconazole IV/PO, 20 Hepatitis A Folliculitis, 71, 130 Immunization Recommendations, 270 Formulary, Capital Health Hospitals, 60-63 Travel Medicine Recommendations, 280 Foscarnet, 21 Hepatitis B Fungal Infections, 240-244 Exposure Aspergillus, 243 Blood/Body Fluids, 263-264 Candida, 241-243 Pregnancy, 317 Dermatophytes, 240-241 Sexual Assault, 267 Malassezia, 241 Immunization Recommendations, 264, 267 Sporothrix, 241 Travel Medicine Recommendations, 281 Zygomyces, 244 Hepatitis C Exposure Fungemia, 243 Blood/Body Fluids, 263-265 Furunculosis, 71, 130 Pregnancy, 317 Recurrent, 71, 130 Sexual Assault, 267 Fusobacterium spp, 355 Herpes G Exposure in Pregnancy, 318 Genital, 198-200 Ganciclovir, 21 Mucocutaneous, 133

Bold numbers indicate empiric therapy recommendations for ADULT patients. INDEX

HIV Lice, 79, 203 Exposure Line related sepsis, 126, 225-226 Blood/Body Fluids, 263-266 Lipid-Complexed Amphotericin B, 4 Pregnancy, 318 Listeria monocytogenes, 336 Sexual Assault, 267 Liver abscess, 183 Perinatal Protocol, 322 Liver fluke, 245 Hookworm, 247 Lung abscess, 107, 174 Hordeolum, 229 M Hospital acquired pneumonia, 105-107, 172-3 Human bites, 78, 138 Malaria, Travel Medicine Recommendations, 278 Malassezia, 241 I Mastitis, 135 Imipenem, 22 Mastoiditis, 93, 157 Immunization Recommendations, 268-271 Measles, Travel Medicine Recommendations, 281 Asplenia, 269 Meningitis, 119-121, 214-215 Influenza, 270 CSF Penetration of Antimicrobials, 65-68 Hepatitis A, 270 Prophylaxis Hepatitis B, 264 H. influenzae, 272 Meningococcal, 269 N. meningitidis, 272 Pneumococcal, 268 Meningococcal disease, Travel Medicine Vaccination Schedule, Alberta, 268 Recommendations, 281 Varicella, 271 Meningococcal vaccine, 269 Impetigo, 71, 130 Meropenem, 25 Infection Prevention and Control, 282-285 Methicillin resistant S. aureus, Influenza See Staphylococcus aureus Prophylaxis, 274 Methylobacterium spp, 346 Treatment, 170 Micrococcus spp, 330 Vaccine, 270 Microsporum spp, 240 Intrapartum Antimicrobial Prophylaxis, 321 Monitoring Iodamoeba buetschlii, 250 Aminoglycosides, 41-47 Isolation Precautions, 282-285 Vancomycin, 50-51 J Moraxella spp, 346 Morganella spp, 340 Japanese Encephalitis, Travel Medicine Moxifloxacin, 26 Recommendations, 279 MRSA, See Staphylococcus aureus Joint MRSA Nasal Carriage, 72, 131 Infections, 85, 150-152 Myositis, 82, 146 Surgical Prophylaxis, 258 Myroides odoratum, 346 K N Keratitis, 233-234 Necator americanus, 247 Bacterial, 233 Necrotizing fasciitis/myositis, 82, 146 Fungal, 234 Needlestick Prophylaxis, 263-266 Protozoan, 234 Neisseria meningitidis, 337 Viral, 233 Prophylaxis, 272 Kingella spp, 352 Travel Medicine Recommendations, 281 Klebsiella spp, 340 Neisseria spp, 337 L Nematodes, 246-247 Neuraminidase inhibitors, 27 Lactation, Antimicrobials in, 313-316 Neurosurgery, Surgical Prophylaxis, 259 Lactobacillus spp, 336 Neutropenia, febrile, 127-129, 227 Lactococcus spp, 330 Pneumonia, 128 Laryngitis, 155 Typhilitis, 129 Leuconostoc spp, 330 Nocardia spp, 336 Levofloxacin IV, 23 Nosocomial sepsis, 125-126, 225-226 Levofloxacin PO, 24 Nursing home acquired Pneumonia, 170

Bold numbers indicate empiric therapy recommendations for ADULT patients. INDEX

O Prophylaxis, 275 Treatment, 95, 156 Obstetric/Gynecologic, Surgical Prophylaxis, Pharyngitis, 86-88, 153-155 253 Pink Eye, 230 Ochrobactrum spp, 346 Pinworm, 246 Odontogenic Infections, 299-300 Piperacillin-tazobactam, 28 Oerskovia spp, 336 Plastics, Surgical Prophylaxis, 257 Oligella spp, 346 Plesiomonas spp, 343 Onychomycosis, 241 Pneumococcal Vaccine, 268 Ophthalmic Pneumocystis carinii, 175 Commensal/Pathogenic Flora, 325 Prophylaxis, 175 Infections, 229-239 Treatment, 175 Surgical Prophylaxis, 259 Pneumonia, 103-107, 166-173 Opisthorchis, 245 Aspiration, 106-107, 173 Oral Infections, 306 Community acquired, 104-105, 166-171 Orbital Cellulitis, 238-239 Febrile neutropenic, 128 Orchitis, 192 Hospital acquired, 105-107, 172-173 Orthopedic Neonatal, 103 Infections, Nursing home acquired, 170 See Bone or Joint Infections Pathway, 166 Prophylaxis Severity Index Scoring System, 171 Dental, 290 Tuberculosis, 176 Surgical, 258 Polio, Travel Medicine Recommendations, 280 Oseltamivir, 27 Porphyromonas spp, 355 Osteomyelitis, 83-84, 147-150 Post-operative wounds, 80-81, 144-145 Diabetic, 148 Pregnancy Intravenous Drug Use, 147 Antimicrobials in, 307-312 Post-operative, 84, 149-150 Asymptomatic Bacteriuria, 205 Prosthetic Joint, 149 Cystitis/Pyelonephritis, 211, 213 Otitis externa, 157 Exposure to Communicable Diseases, 317- Otitis media, 89-95, 157 320 Otitis media with effusion, 89, 95 Prevotella spp, 355 Ova and Parasites, 245-250 Probenecid, 134 P Proctitis, 198 Prophylaxis Pancreatitis, 182 Blood/Body Fluid Exposure, 263-266 Pantoea agglomerans, 340 Contacts of Communicable Diseases, 272- Parapharyngeal space infections, 102, 162 276 Parasitic Infections, Enteric, 245-250 Dentistry, 287-296 Parvovirus, Exposure in Pregnancy, 318 Endocarditis, 261-262 Pasteurella spp, 343 Intrapartum, 321 Pediococcus spp, 330 Meningitis, 272 Pelvic inflammatory disease, 193-195 Perinatal HIV, 322 Penicillin Allergy, 69-70 Sexual Assault, 267 Peptostreptococcus spp, 354 Surgical, 251-260 Pericarditis, 123, 220 Travel Medicine, 277-281 Perinatal HIV Protocol, 322 Propionibacterium spp, 354 Periodontal Infections, 302-305 Prostatitis, 197-198 Periorbital Cellulitis, 237-238 Prosthetic Joint Peri-rectal Cellulitis, 75, 135 Infections, 84, 149-151 Peritonitis, 112-114, 185-188 Prophylaxis, Dental, 290 CAPD, 114, 187-188 Proteus spp, 340 Secondary, 112, 186 Protozoa, 248-250 Spontaneous bacterial, 112, 185 Providencia spp, 341 Tertiary, 113, 187 Pseudomonas spp, 347 Pertussis Pubic Lice, 203 Bold numbers indicate empiric therapy recommendations for ADULT patients. INDEX

Pyelonephritis, 116-117, 213 Splenectomy, Immunizations, 269 Q Spontaneous Bacterial Peritonitis, 112, 185 Quinupristin-dalfopristin, 29 Sporotrichosis, 241 Staphylococcus aureus, 331 R MRSA, decolonization, 285 Rabies, Travel Medicine Recommendations, MRSA, isolation, 283 279 MRSA, nasal carriage, 72, 131 Ralstonia pickettii, 347 MRSA, screening, 285 Rapidly progressive skin and soft tissue Staphylococcus spp, 331 infections, 82, 146 Stenotrophomonas maltophilia, 348 Gas gangrene, 82, 146 Stepdown Recommendations, 64 Necrotizing fasciitis/myositis, 82, 146 Stomatococcus spp, 331 Synergistic necrotizing cellulitis, 82, 146 Streptococcus, Group A, 333 Renal Impairment, Adult Dosing, 52-53 Prophylaxis, 273 Respiratory Tract Streptococcus, Group B, 332 Commensal/Pathogenic Flora, 324 Prevention of Perinatal Infection, 321 Infections, 86-107, 153-176 Streptococcus spp, 332-333 Rhinitis, 97, 156 Strongyloides stercoralis, 246 Rhodococcus equi, 336 Sty, 229 Ribavirin, 30 Subdural empyema, 218 Roseomonas spp, 347 Surgical Prophylaxis, 251-260 Rothia spp, 336 Cardiac, 254-255 Roundworm, 246 Dental, 291-296 Rubella, Exposure in Pregnancy, 319 General, 251-252 Head and Neck, 260 S Neurosurgery, 259 Salmonella spp, 341 Obstetric/Gynecologic, 253 Salmonella typhi, Travel Medicine Ophthalmology, 259 Recommendations, 280 Orthopedic, 258 Scabies, 79, 203 Plastics, 257 Secondary Peritonitis, 112, 186 Spinal, 258 Sepsis, 124-126, 224-226 Thoracic, 256 Community acquired, 124-125, 224 Urology, 253-254 Fungemia, 243 Vascular, 257 Hospital acquired, 125-126, 225-226 Suttonella spp, 352 Line-related, 126, 225-226 Synergisitc necrotizing cellulitis, 82, 146 Septic arthritis, 85, 150-152 Syphilis, 201 Septic bursitis, 85, 152 T Septic pelvic vein thrombophlebitis, 196 Serratia spp, 342 Taenia saginatum, 247 Sexual Assault Prophylaxis, 267 Taenia solium, 247 Sexually transmitted diseases, Travel Medicine Tapeworm, 247 Recommendations, 281 Beef, 247 Shewanella spp, 347 Fish, 247 Shigella spp, 342 Pork, 247 Shingles, 73, 132 Tertiary Peritonitis, 113, 187 Shunt Infections, 121, 215 Tetanus, Travel Medicine Recommendations, Sinusitis, 98-101, 158-161 279 Fungal, 244 Therapeutic Substitutions, 57-59 Hospital acquired, 101, 161 Therapy, Empiric Skin/Soft Tissue Dental Infections, 297-306 Commensal/Pathogenic Flora, 328 Enteric Parasitic Infections, 245-250 Infections, 71-82, 130-146 Fungal Infections, 240-244 Sphingobacterium spp, 347 Ophthalmic Infections, 229-239 Sphingomonas spp, 348 Selected Infections Spinal, Surgical Prophylaxis, 258 Adult, 130-228 Bold numbers indicate empiric therapy recommendations for ADULT patients. INDEX

Paediatric, 71-129 Exposure in Pregnancy, 320 Specific Organisms, 329-355 Immunization Recommendations, 271 Thoracic, Surgical Prophylaxis, 256 Prophylaxis, 276 Thrombophlebitis, Septic Pelvic Vein, 196 Vascular Thrush, 242 Infections, 123, 220-223 Ticarcillin-clavulanic acid, 31 Surgical Prophylaxis, 257 Tinea, 240-241 Veillonella spp, 354 Tobramycin, Vibrio cholerae, Travel Medicine See Aminoglycosides Recommendations, 280 Toxic Megacolon, 111, 180 Vibrio spp, 343 Toxoplasma Viridans Group Streptococci, 297, 333 Brain abscess, 217 VRE, See Enterococcus spp Exposure in Pregnancy, 319 Vulvovaginitis, See Vaginitis Tracheitis, bacterial, 96 W Travel Medicine Recommendations, 277-281 Travellers’ diarrhea Warts, Genital, 202 Travel Medicine Recommendations, 280 Weeksella spp, 348 Treatment, 109, 178 Whipworm, 246 Trematodes, 245 Whooping cough, See Pertussis Trichophyton, 240-241 Wounds, Trichuris trichiura, 246 Bites Tuberculosis, Animal, 76-77, 136-137 Travel Medicine Recommendations, 281 Human, 78, 138 Treatment, 176 Burn, 80 Typhoid Fever, Travel Medicine Classification, 143 Recommendations, 280 Management, 141-142 Mastitis, 135 U Mediastinitis, 81 Ulcers, Nail puncture, 84, 148 Chancroid, 201 Post-episiotomy, 145 Decubitis, 140 Post-operative, 80-81, 144-145 Diabetic, 139 Sternotomy, 84, 150 Duodenal/Gastric, 180 Y Genital, 198-202 Syphilis, 201 Yellow Fever, Travel Medicine Urethritis, 192 Recommendations, 279 Urinary Tract Yersinia enterolitica, 342 Bacterial Infections, 116-118, 204-213 Z Commensal/Pathogenic Flora, 326 Fungal Infections, 242 Zanamivir, 27 Urology, Surgical Prophylaxis, 253-254 Zoster (shingles), 73, 132 UTI, Complicated, 210-212 Zygomyces, 244

V Vaginitis, 115, 189-190 Candida, 189 Trichomonas, 189 Vaginosis, Bacterial, 190 Vancomycin Dosing, 48-49 Monitoring, 50-51 Vancomycin IV, 32 Vancomycin PO, 33 Varicella, 72-73, 131-132

Bold numbers indicate empiric therapy recommendations for ADULT patients. USEFUL PHONE NUMBERS

I.D. Consult (contact STD Clinic 413-5156 switchboard) University 407-8822 Travel Clinic 413-5745 Royal Alex 477-4111 Grey Nuns 450-7000 TB Clinic 413-5755 Misericordia 930-5611 Sturgeon 460-6200 Home IV Therapy Glenrose 471-2262 University 407-7533 Edm. General 482-8111 Royal Alex 477-4714 Grey Nuns 450-7601 Infection Control Misericordia 930-5593 University 407-3244 Sturgeon 460-6297 Royal Alex 477-4549 Grey Nuns 450-7308 Inpatient Pharmacies Misericordia 930-5610 University 407-6989 Sturgeon 460-6320 Royal Alex 477-4464 Glenrose 491-6023 Grey Nuns 450-7415 Edm. General 450-7308 Misericordia 930-5821 Community 413-7618 Sturgeon 460-6214 Glenrose 474-8857 Microbiology Laboratories Edm. General 482-8112 DKML 451-3702 University 407-7121 Outpatient Pharmacies University 407-6990 Provincial Laboratory Royal Alex 491-5296 Virology 407-8985 Parasitology 407-7121 Drug Information Tuberculosis 407-7680 University 407-7404 Royal Alex 477-4463 Public Health 413-7600 after hours 433-3940 Antimicrobial Utilization 407-2683 Needlestick Response Team - Do Bugs Need Drugs? project Community 480-6598 1-800-931-9111 www.dobugsneeddrugs.org Sexual Assault 445-3359 Capital Health Link-Physicians 408-5550 Others 408-5465