National Antibiotic Guidelines 2018

Department of Health Manila, Philippines

Cover Design John Michael L. Roque

Layout Design Adell R. Azuelo Lora Alaine D. Raymundo John Michael L. Roque

National Antibiotic Guidelines Committee Pharmaceutical Division Department of Health Philippine Blood Center, Lung Center Compound, Quezon Avenue, Quezon City, 1100 ISBN - 978-621-95675-1-0

Any part of the book or its entirety may be reproduced or transmitted without any alteration, in any form or by any means, with permission from DOH provided it is not used for commercial purposes.

TABLE OF CONTENTS

Message ...... i

Acknowledgments ...... ii

Editorial Team ...... iv

Abbreviations and Acronyms ...... v

Introduction ...... 1

Blood-Borne Infections and Other Systemic Syndromes ...... 8

Bone and Joint Infections - Pediatric ...... 32

Bone and Joint Infections - Adult ...... 39

Cardiovascular Infections ...... 47

Central Nervous System Infections ...... 62

Dental and Oral Infections ...... 71

Gastrointestinal and Other Intraabdominal Infections ...... 78

Ocular Infections ...... 93

Respiratory Tract Infections

Upper Respiratory Tract Infections……………………………………………………..105

Lower Respiratory Tract Infections…………………………………………………….128

Skin and Soft Tissue Infections - Pediatric ...... 148

Skin and Soft Tissue Infections - Adult ...... 173

Surgical Prophylaxis ...... 194

Urinary Tract Infections ...... 206

National Health Programs

Filiariasis (Selective Treatment) ……………………………………………………..……221

Leprosy………………………………………………………………………..…………….…223

Malaria…………………………………………………………….……………………………225

Schistosomiasis…………………………………………………………………………..….236

Sexually Transmitted Infections………………………………………………………..….238

Tuberculosis…………………………………………………………………………..………261

Republic of the Philippines Department of Health OFFICE OF THE SECRETARY

MESSAGE

The discovery of antibiotics, considered as “Miracle Drugs” in the 1920s revolutionized man’s ability to treat many infectious diseases and save countless lives. However, with their misuse, an increasing number of microorganisms are now resistant to them, thus the emergence of antimicrobial resistance. This public health threat intensifies the risk of falling into more severe and prolonged illness leading to increased mortality and health care costs.

The Philippine Action Plan to Combat AMR: One Health Approach in 2015 has set a strategic direction towards preventing the spread and potential harm caused by AMR, unifying and linking all relevant sectors in the country, to strengthen the prudent use of antibiotics.

The Department of Health created the National Antibiotic Guidelines Committee (NAGCom), a body composed of infectious disease experts and other relevant fields to develop the National Antibiotic Guidelines (NAG). The guidelines aim to strengthen our program implementation on the rational use of antimicrobials. This contains the therapeutic recommendations for the common infectious diseases in the community setting and hospitals that will supplement the knowledge of our physicians on optimizing antibiotic treatment. The NAG will help improve quality of care in the country, improve patient outcomes and lower health care costs.

We all have a responsibility to protect our people from the threat of antimicrobial resistance. As we move to achieve the Philippine Health Agenda, let us harmonize our efforts in the pursuit of better health care system. Together, we can win the war against AMR!

FRANCISCO T. DUQUE III, MD, MSc Secretary of Health

i ACKNOWLEDGMENTS

The participation and assistance of the following experts and reviewers of this document are gratefully acknowledged: Dr. Estrella B. Paje-Villar, former NAG Committee Chair Dr. Ivan Olegario, former editor Dr. Corazon I. Flores, former Director of the Pharmaceutical Division

DOH offices: Disease Prevention and Control Bureau (DPCB) Epidemiology Bureau (EB) Food and Drug Administration (FDA) Health Facilities Development Bureau (HFDB)

Development Partner: World Health Organization

Professional Associations: Pediatric Infectious Disease Society of the Philippines (PIDSP) Pediatric Nephrology Society of the Philippines (PNSP) Philippine Academy of Family Physicians (PAFP) Philippine Academy of Ophthalmology (PAO) Philippine Academy of Pediatric Pulmonologists (PAPP) Philippine Coalition Against Tuberculosis (PhilCAT) Philippine College of Chest Physicians (PCCP) Philippine College of Physicians (PCP) Philippine College of Surgeons (PCS) Philippine Dental Association (PDA) Philippine Dermatological Society (PDS) Philippine Hospital Infection Control Society, Inc. (PHICS) Philippine Neurological Association (PNA) Philippine Obstetrical and Gynecological Society (POGS) Philippine Orthopedic Association (POA) Philippine Pediatric Society (PPS) Philippine Pharmacists Association, Inc. (PPhA) Philippine Society for Microbiology and Infectious Disease (PSMID) Philippine Society of Nephrology (PSN) Philippine Society of Newborn Medicine (PSNBM) Philippine Society of Otolaryngology Head and Neck Surgery (PSO-HNS)

Philippine Society for Pediatric Gastroenterology, Hepatology and Nutrition (PSPGHAN) Philippine Society of Pediatric Surgeons (PSPS) Philippine Urological Association (PUA)

Hospitals: Philippine Children’s Medical Center (PCMC) Research Institute for Tropical Medicine (RITM) San Lazaro Hospital (SLH) The Medical City (TMC) Universirty of the Philippines-Philippine General Hospital (UP-PGH)

iii EDITORIAL TEAM

National Antibiotic Guidelines Committee

Chair MEDIADORA C. SANIEL, MD, MBA-H, FPCP

Members CELIA C. CARLOS, MD, FPPS, FPIDSP, FPSMID CARMINA A. DELOS REYES, MD, FPPS, FPIDSP MARI ROSE A. DE LOS REYES, MD, FPCP BENILDA B. GALVEZ, MD, FPCCP MARY ANN D. LANSANG, MD, MMEDSC CECILIA C. MARAMBA-LAZARTE, MD, MSCID, MSCCT ROSALIND G. VIANZON, MD, MPH CYNTHIA S. FABREGAS, MD, DPCOM OLIVIA M. LIMUACO, RPh, PhD YOLANDA R. ROBLES, RPh, PhD VITO G. ROQUE, Jr. MD

Antimicrobial Resistance Program Secretariat

ANNA MELISSA M. GUERRERO, MD, MPH (HTA) IRENE V. FLORENTINO-FARIÑAS, RPH, MD, MNSA MS. ANNE JULIENNE M. GENUINO, RPH MS. NIÑA ISABELLE M. TOLENTINO, RPH MS. LORA ALAINE D. RAYMUNDO, RPH

ABBREVIATIONS AND ACRONYMS

ABECB Acute bacterial exacerbation of chronic bronchitis ABP Acute bacterial prostatitis ABRS Acute bacterial rhinosinusitis ABSSSI Acute bacterial skin and skin structure infections AL Artemether-lumefantrine ALT Alanine aminotransferase AOM Acute otitis media ARSP Antimicrobial Resistance Surveillance Program ART Antiretroviral therapy AS Artesunate ASB Asymptomatic bacteriuria AUC Acute uncomplicated cystitis BMI Body mass index BUN Blood urea nitrogen CAMRSA Community-associated MRSA CAP Community-acquired pneumonia CBP Chronic bacterial prostatitis CHD Congenital heart disease CMV Cytomegalovirus CNS Central nervous system CRP C-reactive protein CRS Chronic rhinosinusitis CSF Cerebrospinal fluid CSOM Chronic suppurative otitis media CT Computed tomography CVC Central venous catheter CVS Cardiovascular system DAIR Debridement and retention of prosthesis DEC Diethylcarbamazine DFI Diabetic foot infections EIA Enzyme immunoassay ELISA Enzyme-linked immunosorbent assay ENT Ears, nose and throat EPTB Extra pulmonary tuberculosis ESBL Extended spectrum beta-lactamase ESR Erythrocyte sedimentation rate ETEC Entero-toxigenic Escherichia coli FDC Fixed dose combination FQ Fluoroquinolone FTA-ABS Fluorescent treponemal antibody absorption test GIT Gastro-intestinal tract GABHS Group A Beta-hemolytic Streptococci

v GAS Group A Streptococcus GCSF Granulocyte colony stimulating factor GNB Gram-negative bacteria GUT Genitourinary tract HACEK Haemophilus sp., Aggregatibacter sp., Cardiobacterium hominis, Eikinella corrodens, and Kingella sp. HAI Hospital-associated infections HAP Hospital-acquired pneumonia HBIG Hepatitis B Immunoglobulin HBeAg Hepatitis B envelope antigen HBsAg Hepatitis B surface antigen HBV Hepatitis B virus HCV Hepatitis C virus HR Isoniazid + Rifampicin HRZE/S Isoniazid + Rifampicin + Pyrazinamide + Ethambutol/Streptomycin HSV Herpes simplex virus HIV Human immunodeficiency virus ICT Immunochromatographic test IDSA Infectious Diseases Society of America IE Infective Endocarditis I & D Incision and drainage IRIS Immune reconstitution inflammatory syndrome ISPD International Society for Peritoneal Dialysis LBW Low birth weight LP Lumbar puncture MAP Mean arterial pressure MDR-TB Multipledrug resistant tuberculosis MDT Multidrug therapy MIC Minimum inhibitory concentration MMR Mumps, Measles, Rubella MRI Magnetic resonance imaging MSSA Methicillin-susceptible Staphylococcus aureus MRSA Methicillin-resistant Staphylococcus aureus MTB Mycobacterium tuberculosis NAAT Nucleic acid amplification testing NBE Nocturnal blood examinations NT Neutralization test OC Oral contraceptive OGTT Oral glucose tolerance test PANDAS Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcus Infections PCAP Pediatric community acquired pneumonia PCR Polymerase chain reaction PHN Post-herpetic neuralgia

PICC Peripherally inserted central catheter PID Pelvic Inflammatory Disease PLHIV People living with HIV PMDT Programmatic Management for Drug-resistant Tuberculosis PT Prothrombin time PVL Panton-Valentine leukocidin PWID People who inject drugs RHD Rheumatic Heart Disease RPR Rapid plasma reagin RSV Respiratory syncytial virus SIRS Systemic inflammatory response syndrome SLDs Second line drugs SLE Systemic Lupus Erythematosus SOFA Sequential organ failure assessment STD Sexually Transmitted Disease STI Sexually Transmitted Infections TALF Treatment after lost to follow up TB Tuberculosis TMP-SMX Trimethoprim-sulfamethoxazole (Co-trimoxazole) TCA Trichloroacetic acid TSS Toxic shock syndrome TEE Transesophageal echo TPHA Treponema pallidum haemagglutination TTE Transthoracic echocardiogram ULN Upper limit of normal UTI Urinary tract infection VAP Ventilator-associated pneumonia VDRL Venereal Disease Research Laboratory VP Ventriculoperitoneal VSD Ventricular septal defect VZIG Varicella zoster immunoglobulin VZV Varicella zoster virus WHO World Health Organization

vii

INTRODUCTION

The National Antimicrobial Stewardship (AMS) Program, an integral component of the Philippine Action Plan to Combat Antimicrobial Resistance (AMR), gives structure and direction to healthcare facilities to adopt a proactive multidisciplinary approach to promote rational antimicrobial use. One of the six core elements of AMS is the development and implementation of policies, guidelines and clinical pathways to improve antimicrobial prescribing and dispensing. Specifically, Core Element 2 states that “all hospitals shall adopt or adapt to their local context the National Antibiotic Guidelines” to optimize antimicrobial use and help improve the quality of patient care and patient safety. Armed with enhanced knowledge provided by the Guidelines, health practitioners at all levels of healthcare are then empowered to appropriately treat common infectious disease syndromes seen among children and adults (e.g. respiratory and urinary tract infections, diarrhea, skin and soft tissue infections, tuberculosis) as well as other diseases for which much irrational antibiotic use prevails in the country.

The challenging task of formulating the Guidelines was given by the Department of Health to the National Antibiotic Guidelines Committee (NAGCom), a multidisciplinary group of experts in the fields of infectious diseases, epidemiology, pharmacology and public health program management. It was decided from the outset that there would be no need to reinvent the wheel. Divided into subgroups, the NAGCom reviewed existing evidence-based local and international guidelines and relevant literature, with priority given to guidelines that utilized the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Adaptations of available guidelines and treatment recommendations were made taking into consideration the latest national Antimicrobial Resistance Surveillance Program resistance rates, list of approved drugs in the National Formulary, quality of the evidence, balance of potential benefits and harm, cost-effectiveness, availability of diagnostic tests, feasibility and resource implications. Interim recommendations were discussed en banc and a consensus was usually reached. The interim guidelines were then sent to the specialty/subspecialty societies for their inputs prior to finalizing the Guidelines. Consultations with external technical experts and public health program implementers were also done as needed. 1

The Guidelines in this handbook contain treatment recommendations for infectious diseases grouped by organ systems and presented in a tabular format for ease of use. Brief descriptions of disease categories with their etiologic agents, corresponding antibiotic regimens (dose, route, frequency and duration) for pediatric and adult patients, relevant comments and key references are presented. A section on surgical prophylaxis, although not treatment- focused, has been added since antibiotic misuse to prevent surgical site infections also needs urgent attention. The regimens do not include adjustments for renal impairment and optimization strategies (e.g., extended intravenous infusion of beta-lactams). Such dose modifications may be accessed at https://www.medbox.org/antibiotic-guideline-2015- 2016/download.pdf.

How should the Guidelines be used in health facilities? The AMS program stipulates that hospitals should have facility-specific antibiotic guidelines. Depending on local antibiotic susceptibilities, formulary options, costs, and available resources, the AMS Committee of a health facility can adopt or adapt portions of the Guidelines. There are several other ways by which the Guidelines, adopted or adapted, can be used in AMS including: creation of clinical pathways, development of educational modules (print and electronic) for healthcare professionals, implementation of point-of-care interventions (e.g. dose optimization, de- escalation), prospective audit and feedback, and performance evaluation.

The Guidelines are not intended to supersede a healthcare provider’s sound clinical judgment. Variations in a patient’s clinical presentation (such as presence of co-morbidities), patient’s preferences and availability of resources may require judicious adaptation of the Guidelines by individual users.

General Principles of Antimicrobial Therapy The fundamental questions to ask in anti-infective therapy are: A. WHAT am I treating? Microbiologic Factors B. WHO am I treating? Host-related Factors C. WHICH antimicrobial/s is/are most appropriate? Drug-related Factors D. HOW do I administer the appropriate antimicrobial/s? Dosing Regimen A. Microbiologic Factors The disease/clinical syndrome and the likely/proven pathogen(s) determine the choice of therapy. Thus, it is important to know the following:

• Site of infection – attain adequate concentration of the antibiotic at the site of infection; • Severity of infection – obtain appropriate specimens to determine the pathogen because serious life-threatening infections e.g., sepsis, meningitis, endocarditis, etc. require early empiric therapy; • Bacterial load (inoculum size), virulence, regrowth pattern and susceptibility pattern of the pathogen • Infection at sequestered sites – some like nasopharyngeal carriage may not be reached by significant levels of the principal antibiotic being used; • Prior antimicrobial therapy – exert selection pressure for microorganisms resistant to the antibiotic previously given to outgrow the rest of the microflora, invade and cause infection; • Local factors – consider factors that may impair penetration of antibiotic into the affected area such as presence of pus, devitalized tissue, foreign body and pH changes. B. Host-related Factors The patient’s demographic, clinical and behavioral characteristics influence the efficacy and toxicities of antimicrobials. • Age – influences gastric acidity, renal function and hepatic function and propensity to develop hypersensitivity. • Genetic factors – causes adverse reactions to specific antimicrobials, e.g., glucose-6-phosphate dehydrogenase deficiency leads to hemolytic anemia and jaundice with the administration of primaquine, sulfonamides, sulfones, nitrofurans, chloramphenicol, etc.; and aplastic anemia is an idiosyncratic reaction from chloramphenicol. • Hepatic and renal function - determines ability of the patient to metabolize/inactivate or excrete the antimicrobial especially when high serum or tissue levels are potentially toxic. • Pregnancy and nursing status (Refer to Pregnancy Risk Categories by the US FDA) • Host defense mechanism – both humoral and cellular; immunocompetent vs. immunocompromised host e.g., HIV infection, recipients of cytotoxic drugs, transplanted organs, burn patients, with vascular abnormalities, impaired localized phagocytosis, etc. • Co-morbid conditions - HIV/AIDS, diabetes mellitus and other metabolic disorders, atopy, preexisting organ dysfunction, obesity, etc. • Previous history of adverse drug reactions – e.g., allergy, intolerance, etc.

C. Drug-related Factors • Pharmacodynamics – “what the drug does to the pathogen and to the body” – antimicrobial spectrum; bacteriostatic vs. bactericidal; concentration-dependent vs. time-dependent bacterial killing. • Pharmacokinetics – “what the body does to the drug” – includes the processes of absorption, distribution, biotransformation/metabolism, excretion; the relationship between the antimicrobial concentration at the site of action and the minimum inhibitory concentration for the pathogen is the major determinant of successful therapy; poor antimicrobial penetration of the blood-brain barrier, intraocular tissues and prostate, but increased with inflammation. • Adverse effects – risk/benefit ratio. • Drug interactions – may be pharmaceutical, pharmacodynamic or pharmacokinetic in nature. • Cost/benefit ratio – consider the total cost of the regimen not only the unit cost of the drug. • Others – ease and accuracy of dosing, stability and acceptability. General Steps in Appropriate Antimicrobial Therapy 1. Formulate a clinical diagnosis of microbial infection. 2. Obtain appropriate specimen for laboratory exam when applicable. 3. Formulate a specific microbiologic diagnosis. 4. Determine the need for empiric therapy. 5. Institute pharmacologic treatment considering microbial, host and drug factors and using efficacy, safety, suitability and cost of the antimicrobial options in the selection process, and following the “rules of right”. 6. Institute adjunctive and non-pharmacologic therapy. 7. Adjust antimicrobial regimen according to the isolated pathogen and its susceptibility pattern, correlated with the patient’s clinical response (directed or targeted antimicrobial therapy). Sound clinical judgment/assessment remains the most important method to determine the efficacy of the treatment. Antibiotic Combination Therapy Antibiotic combinations provide a broader spectrum coverage than single agents; hence, the physician is often tempted to use a combination of 2 or more for the sense of security they provide. However, when inappropriately used, antibiotic combination can lead to deleterious effects. Rationale for Antibiotic Combined Therapy • Provide broad-spectrum empiric therapy in the initial therapy of critically ill patients and neutropenic patients with severe life-threatening infections, e.g. beta-lactam antibiotic plus aminoglycoside for sepsis in neonates. • Treat polymicrobial infection (e.g., use of anti-aerobes and anti-anaerobes for intraabdominal abscess, diabetic foot infection; however, newer generation Fluoroquinolones, Carbapenems, or beta-lactam plus beta-lactamase inhibitor combinations can be employed as monotherapy). • Prevent/delay emergence of resistance (e.g., diseases due to Mycobacterium tuberculosis, M. leprae, Pseudomonas aeruginosa, etc.). • Decrease dose-related toxicity (e.g. flucytosine plus amphotericin B in cryptococcal meningitis).

• Obtain enhanced inhibition/killing (synergism) (e.g., penicillin plus aminoglycoside in enterococcal endocarditis and Streptococcus viridans endocarditis; sulfamethoxazole plus trimethoprim, etc.). General Adverse Reactions to Chemotherapeutic Agents: • Hypersensitivity reaction – ranges from mild skin rash to severe anaphylactic reactions; not dose- related. • Idiosyncratic reaction – may be genetic in origin; not dose-related. • Toxicity reactions – augmented reactions (dose-related); e.g., ototoxicity, hepatotoxicity, nephrotoxicity, neurotoxicity, etc. • Biologic and metabolic reactions in the host (e.g., alteration of normal microflora; superinfections). • Treatment failure/relapse. • Masking effect. • Adverse drug interactions with other drugs – e.g. metabolic enzyme inhibition or induction, protein binding displacement, etc. Causes of Failure in Antimicrobial Therapy: a. DRUG FACTORS such as wrong choice of antimicrobial, wrong dose, route, intervals and duration of administration; drug interactions; deterioration during storage. b. HOST FACTORS such as poor host defense, inadequate absorption, distribution, impaired elimination, presence of foreign body, anatomic defects, etc. c. MICROBIAL FACTORS such as wrong microbiologic diagnosis, drug resistance, superinfection, bacterial load, dual or mixed infection not detected, etc. Misuse/Abuse of Antimicrobials: • Use in untreatable (viral) infection. • Empiric use on fever of undetermined origin. • Complete reliance on chemotherapy with omission of surgical drainage and other non-pharmacologic therapy when necessary. • Inappropriate chemoprophylaxis. • Inappropriate antibiotic combination. • Inappropriate choice of antibiotic dosage, route, intervals and duration of administration. • Lack of appropriate bacteriologic information when indicated. • Over-the-counter sale of antibiotics. • Recycling antibiotic prescription and/or self-medication. • Use of antimicrobials as growth promoters in farm animals, use in agriculture and aquaculture. Factors that Lead to Inappropriate Use of Antimicrobials: • Good intention – to give the best treatment without regard to spectrum of activity of the antibiotic and its cost. • Inappropriate dosing – e.g. beliefs that higher doses or more prolonged administration is better. • Inappropriate chemoprophylaxis – timing and duration of surgical prophylaxis and a variety of other prophylactic purposes in hospitalized patients, which are not evidence-based.

• Pressure from patients/parents to be treated with antimicrobials. • Time constraint – more time required to explain why antibiotic is not needed than simply writing the prescription. • Use of multiple/broad-spectrum antibiotics to cover the possibility of infection from numerous microorganisms as a substitute for appropriate diagnostic evaluation. • Cost and availability of diagnostic test. • Inadequacy of knowledge of diagnostic procedures and management of infectious diseases. • Malpractice considerations and fear of litigation. • Concern about increasing prevalence of antibiotic resistance. • Easy solution provided by pharmaceutical companies and aggressive promotion. Unwanted Consequences of Misuse/Inappropriate Use of Antimicrobials: • Adverse drug reactions. • Increased cost of therapy. • Increased length of hospital stay. • Emergence of drug-resistant organisms. • Predisposition to secondary infections, complications and even death.

8 National Antibiotic Guidelines BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

Etiology Regimen Comments Sepsis in Children Sepsis: SIRS in the presence of or caused by suspected or proven infection. Systemic inflammatory response syndrome (SIRS) in the presence of 2 or more of the following criteria, one of which must be the first 2: (1) Core temperature (rectal, bladder, oral, or central catheter probe) >38.5°C (101.3°F) or <36°C (96.8°F); (2) Abnormal WBC count or >10% immature neutrophils; (3) Tachycardia or bradycardia; (4) Mean RR >2 standard deviations for age or mechanical ventilation for an acute process not related to an underlying neuromuscular disease or to general anesthesia.

Potentially Septic Asymptomatic ≤28 days old with Ampicillin PLUS (Gentamicin OR Amikacin) For infants who remain asymptomatic and documented maternal risk factors whose initial blood cultures are negative after like history of UTI during the last Gestational Age Ampicillin (25-50 mg/kg IV/IM) 48-72 hours of incubation, antimicrobial trimester, membranes ruptured ≤ 29 weeks 0-28 postnatal days: q12h >28 postnatal days: q8h therapy can be discontinued. >18 hours before delivery, fever 0-14 postnatal days: q12h >14 postnatal days: q8h >38°C before delivery or during 37-44 weeks 0-7 postnatal days: q12h >7 postnatal days: q8h If no pathogen has been isolated but bacterial labor and/or foul-smelling or sepsis cannot be excluded, a negative CRP ≥45 weeks ALL: q6h purulent amniotic fluid test at 72 hours can help support decision to Postnatal Gentamicin Amikacin Gestational Age discontinue antibiotics. days IV/IM IV/IM ≤ 29 weeks 0-7 days 5mg/kg q48h 18mg/kg q48h

8-28 days 4mg/kg q36h 15mg/kg q36h ≥29 days 4mg/kg q24h 15mg/kg q24h 30-34 weeks 0-7days 4.5mg/kg q36h 18mg/kg q36h ≥8-days 4mg/kg q24h 15mg/kg q24h

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poor perfusion, rapid and rapid perfusion, poor negative bacilli, Group B Group B bacilli, negative - distention abdominal feeding, indrawing, central cyanosis central indrawing, Cardiac: Gastrointestinal: weak pulse weak Neonates with bacterial sepsis may may sepsis bacterial with Neonates non- present Clinical criteria: symptoms or focal signs of signs of focal or symptoms infection. Neurologic: Neurologic: activity, decreased unconscious, fontanel bulging Respiratory: breaths/min, Gram streptococci, aureus S. Neonatal Neonatal National Antibiotic Guidelines

National Antibiotic Guidelines BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

Etiology Regimen Comments Dermatologic: skin pustules, 1.2 -2 kg <7 days 25-50mg/kg q12h periumbilical erythema or purulence ≥2 kg <7 days 25-50mg/kg q8h Musculoskeletal: edema or <1.2 kg ≥7 days 25mg/kg q12h erythema overlying bones or joints 1.2 -2 kg ≥7 days 25-50mg/kg q8h Temperature: >37.7°C (99.9°F; or ≥2 kg ≥7 days 25-50mg/kg q6h feels hot) or <35.5°C (95.9°F; or Vancomycin Gestational Postnatal (days) Interval (hours) feels cold) (for MRSA) Age (weeks) Meningitis: ≤29 0-14; >14 18; 2 15mg/kg/dose 30 to 36 0-14; >14 12; 8 IV; Bacteremia: 10mg/kg/dose 37 to 44 0 to 7; >7 12; 8 IV ≥45 ALL 6

2nd line: Ceftazidime PLUS (Gentamicin OR Amikacin) WITH OR Use Ceftazidime if Pseudomonas or WITHOUT (Oxacillin OR Vancomycin) Burkholderia is suspected. Weight (kg) Age (days) Ceftazidime IV/IM <2 kg ≤7 days 50mg/kg q12h ≥2 kg ≤7 days 50mg/kg q8-12h <1.2 kg >7 days 50mg/kg q12h >1.2 kg >7 days 50mg/kg q8h Weight (kg) Age (days) Oxacillin IV/IM <1.2 kg <7 days 25mg/kg q12h 1.2 -2 kg <7 days 25-50mg/kg q12h

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National Antibiotic Guidelines BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

Etiology Regimen Comments Duration: 10-14 days or longer depending on established foci of infection

Intra-abdominal Source Enterobacteriaceae, Bacteroides 1st line: Ampicillin 200-400mg/kg/day IV/IM div q8h (Max: 6-12g/day) sp., Enterococci, P. aeruginosa PLUS Gentamicin 6-7.5mg/kg/day div q8h or 5-7.5mg/kg/day IV/IM OR Amikacin 15-22.5mg/kg/day IV div q8-12h or 15-20mg/kg/day IV/IM PLUS Metronidazole 30-50mg/kg/day IV/PO q6h (Max: 1.5g/day) OR Clindamycin 20-40mg/kg/day IV/IM div q6-8h (Max: 1.8-2.7g/day) 2nd line: Ampicillin-sulbactam 200mg/kg/day IV/IM div q6h (ampicillin component) (Max: 8g/day) OR Piperacillin-tazobactam 300mg/kg IV div q6-8h (piperacillin component) (Max: 9-16g/day) WITH OR WITHOUT Gentamicin 6-7.5mg/kg/day IV div q8h or 5-7.5mg/kg/day IV/IM OR Amikacin 15-22.5mg/kg/day IV div q8-12h or 15-20mg/kg/day IV/IM OR Ceftriaxone 100mg/kg/day IV/IM div q12-24h (Max: 2-4g/day) OR Cefotaxime 200-225mg/kg/day IV/IM div q4-6h (Max: 8-12g/day) PLUS Metronidazole 30-50mg/kg/day IV/PO div q8h (Max: 1.5g/day) OR Clindamycin 20-40mg/kg/day IV/IM div q6-8h (Max: 1.8-2.7g/day) Duration: 10-14 days or longer depending on established foci of infection

antibiotics.

spectrum

Comments broad-

aminoglycosides. aminoglycosides.

rculation (the ABC’s) plus early early plus ABC’s) (the rculation If with previous surgery, IV therapy or other other or IV therapy surgery, previous with If is infection and staphylococcal instrumentation . Vancomycin add , suspected The initial assessment and treatment of of the and treatment assessment The initial include should shock patient pediatric and breathing, airway, of stabilization ci of administration on depends agents antimicrobial of The choice situation, clinical factors, risk predisposing the be should therapy antibiotic empiric of Choice susceptibility antimicrobial on current based institution. an within pattern Pseudomonas with infections severe For , suspected is resistance antimicrobial if and/or ADD

)

12h ) - OR ay ) OR

OR q8

) ay ay div ay 6g/d

12g/d -

4g/d 10mg/kg/dose -

ay) 6g/d ay) 6g/d div q6h (Max: 2- (Max: q6h div )

- (piperacillin (piperacillin - IV/IM

8h(piperacillin IV - in Neonatal Sepsis Neonatal in

6 (Max: 8

q q8h

(Max: 6g/d (Max: (Max: 2

ay 4g/d 6h - (Max: 4 div div div

q8h 24h - 1.5 q8h (Max: q4 Bacteremia: -

s complication

IV IV

iv q8h

div d div

q8h (Max: 1.5 q8h (Max:

q12 iv

/day 60mg/kg d /day /day 22.5mg/kg IV

div div div 40-

IV/IM 15- IV/IM

IV (Max dose: 2- dose: (Max Regimen OR

IV/IM /IM

) ) IV /day

/day q6h

Dosing Interval Chart Chart Interval Dosing /day 300mg/kg 300mg/kg 15mg/kg/dose; 15mg/kg/dose;

div /day n the absence of of absence n the i Amikacin See See ay 16g/d ay 16g/d ( /day 120mg/kg Vancomycin ays 200mg/kg 60- 225mg/kg - d

/day 120mg/kg -

/day 150mg/kg Meningitis: 14

60- 150 : 100mg/kg tazobactam tazobactam 200

- - 100- 10- old

/day 60mg/kg BORNE INFECTIONS OTHERAND SYSTEMIC SYNDROMES -

cillin Vancomycin ) 40- ays

Meropenem /day 20mg/kg 15- WITHOUT OR WITH ay 4g/d WITH OR WITHOUTOR WITH component) (Max: 9- (Max: component) Piperacillin Meropenem ≤28 PLUS Duration: Pipera 9- (Max: component) Child: Ceftriaxone Cefotaxime Ceftazidime Cefepime OR BLOOD

or more

S. aureus

nd Septic Shock Shock nd Septic H.influenzae, N. Sepsis plus one of one of plus Sepsis

, : Etiology Associated Sepsis Associated

- s i negative bacilli, negative instances of organ of instances - Splenectomy/ Functional Asplenia Functional Splenectomy/

- dysfunction as defined in the the in defined as dysfunction statement consensus other Severe Sepsis Severe organ cardiovascular following: the respiratory acute dysfunction, or syndrome distress Severe Sepsis a Sepsis Severe Healthcare Gram S. pneumoniae S. meningitid Post National Antibiotic Guidelines

National Antibiotic Guidelines BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

Etiology Regimen Comments Septic Shock: Sepsis and and the antibiotic resistance patterns in the cardiovascular organ dysfunction community and/or hospital setting. Modify antibiotic regimen based on culture and sensitivity.

Infant 0-28 days old Ampicillin 50mg/kg IV PLUS Cefotaxime 50mg/kg IV PLUS The initial assessment and treatment of the Gentamicin 2.5mg/kg IV initial dose pediatric shock patient should include stabilization of airway and breathing, and rapid fluid resuscitation. If highly suspecting MRSA, give Vancomycin 15mg/kg IV instead of The choice of antimicrobial agent depends on Ampicillin. the predisposing risk factors, clinical situation, and the antibiotic resistance patterns in the For subsequent doses, see Dosing Interval Chart in Neonatal Sepsis community and/or hospital setting. Administer first dose of empiric antimicrobial therapy within the 1st hour of presentation, preferably after obtaining appropriate cutures. Give subsequent doses as scheduled. Establish two sites of IV access: one for fluid resuscitation and the other for antimicrobial delivery. When treating empirically, administer antibiotics which can be given by rapid IV bolus (eg, beta-lactam agents or

. (Vancomycin)

Comments

y antibiotic regimen based on culture and culture on based regimen y antibiotic

that are infused more slowly are infused that Modif cephalosporins) first, followed by antibiotics by antibiotics followed first, cephalosporins) ( sensitivity.

OR OR OR Ceftriaxone 24h 24h 24h 8h 8h 8h - 50mg/kg IV 50mg/kgIV or

15mg/kg IV initial initial IV 15mg/kg - q12 then , q6 , then

q8h then 2g),

Cefotaxime :

(Max: 2g) (Max:

Vancomycin

, dose, initial

Regimen IV

initial dose initial initial dose (Max initial 2.5mg/kg

is highly suspected, give Ceftazidime give suspected, highly is cin i 2g), thenq6h 2g), 75mg/kg IV initial dose (Max: 2g), then q12- then 2g), (Max: dose initial IV 75mg/kg 75mg/kg IV initial dose (Max: 2g), then q12- then 2g), (Max: dose initial IV 75mg/kg 75mg/kg IV IV 75mg/kg 100mg/kg IV IV 100mg/kg 100mg/kg IV initial dose (Max: 2g), q6- then 2g), dose (Max: initial IV 100mg/kg 100mg/kg IV initial dose (Max: 2g), q6- then 2g), dose(Max: initial IV 100mg/kg BORNE INFECTIONS OTHERAND SYSTEMIC SYNDROMES - Gentam Pseudomonas Pseudomonas : SOURCE GASTROINTESTINAL POSSIBLE OR : SOURCE GENITOURINARY POSSIBLE OR Cefotaxime Cefotaxime Ceftriaxone Ceftriaxone F Cefotaxime If If initial dose (Max: 2g), then q8h instead of of q8h instead then 2g), dose (Max: initial Ceftriaxone PLUS Cefotaxime ADD suspected, highly MRSA is If - dose (Max:1 F BLOOD

Etiology Normal child >28 daysold >28 child Normal National Antibiotic Guidelines

National Antibiotic Guidelines BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

Etiology Regimen Comments PLUS Gentamicin 2.5mg/kg IV initial dose, then q8h PLUS PIperacillin-tazobactam <2 months: 80mg/kg IV initial dose (Max: 3g), then q6h 2-9 months: 80mg/kg IV initial dose (Max: 3g), then q6-8h >9 months:100mg/kg IV initial dose (Max: 3g), then q6-8h OR Clindamycin 10mg/kg IV initial dose (Max: 600mg), then q6-8h OR Metronidazole 10mg/kg IV initial dose (Max: 500mg), then q8h Immunocompromised Child >28 Vancomycin 15 mg/kg IV initial dose (Max: 1-2g), then q6h PLUS Use carbapenems (eg, imipenem, days old at risk for infection with Cefipime 50mg/kg IV initial dose (Max: 2g), then q8h OR Ceftazidime meropenem) in settings where extended- Pseudomonas sp. 50mg/kg IV initial dose (Max: 2g), then q8h OR Meropenem 20- spectrum beta-lactamase (ESBL) resistant 40mg/kg IV initial dose (Max: 2g), then q8h organisms are prevalent or if with recent (within two weeks) treatment with broad- Add an aminoglycoside Gentamicin 2.5mg/kg IV initial dose, then q8h spectrum antibiotics (eg, third-generation OR Amikacin 5mg/kg IV initial dose, then q8h if resistance is cephalosporin, or fluoroquinolone). considered Children who cannot receive Vancomycin 15mg/kg IV initial dose (Max: 1-2g) PLUS Meropenem penicillin or who have recently 20-40mg/kg IV initial dose (Max: 2g), then q8h received broad-spectrum antibiotics OR Vancomycin 15mg/kg IV initial dose (Max: 1-2g) PLUS Aztreonam 30- 40mg/kg IV initial dose (Max: 2g), then q6-8h PLUS Clindamycin 10mg/kg IV initial dose (Max: 600mg), then q6-8h

existing existing

Comments every other day until dosage is is dosage day until other every

ible with sodium chloride. Monitor K, K, Monitor sodium chloride. with ible

3mg/dL or if liver function tests are abnormal. abnormal. are tests function liver if or 3mg/dL stabilized, then every week. Monitor CBC Monitor every week. then stabilized, week. every Cr if or over 40mg/dL BUN if Discontinue > renal impairment. If creatinine increases during during increases creatinine If impairment. renal dosecanbe decreased daily total the therapy, other dose every or the can be given by50% day. Caution: Incompat SGOT, phosphatase, alkaline Cr, BUN, Mg, or once daily ObserveIV site for irritation; phlebitis is dosing usual however Nephrotoxic; common. - pre with patients to administered is

Administration: For intravenous infusion, infusion, intravenous For Administration: water sterile 10mL with vial each reconstitute produce to immediately and shake injection for 8h

6 hours then q6-

iprofloxacin iprofloxacin C once daily IV IV daily once

600mg,

PLUS

12h 2g) - (Max: 1 once daily IV infusion over 2 over infusion IV daily once

ose 3mg/kg/d then q8- then

premedication prior min30 without initial dose initial

and increased with increments of of increments with and increased once daily IV infusion over 2- over infusion IV once daily Regimen 400mg), ose 5mg/kg/d

initial dose (Max:initial

6 hours 1mg/kg (Max:

10mg/kg IV 10mg/kg

over 2- over 15mg/kg IV 15mg/kg 2 hours

initialdose

dose 1mg IV infusion over 20- over infusion IV 1mg IV BORNE INFECTIONS OTHERAND SYSTEMIC SYNDROMES over over lindamycin lindamycin - C

Amphotericin Deoxycholate B Amphotericin

ours - 0.5 dose: Maintenance (Use final concentration of 0.1mg/mL in 5% dextrose solution) then solution) 5%dextrose in 0.1mg/mL of concentration final (Use 3 hours. to up effects adverse possible for observe obtained. dose is the target until 0.25mg/day If initial dose is tolerated, the next dose should be started at at be started dose should next the tolerated, dose is initial If 0.25mg/kg/

Test dose: dose: Test OR Vancomycin ADD PLUS 10mg/kg 10mg/kg

: neutropenia febrile for therapy Empiric Amphotericin B Liposomal B Amphotericin 3- infections: fungal Systemic h infusion infusion Test dose: An initial test dose of 1mg should be infused intravenously intravenously infused be should 1mg dose of test initial An dose: Test 15 minutes. over BLOOD

Etiology

infection (eg, identified fungal fungal identified (eg, infection with immunocompromised source, on broad spectrum fever persistent antibiotics) Patients at increased risk of fungal of fungal risk increased at Patients National Antibiotic Guidelines

National Antibiotic Guidelines BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

Etiology Regimen Comments (Using the final concentration of 1-2mg/mL). Infusion should then be a 5mg/mL colloidal solution; dilute further in stopped, and the patient be observed for 30 minutes for adverse 5% dextrose to a concentration of 0.1mg/mL reactions. (in fluid restricted children, up to 0.4mg/mL may be given via a central line); pH of the If without hypersensitivity reaction, the infusion may be continued Max: dextrose solution must not be below 4.2 5mg/kg/dose once daily IV infusion over 2 hours (check literature for details of buffer); infuse over 4-6 hours, or if tolerated over a minimum of 2 hours (initial test dose given over 20-30 minutes); begin infusion immediately after dilution and protect from light; incompatible with sodium chloride solutions - flush existing intravenous line with 5% dextrose prior to infusion or use separate line.

Staphylococcal Toxic Shock Syndrome Clinical Findings: • Fever: Temperature ≥38.9°C (102°F) • Involvement of ≥3 of the following organ systems: • Rash: Diffuse macular erythroderma − GIT: Vomiting or diarrhea at onset of illness • Desquamation: 1-2 weeks after onset of − Muscular: Severe myalgia or creatinine phosphokinase >2x the upper limit of normal illness, on palms, soles, fingers, and toes − Mucous membrane: Vaginal, oropharyngeal, or conjunctival hyperemia • Hypotension − Renal: BUN or serum creatinine >2x upper limit of normal or ≥5 wbc/hpf in the absence of UTI • Negative results on the following tests, if − Hepatic: Total bilirubin, AST, or ALT >2x upper limit of normal for the laboratory obtained: Blood, throat, or cerebrospinal fluid − Hematologic: platelets <100,000/mm3 cultures (blood culture may be positive for S. − CNS: disorientation or alterations in consciousness without focal neurologic signs when fever and aureus, Serologic tests for Rocky Mountain hypotension are absent spotted fever, leptospirosis, or measles)

) may be )canbe

. IV IG IV IG

multisystem multisystem

Comments

Surgical debridement. debridement. Surgical of management Anticipatory failure. organ ( immunoglobulin Intravenous of hours several to refractory if considered of presence in the or therapy aggressive with oliguria persistent or focus undrainable edema. pulmonary Immediate aggressive fluid management; management; fluid aggressive Immediate anticipatory debridement; surgical failure. organ multisystem of management ( noglobulin immu Intravenous TSS staphylococcal severe in considered measures. therapeutic other to unresponsive management. fluid aggressive Immediate ) 24

- -

OR 3 ) - ay 2.7g/d - 2 OR ay 1.8 (Max: 12 (Max:

24h (Max: 2- 24h (Max: (Max: 1.8 6h 12g/d - - 2 g/kg ay) 6g/d q12- (Max: q6h drip x 1h (Max: x1h (Max: q6h drip 8h q4

8h q6- div div div div div

IV q6- IV div div

6h (Max: 4 (Max: 6h IV/IM -

500mg on days /kg div div /IM /day q8h (Max: 3- q8h (Max: q4 IV

IV or 1 1- or dose of div div div

ays d Regimen /IM /IM /daymg/kg 60 - IV IV

/day100mg/kg 300,000 U/kg 300,000 - /day 40mg/kg /day 40mg/kg /day /day g complication a absence of the in or longer depending on established foci of of foci on established depending longer or 30- 30- ays ays

d 400mg/kg x 5 400mg/kg d 200,000

(forMRSA): 40 100mg/k 200mg/kg 14 14 - Ceftriaxone - Na 150- , followed by followed on day 1, 1g/kg

75- 10-

150 OR ) ) BORNE INFECTIONS OTHERAND SYSTEMIC SYNDROMES

- )

) Clindamycin Clindamycin IV IG IV IG Clindamycin ay

ay 4g/d - PLUS PLUS : Duration infection 2 Vancomycin Vancomycin ay 2.7g/d PLUS 10: Duration Penicillin G MU/d PLUS Oxacillin Cefazolin ay 4g/d BLOOD

Hypotension plus 2 plus Hypotension Clinical criteria plus plus criteria Clinical

Etiology A case with all 6 of the clinical findings above, including desquamation, unless the patient dies before desquamation could occur could desquamation diesbefore patient the unless desquamation, including above, findings clinical 6 of the all Acasewith A case with 5 of the 6 clinical findings above findings clinical 6 5 of the casewith A from a nonsterile site a nonsterile from

froma normallysterile site streptococcus

. necrosis tissue - Probable: Group A A Group Definite: Clinical Criteria: renal of the following: more or hepatic coagulopathy, impairment, respiratory adult involvement, generalized syndrome, distress and rash, macular erythematous soft Streptococcal Toxic Shock Syndrome Syndrome Shock Toxic Streptococcal definition: Case : Confirmed Case Classification: Case : Probable National Antibiotic Guidelines

National Antibiotic Guidelines BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

Etiology Regimen Comments Febrile Neutropenia in Children Neutropenia is defined as an ANC Cefepime 150mg/kg/day IV/IM div q8h OR Piperacillin-tazobactam Start empiric antibiotics as soon as possible of <500 cells/mm3 or an ANC that is 300mg/kg/day IV div q6h (piperacillin component) OR Meropenem 60- after taking blood cultures and refer to an ID expected to decrease to <500 120mg/kg/day IV div q8h (Max: 2-4g) specialist. cells/mm3 during the next 48h. If antimicrobial-resistant pathogens are suspected, consider adding Baseline laboratory tests to request for are: Staphylococci including MRSA, Amikacin 15-20mg/kg/day IV/IM. In cases of suspected catheter- 1. CBC with differential leukocyte count and Streptococcus, Enterococci, P. related infection, or skin or soft-tissue infection, pneumonia, or platelet count aeruginosa and other Gram- hemodynamic instability consider adding Vancomycin 40-60mg/kg/day 2. creatinine and BUN; negative bacilli, Fungi IV q6h (Max: 2-4g/day). 3. electrolytes; 4. hepatic transaminase enzymes; If with abdominal symptoms (pain or blood per rectum) or suspected C. 5. bilirubin; difficile infection, consider adding Metronidazole 6. blood cultures, at least 2 sets of which are IV: 22.5-40mg/kg/day q8h (Max: 1.5g/day) recommended, with a set collected PO: 30-50mg/kg/day q8h (Max: 2.25g/day). simultaneously from each lumen of an existing Empiric antifungal coverage should be considered in high-risk patients central venous catheter (CVC), if present, and who have persistent fever after 4-7 days of a broad-spectrum from a peripheral vein site; 2 blood culture sets antibacterial regimen and no identified fever source. Treatment is from separate venipunctures should be sent if continued until patient is afebrile and ANC >500 cells/μL. no central catheter is present. 7. Culture of specimens from other sites of suspected infection should be obtained as clinically indicated. 8. CXR for patients with respiratory signs and symptoms. GCSFs are not routinely recommended.

21 should should

first 3 hours. e.g. ESBL e.g. 100 mmHg the the

if withif risk for

≤

Comments Ertapenem

Use Use /kg should be given in in given be should /kg L entation; 3) systolic BP systolic 3) entation; hour. Initial fluid resuscitation of crystalloid crystalloid of resuscitation fluid Initial hour.

30m

st antibiotic resistance. antibiotic at Base recommendation on local/ hospital hospital on local/ recommendation Base risk for assess Always results. antibiogram ( resistance antibiotic for factors ). production Do source control, if possible. Intravenous Intravenous if possible. control, source Do as soon as sepsis be given should antibiotics the and within recognized shock is septic or 1 receiving patients >65mmHg in to MAP Target routine Appropriate vasopressors. blood) (including cultures microbiologic fore starting antimicrobial antimicrobial starting before obtained be or sepsis suspected with patients in therapy no in so results doing shockif septic . of antimicrobials the start in delay substantial 22/min; 2) altered m altered 2) 22/min; 30mg/kg 30mg/kg 1g loading loading 1g

25- threatening organ dysfunction represented by a quick SOFA SOFA bya quick represented organ dysfunction threatening - PLUS

6h 8h - -

Metronidazole Vancomycin 4.5g IV q8 4.5g 4.5g IV q6 4.5g PLUS Regimen

1g IV q8h IV 1g 2g IV q12h PLUS IV 2g

tazobactam tazobactam tazobactam tazobactam - - 30mg/kg loading dose then 1g IV q8h 1g IV dose then loading 30mg/kg 25- Meropenem Ceftriaxone BORNE INFECTIONS OTHERAND SYSTEMIC SYNDROMES Piperacillin Piperacillin -

line: line: line: line:

nd st nd st loading dose then 1g IV q8h IV 1g dose then loading dose then 500mg IV q6h or 1g IV q12h OR 1g IV q6h or IV 500mg then dose 2 Vancomycin 1 2 1 BLOOD

Gram

bdominal Source bdominal a

- is defined as sepsis plus need for vasopressor to increase MAP to >65 mmHg and lactate >2mmol (18 mg/dL) (18 >2mmol >65lactate and to mmHg MAP increase to vasopressor for need plus assepsis defined is Neutropenic Etiology - n Adults n i is defined as presence of suspected or documented infection associated with life with associated infection documented or suspected of aspresence defined is

Aerobic and anaerobic and anaerobic Aerobic bacilli negative Suspect Intra Suspect

Source is unclear. is Source Sepsis, Non Sepsis, llowing: 1) respiratory rate > rate 1)respiratory llowing: of the fo 2 or more of score Assessment) Failure Organ (Sequential Shock Septic Sepsis Sepsis Sepsis National Antibiotic Guidelines

National Antibiotic Guidelines BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

Etiology Regimen Comments Ciprofloxacin 400mg IV q12h OR Levofloxacin 750mg IV q24h PLUS Metronidazole 1g loading dose then 500mg IV q6h or 1g IV q12h

Suspect Urinary Tract Infection Aerobic Gram-negative bacilli (E. 1st line: Piperacillin-tazobactam 4.5g IV q8-6h coli), Enterococci 2nd line: Ceftriaxone 1g IV q24h OR Ertapenem 1g IV q24h

Suspect Community-Acquired Pneumonia (See treatment of high-risk pneumonia) Suspect Illicit IV Drug Use Source S. aureus Vancomycin 25-30mg/kg loading dose then 1g IV q8h PLUS Piperacillin-tazobactam 4.5g IV q8-6h

Suspect Meningococcemia N. meningitidis Ceftriaxone 2g IV q12h Septic Shock, Post Splenectomy Ceftriaxone 2g IV q12h Increase dose if considering meningitis Staphylococcal Toxic Shock Vancomycin 25-30mg/kg loading dose then 1g IV q8h PLUS Intravenous Immunoglobulin has the potential Clindamycin 900mg IV q8h PLUS IV IG 1g/kg on day 1 then 500mg/kg to neutralize super antigen and to mitigate daily for 2-3 days subsequent tissue damage. Streptococcal Toxic Shock 1st line: Penicillin G 24 MU daily IV in 4-6 div doses PLUS If with Penicillin allergy: Clindamycin 900mg Clindamycin 900mg IV q8h IV q8h PLUS Vancomycin 25-30mg/kg

IV 3 for - 2 IVIG days after taking taking after based - of neutropenia, neutropenia, of gnificant liver liver gnificant

ays should be admitted admitted be should d ASAP

able to take oral oral take to able with . GCSFs are not not are GCSFs . and Comments atients P of neutropenia profound morbidities, no si no morbidities,

>7 fever and anticipated : ays on d 500mg/kg 1 then the following following the for severe disease at at disease severe for

not an not FQ

with and

mpiric antibiotic Rx Rx antibiotic mpiric

routinely recommended as an adjunct to to as an adjunct recommended routinely Rx. antibiotic should be given an given be should prophylaxis antibacterial risk high for as recommended regimen patients L cells/μ <100 comorbidities, medical significant and/or or renal hepatic instability, hemodynamic patients unresponsive to vasopressor. vasopressor. to unresponsive patients dysfunction, renal or medications. Start e Patients hospital the in progressive or uncontrolled insufficiency, loading dose then 1g IV q8h. Also start Alsostart q8h. IV 1g dose then loading day on 1g/kg <7 anticipated Those with co- medical no cultures. blood

PLUS

daily 2g IV q8h IV 2g -

900mg IV q8h IV 900mg 3

300mg PO q6h PO 300mg 750mg PO PO 750mg

days 2- Meropenem Meropenem

Clindamycin OR if if with bacteremia. 750mg PO bid OR 750mg bid PO

Clindamycin ays Levofloxacin d

PLUS

consecutive readings of >38.0°C for >1h and an absolute neutrophil count (ANC) of count (ANC) neutrophil an absolute and >1h for >38.0°C of readings consecutive

2 Regimen PLUS

OR 4.5g IV q6h IV 4.5g 2g IV q8h IV 2g then 500mg/kg on 500mg/kg then daily

Min of14 Ciprofloxacin

2g IV q24h q24h IV 2g

Cefepime Cefepime tazobactam tazobactam - 625mg tid 625mg 750mg PO bid bid PO 750mg 750mg PO PO 750mg

on day 1 1g/kg

individualized; Until patient is afebrile and absolute neutrophil count count neutrophil absolute and afebrile is patient Until

Ceftriaxone BORNE INFECTIONS OTHERAND SYSTEMIC SYNDROMES - IV IG Piperacillin amoxiclav line:

nd Duration: L >500cells/μ If withIf Penicillin allergy: OR Ciprofloxacin Co Levofloxacin Initial therapy forfever: with Monotherapy 2 PLUS Duration: BLOOD

, efined as an oral temperature of >38.3°C or or of>38.3°C temperature as an oral efined

n Adults n i

ylococci is d

), aureus S. and Etiology

, enterococci) and enterococci) ,

uncommon

negative bacilli; fungal fungal bacilli; negative negative bacteria w/ GNB w/ GNB bacteria negative positive (staph positive positive organisms organisms positive - - - - ) causing the the ) causing P. aeruginosa tococci infection Gram (e.g. (predominantly coagulase negative negative coagulase (predominantly staphylococci strep Gram High risk risk High Gram Gram Low risk Low <500/μL, or <1000/μL and expected to fall below 500/μL over the next 48h. Assess for risk (low or high risk) of complication complication of risk) high or (low risk for Assess 48h. next the over 500/μL below fall to expected and <1000/μL or <500/μL, fever. of presentation Febrile Neutropenia Neutropenia Febrile neurtropenia Febrile National Antibiotic Guidelines

National Antibiotic Guidelines BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

Etiology Regimen Comments more serious infections; fungi (esp. PLUS Aminoglycoside OR Fluoroquinolone OR Vancomycin if with cancer, pneumonia or other complex Candida and Aspergillus) suspected central line infection, severe mucositis, skin and soft tissue infections, mucositis grade 3 or 4, new onset infection, pneumonia, hypotension neurologic/mental changes, IV catheter infection, inpatient status at time of PLUS Antifungal treatment if fever continues beyond 4-7 days and no development of fever, and GI symptoms. source is identified Start empiric antibiotic Rx ASAP after blood Duration: should be dictated by particular organism and site: Treat cultures. Continue treatment until patient is Staphylococcus bacteremia for at least 2 weeks after negative blood afebrile and absolute neutrophil count is culture; prolonged (4-6 weeks) if disseminated or deep infection. Other >500 cells (some >1000 cells). Modify initial infections may be treated for 14 days. In patients with unexplained antibiotic regimen guided by clinical and fever, initial regimen should be continued until marrow recovery. microbiologic data. Use of CSF is controversial; may be considered in the presence of serious infectious complications such as progressive course, pneumonia, and invasive fungal infection.

Antibacterial Prophylaxis For high risk patients with expected 1st line: Levofloxacin 500-750mg PO/IV daily Not routinely recommended for low risk duration of neutropenia of >7 days patients. 2nd line: Ciprofloxacin 500-750mg PO or 400mg IV q12h and ANC ≤100 cells/mm3

Anticandidal Prophylaxis Allogeneic hematopoietic stem cell Fluconazole 400mg IV/PO daily OR Micafungin 150mg IV daily OR For high risk patients with expected duration of transplant (HSCT) recipients, acute Itraconazole 200mg PO bid neutropenia of >7 days and ANC ≤100 3 Duration: until recovery of neutropenia cells/mm

25 in The use . . trimoxazole -

Co and

Ciprofloxacin and

Comments Ampicillin

. MDRTF is defined as typhoid fever fever as typhoid defined is MDRTF

trimoxazole - engraftment allogeneic or autologous autologous or allogeneic engraftment -

Co , Prophylaxis against aspergillus infection infection aspergillus against Prophylaxis pre be to shown been has not recipients transplant efficacious Chloramphenicol ely

qid -

POtid tid 200mg Ampicillin, Chloramphenicol Ampicillin,

400mg

drug resistant typhoid fever (MDRTF). fever typhoid drug resistant

Multi-

Regimen d Aciclovir

suspension oral OR

remained at <5% for for <5% at remained

line recommended drugs for treatment nam treatment for drugs recommended line - typhi

200mg PO/IV bi PO/IV 200mg

Posaconazole

800mg PO bid PO 800mg bid

: BORNE INFECTIONS OTHERAND SYSTEMIC SYNDROMES - almonella : ears y S

Pediatric Aciclovir Voriconazole ≥13 BLOOD

7 days treatment with a first line antibiotic; line a first with 7 daystreatment

strains which are resistant to first to the resistant are which strains

typhi Etiology

. induction or or therapy. salvage induction - should be suspected in any of the following situations: following the of any in be suspected should Aspergillus Prophylaxis Aspergillus - Clinical deterioration or development of complications during conventional antibiotic treatment. antibiotic conventional during complications of development or deterioration Clinical Failure to respond after 5- after to respond Failure and/or MDRTF; of an epidemic during or case a documented with contact Household

• • •

caused by S caused by MDRTF Based on 2017 ARSP data, resistance of resistance data, ARSP 2017 on Based proven or suspected for reserved be should antibiotics secondline of Uncomplicated Typhoid Fever Typhoid Uncomplicated Typhoid Fever Typhoid undergoing allogeneic HSCT or or HSCT allogeneic undergoing leukemia acute for induction Antiviral Prophylaxis Antiviral patients seropositive HSV Patients undergoing chemotherapy chemotherapy undergoing Patients and neutropenia with AML/MDS for recipients HSCT allogeneic Anti leukemia undergoing intensive intensive undergoing leukemia remission National Antibiotic Guidelines

National Antibiotic Guidelines BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

Etiology Regimen Comments 1st line: Amoxicillin 75-100mg/kg/day PO div q8h x 14 days (Max: Serious and fatal blood dyscrasias (aplastic 500mg 2 caps q6h) anemia, hypoplastic anemia, thrombocytopenia and granulocytopenia) are OR Ampicillin 100-200mg/kg/day IV/IM div q6h x 14 days (Max: known to occur after the administration of 12g/24h) OR Chloramphenicol 50-75mg/kg/day IV/PO div q6h x 14-21 Chloramphenicol. An irreversible type of days (Max: 500mg 2 caps q6h) OR Co-trimoxazole 8mg/kg/day marrow depression leading to aplastic anemia (trimethoprim component) PO div q12h x 14 days (Max: 160/800mg PO with a high rate of mortality may occur after q12h) short or long-term use of chloramphenicol. 2nd line: Cefixime 15-20mg/kg/day PO div q12h x 10-14 days (Max: Ciprofloxacin is not recommended for 200mg PO q12h) OR Azithromycin 10-20mg/kg/day x 5-7 days (Max: pregnant women. It can be used among 500mg 1-2 tabs q24h) OR Ciprofloxacin 30mg/kg/day div q12h x 7-10 children if the benefits outweigh the potential days (Max: 500mg PO q12h) harms. High–dose parenteral Ampicillin can Adult: be used if FQ is not well tolerated. 1st line: Amoxicillin 1g q6h x 14 days OR Co-trimoxazole 160/800mg Stepping down to an oral antibiotic may be PO q12h x 14 days OR Chloramphenicol 1g PO q6h x 14 days OR done if patient is afebrile for 48 hours and is Ciprofloxacin 500mg PO q12h x 7-10 days able to tolerate oral medications. De- escalation to oral antibiotics should be based 2nd line: Cefixime 200mg PO q12h x 7-10 days OR Azithromycin on results of culture and sensitivity if available. 500mg-1g PO daily x 5-7 days

Severe/Complicated Typhoid Fever Gastrointestinal bleeding, intestinal Pediatric perforation, typhoid 1st line: Ceftriaxone 75mg/kg/day IV/IM x 10-14 days (Max: 2-3g q24h) encephalopathy, etc. OR Ciprofloxacin 30mg/kg/day IV div q12h x 7-10 days (Max:

Comments

)

- IV

ays d ays - d

10 400mg 7 - q12h xq12h 7 -

(Max:

PO ays (Max: 200mg d IV x 5

Azithromycin

7 q12hx 7

ays OR 500mg /day d

PO ays d ay 12g/d (Max: weeks x 4 /kg 10

Ciprofloxacin ays -

q24hx 5-

q6h OR 0mg q12hx 4 weeks (Max: 1 10

2 -

PO 30mg/kg iv div

d ays

10 q12hx 7

IV d q12h x28 q12h

Ciprofloxacin PO

14 PO PO q12hx 7- 0mg/kg

OR 2 Regimen - PO 10 ays

750mg 750mg Ciprofloxacin 20mg/kg

7 - /day 200mg/kg 2g IV x10- IV 2g Azithromycin

- /day 30mg/kg for 1 year or or more year 1 for 200mg 15 OR

500- 1

100- OR

q12h)

Azithromycin ays

PO ) d Cefixime Cefixime

tabsq24h x 5- S. enterica ay

OR 10

2 tabsq24h) 2

: BORNE INFECTIONS OTHERAND SYSTEMIC SYNDROMES - - Ceftriaxone Ampicillin ) - Ciprofloxacin

Ciprofloxacin ay

: ays q12h) line:

line: d line:

st st nd (Max:500mg 10 500mg1 500mg1 PO Stepdown: Adult 1 x7- q12h Pediatric 1 Adult: 500mg/dose q12h) q12h) 500mg/dose 1g/d (Max: Stepdown: 2 1.5g/d BLOOD

Etiology Indications for antibiotic treatment include any of the following: the anyof include treatment antibiotic for Indications Nontyphoidal Salmonellosis Nontyphoidal

Chronic Carrier Chronic typhoidal of shedding asymptomatic as Defined

National Antibiotic Guidelines

National Antibiotic Guidelines BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

Etiology Regimen Comments • ≤3 months old • Collagen vascular disease • HIV/AIDS • Inflammatory bowel disease • Other immunodeficiencies and chronic granulomatous disease • Achlorhydria or use of antacid medications • Immunosuppressive and corticosteroid therapies • Impaired intestinal motility • Malignancies, especially leukemia and lymphoma • Schistosomiasis, malaria • Hemolytic anemia, including sickle cell disease, malaria, and bartonellosis • Malnutrition Based on ARSP 2017, nontyphoidal Salmonella is also susceptible to Chloramphenicol and Ciprofloxacin. Salmonella gastroenteritis 1st line: Cefotaxime 100-200mg/kg/day IV/IM div q6h x 5-14 days Antibiotics are not generally recommended for (Max: 8-12g/day) OR Ceftriaxone 75mg/kg/day IV/IM x 7 days (Max: 2- the treatment of uncomplicated Salmonella 4g/day) OR Cefixime 15mg/kg/day PO div q12h x 7-10 days (Max: gastroenteritis because these may suppress 400mg/day) normal intestinal flora and prolong both the excretion of Salmonella and the remote risk for 2nd line: Ciprofloxacin 10-20mg/kg/day PO div q12h x 7-10 days (Max:1- creating the chronic carrier state. 1.5g/day) OR Chloramphenicol 50-75mg/kg/day IV/PO div q6h x 7 days (Max: 2-4g/day) Extra-Intestinal Infections Ceftriaxone 100mg/kg/day IV/IM div q12-24h (Max: 2-4g/day) Revise antibiotics depending on the S. typhi Duration: Bacteremia: 10-14 days; Meningitis: 4 weeks; susceptibility pattern. Osteomyelitis: 4-6 weeks

Leptospirosis Suspected leptospirosis case: • Fever of at least 2 days • Either residing in a flooded area or has high-risk exposure (wading in floods or contaminated water, contact with animal fluids, swimming in flood water or ingestion of contaminated water with or without cuts or wounds);

- 29 to tolerate tolerate to food or after

children <8 <8 children

with

not 100% effective; effective; 100% not is alls, and rubber gloves. gloves. and rubber alls,

- risk exposure. If If exposure. risk Comments Doxycycline administered with iron, iron, with administered

- high of

down therapy can be instituted once once can be instituted therapy down - aundice or oliguria or aundice

a meal. The most effective preventive measure is is measure preventive effective The most avoidance as such measures protective use unavoidable, over goggles, boots, prophylaxis Antibiotic be used. Post still should measures protective Precautions for for Precautions control birth with interaction pregnancy, years, and GI upset diarrhea, photosensitivity, pills, co- if interaction and antibiotics other statins, supplements, Take Doxycycline laxatives. Step able and stable clinically is patient under mild antibiotic Any oral medication. oral canselected. be leptospirosis

(Max: OR

ays ays d d

ays d

6h x7 6h - 8h x7 8h q24h x7 q24h

(Max: 500mg/day) 500mg/day) (Max: q4

q6- div div div

div div (Max: 500mg q8h) 500mg (Max: IV

IV/IM

ays /day

days d IV/IM

2 /kg for 10mg/kg IV q24h IV 10mg/kg ay) 200mg/d (Max: q8h x 7 Regimen ays d /day100mg/kg - 400,000 U 400,000 - 0 /day 150mg/kg is not tolerated. not is 8

0mg/kg PO (Max: 500mg/day) followed by followed 500mg/day) (Max: PO 0mg/kg 1 100-

daily Azithromycin

250,000

8h) div /day 0mg/kg 5 OR 4mg/kg x 1 dose (Max: 200mg regardless of age) Take age) of regardless 200mg dose x 1 (Max: 4mg/kg 2mg/kg bid x 7 bid 2mg/kg

30- Ceftriaxone

Cefotaxime Azithromycin BORNE INFECTIONS OTHERAND SYSTEMIC SYNDROMES

Penicillin -

line: line: line: line:

st nd st nd followed by 5mg/kg/day IV (Max: 250mg/day) q24h 250mg/day) (Max: IV by 5mg/kg/day followed 5mg/kg/day PO (MaxK 250mg/day) 250mg/day) (MaxK PO 5mg/kg/day (Max: 2g q24h) 2g q24h) (Max:

2 1 MU- q6 1.5 (Max: OR q6h) 1g Doxycycline 200mg if bid 100mg 1 Amoxicillin 2 Doxycycline BLOOD

is not not is septic septic can take

and A suspected

. Etiology of the following: myalgia, calf tenderness, conjunctival suffusion, chills, abdominal pain, headache, j headache, pain, abdominal chills, suffusion, conjunctival tenderness, calf myalgia, of the following:

2 related recreational and and recreational related - prophylaxis exposure - At least eningismus/ meningeal irritation, irritation, meningeal eningismus/

Pre Antibiotic Prophylaxis Antibiotic routinely recommended except for for except recommended routinely those engaged soldiers, travelers, water in Moderate to Severe Severe Leptospirosis to Moderate leptospirosis of case suspected A jaundice/ signs, vital unstable with pain, abdominal sclera, icteric diarrhea, and vomiting nausea, meningismus/ oliguria/anuria, sepsis/ irritation, meningeal shock, altered mental states or or states mental altered shock, hemoptysis of breathing, difficulty sepsis/ septic shock, difficulty of of difficulty shock, septic sepsis/ jaundice, breathing, Mild Leptospirosis Mild stable with leptospirosis case of good sclera, anicteric signs, vital evidence no of output, urine m • oral medications oral National Antibiotic Guidelines

National Antibiotic Guidelines BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES

Etiology Regimen Comments occupational activities in highly exposure doses may be repeated once weekly endemic areas. if with continued exposure to risk factors (e.g. staying in a constantly flooded area). Post-exposure prophylaxis depends on type of risk.

31 - ed. Elk Grove Grove Elk ed. with

th 30

- children - in - ey SB,Kaplan SL, ed. UpToDate. : : UpToDate. SL, ed. eySB,Kaplan

Update by the Infectious Diseases Diseases Infectious Update bythe

ay2009.

Book 2015 Report of the Committee on Infectious Diseases, on Infectious Committee the of 2015 Report Book Recommendation: Clinical Practice Guidelines on Childhood Leptospirosis 2019 Leptospirosis Childhood on Guidelines Practice Clinical Recommendation:

93. 93. neonate: assessing the risk for cardiopulmonary adverse events. Pediatrics.2009;123 (4): e609- (4): Pediatrics.2009;123 events. adverse cardiopulmonary for risk the assessing neonate: induced neutropenia. Available at: http://www.uptodate.com/contents/fever at: Available neutropenia. induced . Manila: Department of Health; 2017. of Health; Department Manila: . Red MT, etal.eds. Brady

Report

BORNE INFECTIONS OTHERAND SYSTEMIC SYNDROMES -

BLOOD

. neutropenia positive toxic shock syndrome. The Lancet Infectious Dis. 9 (5): M 9 (5): Dis. Infectious Lancet The shock syndrome. toxic positive -

http://www.uptodate.com - induced -

2015.

Society of America. Clin Infect Dis. 2011 Feb 15;52(4): e56- 2011 15;52(4): Feb Dis. Infect Clin America. of Society c. In UpToDate (DRAFT). e613. www.ccmjournal.org. Village. chemotherapy f Childhood Illness Chart Booklet. Geneva: World Health Organization; March 2014. March Organization; Health Geneva: World Booklet. Chart Illness Childhood of Management Integrated Freifeld A, et al. Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Cancer: with Patients in Neutropenic Agents Antimicrobial of Use the for Guideline Practice Clinical al. A, et Freifeld 2016. Elsevier, PA: Philadelphia, 20th ed. Pediatrics. of Textbook Nelson eteds. al., RM, Kliegman Group Core PIDSP the Philippines. of Society Diseases Infectious Pediatric Weiss SL and Pomerantz WJ.Septic shock in children: Rapid recognition and initial resuscitation (first hour).Randolph GR,Torr hour).Randolph (first resuscitation and initial Rapid recognition children: shockin WJ.Septic and Pomerantz SL Weiss iladelphia: Elsevier Inc., 2014. Inc., Elsevier iladelphia: Ph Diseases. Infectious Pediatric of Textbook Cherry’s and PJ. Feigin Hotez WJ, Steinbach SL, Kaplan GJ, Harrison JD, Cherry the in and calcium ceftriaxone Intravenous al. et JS, Bradley at: Available 2012. Shock: Septic and Sepsis Severe of Management for Guidelines International Campaign: Sepsis Surviving etal. RP, Dellinger Gram al. et Lappin Emma Antimicrobial Resistance Surveillance Program Surveillance Resistance Antimicrobial American Academy of Pediatrics, In: Kimberlin DW, Kimberlin In: Pediatrics, of Academy American National Antibiotic Guidelines

REFERENCES – chemotherapy with children Fever in al. et NM, Ahmed

32 . only lactams

Oxacillin

is typically

negative bacilli -

dose betadose - Start empiric therapy therapy empiric Start negative organisms. - 57%. is deemed unlikely. is deemed at

Comments

positive Gram or - showed increased resistance of S. resistance increased showed

is an alternative if there are no signs signs there no are if alternative is an

Oxacillin aeruginosa

to .

are possible pathogens, Vancomycin possible pathogens, are and high - SA MR toused cover Gram cover given to are Clindamycin shiftto MSSA, If cultures grow of sepsis. Cefotaxime use regimens, In primary the when is recommended MRSA against antibioticAn active following: for the Select antibiotics appropriate for the patient age. patient for the Select antibiotics appropriate totherapy according to quickly specific Revise is long bones the of Osteomyelitis culture results. in children. is Vertebral osteomyelitis common more less are bones in adults. Other common most involved. commonly The ARSP 2017 aureus of collection after MRSA with against antibiotics stain Gram review culture; for fluid blood and joint fluid. of joint GramWhen either

aily

aily aily aily

d d d

PEDIATRIC

- aily

dose d 4 doses** dose dose

in 4 doses 4 in

4 dosesd doses

in 1 doses** 2 in in 3 ay

in 3 in 2 doses3 in doses2 in

ay ay day ay ay ay 6 weeks. - Ceftriaxone

INFECTIONS Cefotaxime Vancomycin

weeks of life of weeks OR

200mg/kg/d 200mg/kg

- defined but 3 weeks is is 3 weeks but defined - 15mg/kg/d q18h** 15mg/kg 30mg/kg/d 60mg/kg/ - - - - - JOINT

10 10 20 40 100 150 100mg/kg in 2 doses in 100mg/kg 100mg/kg/d 150mg/kg/d 100mg/kg/d is administered at 20 mg/kg/dose; 20 mg/kg/dose; at administered is

Regimen

Cefotaxime

. days days days days old is not well not is old

Age 7 7 BONE AND - - 4 weeks - PLUS >7 >7 = gestational age + age + gestational = 0 0

ays 0

34 41 42 - - 26 28

- < >

0 27 35 7 days

(g) For

2,000

Vancomycin

- conceptual age (weeks)* conceptual <1,200 >2,000 PEDIATRIC Weight line:

Post Post 1,200 st *Post conceptual age conceptual *Post Vancomycin life, 28 days of **at same the remains interval 1 Duration: 3 groups, age other For adequate. considered

is increasingly increasingly is

Etiology . should be should sp. in children under age 4 under children in , Group A Streptococci, A Streptococci, Group , , Group B Streptococci, B Streptococci, Group ,

Kingella kingae kingae Kingella

recognized years. Enterobacteriaceae are uncommon are Enterobacteriaceae S. aureus S. Salmonella countries developing in considered cell sickle with patients among or caused Infections disease. by Enterobacteriaceae S. aureus S. adolescents to 4 months Osteomyelitis (Hematogenous) Osteomyelitis months <4 0 to BONE BONE JOINTINFEC AND TIONS - National Antibiotic Guidelines

can

binding sites, sites, binding

: Because of its its Because of : calcium salt. calcium - Ceftriaxone Ceftriaxone line treatment line

st Comments Ceftriaxone

Ceftriaxone intravenously if also receiving receiving also if intravenously in jaundiced neonates. neonates. jaundiced use in its regimen under 1 under regimen Patients who have failed initial recommended initial recommended failed have Patients who MSSA antibiotic against treatment host defences impaired markedly Those with hypotension and SIRS Those with

• • • for Precautions binding, protein extensive - albumin from bilirubin displace kernicterus. inducing of risk potential the with avoid Thus, receive not should neonates Likewise, Ceftriaxone including form, any in calcium intravenous for risk the of because nutrition, parenteral of precipitation See

aily

daily daily

ose

PEDIATRIC daily daily daily

) -

aily d aily dose ) ay

d 2 doses

- 2 dosesd 4 doses ay - 4 doses (Max: 4 doses(Max:

- in 1

Ceftriaxone

) 2.7g/d ay (max: 4g/d (max: : max: 12g/d ay max: : OR + INFECTIONS Ceftriaxone

g/d 10mg/kg in 2 doses in 10mg/kg 2 doses in 10mg/kg 3 doses in 15mg/kg 3 doses in 15mg/kg in 20mg/kg 8 200mg/kg in 1 in 200mg/kg 50mg/kg in 1 dose in 50mg/kg 1 dose in 75mg/kg 50mg/kg in 1 dose in 50mg/kg 40mg/kg in 3 in 40mg/kg - 200mg/kg -

Clindamycin IV Clindamycin - ax: ax: 25

100 100 (M Meningitis Cefotaxime

Regimen

days days days PLUS days days days

Age Age 7 7 7 BONE AND JOINT - - - 4 weeks 4 weeks - - >7 >7 >7 0 0 0 0 0

and older children and older and older children and older and older children and older )

(g)

ays ays ays Clindamycin IV Clindamycin 2,000 - d d

<1,200 >2,000 >2,000 <1,200 <2,000 line: >28 d >28 >28 >28 Weight ( Weight Weight

1,200 nd 2

Etiology

National Antibiotic Guidelines

34 is

. Clindamycin %.Start empiric

Oxacillin 57 at

Comments showed increased resistance resistance increased showed

Oxacillin 7 to 201 ves long bone or post internal fixation of of fixation internal post bone or ves long aureus S.

therapy with antibiotics against MRSA after after MRSA against antibiotics with therapy culture; for fluid andblood joint of collection review Gram stain of joint fluid. an alternative if there are no signs of sepsis. If If sepsis. of no signs are there if alternative an to shift MSSA, grow cultures Invol septic in indicated is therapy Empiric fracture. may It results. culture await Otherwise, patients. and use remove hardware to necessary be The ARSP of -

) )

ay ay IV in2

PEDIATRIC )

ay /day /day 30mg/kg (Max: 6g/d 20- ay) 1.2g/d (Max: ay) 12g/d (Max:

4 doses (Max: 4 doses(Max: 30mg/kg - - ay) 6g/d (Max:

4 doses (Max: 4 doses(Max: - 20 in 3

in 4 doses (Max: 4g/d (Max: doses 4 in INFECTIONS

3 doses 6 doses

in 2 doses2 (trimethoprim in - in 3

div in 3 doses in div IV

3 doses in 2 Ciprofloxacin in 4 -

JOINT 3 doses (Max: 1.2g/d 3 doses(Max:

- /day in 2

in 2

PLUS

ay 60mg/kg/d /day 150mg/kg Regimen Ciprofloxacin

/day12mg/kg - 45- /day 8 40mg/kg /day 30mg/kg -

in 3 doses3 in /day 150mg/kg BONE AND PLUS

/day 200mg/kg

20-

in 2 doses in IV

100- 150mg/kg/day

ay) 320mg/d 30mg/kg

- /day 20 100- g

Vancomycin trimoxazole

ay) 1.2g/d (Max: - .2 (Max:

/day 30mg/kg

OR Co Linezolid Vancomycin

ay) 1.2g/d (Max: Clindamycin

) Ceftazidime Ciprofloxacin : ears y : years 3 doses Cefepime

line:

st component) component) in 2 PLUS OR <12 Option 4: Option ay 4g/d 1 ay) 2.7g/d results: based on culture therapy Specific Ciprofloxacin Oxacillin 100 infections: moderate to Mild - 150 infections: Severe Option 2: Option 3 doses 3: Option ≥12 PLUS

negative negative aeruginosa -

P. negative bacillus negative

- Contiguous Focus Contiguous sp.,

ram Etiology G sensitive staphylococci sensitive - , Coagulase ,

Susceptible Susceptible Methicillin

S. aureus S. Enterobacteriaceae, staphylococci, Streptococcus Osteomyelitis, Osteomyelitis,

National Antibiotic Guidelines

35 -

6 months

hardware if possible and treat for 6 for treat and possible if

Comments nfection (symptoms <4 weeks): <4 (symptoms nfection

Surgical debridement (critical) debridement Surgical flaps muscle Vascularized techniques (IIizarov) osteogenesis Distraction orthopaedic of Removal

weeks. 3- for treat retained, is hardware the If removed. hardware the until or • • • Important therapeutic adjuncts include: include: adjuncts therapeutic Important • external fixation if there is persistent bone non persistent is there if fixation external union. i hardware Early weeks. 6 for treat removed, is hardware If or bony fusion until treat retained, is hardware If removal. hardware infection: Late , hardware the Remove

OR PLUS ) PEDIATRIC ay

) (Max: 3g/day) (Max: ay) 6g/d (Max: ay) 6g/d dose: (Max (Max: 1.2g/d (Max:

INFECTIONS

in 3 doses3 in

in 3 doses 3 in 3 doses

- in 3 doses3 in

ay 6g/d 3 doses(Max: - IV in2 ay) 600mg/d 2 doses(Max:

- Regimen in 2

/day 50mg/kg

in 1 /day IV in 3 doses3 in IV /day 150mg/kg IV in 2 doses in IV BONE AND JOINT

/day 150mg/kg weeks may be adequate if surgical debridement debridement surgical if be adequate may weeks nknown. Prolonged course of therapy is typically typically is therapy of course Prolonged nknown.

100- 30mg/kg - /day 150mg/kg 20

/day 20mg/kg/day

ay 1200mg/d ay 30mg/kg/d 100- Optimalu Not well defined but 6 weeks is generally recommended, recommended, generally is weeks 6 but defined Not well

(Empiric) 10-

Ceftazidime Ceftazidime : ears : ears y y Cefazolin

line:

nd Cefepime Cefepime >12 PLUS Ciprofloxacin Rifampin by guided be should Treatment not recommended. is therapy Empiric studies and sensitivity cultures valid Duration: OR infections: to moderate Mild 100- infections: Severe 2 Linezolid <12 Duration: . retained hardware if longer recommended but 6 but recommended suppressive chronic or therapy intermittent Consider performed. is not or unsuccessful was debridement surgical if relapses for therapy feasible.

- standing standing

(culture

Etiology Streptococci resistant staphylococci resistant susceptible or methicillin or susceptible - - , Enterobacteriaceae, P. Enterobacteriaceae, , staphylococci It implies a long- implies It

ethicillin proven) surgery. occurs in adults following trauma or or trauma following adults in occurs bone. aureus S. Chronic Osteomyelitis Chronic usually osteomyelitis Chronic dead presence of and the infection aeruginosa, resistant resistant Methicillin M National Antibiotic Guidelines

Oxacillin showed showed

2017 57%.Start empiric are rare occurrences. No No occurrences. rare are at

Comments ent joint fluid (needle (needle fluid ent joint accumulated fluid) is a critical a critical is fluid) accumulated showed increased resistance of S. of resistance increased showed

7 201 lection of blood and joint fluid for culture; culture; for fluid andblood joint of lection %. Start empiric therapy with antibiotics antibiotics with therapy empiric Start 57%.

at andblood joint of collection after MRSA against fluidfor culture; review Gram stain of jointfluid. with infections period, neonatal the Beyond Enterobacteriaceae joints into agents antimicrobial inject to need Mark penetration. excellent their of because S. aureus of resistance increased ARSP Oxacillinto aureus purul of Drainage as repeated cases, in most sufficient aspiration - re needed for ARSP therapy. of component therapy with antibiotics against MRSA after after MRSA against antibiotics with therapy col review Gram stain of joint fluid. both requires arthritis septic of Treatment and fluid joint purulent of drainage adequate no There is therapy. antimicrobial appropriate to joints in agents antimicrobial inject to need penetration. excellent their of because

- ons for OR OR PEDIATRIC

PLUS

INFECTIONS ay) 4g/d (Max:

ay) 4g/d (Max: ay) 4g/d (Max:

JOINT ay) 12g/d 4 doses (Max: ay) 12g/d 4 doses (Max:

- - 4 doses - negative organisms: organisms: negative - 2 doses 2 doses in 3 in 3 - -

in 3

Regimen . in 1 in 1

BONE AND Oxacillin /day 200mg/kg /day 200mg/kg /day 60mg/kg is an alternative if with no signs of sepsis. If cultures cultures If sepsis. no signs of with if an alternative is 40-

100mg/kg/day 100mg/kg/day 100- 100-

Refer to OSTEOMYELITIS (HEMATOGENOUS) Option 1 Option (HEMATOGENOUS) OSTEOMYELITIS Refer to Refer to OSTEOMYELITIS (HEMATOGENOUS) Refer to OSTEOMYELITIS stain is negative OR if Gram stain is positive for Gram for positive is stain Gram if OR negative is stain

- line: line: line:

st st nd Ceftriaxone Ceftriaxone Gram for positive is stain Gram If Modify regimen to treat specific pathogen based on results of blood or or blood of results based on pathogen specific to treat regimen Modify Adjacent positive. frequently are Blood cultures culture. fluid joint on precauti comments See patients. of 2/3 in involved is bone . Ceftriaxone Clindamycin grow MSSA, shift to 1 GramIf cocci: positive Vancomycin Cefotaxime 1 2 Cefotaxime

, toxemia toxemia

influenzae H. N.gonorrhoeae S. pyogenes or S. S. S. or pyogenes ) (14%), Unknown Unknown )(14%),

Etiology (14%), negative bacilli (6%), - Group BStreptococci (27%),

(36%) N.meningitidis N. gonorrhoeae, N. gonorrhoeae, (including Others pneumoniae pneumoniae (3%), Gram change may be the only sign. sign. only be the change may aureus S. symptoms such as pain with diaper diaper with pain such as symptoms occur. can Pseudoparalysis years 14 to 3 months withfever and irritability; subtle with septic arthritis may present may present arthritis septic with or leucocytosis is present. Infants Infants present. is leucocytosis or In most neonates, no fever, no fever, neonates, most In S.aureus, Suppurative Arthritis Suppurative old months <3 Enterobacteriaceae, National Antibiotic Guidelines

since use of of use since Comments is an alternative if with no signs of no signs of with if an alternative is H. influenzae influenzae H. has no association with sickle cell cell sickle with association has no

cultures grow MSSA, shift to to shift grow MSSA, cultures .

decrease in in decrease to due arthritis Septic vaccine. conjugate Salmonella osteomyelitis. Salmonella unlike disease, Clindamycin If sepsis. Oxacillin ) PEDIATRIC

ay 12g/d (Max:

4 doses (Max: 4 doses(Max: - ay) 4g/d (Max:

INFECTIONS

4 doses -

IV in3 in 3

2 doses -

in 1

Regimen

/day 40mg/kg in 3 doses3 in in 2 doses in /day 200mg/kg

BONE AND JOINT 25- 3 weeks. 100- /day 100mg/kg Linezolid IV Linezolid 6 weeks. Minimum duration should be 3 weeks because should because weeks 3 be duration Minimum 6weeks. - /day 1200mg

/day /day 30mg/kg

After initial response, therapy is usually completed with oral oral with completed is usually therapy response, initial After

Clindamycin Clindamycin Cefotaxime : ears : ears y y

Ceftriaxone Ceftriaxone

line:

nd some cases may actually have coincident bone infection. coincident have actually may cases some : 3 : Duration <12 OR ay) 2.7g/d ≥12 PLUS Duration: of a 2- total for therapy 2

Etiology National Antibiotic Guidelines

38 Resistant Resistant - entof Methicillin

PEDIATRIC

55. INFECTIONS

JOINT ed. Manila: Philippine Pediatric Society. Pediatric Philippine Manila: ed.

th ed. New York: Elsevier; 2009. Elsevier; York: New ed.

th BONE AND

edition. Makati: MIMS; 2016. MIMS; Makati: edition.

Infections in Adults and Children. Clin Infect Dis 2011:52; e18 - 2011:52; Dis Infect Clin Children. and Adults in Infections aureus Staphyloccocus MIMS Philippines 1/2016, 147 1/2016, Philippines MIMS The Sanford Guide to Antimicrobial Theraphy 2014. Available at http://webedition.sanfordguide.com/. at Available Theraphy 2014. to Antimicrobial Guide The Sanford Treatm the for America of Society Diseases Infectious bythe Guidelines Practice Clinical al. et SE, A, Cosgrove Bayer C, Liu Feigin R, Cherry J, et al. Textbook of Pediatric Infectious Diseases, 6 Diseases, Infectious Pediatric of J, Textbook et al. Cherry R, Feigin

REFERENCES 5 Guide Easy an Disease Infectious Pediatric of Handbook al. et L, Bravo National Antibiotic Guidelines

. 39

biopsy for for biopsy

indings are seen: are indings

Comments adults. Etiologic diagnosis is is diagnosis Etiologic adults. guided aspiration guided -

Surgical intervention, other than than other intervention, Surgical

Spondylitis without disc involvement without Spondylitis Destruction of 2 or more vertebrae and 2 or more vertebrae of Destruction endplates opposed longitudinal anterior the along Spread ligament mass paraspinal or without with infection Disk or fluidcollection

• Not common in in common Not blood and bone cultures Collect essential. Adjust therapy. antibiotic empiric giving before sensitivity and based on culture treatment results. required not usually specimen, tissue obtaining image Perform when cultures appropriate or histopathology byblood established not is diagnosis etiologic diagnostic optimal is The MRI the cultures. when etiology tuberculous Consider imaging. following the and subacute is course f radiologic characteristic • • •

ADULT 2g IV q8h q8h IV 2g

IV q24h g IV q8h OR g IV

2 Ceftazidime

12h - 750mg INFECTIONS

PLUS 12 weeks. weeks. 12

Ceftazidime Ceftazidime

12h - Levofloxacin 20mg/kg IVq8 20mg/kg

Regimen

- 15

BONE AND JOINT

2g IV q24h OR IV 2g is unknown; usually 6- usually unknown; is

l 20mg/kg IV q8 IV 20mg/kg - 2g IV q24h OR q24h IV 2g

750mg IV q24h) IV 750mg 15 Vancomycin

6weeks -

Optima negative bacilli seen on Gram stain: on Gram seen bacilli negative Ceftriaxone Ceftriaxone - ( ADULT

Ceftriaxone

Duration: Duration: Levofloxacin Levofloxacin : 4 : Duration Vancomycin Vancomycin PLUS EXCEPT established is diagnosis etiologic until antibiotics start not Do or severe instability, hemodynamic sepsis, situations: following the in symptoms. and signs neurological progressive MRSA likely: If Gram OR

negative bacilli negative - Etiology

sites and other most common, common, most

, Group A streptococci A Group , negative bacilli rarely bacilli negative - streptococci, Gram streptococci, S. aureus S. , infections Vertebral, including disc space disc including Vertebral, S. aureus S. Osteomyelitis (Hematogenous) Osteomyelitis bones Long Gram National Antibiotic Guidelines

BONE BONE JOINTINFEC AND TIONS -

negative bacilli bacilli negative - ant. External External ant.

implant removal, removal, implant

early debridement, debridement, early

: cm², positive probe probe to positive cm², Comments ays): ays d d

(>30 even without bone union because of of because union bone evenwithout

debridement, and definitive antibiotic x 6 weeks antibiotic and definitive debridement, of Culture essential. culture biopsy Bone/tissue Osteomyelitis unreliable. ulcer overlying of swab >2 ulcer likely: more Obtain bone biopsy culture (gold standard). standard). (gold culture bone biopsy Obtain results. based on susceptibility antibiotic Adjust Needs debridementand removal offoreign body. is hardware fixation internal of Removal necessary impl on metal formation biofilm Gram If needed. is Debridement based on antibiotic add appropriate likely, is profile. susceptibility local 30 within Onset x 3 antibiotic and definitive of implant, retention months onset Late . fracture stabilize can to done be fixation

ADULT

4.5g IV q8h IV 4.5g

4.5g IV q8h) 4.5g IV q8h) 4.5g

750mg PO q24h PO 750mg

tazobactam -

INFECTIONS

tazobactam tazobactam - -

Levofloxacin

PLUS PLUS

OR Piperacillin 12h 12h 12h - - - Regimen OR Piperacillin Piperacillin

OR OR BONE AND JOINT

Approximately 6 weeks from the last last the weeks6 from Approximately

750mg PO bid PO bid 750mg :

2g IV q8h 2g q8h IV 20mg/kg IV q8 IV 20mg/kg q8 IV 20mg/kg 20mg/kg IV q8 IV 20mg/kg - - - 2g IV q8h 2g IV q8h 2g IV 15 15 15

Ceftazidime

Ciprofloxacin

line:

line: ebridement st nd Ceftazidime Ceftazidime d ( Vancomycin Vancomycin ( antibiotic Choose ill. acutely unless is indicated not treatment Empiric . results basedon culture/sensitivity treatment 1 2 Vancomycin : (IVoral) to Duration

ith Vascular Insufficiency) Vascular ith ithout Vascular Insufficiency) Vascular ithout w w

negative bacilli negative negative bacilli, bacilli, negative bacilli negative internal fixation of of fixation internal

- - - - surgery

Etiology )

, Gram, Gram,

Usually follows trauma, bone or joint surgery joint bone or trauma, follows Usually Mostly seen in diabetics (See (See diabetics seen in Mostly Foot Diabetic Osteomyelitis (Contiguous (Contiguous Osteomyelitis anaerobic) and (aerobic Usually polymicrobial in etiology etiology in polymicrobial Usually S. aureus, Gram aureus, S. less often less implant Spinal Sternum, post Sternum, aureus S. S. aureus S. aeruginosa Long bone, post bone, Long fracture puncture wound wound puncture aeruginosa P. Foot bone (calcaneus) following following bone (calcaneus) Foot Osteomyelitis (Contiguous (Contiguous Osteomyelitis National Antibiotic Guidelines

41 best

–

ray. MRI MRI ray. - X

Comments >70, abnormal abnormal >70,

infections implant orthopedic bone, ESR bone, possible. if Revascularize, imaging.

allows higher concentration of antibiotics without without antibiotics of concentration higher allows

ADULT

chronic staphylococcal and staphylococcal chronic INFECTIONS

Regimen BONE AND JOINT

- delivery antibiotic local for cement impregnated -

Rifampin combined w/ another active agent for active another w/ combined Rifampin Hyperbaric oxygen Hyperbaric effects toxic systemic Antibiotic

• • •

Empiric treatment is not recommended. Antibiotics must be chosen based on culture/sensitivity results. culture/sensitivity chosen on be must based Antibiotics is recommended. not treatment Empiric dead bone. with associated months, to weeks for present spread, contiguous by occurs Usually is therapy, antibiotic with together hardware, orthopaedic of boneand removal infected or of necrotic resection Surgical prolonged usually is treatment antibiotic is uncertain; and route duration treatment The optimal care. of standard weeks). 6 (usually include: adjuncts Treatment

(Chronic) Enterobacteriaceae Etiology

Staphylococci, Staphylococci, aeruginosa P. Osteomyelitis Osteomyelitis

National Antibiotic Guidelines

stain negative arthritis arthritis negative stain - Comments disseminated gonococcal gonococcal disseminated Gram Differentials for crystals Look for and pseudogout. gout include in joint fluid. If occurringafter articular injection, Empiric result. culture fluid joint based on treat . recommended not is therapy as manifest May of triad classic the with presenting infection, and polyarthritis. tenosynovitis, dermatitis, and throat. cervix, urethra, sites: other Culture

8h ) - ADULT

4.5g IV q6 IV 4.5g

. tazobactam - INFECTIONS

tazobactam

- Piperacillin

12h - Regimen Collect blood and joint fluid for culture before starting empiric antibiotic treatment. Empiric Empiric treatment. antibiotic empiric starting before for culture fluid blood and joint Collect

. Piperacillin

BONE AND JOINT OR

Ceftazidime

(

minimum 20mg/kg IV q8 IV 20mg/kg

- 1g PO1g x 1 dose PLUS 15 ays

2g IV2g q8h 1g IV1g q24h IV1g q24h

4weeks

d -

s essential. 2 : 7 : Vancomycin Consider as an emergency as an Consider Joint results. basedculture/sensitivity on treatment Adjust stain. Gram fluid be basedon joint should choices antibiotic i drainage Ceftriaxone infection: Chlamydia concomitant for presumptively Treat Azithromycin Duration Duration: Vancomycin Ceftriaxone Ceftazidime

spp

negative bacilli bacilli negative tococcus tococcus negative bacilli negative - - S.aureus,

N.gonorrhoeae

Strep

Etiology and

negative cocci cocci negative bacilli negative positive cocci positive

- - -

20% - Negative on Gram stain on Gram Negative Gram Gram Gram Not at risk for STI: Gram streptococci, in 5 infection (STI): likely Monoarticular transmitted sexually for risk At predominate. Gram predominate. Joint fluid WBC count usually >50,000/mm³ but lower counts do not exclude the diagnosis the exclude do not counts but lower >50,000/mm³ usually count WBC fluid Joint aureus S. Acute Bacterial Arthritis Bacterial Acute Joint Infections Joint National Antibiotic Guidelines

osthesis osthesis

Comments - and intra aspirate operative prosthesis the surrounding

re bursectomy. re

. Debridement and retention of prosthesis prosthesis of retention and Debridement pr 30 days of within (DAIR): a with weeks, <3 orsymptoms implantation

1. Surgical strategies: Surgical reactive causes other including up for Work arthritis daily and antibiotics includes Treatment cases Some sterile. until bursa of aspiration requi may

ADULT

INFECTIONS

- pre of in a combination or cultures operative

ent spacers. Antibiotic cement cement Antibiotic spacers. ent -

2g IV2g q8h

12h - 1g IV q24h IV 1g Regimen

Cefazolin

BONE AND JOINT

OR ays Ceftriaxone 20mg/kg IV q8 IV 20mg/kg d -

15 21

2g q4h IV

: 14: (or other virulent organism) in tissue biopsy or synovial fluid. synovial or biopsy tissue in organism) virulent other (or

ureus the prosthesis itself should be sent for aerobic/anaerobic cultures. aerobic/anaerobic be for should sent itself prosthesis the or specimens tissue 6 periprosthetic Duration Oxacillin Vancomycin Treat not recommended. is therapy Empiric specialist. to Referral results. sensitivity based on culture/ on the a recommendation make to evidence insufficient is There cem antibacterial of and efficacy safety active, sexually If

S. a

- acute inflammation on histopathology examination of periprosthetic tissue obtained at the time of debridement or prosthesis or prosthesis debridement time of the at obtained tissue periprosthetic of examination histopathology on inflammation acute

growth of the same organism in at least 2 intra 2 at least in organism the same of growth

- 39%),

presence of a sinus tract communicating with the prosthesis or purulence (without another etiology) another (without or purulence prosthesis the with communicating tract a sinus of presence

12%),

12%), Gram 12%), , Acute rheumatic rheumatic Acute , - (2 Anaerobes 8%), 43%), Coagulase 43%),

Etiology -

is based on aspiration of fluid from the bursa for WBC count (usually >1,000/mm³), Gram stain and culture/sensitivity. stain Gram >1,000/mm³), (usually WBCcount for bursa the from of fluid aspiration based on is

(21

Propionibacterium acnes Propionibacterium MSSA MRSA Other diagnostic evidence: diagnostic Other Highly suggestive diagnosis: suggestive Highly operative cultures; or growth of or growth cultures; operative removal. At least 3 and optimally 5- 3 and optimally At least removal.

6%), S. aureus S. - (17 staphylococci negative - (1 Enterococci • • - (7 Streptococci - (5 bacilli negative Definitive diagnosis: Definitive Prosthetic Joint Infections Joint Prosthetic Diagnosis Diagnosis 80% > in aureus S. Septic Bursitis Septic bursae and postpatellar prepatellar olecranon, involves Usually fever, Viruses fever, Polyarticular gonorrhoeae N. National Antibiotic Guidelines

and and

Rifampin Rifampin

virulence virulence -

Comments aminoglycoside (optional). aminoglycoside fixed prosthesis, low prosthesis, fixed - stage/direct exchange stage/direct stage exchange stage - - well tract a sinus of and absence organism, 1 2

3. 2.

an add May Confirmisolate susceptibility to . Fluoroquinolones Confirmisolate susceptibility to . Fluoroquinolones

ADULT

Rifampin

Ciprofloxacin Ciprofloxacin

PLUS 2g IV q8h) q8h) IV 2g

6 weeks

12h continuously (or in 6 (or continuously in 6 div (or continuously - INFECTIONS

h h 6 weeks 6 weeks 6 weeks

- -

q24h x4- q24h Cefazolin

6 weeks - 6 weeks (coverage for BIOFILM) BIOFILM) for 6 weeks (coverage AIR for 3 months

OR 300mg PO bid for 3 months 3 months for 300mg bid PO

300mg PO bid for 3 months 3 months for 300mg bid PO 750mg PO q24h OR PO 750mg 750mg PO q24h OR PO 750mg 2g IV IV 2g

MU MU q24IV MU MU q24IV

Regimen 20mg/kg IVq8 20mg/kg - 24 24 - - 15

20 20 6 weeks 6 weeks

- BONE AND JOINT 2g IV q4h q4h IV 2g G Rifampin 2g IV q4h x 4 q4h IV 2g

Rifampin

Ceftriaxone

6 weeks Levofloxacin Levofloxacin ( 300mg PO bid x 2- x bid PO 300mg

PLUS

PO regimen as for D asfor PO regimen PO regimen as for DAIR for 3 months for DAIR asfor PO regimen PO regimen as above for 4 asabovePO for regimen 4 asabovePO for regimen

Oxacillin Penicillin G Vancomycin Penicillin (

    Ampicillin

OR Rifampin PLUS PLUS PLUS PLUS

stage: as above x 4 stage: - stage: IV IV stage: stage: IV IV stage: stage: IV IV stage: IV stage: /2 - - - - - (6 months for total kneearthroplasty) total for months (6 1 ) bid PO 750 mg DAIR doses) FOLLOWED BY ( BY FOLLOWED 2 DAIR x 2- po bid 300mg 2 DAIR OR doses) divided 1 spacers are used to deliver higher concentrations of local antibiotics antibiotics of local concentrations higher deliver used to are spacers . contractures joint prevent to and effects side systemic without DAIR PLUS ) bid PO 750mg FOLLOWED BY (6 months for total kneearthroplasty) total for months (6 1

susceptible) S. aureus S.

S. aureus aureus S. P. acnesP.

Etiology resistant resistant susceptible susceptible - - epidermidis

Enterococci (penicillin Enterococci Streptococci or or Streptococci Methicillin S.

Methicillin epidermidis associated with shoulder shoulder with associated infection arthroplasty National Antibiotic Guidelines

resistant resistant

- 322. Comments e Vertebral Vertebral e Nativ of ment ent of methicillin

407. 393–

May add an aminoglycoside (optional). aminoglycoside an add May (optional). an aminoglycoside add May

ADULT

2g IV q12h IV 2g based on based

6 weeks -

Available at: at: Available INFECTIONS

Cefepime

Fluoroquinolone

Regimen OR

15mg/kg IV q12h IV 4 x 15mg/kg

2g IV q8h IV 2g

6 weeks 6 weeks 6 weeks 6 weeks 6 weeks - - - - BONE AND JOINT lactam - beta Ceftazidime Vancomycin IV /antibiotic_guidelines.pdf

PLUS PLUS PLUS stage: as above x 4 as stage: stage: as above x 4 stage: as above x 4 stage: as above x 4 stage:

- - - - /2 /2 /2 /2 - - - - DAIR DAIR 1 1 DAIR 1 DAIR - x 4 results susceptibility 1

infections in adults and children. Clin Infect Dis 2011; 52: e18. 52: 2011; Dis Infect Clin and children. adults in infections 2016. Treatment Recommendations for Adult Inpatients. Inpatients. Adult for Recommendations Treatment 2016. Surveillance Program. Manila: Department of Health; 2015. Health; of Department Manila: Program. Surveillance resistant)

Etiology antibiotic treatment of staphylococcal bone and joint infections in adults. J Antimicrob Chemother 2014; 69: 309– 69: 2014; Chemother Antimicrob J adults. in infections joint and bone Nam K, et staphylococcal al. of treatment Oral antibiotic - aureus lococcus Staphy e1. 2013;56: Dis Infect Clin America. of Osteomyelitis in Adults. Clin Infect Dis Advanced Access. Published July 29, 2015. 2015. 29, July Published Access. Dis Advanced Infect Clin Adults. in Osteomyelitis http://www.hopkinsmedicine.org/amp/guidelines P. aeruginosa P. Enterobacteriaceae Enterococci (penicillin Enterococci Spellberg B, Lipsky B. Systemic Antibiotic Therapy for Chronic Osteomyelitis in Adults. Clin Infect Dis 2012;54(3): Dis Infect Clin Adults. in Osteomyelitis Chronic for Therapy Antibiotic Systemic B. Lipsky B, Spellberg Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases, 8th ed. New York: Elsevier; 2015. Elsevier; York: New ed. 8th Diseases, Infectious of Practice and Principles Bennett’s and Douglas Mandell, Society Diseases Infectious bythe guidelines practice clinical infection: joint prosthetic of ment and manage Diagnosis et al. AR, Berendt EF, Berbari DR, Osmon Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the Infectious Diseases Society of America for treatm the for America of Diseases Society Infectious bythe guidelines practice Clinical al. et SE, A, Cosgrove Bayer C, Liu Berbari EF et al. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treat theDiagnosis for Guidelines Practice Clinical (IDSA) America of Society Diseases 2015 Infectious et EF al. Berbari National Antibiotic Guidelines

Baek REFERENCES Antimicrobial Resistance Resistance Antimicrobial Antibiotic Guidelines 2015- Guidelines Antibiotic

46 403.

ADULT

INFECTIONS

345. BONE AND JOINT - Rep 10:394 Dis 2008; Infect Curr and Osteomyelitis. Arthritis Septic Associated -

- 2014;302 Rev Microbiol Clin Infections. Joint Prosthetic R. Patel Tande A, The Sanford Guide to Antimicrobial Therapy 2016. Available at: http://webedition.sanfordguide.com/. http://webedition.sanfordguide.com/. at: Available Therapy 2016. to Antimicrobial Guide The Sanford of Implant Treatment and Diagnosis W. Zimmerli A, Trampuz National Antibiotic Guidelines

47 ructures, in in the ructures,

ing st ing

including nutritional variant variant nutritional including

S. bovis S.

not sufficient)

criterion 1 pathological , in the absence of a primary focus) absence a primary the of in , OR

existing murmur existing enterococci

5 minor criteria

OR acquired CARDIOVASCULARI INFECTIONS - or community ,

3 minor criteriaare fulfilled

ulonephritis, Osler’s nodes, Roth spots, rheumatoid factor rheumatoid spots, nodes, Roth Osler’s ulonephritis, OR

criteria and 3 minor 1 major

OR TIONS

detected by at least one positive blood culture or IgG antibody titer for Q fever phase 1 antigen >1:800. >1:800. antigen 1 phase Q for fever titer IgG antibody or culture blood one positive least at by detected

(IE)

wn >12 hours dra hours >12 wn samples blood of cultures positive two least (at blood cultures positive persistently from IE with consistent roorganisms Coxiella burnetii Coxiella Typical microorganism consistent with IE from 2 separate blood cultures (viridans group streptococci, or or streptococci, group (viridans blood cultures separate 2 IE from with consistent microorganism Typical Mic strains, or HACEK group, or S. aureus group, or HACEK or strains, hour1 > apart) drawn sample and last first with blood, of cultures ofseparate 4 ofor3 a or all majority apart, 2 major clinical criteria

1 major and 1 minor criterion and 1 minor 1 major

Immunological problems: glomer problems: Immunological with consistent organism with infection of evidence serologic or criterion) a major meet doesn't (that culture blood Positive evidence: Microbiologic drug injection recreational lesion, cardiac known factor: Predisposing >38°C Fever hemorrhages conjunctival/intracranial lesions, Janeway infarcts, pulmonary emboli, arterial evidence: Embolism Evidence of endocardial involvement with positive echocardiogram defined as oscillating intracardiac mass on valve or support mass or valve on intracardiac as oscillating defined echocardiogram positive with involvement endocardial of Evidence Positive blood culture with typical IE microorganism, defined as one of the following: the as one of defined microorganism, IE typical with culture blood Positive IE but not satisfying major criterion major notsatisfying but IE • of dehiscence partial new or abscess, or explanation, anatomic alternative an of absence in the material on or implanted jets, regurgitant of path - pre changing of or (worsening regurgitation new or valvular valve prosthetic • •

Minor criteria Major criteria vegetation, or intracardiac abscess from the heart revealing microorganisms revealing the heart from abscess or intracardiac vegetation, an embolized vegetation, a cardiac of culture or Histology endocarditis Active d. e. a. b. c. b. a.

Clinical Criteria: Pathological criteria (anyone): criteria Pathological 2. 1. 1. 2.

Possible: Definitive B. Diagnostic Criteria (Modified Duke’s Criteria) Duke’s (Modified Criteria Diagnostic A. Infective Endocarditis Endocarditis Infective National Antibiotic Guidelines

CARDIOVASCULAR INFEC CARDIOVASCULAR

48 in

ransthoracic ransthoracic ransesophageal ransesophageal

conduct t conduct

t 3 sets of blood cultures. cultures. blood tsets3 of

t least S. bovis . S. is agent etiologic the when , cases suspected n all I echocardiogram (TTE). (TTE). echocardiogram ongoing is there if negative is TTE When intracardiac concern about or IE of suspicion t conduct , complications echo (TEE). ntified,ide is antibiotic pathogen Once Rx Obtain a Obtain pattern. susceptibility to be adapted must

• • • • tumor) (e.g., pathology bowel occult Suspect adults

OR PLUS

6 doses 2g IV IV 2g -

1mg/kg IV 1mg/kg IV ] q8h Ceftriaxone

300,000 300,000 div - IV div 4 OR ay) 4g/d - Gentamicin IV/IM 2 ay) 6g/d (Max: Ceftazidime

Gentamicin 200,000 (Max: 2g q12h) x 4 2g q12h) (Max: INFECTIONS 12h ay) 2g/d q6h (Max: OR PLUS (Max: Na

q8-

div div PLUS 12h q8h 300/day mg/kg h IV div 6mg/kg/day 6

- div div 3 200- 2g q8h IV IV q

Penicillin G /day /day 80mg/kg or 3g ) ay) weeks x4 MU/d 24

IV q8h IV q12h /day 60mg/kg CARDIOVASCULAR 20mg/kg IV q8- IV 20mg/kg /day 150mg/kg Cefepime

Gentamicin ( sulbactam -

div div 15- (Max: 12- (Max: 100- sulbactam /day 150mg/kg

- q4h PLUS PLUS 6mg/kg/day IV/IM )

- 100- 3

div div acquired ay associated -

Specific Treatment Specific - d - Ampicillin Vancomycin Aqueous crystalline crystalline Aqueous IV

: : Cefepime [

Vancomycin Ampicillin

: : /day

) eeks

Adult Ceftazidime PLUS w Adult Healthcare Pediatric Gentamicin q8h IV 1mg/kg q8h Pathogen Pediatric: U/kg Empiric Therapy Empiric Community Pediatric 12g/ (Max: q8h /day 100mg/kg

40%), 40%), - Eikenella Eikenella , species species sp.,

(30 S. 25%), 25%),

(

hominis sp.,

18%), Staphylococci Staphylococci 18%), S. bovis or ) with) Penicillin G MIC

Haemophilus

35%), - , and Kingella , corrodens 10% 10% (HACEK) (5%), Culture negative negative Culture (5%), (HACEK) Cardiobacterium gallolyticus mcg/mL ≤0.12 S. viridans

Streptococcus viridans Streptococcus (15 - streptococci Other - (5 Enterococci Aggregatibacter Native Valve Infective Endocarditis Infective Valve Native (20 National Antibiotic Guidelines

49 : ntration

eeks

. Ceftriaxone regimen

may be used when when be used may

(ex. creatinine creatinine (ex. actam l -

Ceftriaxone Penicillin beta Gentamicin ) Ceftriaxone must achieve trough conce trough achieve must w q12h x 4 IV 15mg/kg

mcg/mL. Obtain the trough level before before level trough the Obtain mcg/mL. dose. dose.

20 - th week combination regimen is reasonable reasonable is regimen combination week 5 4 - Ampicillin unable to use to unable clearance <50 mL/min) <50 clearance Alternative double double Alternative ( A 2 A response treatment rapid IE, uncomplicated with with Treatment disease. renal and without Vancomycin of 1 the to susceptibility Check unableIf to tolerate Vancomycin ) ay 2g IV IV 2g

- IV x 4 15mg/kg 15mg/kg

2g IV IV 2g

or (Max: 12g/d (Max: 2g/day

PLUS 1mg/kg IV q8h x 1mg/kg q12h Ampicillin 6h Ceftriaxone -

] x 2 weeks div div q4 OR Gentamicin

Vancomycin Ceftriaxone

, >3 months symptoms if div div

q4h IV/IM q4h IV

PLUS Ceftriaxone

div div PLUS Gentamicin div div q4h x 4 weeks q4h x 4 weeks IV /day 3mg/kg/day OR /day

IV q4h 4 weeks;

div div div div : Ceftriaxone

PLUS /day IV div IV

/day or

IV eeks /day100mg/kg MU /day w 300mg/kg /day

- 30 MU 30 ] x 2 weeks - 18 Gentamicin CARDIOVASCULARI INFECTIONS MU - MU ) 6 weeks

18 200

12 12g/day 18

Penicillin 24

q8h x 2 PLUS PLUS 2g IV4 weeks 2g q24h x 12-

div div q4h x 4- Ceftriaxone eeks ] x 4 weeks 2g q12h) (Max: /day 3mg/kg IV

div div

Ampicillin , months <3 symptoms if

[

Penicillin G Ampicillin : IV (

Penicillin G Penicillin G

x 2 weeks [ [(

: : Penicillin G Ceftriaxone line:

line:

6 weeks - st nd 6 weeks IV q12h x q12h 4 w IV If unableIf to tolerate q12h x6 weeks q12h Duration: /day 6mg/kg 2 OR OR g/day 80mg/k 4 Pediatric OR x 4 weeks Adult Gentamicin weeks 1 12g/day Adult q24h)

MIC

/ S. S. ( (

Penicillin G Ampicillin S. bovis S. bovis , , Vancomycin (synergy positive) (synergy , or or ) with) ) with) Penicillin G MIC G

susceptible to to susceptible gallolyticus Enterococci and mcg/mL >0.5 Penicillin Gentamicin S. viridans

gallolyticus ≤0.5mcg/mL to >0.12 S. viridans National Antibiotic Guidelines

50 target trough trough target Refer to 20 mcg/mL. mcg/mL. 20

and nephrotoxicity increased Potential be must Dose combination. this with ototoxicity Vancomycin achieve to adjusted 15- of concentration specialist.

) x) ay PLUS

) )

ay ay 2g IV q12h x q12h IV 2g IV/IM q8h 2g IV q8h x6 IV 2g (Max dose (Max

q12h or or q12h

6h Gentamicin div -

INFECTIONS ay 6mg/kg/d IV/IM Ceftriaxone q6h (Max: 2g/d q6h (Max: q6h (Max: 2g/d q6h (Max: - Cefazolin PLUS

eeks 6 doses (Max: 12g/d 6 doses(Max:

3 IV div q4 div IV div div div div

12h 12h x 6 weeks - x 6 w IV IV

/day IV div 4

eeks q8h IV q8 /day /day ay d 6 w div div Gentamicin /day 100mg/kg

IV PLUS q4h div IV 300mg/kg

- 60mg/kg 60mg/kg CARDIOVASCULAR 20mg/kg 20mg/kg q8- IV 20mg/kg ay

d 200

15- 15- 200mg/kg/

2g/ 1

2g IVx q4h 4- Ceftriaxone

6mg/kg/day - (Max: 2g q12h) x 6 weeks 2g q12h) (Max: 3

Oxacillin Vancomycin Ampicillin Vancomycin PLUS

: : : :

Oxacillin Vancomycin Vancomycin Ampicillin

ays : : : : d

5 eeks - Adult 3 Adult wks6 q8h x IV 1mg/kg specialist. to Refer Pediatric WITHOUT or WITH 6 weeks w Pediatric Adult Pediatric ay) 12g/d 6 weeks Pediatric Gentamicin /day /day 80mg/kg Adult

and (MSSA)

resistant, resistant, susceptible, - - -

S. aureus S.

resistant or resistant sensitive resistant MIC >500 mcg/mL), >500MIC mcg/mL), - Penicillin Penicillin penicillin resistant susceptible - -

Gentamicin Methicillin (MRSA) Methicillin aureus Staphylococcus - aminoglycoside Vancomycin Enterococci, Enterococci, - aminoglycoside ( susceptible streptomycin Enterococci, - aminoglycoside Enterococci, Enterococci, National Antibiotic Guidelines

51 7 days of 7 daysof

Caused by fungal or highly resistant resistant highly or by fungal Caused Heart block, annular or aortic abscess aortic or annular block, Heart emboli Recurrent Signs and symptoms of congestive heart heart congestive of and symptoms Signs dehiscence due to valve failure valve and prosthetic fistula Intracardiac dysfunction 5- despite bacteremia Persistent treatment organisms

• • • • • • is recommended. consultation surgical Early indications: Surgical

/day

300 mg/kg -

200

3g IV q6h x4 IV 3g

PLUS

Gentamicin 8h q12h or 80mg/kg or q12h - q6 div div

PLUS sulbactam div - sulbactam

- 12h

IV/IM

/day

q8h /day 600mg 600mg q24h PO

IV/PO div 3 doses x 6 weeks (Max: div(Max: weeks x6 3 doses IV/PO div div Ampicillin Ampicillin

IV 60mg/kg -

40 CARDIOVASCULARI INFECTIONS 20mg/kg IV q8- IV 20mg/kg

100mg/kg

Rifampin 15- 2g q24h x 4 weeks IV

20mg/kg/day

6mg/kg/day -

3 )

6 weeks

Vancomycin Ceftriaxone

: : lactamase producing: lactamase producing: lactamase Rifampin

Ceftriaxone Vancomycin - -

IV div 4 or 6 4 or doses x 4 weeks div IV : : q24h Adult weeks Duration: Empiric Therapy Empiric Pediatric Gentamicin q8h PLUS IV 1mg/kg Pediatric x 4 weeks 2g q12h) (Max: betaIf betaIf PLUS ays 900mg/d Adult

mostly , surgery): - surgery): surgery): -

hominis

S. aureus S. aureus Aggregatibacter

, . sp

, S. aureus S. , , and Kingella , corrodens Cardiobacterium , Eikenella species (HACEK) species

enterococci epidermidis, S. viridans, S. viridans, epidermidis, Late (>2 months post months (>2 Late Early (<2 months post (<2 months Early and epidermidis S. Prosthetic Valve Valve IE Prosthetic sp. Haemophilus National Antibiotic Guidelines

susceptibility. Choice based on in vitro vitro basedin on Choice

PLUS

300mg

IV/IM div 3 doses IV/IM

x 6 weeks (Max: (Max: x 6 weeks Rifampin 80mg/kg/day or q12h IV/IM div 3 dosesx2 div IV/IM q6h INFECTIONS weeks dosesx6

div div 4 300mg PO q8h x q8h PO 300mg weeks 6 6 doses x 6 weeks (Max: (Max: weeks 6 dosesx6 PLUS

div div –

ay 6mg/kg/d

q8h IV ] - q8h x 6 weeks (Max: 2- (Max: q8h x 6 weeks

12h 1mg/kg IV q8h x 2 weeks1mg/kg IV 3 IV div

div div div div IV div 4 ay

ay 6mg/kg/d IV Rifampin -

3 ay

/kg/d PLUS /day100mg/kg 20mg/kg q24h IV/PO div 3 div doses x 6 weeks IV/PO q24h 20mg/kg

Gentamicin Gentamicin 0mg /day 200mg/kg 6 IV/PO div 3 doses x 6 weeks (Max: (Max: weeks 3 dosesx6 div IV/PO CARDIOVASCULAR 20mg/kg IV q8- IV 20mg/kg

/day 6mg/kg - ay 15- 200mg/kg/d 3 1mg/kg IV q8h x 2 weeks1mg/kg IV

Gentamicin PLUS 150mg/kg/day 2g IV q4h Rifampin

100- Ceftriaxone

PLUS Cefotaxime

specific Treatment Treatment specific ay) 2g/d 24h x 6 weeks (Max: 6 weeks - 20mg/kg/d

Vancomycin Oxacillin

OR PLUS

: : : OR ) ) Gentamicin Gentamicin

Vancomycin Oxacillin q12-

: : d US div

Ceftazidime PL IV ay) 12g/d ay) 900mg/d weeks Adult ay 4g/d Pediatric Rifampin PLUS q8h x 6 weeks PO Pediatric [ Pathogen Pediatric 12g/ ay) 900mg/d (Max: x 2 weeks Adult PLUS Duration:

S. aureus S.

enteric bacilli enteric resistant susceptible - -

negative negative -

Gram Methicillin (MRSA) (MSSA) Methicillin

National Antibiotic Guidelines

53 as

)

Comments

xis for dental procedures is reasonable. is procedures dental for xis

procedures that involve manipulation of of manipulation involve that procedures dental dental all

dental procedures even if such prophylactic therapy w therapy suchprophylactic if even procedures dental

Placement of orthodontic brackets orthodontic of Placement teeth deciduous of Shedding

− −

dministration of antibiotics solely to prevent endocarditis is not not is endocarditis prevent to solely of antibiotics dministration prosthetic patch or prosthetic device (which inhibit endothelialization) inhibit (which device prosthetic or patch prosthetic

Regimen

CARDIOVASCULARI INFECTIONS

infected tissue infected -

hylaxis is no longer recommended for any other form of CHD form other any for recommended longer no is hylaxis prop antibiotic above, listed conditions the for xcept (e needprophylaxis:

Prophylaxis is reasonable because endothelialization of prosthetic material occurs within 6 months after the procedure. the 6 months after within occurs material prosthetic of endothelialization because reasonable is Prophylaxis

HD NOT

do injections through non through injections

that Etiology , tissue gingival the of manipulation involve that procedures dental all for reasonable is prophylaxis conditions, cardiac these underlying

conduits and shunts palliative including CHD, cyanotic Unrepaired 6 the first during intervention, bycatheter or surgery by placed whether or device, material prosthetic with defect heart congenital repaired Completely a of thesite to adjacent or thesite at defects residual with CHD Repaired Routine anaesthetic Routine radiographs Dental . procedure the after months , a , procedure tract gastrointestinal or a genitourinary undergo who patients or

n an increased lifetime risk of acquisition of IE. of IE. acquisition of risk lifetime increased on an solely based recommended not is Prophylaxis F Only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE, IE prophyla IE IE, from outcome adverse of risk highest the with associated conditions cardiac underlying with patients for Only with patients For or the periapical region of teeth, or perforation of the oral mucosa. oral of the perforation or teeth, of region periapical the or . recommended Only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for for prophylaxis byantibiotic prevented be might IE ofcases of number small an extremely Only effective. 100% Cardiac transplantation recipients who develop cardiac valvulopathy cardiac develop who recipients transplantation Cardiac Previous IE Previous ordisease C heart Congenital Prosthetic cardiac valve or prosthetic material used for cardiac valve repair valve cardiac used for material prosthetic or valve cardiac Prosthetic − − − − −

rocedures and events and events rocedures

• • • • • rthodontic bands) oforthodontic placement removal, suture (biopsies, mucosa oral of the perforation or of teeth region the periapical or tissue gingival P • for above statements) (see conditions cardiac specified with patients for reasonable is Prophylaxis IE • • dverse outcome from IE where prophylaxis for dental procedures is reasonable: is procedures dental for prophylaxis where IE from outcome ofadverse risk highest the with conditions Cardiac • Infective Endocarditis (IE) Prophylaxis (IE) Endocarditis Infective National Antibiotic Guidelines

54 individual individual

generation oral oral generation - equivalent adult or pediatric or pediatric adult equivalent or second

oral mucosaoral

with a history of anaphylaxis, angioedema, or or angioedema, anaphylaxis, of history a with orurticaria ampicillin. penicillin with Orother first in cephalosporin dosage. an in used be not should Cephalosporins

Adult

00mg Bleeding from trauma to the lips or the lips to trauma from Bleeding 500mg IM/IV 600mg 2g 2g IM/IV 1g IM/IV 1g IM/IV 2g 6 500mg 1g IM/IV

− INFECTIONS

or IV

Pediatric 50mg/kg IM or or IV IM 50mg/kg IM 50mg/kg 50mg/kg 20mg/kg 15mg/kg 15mg/kg or IV IM 50mg/kg or IV IM 20mg/kg 50mg/kg or IV IM 50mg/kg CARDIOVASCULAR

60 min. before procedure before min. 60 - OR

OR OR

Agent

Cefazolin Ceftriaxone Cephalexin Clindamycin Clarithromycin Cefazolin Ceftriaxone Clindamycin Single dose 30 Single Amoxicillin Ampicillin Azithromycin

—

Placement of removable prosthodontic or orthodontic appliances orthodontic or prosthodontic removable of Placement appliances orthodontic of Adjustment

− − Allergic to penicillins orampicillin medication oral take to and unable oral Allergic to penicillins orampicillin Unable to take oral medication oral take to Unable Situation Oral

Dental Prophylaxis Dental

National Antibiotic Guidelines

) -sided native

IE involving prosthetic a

S. or aureus vancomycin-

Staphylococcus lugdunensis

-negative bacteria istant enterococci) rare infections and caused Late prosthetic valve endocarditis with heart failure caused by prosthetic dehiscence or obstruction, or other indications for surgery Virtually all cases of prosthetic valve endocarditis caused by S. aureus Virtually all cases of prosthetic early valve endocarditis Fungal IE Pseudomonas aeruginosa IE causedmultiresistant by organisms (e.g. methicillin-resistant res by Gram IE caused by other aggressive organisms (Brucella, Staphylococcus aureus valve most and cases a left involving valve Relapsing IE,especially when caused by organisms other than sensitive streptococci or in patients with prostheticvalves extracardiac sourcessepsis of have been excluded

• • Prosthetic valve endocarditis • • • • • Difficult organisms • •

7. 6.

Surgery contraindicated is for at least one In all cases, surgeryfor the prevention of embolism

CARDIOVASCULARI INFECTIONS Fever or positivecultures blood persisting for >5 to 7 days despite an appropriate antibiotic regimen, assuming thatvegetations or other lesions requiring surgery persist and that Ischemic stroke other and surgical indications, provided that cerebral hemorrhage has been excluded and neurological complications are not severe (e.g., coma) Silent neurological complication or transient ischemic ischemic or transient complication Silent neurological l indications surgica other and attack Very large vegetations mm) (>15 without embolic complications, especially if valve-sparing surgery is likely (remains controversial) Large vegetations (>10 mm) after more 1 or clinical or silent embolic events after initiation of antibiotic therapy Large vegetations and other predictorsof a complicated course

Note: month after intracranial hemorrhage unless neurosurgical or endovascular intervention can be performed to reduce bleeding risk. Persistent sepsis • Cerebrovascular complications • • must be performed very early since embolic risk is highest highest is risk embolic since early very performed be must therapy. of days first the during Note: • • •

5. 4.

(Most patients abscess with

and no other reasons for surgery,

Surgery should be performed immediately, Recurrent emboli despite appropriate antibiotic Congestive heart failure as a result prosthetic of dehiscence or obstruction Severe acute aorticmitral or regurgitation with echocardiographic signs of elevated left ventricular-diastolic end pressure or significant pulmonary hypertension Congestive heart failure caused by severe aortic or mitral regurgitation or, more rarely, by valve obstruction caused by vegetations therapy

Note: Note: irrespective of antibiotic therapy, in patients with persistent pulmonary edema or cardiogenic shock. If congestive heart failure disappears with medical therapy and there are no other surgical indications, intervention can be postponed to allow a period of days or weeks of antibiotic treatment under careful clinical and echocardiographic observation. In patients with welltolerated severe valvular regurgitation or prosthetic dehiscence conservative therapy under careful clinical and echocardiographic observationrecommended is with consideration of deferred surgery after resolution of the infection, depending upon tolerance of the valve lesion. Periannular extension formation or fistulous tractformation) Systemic embolism • • • Congestive heart failure •

2. 3. 1. Indications for for Surgery Indications National Antibiotic Guidelines

usually necessary. usually

Comments surgery after occurs pericarditis purulent UTI with association in

in the immunocompromised the in

1. 2. An aminoglycoside should be added when: be added should aminoglycoside An Initial antibiotic regimen should consist of 2 or 2 or of consist should regimen antibiotic Initial be cannot agent etiologic when drugs, more isDrainage rapidly. detected

)

ay 15 mg/kg/day)] 12g/d

750mg IV q24h q24h IV 750mg

INFECTIONS Amikacin (Max:

(Max: 2g q12h) (Max: 24h (Max: 2 g q12h) g q12h) 2 (Max: 24h

- 8h OR ) -

12h ay 24h q6 div q6h (adjusted based on TDM) TDM) on based (adjusted q6h div div div

q12- Levofloxacin

12g/d IV div q12 div IV - IV

/day div div Regimen 5mg/kg/day 5mg/kg/day /day IV q6h (adjusted based on TDM) TDM) on based q6h (adjusted

/day

ay CARDIOVASCULAR 20mg/kg IV q8- IV 20mg/kg 60mg/kg

15- 2g IV q24h OR and determined partly by the nature of concomitant of concomitant nature the by partly and determined 100mg/kg 4 weeks.

Gentamicin - 300mg/kg ( - 60mg/kg/d

100mg/kg/day 200 0mg/kg/day (Max: 4 (Max: 0mg/kg/day

Empiric 20

Vancomycin

Ceftriaxone Vancomycin Ceftriaxone [

Adult: Vancomycin : Duration antimicrobial the and isolated a pathogen Once is infection. agent is antimicrobial specific most the areknown, susceptibilities 3 for IV continued Oxacillin Cefotaxime Ceftriaxone Pediatric: PLUS PLUS Aminoglycoside

- ,

S. aureus S. S. aureus aureus S. (for children who who children (for

, N., meningitidis,H. (including penicillin (including b resistant to to resistant

Etiology type type Group A A Streptococcus Group resistant resistant sensitive sensitive spectrum cephalosporins, cephalosporins, spectrum - - resistant strains) resistant influenzae S. pneumoniae S. Methicillin pneumoniae S. immunized) be inadequately may clinicalfeatures for MRSA infection; infections nosocomial or Methicillin and history with and/or isolated - extended S. aureus, aureus, S. Enterobacteriaceae pneumoniae, S. Bacterial Purulent Pericarditis Purulent Bacterial National Antibiotic Guidelines

ofrheumatic fever.

Comments

individualwith a previous attack of rheumatic fever in whomGAS pharyngitis develops is at high risk afor recurrentattack on patient depends prophylaxis oral Successful agents are oral and (compliance), adherence for low risk at for patients appropriate more recurrence. fever rheumatic Referral to apediatric cardiologist isimportant. Prevention of recurrent episodesof Group A Streptococcus pharyngitis(GAS) is themost effectivemethod to preventsevere RHD.

Duration of Last Attack of Duration longer) is age (whichever years 40 of until or years 10 islonger) (whichever age of years 21 or years 10 is longer) age (whichever of 21 years or 5 years

bid (Max: 250mg 250mg (Max: bid

ay 20mg/kg/d residual heart disease disease heart residual (Max: 250mg) (Max:

Regimen

(every 3 weeks*) (every

Erythromycin CARDIOVASCULARI INFECTIONS

/day 5mg/kg

250mg bid PO

nicillin G Pe

Azithromycin OR Penicillin V If withIf Penicillin allergy: >27 kg: 1,200,00 U IM U 1,200,00 kg: >27 OR Rheumatic fever without carditis without fever Rheumatic bid) Category Prophylaxis Fever Rheumatic Secondary of Duration findings orechocardiographic **Clinical disease heart and residual carditis with fever Rheumatic disease**) valvular (persistent but no carditis with fever Rheumatic disease**) valvular (no Therapy for acute rheumatic fever is symptomatic to control the inflammation, decrease the fever, and keep cardiac cardiac and keep fever, decrease the the inflammation, control to symptomatic is fever rheumatic acute for Therapy in check. failure Benzathine IM U 600,000 kg: ≤27

revention revention P

: See section on section See

: Etiology

Secondary Prevention Secondary attacks recurrent of Streptococcal Tonsillopharyngitis Streptococcal Acute Rheumatic Fever Rheumatic Acute Prevention Primary National Antibiotic Guidelines

itive blood itiveblood

Comments day treatment course is is course day treatment - to 7

specialist is recommended. is recommended. specialist

ed and blood cultures clear promptly. clear cultures blood and ed Once the causative organism is identified, identified, is organism causative the Once on based be selected should therapy targeted testing. susceptibility 5- shorter A - coagulase to due CLABSI for reasonable is catheter the if staphylococci negative remov

is an is

psis for dressing changes dressing for psis tazobactam

Disinfection of hubs of Disinfection Daily review of line necessity and replacement necessity of line review Daily Strict ase INFECTIONS

• • •

Piperacillin of appropriate systemic systemic appropriate of

of systemic antibiotic therapy therapy antibiotic systemic of

ays Aminoglycoside d

PLUS days

14 14 q6h

spp. Regimen PLUS 10– 10-

div

q8h

CARDIOVASCULAR

/day div div Candida IV

n Adults n 60mg/kg i 12mg/kg PO/IV as loading dose, then 6mg/kg/d then dose, as loading PO/IV 12mg/kg

components of both insertion and maintenance bundles: and maintenance insertion both of components

resistant resistant

candidemia e of clearanc up weeks2 after to /day 300mg/kg therapy. therapy. : is retained catheter the If . culture blood negative first date of the the from is removed: catheter the If

Fluconazole have to and ill unlikely notcritically if alternative acceptable - fluconazole Vancomycin 200- Duration: Duration: • •

- ,

coli

. E s include lines IV term S. ), ),

spp., spp.,

Associated Bloodstream Infection Infection Bloodstream Associated Associated Bloodstream Infection (CLABSI) In Children (CLABSI) Infection Bloodstream Associated Etiology

- - Fever AND: 1) positive percutaneous blood culture and same organism cultured from central venous catheter (CVC) tip OR 2) pos OR 2) tip (CVC) catheter venous central from cultured organism same and culture blood percutaneous positive 1) AND: Fever negative staphylococci staphylococci negative

S. epidermidis S. - spp., Other enteric Gram enteric Other spp.,

spp.

Enterococcus , Maximal sterile barrier precautions during catheter insertion catheter during precautions barrier sterile Maximal Hand washing washing Hand

bacteria negative Klebsiella aureus • • - long of prevention Infection Diagnosis: to Referral culture. vein peripheral the than 2 hours earlier least at CVC positive with drawn simultaneously cultures Central Line Central Candida (especially (especially Central Line Central Coagulase National Antibiotic Guidelines

Comments

thrombophlebitis; septic w/ associated Often out fungal rule to recommended vein of biopsy or ligation drainage, surgical fungal, If etiology. Rx. antifungal + indicated often removal If subcutaneous tunnel infected, remove infected, tunnel subcutaneous If catheter. a guidewire. over catheter new insert not Do

6 or

14 days14 plus 2g q8h IV Ceftazidime

Piperacillin ( Standardized administration set changes set administration Standardized OR

Cefepime ( •

2g IV q8h IV 2g

PLUS

PLUS 12h

2g IV2g q4h

12h 12h - - Cefepime

and treat for 2 weeks. Prolong to 4- Prolong 2 weeks. for and treat Regimen term

- /day 15mg/kg OR 8h

CARDIOVASCULARI INFECTIONS

20mg/kg IV q8- IV 20mg/kg

15- Amikacin 20mg/kg IV q8 IV 20mg/kg 20mg/kg IV q8 IV 20mg/kg - - alcohol) 15 15 remove catheter remove

2g IV2g q8h ) 4.5g IV IV q6- 4.5g

for skin antisepsis antisepsis skin for

PLUS 2g IV q8h IV 2g

ic lock therapy (in the absence of absence of complications) the (in therapy lock ic Vancomycin , S. aureus - 10 for treat and catheter , may “save” S. epidermidis 2g IV q8h) IV 2g Cefazolin OR tazobactam weeks if transesophageal echocardiogram positive for vegetation or if or if vegetation for positive echocardiogram transesophageal if weeks osteomyelitis) thrombosis, septic (e.g. complications other are there antibiot Oxacillin MSSA: documented For Vancomycin Ceftazidime Vancomycin If If

S. ,

sp.

alcohol provides greater protection against short against protection greater provides alcohol S.epidermidis Candida sp., sp., Candida Candida (burn, neutropenic) (burn, central venous

S.aureus

, Etiology indwelling venous

– iodine povidone than infections related - (MSSA/MRSA)

Tunneled: - catheter vessels femoral of Avoidance Use of >0.5% chlorhexidine prep with alcohol with prep chlorhexidine >0.5% of Use – (chlorhexidine epidermidis, S. aureus S. epidermidis,

(MSSA/MRSA), (MSSA/MRSA), Impaired Host Impaired S. sp., Pseudomonas Enterobacteriaceae, jeikeium Corynebacterium Rhizopus Aspergillum, (MSSA/MRSA), cathetersand ports (Broviac, Groshong,), dualHickman, lumen hemodialysis catheters(Permacath): S.epidermidis catheter (PICC): jugular),peripherally inserted central Non (subclavian,catheter internal • • aureus TunnelType: National Antibiotic Guidelines

60 Candida.

Comments if possible. Ophthalmologic consultation consultation Ophthalmologic possible. if

antimicrobial Stop catheter. venous Remove , agents to suspected is candidemia when recommended all Treat involvement. ophthalmic early detect for cultures blood positive with patients

sp. INFECTIONS

200mg IV loading dose then then dose loading IV 200mg

Candida 12mg/kg PO or IV as loading dose, dose, IV asloading or PO 12mg/kg Regimen

. resistant resistant CARDIOVASCULAR Anidulafungin is an acceptable alternative if not critically ill and ill not critically if alternative an acceptable is

up to 2 weeks after clearance of candidemia of clearance up weeks2 after to staphylococcal infections staphylococcal Duration: Duration: See See (e.g. echinocandin An Fluconazole daily). IV 100mg ay 6mg/kg/d then - havefluconazole to unlikely

(MSSA/ (MSSA/

Etiology

Candida sp Candida If Candida: If MRSA), MRSA), Hyperalimentation aureus S. epidermidis, S.

National Antibiotic Guidelines

54 61 193. 193. - 2007;116(15):1736

. 2011 May;52(9): e162– May;52(9): 2011 . Complications: A Scientific Scientific A Complications:

Circulation 09 Update by the 2009by the Update infection: related -

1486. 1486.

related infections. Clin Infect infections. related Dis -

- 132:1435 2015;

1152.

Circulation 45. CARDIOVASCULARI INFECTIONS

Clin Infect- Dis. 1 Jul 49(1):1 2009;

50.

- 121:1141 2010; Circulation Endocarditis. Infective for

1515. 2016;62: e1- 2016;62:

132:1487-

sociation. sociation. As Heart American the From c Statement Scienti 2015 A Update Childhood: in Endocarditis Infective et al. L, Baddour M, Gewitz Clin Infect Dis

2016; 5:16. 2016;

Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Group. Working Interdisciplinary Research and Outcomes of Care Quality the and and Anesthesia, Surgery Cardiovascular e, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Council Cardiology, Clinical on and theCouncil Young, the in Disease Cardiovascular on e,Council Committe Disease Kawasaki and Endocarditis, America. Infectious Diseases Society of America. America. of Society Diseases Infectious Epub 2011 Apr 1. 2011 Apr Epub Control Circulation. 2015; Circulation. Statement for Healthcare Professionals from the American Heart Association. Association. Heart American the from Professionals Healthcare for Statement Guidelines from the American Heart Association: A Guideline from the American Heart Association Rheumatic Fever, Fever, Rheumatic Association Heart American from the A Guideline Association: Heart American the from Guidelines et M, al. Gewitz CA, Taubert W, Wilson Prendergast BD, Tornos P. Surgery Surgery TornosP. BD, Prendergast fectious Diseases Society of of Diseases Society fectious In by the 2016 Update Candidiasis: of Management the for Guideline Practice Clinical et al. DR, Andes CA, Kauffman PG, Pappas Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter intravascular of and management diagnosis the for guidelines practice Clinical al. et M, Allon E, Bouza LA, Mermel O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter intravascular of the prevention for Guidelines LA, et al. Burns M, Alexander NP, O’Grady Antimicrob Resist Infect Infect Resist Antimicrob (CLABSI). Infections Bloodstream Associated Line Central of preve ntion guide for APSIC et N, al. Jaggi A, Apisarnthanarak ML, Ling National Antibiotic Guidelines

REFERENCES of Management and Therapy, Antimicrobial Diagnosis, Adults: in Endocarditis al. Infective et AS, Bayer WR, Wilson LM, Baddour BaltimoreR,

- 62

isnot Gram has no has ntibiotic puncture or,

lumbar Cefotaxime if

Dexamethasone Comments tality. as proven by a positive by a positive asproven iately after a

bacterial meningitis is is meningitis bacterial

Ceftriaxone immed y sterilization of the CSF in CSF sterilizationof the y

if if this isdelayed, afterobtaining blood cultures. transmission. maternal to due usually onset Early use May jaundiced. not is neonate the and available Repeatlumbar tap in the neonatenecessary is verifto negative meningitis. meningitis. neonatal in role Adjust therapy based on culture. Start a Start on culture. based therapy Adjust therapy

F markers of inflammation (an abnormal number of of number abnormal (an inflammation of F markers /day

are subtler subtler are and symptoms signs neonates, In seizures.

and

5mg/kg

Age >7 days >7 Age 50mg/kg q8h 50mg/kg q6h 50mg/kg Gentamicin

INFECTIONS

q24h 7 days -

Regimen IV/IM

Age 0 Age IV/IM

/day 50mg/kg q12h 50mg/kg q8h 50mg/kg

15mg/kg

Cefotaxime

or CENTRAL SYSTEMNERVOUS

dependent on the etiology of bacterial meningitis. bacterial of etiology on the dependent

Amikacin

q24h

Body weight Body

Duration: Ampicillin kg <2 kg ≥2 PLUS IV/IM stain or antigen test; or suspected by clinical characteristics and/or CS and/or characteristics by clinical suspected or test; or antigen stain EM INFECTIONS

Etiology , Group B B Group , iaceae the classic triad of acute bacterial meningitis consists of fever, nuchal rigidity, and a change in mental status. mental and a change in rigidity, nuchal fever, of consists meningitis bacterial of acute triad classic the ths old ths Escherichia coli, Streptococcus Streptococcus coli, Escherichia Klebsiella, pneumoniae, Enterobacter Streptococcus (rare) Streptococcus In adults, adults, In mor and complications prevent to away right be started should therapy empiric results, laboratory awaiting and suspected Once and may resemble neonatal sepsis. There is no single or combination of signs which are diagnostic of bacterial meningitis. If meningitis. of bacterial diagnostic whichare signs of combination or single no is There sepsis. neonatal resemble and may diagnosis. the to confirm be performed should culture and analysis CSF suspected, In children, common signs and symptoms include fever, irritability, poor feeding, bulging fontanel, fontanel, bulging poorfeeding, irritability, fever, include and symptoms common signs children, In bacterial CSF culture, PCR, Gram levels). and low glucose protein elevated cells, blood white Community Acute Bacterial Meningitis Acute Bacterial Community cord spinal and brain the surrounding tissues the leptomeninges, the of disease inflammatory an is meningitis bacterial Acute < 2 mon < CENTRAL NERVOUS SYST NERVOUS CENTRAL National Antibiotic Guidelines

H. 63 >12h >12h or those

meningitis, if the

for treatment of treatment

before or give with the with the give or before

Comments Cefuroxime

negative meningitis. For - . Do not start Dexamethasone

is improving, repeat LP is not necessary. not is LP repeat improving, is Gram

Dexamethasone antibiotic dose. The first dose should be should dose dose. first The antibiotic

st 4 days. - patient Do not use not Do delayed of because meningitis bacterial hearing of incidence and greater sterilization loss. the before shortly or along be started should It 1 starting 4 hours of within administered antibiotic afterstarting antibiotics. Repeat lumbar puncture (LP) is recommended in patients with poor clinical response despite 36 hours of appropriate antibiotic with influenzae and S. pneumoniae Start x IV q6h 0.15mg/kg at antibiotics doseof first 2

is of

) )

OR prophylaxis prophylaxis

) is suspected: suspected: is OR ay

)

ay Rifampin (max: 10mg) div q6hdiv x 4 10mg) (max:

2g IV q12h IV 2g ADD

day (Max: 4g/d (Max:

24h (Max: 4g/d 24h (Max: S. pneumoniae - 12h. ay) 600mg/d (Max: ay 4g/d q8h (Max: div IV ay 4g/d (Max: q8h div IV

Regimen ays resistant resistant d ays; Ceftriaxone b meningitis: IV div q12h div IV IV div q12 div IV

/day /day ) to eradicate the carrier state. state. carrier the eradicate ay) to 600mg/d (Max: Dexamethasone suspected: is meningitis

prophylaxis to eradicate the carrier state. state. carrier the eradicate to prophylaxis PLUS 20mg/kg IV q8- IV 20mg/kg

- b /day 100mg/kg /day 100mg/kg ays

15 d type type 100mg/kg IV2g q12h 100mg/kg

20mg/kg/day x 4 20mg/kg/day - or cephalosporin Rifampin 2g IV2g q4h CENTRAL SYSTEMNERVOUS INFECTIONS

with confirmed Hi confirmed with - 10mg/kg/day x 4 10mg/kg/day

ADD ears Vancomycin ears: 5 years: y -

H. influenzae H.influenzae ays. <3 / a 0.15mg/kg at of dose for value proven d add If If penicillinIf y <10 ≥3 Ceftriaxone Chloramphenicol x 4 20mg/kg/day Ceftriaxone Ampicillin Ceftriaxone Chloramphenicol

S. pneumoniae, N. N. S. pneumoniae, S. pneumoniae, N. N. S. pneumoniae,

negative bacilli negative - Etiology 5 years: (less common) (less

L. monocytogenes, ,

S. pneumoniae, N. N. pneumoniae, S. -

meningitidis >50 years: >50 Gram aerobic meningitidis 18 to 50 years: 50 to 18 >5 to 18 years: to >5 meningitidis meningitidis >2 months months >2 N. influenzae, H. pneumoniae, National Antibiotic Guidelines

hematogenous spread from from spread hematogenous Comments n or n or

21 days21

Ceftazidime

ays ays Ceftazidime 14 d 14 - PLUS 400mg IV q12h IV 400mg : 10: PLUS INFECTIONS

12h -

negative - negative enteric bacilli: bacilli: enteric negative IV/IM div q6h div IV/IM -

Ciprofloxacin

ay /d 12h Culture : 21 monocytogenes d L. Gram - OR Regimen 8h

60mg/kg 20mg/kg IV/IM q8 IV/IM 20mg/kg

Open Trauma Head 15-

14 days14 ays - - q6 IV 2g

ays 20mg/kg IV q8 IV 20mg/kg - and div q8h q8h div :d 7

6weeks - ay CENTRAL SYSTEMNERVOUS

3 Vancomycin (regardless of of (regardless

q8h Aztreonam Vancomycin

N.meningitidis Pediatric: /d 150mg/kg 2g/day Vancomycin PLUS Duration age): 10: pneumoniae S. 7: d influenzae H. Adult: Duration: Duration:

infection Gram

Etiology . infection of source the depend on and treatment

Etiology Imaging studies such as CT scan and MRI are necessary for diagnosis although this cannot determine the etiology. etiology. the determine cannot this although diagnosis for necessary are MRI scan and as CT such studies Imaging a distant site of infection. site a distant Brain abscess is a focal collection of pus within the brain parenchyma. The etiology may be trauma, direct spread of infectio of spread direct be trauma, may etiology The parenchyma. brain the within pus of collection focal a is abscess Brain

In the presence of dental of dental presence the In • • Brain Abscess Brain • including bacilli negative Pseudomonas Anatomic Defects, Neurosurgical Complications, Complications, Neurosurgical Defects, Anatomic S. epidermidis, aureus, S.

For severe penicillin allergy penicillin severe For National Antibiotic Guidelines

65 is >2.5

is is

. .

8 weeks. aureus S. aureus S. S. Oxacillin Oxacillin Comments sensitive sensitive sensitive sensitive - - unclear, usually 6- usually unclear, lesion the if required usually is

documented, shift to to shift documented, methicillinIf to shift documented, Consult a neurosurgeon; aspiration of of the aspiration a neurosurgeon; Consult abscess cm. Duration: methicillinIf

)

is 2g IV2g q12h

2g IV IV 2g q12h] PLUS 7.5mg/kg IV/IM IV/IM 7.5mg/kg PLUS Ceftriaxone

E.faecalis Ceftriaxone

(If (If PLUS Ceftriaxone IV/IM div q6h div IV/IM

PLUS

q24h

Metronidazole

) ay IV/IM div q8h div IV/IM IV/IM div q12h (Max: 4g/d q12h (Max: div IV/IM IV/IM div q6h div IV/IM q6h IV

/d 12h 12h

ay ay ay IV/IM ay

/d PLUS /d U/kg

ay Regimen

q8h

ay)] 4g/d q12h div (Max: IV/IM

ay 60mg/kg/d 400,000

150mg/kg 100mg/kg 1g IV/IM q6h IV/IM 1g /d 100mg/kg

- q8 IV 20mg/kg

/d 6mg/kg - MU IV/IM q4h PLUS IV/IM MU -

3 4 2g IV/IM 15

7.5mg/kg IV/IM q6h or 15mg/kg IV/IM q12h 15mg/kg IV/IM or q6h IV/IM 7.5mg/kg ay 4g/d (Max: q12h IV/IM

100mg/kg/d

CENTRAL SYSTEMNERVOUS INFECTIONS Penicillin G [ Ceftazidime Vancomycin Ceftriaxone

Gentamicin Penicillin G Vancomycin [ Ceftazidime

Chloramphenicol Chloramphenicol Adult: documented, give q8h) give documented, Adult: Pediatric: Metronidazole Adult: q12h IV/IM 15mg/kg q6h or Pediatric: ay 100mg/kg/d Pediatric: PLUS Pediatric: Ceftriaxone OR OR

, ,

- , Gram

, Gram,

and H. influenzae ,

e P.aeruginosa viridans Etiology S. aureus S. . aureus, sp, Fusobacterium , S , , enteric bacilli, Bacteroides H.influenza aeruginosa

negativeenteric bacilli, P. -

, Strep viridans, other strep, other strep, viridans, Strep Enterococci In the presence of Endocarditis (native valve) (native of Endocarditis presence the In negative enteric bacilli bacilli enteric negative Streptococci (aerobic and anaerobic) of trauma head presence the In spp. Streptococci (anaerobic and (anaerobic Streptococci aerobic) negative Gram Bacteroides otitis media, sinusitis, ormastoiditis sinusitis, media, otitis of chronic presence the In Streptococci ( Streptococci anaerobic), Bacteroides National Antibiotic Guidelines

Comments

- 3

) PLUS IV/IM ) ay 6mg/kg 6mg/kg ay -

kg/day

7.5mg/kg IV IV 7.5mg/kg Gentamicin 7.5mg/kg IV q6h IV 7.5mg/kg

6mg/ - q8h)

PLUS div Gentamicin INFECTIONS q8h)

div

PLUS IV div q6h PLUS div IV Metronidazole

Metronidazole IV/IM div q12h (Max: 4g/d q12h (Max: div IV/IM

Gentamicin IV q6h IV div

IV/IM div q12h (Max: 4g/d (Max: q12h div IV/IM 12h

/d ay ay IV div q6h div IV

ay q8h) /d /d is documented, documented, is

Regimen PLUS ay U/kg div div is documented, documented, is

60mg/kg 20mg/kg q8- 20mg/kg

100mg/kg

7.5mg/kg IV q6h or 15 mg/kg IV q12h IV q6h or15 mg/kg IV 7.5mg/kg 400,000 2g IV q12h PLUS IV 2g /d 100mg/kg

2g IV q12h PLUS IV 2g 15- 2g q12h IV /d 100mg/kg

7.5mg/kg IV q6h or 15 mg/kg IV q12h IV 15 mg/kg q6h or IV 7.5mg/kg

is documented, documented, is

IV/IM (If E.faecalis CENTRAL SYSTEMNERVOUS Ceftriaxone Vancomycin

Penicillin G Ceftriaxone Ceftriaxone Ceftriaxone

Metronidazole Vancomycin Ceftriaxone

line: line: line:

E. faecalis

st nd st Adult: Adult: Chloramphenicol Adults: 1 q12h 15mg/kg q6h or IV/IM q24h (If E. faecalis Pediatric: PLUS IV q12h 15 mg/kg or Pediatric: 1 Metronidazole 2 Adult: (If Pediatric: /day 6mg/kg

spp.

Etiology

, Haemophilus , , S., aureus , H., influenzae pneumoniae viridans viridans the presence of Endocarditis (prosthetic valve) (prosthetic of Endocarditis presence the S. NO FOCUS NO

In the presence of congenital heart disease heart of congenital presence the In S. S. In National Antibiotic Guidelines

67 breaks in in breaks

necessary.

are .

estations of of estations shock.

and S. aureus S. Oxacillin

Comments ith diffuse or focal neurologic neurologic or focal diffuse ith sensitive sensitive - diagnosis.

ndice, hepatomegaly, hepatomegaly, ndice, Early diagnosis and treatment treatment and diagnosis Early If methicillinIf to shift documented,

1g IV q6h IV 1g

6 years old. level of consciousness, neck pain, stiffness, photophobia, photophobia, stiffness, neck pain, consciousness, of level 20mg/kg IV q8 20mg/kgIV - hour q8h hour of the CSF is the gold standard for gold standard CSF the ofis the

Chloramphenicol

Culture PLUS hour q8h hour Regimen IVdiv q6h (pediatric) or 15 q6h (pediatric) IVdiv

ay MU IV q4h MU

/d 4

60mg/kg 21 days21

CENTRAL SYSTEMNERVOUS INFECTIONS

(<12 years): 20mg/kg IV infused over 1 over IV infused 20mg/kg years): (<12 14-

Penicillin

1 over infused IV 10mg/kg

line:

nd Supportive treatment Supportive and varicella (MMR), rubella mumps, measles, and months, 9 at vaccine measles with be immunized should Children 4- at given MMR is of booster A months. 12 at vaccines Aciclovir Pediatric: Adults: Duration: 2 Vancomycin 12h (adult)

Etiology

may enter the central nervous system by hematogenous spread, at the time of craniotomy, or through a ventricular shunt. Manif shunt. a ventricular or through craniotomy, time of the at spread, by hematogenous system nervous the central enter may meningitis. bacterial acute thoseof to similar be may meningitis

, Streptococci , with or birth from surface ting presen the over lesions skin herpetic following: the include may neonates in infection (HSV) virus simplex herpes of Findings Candida Candida the skin, oropharyngeal involvement, keratoconjunctivitis, seizure, irritability, bulging fontanels. Severe signs include jau include signs Severe fontanels. bulging irritability, seizure, keratoconjunctivitis, involvement, oropharyngeal skin, the symptoms, including the following: behavioral and personality changes, with a decreased with changes, personality and behavioral following: the including symptoms, seizures. focal or generalized Encephalitis is an inflammation of the brain usually caused by viral infections. The classic presentation is encephalopathy w encephalopathy is presentation The classic infections. viral caused by brain usually the of an inflammation is Encephalitis

• Fungal Meningitis Fungal simplex Herpes Viral including, measles, influenza, influenza, measles, including, Viral arboviruses enteroviruses, • Encephalitis • Spinal Abscess Spinal aureus S. National Antibiotic Guidelines

68 in the the in

n fluid and n fluid

lucytosine K+ at least least at K+

F and Comments

0, repeat the lumbar tap to drai tap the lumbar repeat 0, 2 antifungal of 5 weeks for allow to ART Defer signs until daily tap lumbar Repeat therapy. intracranial increased of and symptoms improve. consistently pressure MonitorBUN, creatinine recommended. is shunts of Removal weekly. includes regimen The ideal not available is drug this but phase, induction cm >25 If pressure CSF Philippines. the in H control pressure. control

) ours and altered mental status, personality changes, changes, personality status, mental altered and dult h

a ( 6 6 hours - - once daily daily once , and , ours

IV y fatal without appropriate therapy, and death may occur occur may and death therapy, appropriate without y fatal 6 over 2 over 400mg

headache /day 800mg ;

1mg/kg 1mg/kg once over 2 once over once - IV IV

0.7

qd INFECTIONS pediatric);

( /day /day

q24h 1mg/kg 1mg/kg ediatric) (p 12mg/kg IV - - - 200mg PO PO 200mg 6 0.7 0.6

Regimen can result in harmless colonization of the airways, meningitis or disseminated disease, disease, disseminated or meningitis the airways, of colonization harmless in can result

is afebrile and cultures are negative negative are cultures and afebrile is

/day 12mg/kg Fluconazole -

negative is CSF culture after weeks 12

Fluconazole 6 patient

10- Amphotericin deoxycholate B Amphotericin

dose of 0.1mg/kg/dose IV to a maximum dose 1mg of maximum a IV to 0.1mg/kg/dose dose of

until negative is culture CSF weeks12 after

) test CENTRAL SYSTEMNERVOUS several weeks until resolution of CSF, radiographic and radiographic CSF, of resolution weeks until several 10- daily x daily

ours dult h 60 min. If tolerated, initiate with 0.25mg/kg over 2- over 0.25mg/kg with initiate If tolerated, min. 60 a

(

Fluconazole 6

mediated immunity. Cryptococcal meningitis is usuall is meningitis Cryptococcal immunity. mediated - Cryptococcus neoformans Cryptococcus clinical abnormalities clinical For less severely ill: ill: severely less For /day by0.25mg/kg increase IV/PO Duration: Induction Phase: Induction 2- over Duration: Duration: deoxycholate B Amphotericin PLUS Amphotericin B deoxycholate B Amphotericin Start with a 20- over (approximately 6 weeks) (approximately phase: Consolidation

AIDS) -

Etiology Meningitis from 2 weeks to several years after symptom onset. The most common symptoms include include symptoms most common The onset. symptom after years several to weeks 2 from and coma. obtundation, lethargy, confusion, Infection with the encapsulated yeast yeast encapsulated the with Infection cell defective with persons in especially

Cryptococcal meningitis associated with HIV/AIDS with associated meningitis Cryptococcal Phase Induction Cryptococcal meningitis (non meningitis Cryptococcal

Candida Candida • National Antibiotic Guidelines

viral load. viral

Comments Begin after successful induction therapy therapy induction successful after Begin improvement clinical as substantial (defined tap). on repeat culture CSF and negative 3 least at x cells/μL >100 CD4 once stop May undetectable and with months

200mg PO

; ; 400mg IV or IV or 400mg ; pediatric) (

pediatric) (

q24h once daily

/PO Regimen

q24h IV

/day /day 12mg/kg - 6 3mg/kg

CENTRAL SYSTEMNERVOUS INFECTIONS daily at least 8 weeks 8 at least daily year1 at least daily daily at least 2 weeks 2 at least daily

) ) dult dult a a Duration: Fluconazole ( Fluconazole ( Duration: Duration:

Etiology

therapy) Suppression (chronic maintenance maintenance (chronic Suppression Consolidation phase Consolidation National Antibiotic Guidelines

659. 679. Practices(ACIP).

o Antimicrobial Therapy Therapy o Antimicrobial unization unization ne on the management of of management the on ne of Pediatric Infectious Diseases Diseases Infectious Pediatric of

op Med Int Health 2011;16(6): 672- 2011;16(6): Health Int Med op prognosis on January 13, 2016. 13, on January prognosis 10. and- -

treatment

outcome on January 13, 2016. 13, January on outcome devices. - 30. - month and- INFECTIONS -

other

one- and- - than - treatment al meningitis in older children and adults. Europ J Neurol 2008; 15: 649- 15: 2008; J Neurol Europ and adults. children older in meningitis al - e - shunts older Handbook CA. Reyes delos MR, AT, Pagcatipunan Lim - neonat - h: Treatment and prognosis. UptoDate 2016. Accessed from from Accessed 2016. UptoDate prognosis. and Treatment h: system - children the - - in in - - - nervous - - Ong CC, Lazarte CENTRAL SYSTEMNERVOUS meningitis meningitis - - central - of -

85.

r CY. Etiology of neonatal sepsis in five urban hospitals in the Philippines. PIDSP J PIDSP Philippines. the in hospitals urban five in sepsis neonatal of Etiology CY. r LoboAguila LimJJ, JG, EE, Gallardo MAC, Bunyi CC, Lazarte

2011; 12(2): 75- 12(2): 2011; 2016 http://www.uptodate.com/contents/bacterial MMWR 2013; 62 (No.2). 2013; MMWR community meningitis: report of an EFNS Task Force on acute bacteri ofon acute an EFNSTask Force report meningitis: community http://www.uptodate.com/contents/bacterial 2012, 5th edition. Section of Infectious and Tropical Diseases, Manila 2012, pp 28- 2012, Manila Diseases, and Tropical Infectious of Section edition. 5th 2012, www.uptodate.com/contents/infections - Maramba Furyk, J.S., O. Swann, and E. Molyneux. Systematic review: neonatal meningitis in the developing world. Tr world. developing in the meningitis neonatal review: Systematic Molyneux. and E. O. Swann, J.S., Furyk, t Guide Sanford editors. BS Schwartz Kim K, DO, Freedman DB, AT, Black Pavia GM, MS, Saag Eliopoulis HF, DN, Chambers Gilbert Kaplan SL, Bacterial meningitis in children older than one mont one than older children in meningitis Bacterial SL, Kaplan - 24:1 2008; Focus Neurosurg. Children. in Abscesses Brain of Management GI, Jallo ES, Ahn JL, Frazier - Maramba ML, Gonzales SR, Gatchalian LC, Bravo the Imm of Recommendations Disease. of Meningococcal and Control Prevention 2013. Prevention. and Disease Control for Centers Chaudhuri, A., Martin PM, Kennedy PGE, Seaton RA, Portegies P, Bojar M, Steiner I for the EFNS Task Force. 2008. EFNS guideli EFNS 2008. TaskForce. EFNS the I for M, Steiner Bojar P, Portegies RA, Seaton PGE, Kennedy PM, Martin A., Chaudhuri, Edwards MS, Baker CJ. Bacterial meningitis in the neonate: Treatment and outcome. UptoDate 2016. Accessed from Accessedfrom 2016. UptoDate and outcome. Treatment neonate: in the meningitis Bacterial Baker CJ. MS, Edwards REFERENCES at: Accessed 2016. UptoDate devices. other and shunts system nervous central of Infections T. Fekete PM, Flynn LM, Baddour National Antibiotic Guidelines

Comments

There has been a marked decrease in in decrease a marked has been There influenzae H. universal with areas in incidence cheek as marked Manifests immunization. symptoms. systemic and trismus with swelling in recommended not generally is Treatment may Paracetamol patients. immunocompetent be should aspirin but analgesic, as an used be third One syndrome. Reye prevent to avoided sores). (cold lesions recurrent have would

INFECTIONS ays d

7 -

. This may be triggered by any condition which would depress the immune immune the depress would which by any condition This triggered be may .

(amoxicillin component) PO div div PO component) (amoxicillin

ay q8h x 5

2g PO2g q12hdoses x2

Regimen ay Candida /d

/d 45mg/kg DENTAL AND ORAL 50mg/kg IV q24h IV 50mg/kg

15mg/kg

Valaciclovir ays d ays 14 d amoxiclav -

7 7

Aciclovir

Co Ceftriaxone

significant mouth discomfort, fever, lymphadenopathy, and oropharyngeal vesicular eruptions leading to difficulty difficulty to leading eruptions vesicular and oropharyngeal lymphadenopathy, fever, discomfort, mouth significant

line: line:

st nd q12h Duration: Pediatric: Adult:and yrs >12 Duration: 1 2

CTIONS Usually with a history of a recent upper respiratory tract infection or sinusitis. infection tract respiratory upper ofrecent a a history with Usually

;

1 and 2

years old years

limiting disease may cause cause may disease limiting - Etiology

system (diabetes, malignancy, immunodeficiency, AIDS, corticosteroids, radiation, etc.) or intake of antibiotics. of or intake etc.) radiation, corticosteroids, AIDS, immunodeficiency, malignancy, (diabetes, system Oral candidiasis Oral of by an overgrowth caused is condition this thrush, oral called Also

in eating and drinking. This may lead to dehydration in young children and may require hospitalization. require and may young children in dehydration to lead may This and drinking. eating in virus simplex Herpes This usually self usually This Herpes Simplex Virus Gingivostomatitis Simplex Herpes H. influenzae, S. pneumoniae influenzae, H. Buccal Cellulitis <5 children in Seen National Antibiotic Guidelines

DENTAL ORAL INFE AND

5 days. 14 days to -

is preferred for for preferred is y take 10 y take Comments welling inferior to the mandible, mandible, to the inferior welling

C,or osteomyelitis. Initial IV therapy is o preferred and may step down to oral therapy therapy oral step to may down and preferred 3- in improvement clinical once with Recurrent infections may be the first signs of signsof first the be may infections Recurrent HIV infection. Fluconazole disease. severe to moderate deep because needed is consult Dental is of the tooth extraction or scaling periodontal pulp. infected the eliminate to necessary any of if necessary is only treatment Antibiotic or facial onset acute arepresent: following the oralswelling, s fever lymphadenopathy, dysphagia, trismus, >38.3 oral

(amoxicillin q6h (ampicillin Miconazole Miconazole

div div OR amoxiclav - IV

q8h

Co div q12h div ay

div

daily PO 200mg ay

100- ay /d 400mg /d

/d 45mg/kg 200- q6h IV 3g Regimen /kg40mg Fluconazole Fluconazole DENTAL AND ORAL INFECTIONS , until local inflammation has resolved has resolved inflammation local until ays, 20- 300mg PO q8h PO 300mg d

amoxiclav sulbactam sulbactam sulbactam - - - 14 - ays 7 Co

about 7

oral suspension 100,000 U/mL, 4mL qid qid 4mL U/mL, 100,000 suspension oral

Clindamycin Clindamycin Clindamycin Ampicillin Ampicillin

: :

line line line: line:

st nd st nd Adults: 875/125mg bid 875/125mg 2 component) component) 2 component) component) : Duration Pediatric: 1 1 completely. Nystatin qid area affected to apply 2%, gel adult: for option Another Duration: apical abscessapical

- , peri sp.

other other

and

Etiology

, Actinomyces, Actinomyces, , mutans Poryphoromonas, Prevotella Fusobacterium, S. Abscesses may form because of extension of microorganisms through the root apex. Radiographic evidence of bone destruction ma destruction bone of evidence apex. Radiographic root the through microorganisms of extension because of form may Abscesses malaise. and pain face, swollen ver, fe with and present cellulitis causing tissues the through spread may Infections develop. Anaerobes Dentoalveolar infection or or infection Dentoalveolar Odontogenic Infections Odontogenic Candida albicans Candida National Antibiotic Guidelines

ere pain or HIV HIV or pain ere

. Comments f the oral cavity, the gingiva is is the gingiva cavity, oral the f or associated with puberty, blood blood puberty, with associated or C,or osteomyelitis

Also called trench mouth or Vincent’s angina. angina. Vincent’s or mouth trench called Also and adults. adolescents older in found Usually a within shouldbe followed therapy Antibiotic by a curettage gingival daysby localized few hydrogen 0.5% with rinses and oral dentist chlorhexidine. 0.12% or peroxide Acute gingivitis in children may be induced by induced be may children in gingivitis Acute plaque other or deficiency, nutritional dyscrasias, fungi. or such asherpes infections any of if necessary is only treatment Antibiotic or facial onset acute arepresent: following the mandible, to the inferior swelling swelling, oral fever lymphadenopathy, dysphagia, trismus, º >38.3

500mg PO PO 500mg bid 875/125mg 500mg PO q8h) PO 500mg amoxiclav - INFECTIONS Co amoxiclav Metronidazole Metronidazole -

OR Co

) Metronidazole Metronidazole PLUS PLUS OR 8h -

Regimen PLUS PO div q6- div PO

POq6

ay ay DENTAL AND ORAL 300mg PO/IV q8h PO/IV 300mg 500mg PO q6h PO 500mg

300mg PO/IV q8h 300mgPO/IV ay 4g/d q6h (Max: div necessary are antibiotics systemic if ays,

d 0.12% oral rinse oral 0.12%

500mg q6h PO /d 75mg/kg /d 500mg

ays PO d

10 - 50-

7 ay 250- : 10 Penicillin

Clindamycin s

Penicillin VK (

OR Clindamycin Clindamycin

is Penicillin VK Adult: /d 30mg/kg : ears y 12 Duration: 875/125mg bid 875/125mg Duration: q8h) q8h) ( OR Chlorhexidine Pediatric: year <12

Spirochetes Spirochetes

systemic antimicrobial therapy. Antiseptic rinses are adequate in most cases. In patients with rapidly advancing disease, sev disease, advancing rapidly with patients In cases. most in adequate are rinses Antiseptic therapy. antimicrobial systemic Etiology Oral anaerobes, anaerobes, Oral Signs and symptoms include foul breath, gingival pain, malaise, and thick ropy saliva with or without fever. On examination o examination On fever. without or with saliva ropy thick and malaise, pain, gingival breath, foul include and symptoms Signs contagious. not is The condition papillae. interdental the on pseudomembrane a with and ulcerated edematous Acute necrotizing ulcerative gingivit ulcerative necrotizing Acute Oral anaerobes, anaerobes, Oral Rarely requires requires Rarely necessary. be may therapy systemic infection, Acute gingivitis Acute National Antibiotic Guidelines

gival pocketing pocketing gival C,or

does not respond respond doesnot trismus, dysphagia, dysphagia, trismus,

Comments

Dental consult is necessary; it can usually be usually can it necessary; is consult Dental plaque and debridement root with controlled condition If the only. control of drainage because needed is consult Dental After performed. be pusshould loculated tissues pulpal infected resolution, abscess and scaling subgingival by removed be should only is treatment Antibiotic planing. root present: are anyof thefollowing if necessary swelling swelling, or oral facial onset acute mandible, to the inferior to conservative management then antibiotics antibiotics then management conservative to started. be should º >38.3 fever lymphadenopathy, osteomyelitis.

q8h

(amoxicillin component) (amoxicillin

div

bid

PO div q8h div PO PO

div div

/day /day ay Regimen 300mg PO q8h PO 300mg 50mg/kg /kg40mg

200mg PO 200mg /d 45mg/kg bid 875/125mg DENTAL AND ORAL INFECTIONS 20- 150- ays ays d d amoxiclav amoxiclav

- -

Doxycycline 7 7 Metronidazole

: Clindamycin Clindamycin Co Co : :

: ears ears line line y y line: line:

st nd st nd 2 Adult: 2 Duration: Duration: Duration: Duration: Pediatric: 1 1 <8 ≥8

red, fluctuant swelling of the gingiva, which is extremely tender to palpation. The abscess is always in communication with a with communication in always The abscess is palpation. to tender extremely is which gingiva, of the swelling fluctuant red, ,

20 years old. This condition occurs in otherwise healthy children and is localized to the molar and incisor regions. Deep gin Deep regions. and incisor themolar to localized and is children healthy otherwise in occurs condition This 20old. years

(Actinobacillus) (Actinobacillus)

Etiology

Anaerobes periodontal pocket. periodontal Fusiform, mutans, Streptococcus Periodontal abscess Periodontal a as manifests condition This Capnocytophaga Aggregatibacter Actinomycetemcomitans Affects children 10 children Affects area. in this loss tooth cause and may occur and bone resorption Juvenile periodontitis Juvenile National Antibiotic Guidelines

75 negative negative - and

he infection is is infection he

Gram

Comments ting permanent teeth. If the the If teeth. permanent ting pathy. Immunocompromised Immunocompromised pathy. , drooling neck, stiff pain, outh of management include treatment of Mainstays is Surgery antibiotics. empiric airway, the by identified are abscesses if only necessary necessary only is treatment Antibiotic imaging. and such asfever signs systemic for lymphadeno or have MRSA may patients Mainstays of treatment include saline gargle, saline include treatment of Mainstays pain hygiene, oral good of maintenance drainage and incision and local management only is treatment Antibiotic dentist. bya such asfever signs systemic for necessary . and lymphadenopathy

PLUS

induration.

may present with fever, m fever, with present may

doses 4 OR INFECTIONS

q6h (ampicillin q6h (ampicillin

atient div div p

8h) 500mg q8h 500mg div

equally div doses div equally q6- IV

The ay 8h ay /d q6-

U/kg Regimen IV Amoxicillin

/d 400mg OR DENTAL AND ORAL 200-

400,000 40mg/kg/day IV in in IV 40mg/kg/day ay 40mg/kg/d

- 22.5 500mg q6h 500mg 20- ays

250,000-

OR d

tam sulbac

- 7

Penicillin G Clindamycin Metronidazole component) component) ( Adult: Pediatric: Ampicillin Penicillin VK Duration:

, . , sp

sp.

, rapidly spreading, bilateral cellulitis of the submandibular space which includes the sublingual space and the mylohyoid. T mylohyoid. the space and sublingual the includes which space of the submandibular cellulitis bilateral spreading, rapidly ,

and other other and

Etiology denticola

drainage is blocked, this may lead to infection of adjacent soft tissues and fascial spaces. and fascial tissues soft adjacent of infection to lead may this blocked, is drainage an aggressive an threatening due to the possibility of asphyxia and aspiration pneumonia. pneumonia. and aspiration ofasphyxia possibility due tothe threatening - S. mutans, Actinomyces, Actinomyces, mutans, S. Prevotella Fusobacterium, dysphagia. Typically, there is no lymphadenopathy, but with tender, symmetric, “woody” symmetric, tender, with but no is lymphadenopathy, there Typically, dysphagia. Poryphoromonas anaerobes It isIt life Ludwig’s Angina Ludwig’s Prevotella, Porphyromonas Prevotella, Treponema Microorganisms and debris may be impacted under the soft tissue overlying the crown of the tooth in a third molar orany erup molar a in third the tooth of crown the overlying tissue soft the under be impacted may and debris Microorganisms natural Pericoronitis Pericoronitis National Antibiotic Guidelines

Comments infections. Broad spectrum coverage is is coverage spectrum Broad infections. patients. these for required

8h)

500mg IV q6- IV 500mg

Metronidazole

OR 8h Regimen PLUS 6h DENTAL AND ORAL INFECTIONS 3g IV q6h q6h IV 3g

600mg IV q6- 600mgIV 4 MU IV q4- 4 MU IV - 2

3 weeks until clear evidence of clinical improvement is is improvement clinical of evidence clear until 3weeks - sulbactam

- 2

Clindamycin Clindamycin

Penicillin G present, and fever and leukocytosis have disappeared. If complications complications If disappeared. have and leukocytosis fever and present, be necessary. may courses longer arise, Duration: Ampicillin ( OR

Etiology

National Antibiotic Guidelines

77 Waltham,MA.

of Pediatric Infectious Diseases Diseases Infectious Pediatric of d Guide to Antimicrobial Therapy Therapy Antimicrobial to d Guide Waltham, MA. (Accessed on February on February (Accessed MA. Waltham, SB, (Eds), A SB, Bloom

edition. Volume 1, Cherry JD, Harrison Harrison JD, Cherry 1, Volume edition.

th Handbook 802. Program 2015 Annual Report, Manila, Philippines Philippines Manila, Report, Annual 2015 Program Calderwoood

SB, Bloom A (Eds), UpToDate, A (Eds), Bloom SB, 78.

summary_1.pdf on September 7, 2016. 7, September on summary_1.pdf - report - SB, Bloom A (Eds), UpToDate, A (Eds), Bloom SB,

INFECTIONS annual - 44:57 2011; Amer N

155.

ARSP- MR, delos Reyes CA. CA. Reyes delos MR, AT, Pagcatipunan Lim Otolaryngol Clin

DENTAL AND ORAL a review. Journal of clinical and diagnostic research 2014;8 2014;8 research diagnostic and clinical of Journal —a review. childhood in diseases Gingival H.

2017).

23, - Ong CC, Lazarte

Parthasarthy

- content/uploads/2016/06/2015 Calderwoood UpToDate, in fections in odontogenic of treatment and GM, Saag MS, Pavia AT, Black DB, Freedman DO, Kim K, Schwartz BS editors. Sanfor editors. BS Schwartz Kim K, DO, Freedman DB, AT, Black Pavia GM, MS, Saag

Eliopoulis bach WJ, Hotez PJ. Elsevier, Philadelphia, 2014. pp 140- pp 2014. Philadelphia, PJ. Elsevier, Hotez WJ, bach

4. Waltham, MA. (Accessed on February on February (Accessed MA. Waltham,

2017.) A, Ilango P, Subbareddy V, Katamreddy V, V, Katamreddy V, P, Subbareddy A, Ilango 2016. VA: Antimicrobial Therapy, Inc.; 2016. Inc.; Therapy, Antimicrobial VA: 2016. (10): Ze01– (10): UpToDate, 2012, 5th edition. Manila: Section of Infectious and Tropical Diseases; 2012. Diseases; Tropical and ofInfectious Section Manila: edition. 5th 2012, - http://arsp.com.ph/wp at Accessed 2016. GJ, Kaplan SL, Stein SL, Kaplan GJ, (Accessed on February 23 2017.) 23 on February (Accessed 23 Simos C, Gonzalez BE. Infections of the Oral Cavity. Feign and Cherry’s Textbook of Pediatric Infectious Diseases, 7 Diseases, Infectious Pediatric of Textbook Cherry’s and Feign Cavity. of the Oral Infections BE. Gonzalez C, Simos - Maramba ML, Gonzales SR, Gatchalian LC, Bravo 008; 77(55): 797 - 77(55): 008; 2 FamAm Physician Setting. Care Primary the in Infections Dental JT. Common Martin DHN, Do Pari Chow AW. Epidemiology, pathogenesis and clinical manifestations of odontogenic infections in UpToDate, UpToDate, in infections odontogenic of manifestations clinical and pathogenesis Epidemiology, AW. Chow Chow AW. Complications, diagnosis, diagnosis, Complications, AW. Chow

Gilbert DN, Chambers HF, HF, Chambers DN, Gilbert National Antibiotic Guidelines

REFERENCES Surveillance Resistance Health.Antimicrobial of Department Laboratory, Surveillance Resistance Antimicrobial

Levi ME, Eusterman VD. Oral Infections and Antibiotic Treatment. and Antibiotic Infections Oral VD. Eusterman ME, Levi Calderwoood in UpToDate, Angina) (Ludwig’s space infection Submandibular AW. Chow 78

Comments

For children with severe dehydration living in in living severe dehydration with children For give cholera, cases of reported with area an acute cases of For cholera. for antibiotic stool), the in (blood dysentery with diarrhea

(when 2 of the following signs are present) are signs following the (when2 of

(when there are not enough signs to classify patient’s patient’s classify enoughto not signs are there (when

250mg PO qid x qid PO 250mg

ays Skin pinch goes backslowly pinch Skin Restless, irritable Sunken eyes Sunken thirsty eagerly, Drinks

d dehydration No - Some dehydration Some - severe) or as some status - -

Tetracycline

x 3

ays INFECTIONS d

2 doses Regimen div div Cryptosporidium

PO MINAL

/day (ETEC),

250mgPO qid x 3

e GASTROINTESTINAL AND OTHERINTRAABDOMINAL INFECTIONS 30mg/kg

: rs

ays Escherichia coli Escherichia

5 d -

Ciprofloxacin 0 Erythromycin 3 Vibrio cholera

, Shigella

AND OTHERAND INTRAABDO

Shigella

(when 2 of the following signs are present) are signs following of 2 the (when

is defined as diarrhea lasting less than 14 days. Mainstay of treatment is to give fluids, zinc supplements, and food. and food. supplements, zinc give fluids, to is treatment of Mainstay 14 days. than less lasting as diarrhea defined is

Rotavirus, ETEC, ETEC, Rotavirus, Rotavirus, Rotavirus,

: : Etiology Rotavirus, Enterotoxigenic Rotavirus,

: 23 months 23 59 months 59 - Skin pinch goes back very slowly goes backvery pinch Skin Sunken eyes Sunken poorly or drinking drink able to Not Lethargic or unconscious Lethargic

- 12- - - Suspected cholera Suspected Suspected dysentery Suspected 24 Etiology by age: Etiology months <12 - Classification of dehydration status of children 2 months to 5 years of age (IMCI 2014): age (IMCI 5 yearsof to months 2 children of status dehydration of Classification dehydration Severe Acute diarrhea diarrhea Acute Acute Diarrhea and Gastroenteritis Diarrhea Acute in Children Diarrhea Acute

GASTROINTESTINAL National Antibiotic Guidelines

79 diarrhea diarrhea

Vancomycin

mild disease does does disease mild

10 days after daysafter 10

ries and the pentavalent pentavalent the and ries for 3 days. For suspected suspected For days. 3 for

Comments e locally. dose se

associated colitis, associated - Ciprofloxacin dose series. dose series. - not warrant antibiotic treatment since since treatment antibiotic warrant not 7- within resolve symptoms human bovine rotavirus vaccine is given as a as given is vaccine rotavirus bovine human 3

give give antibiotic Probiotic antibiotics. precipitating discontinuing treatmentof children with C. difficile Oral studied. been well has not availabl not is Immunization of infants starting at 6 weeks of starting of infants Immunization attenuated live 2 available of either age with afford to recommended is vaccines rotavirus disease. rotavirus severe against protection is vaccine rotavirus human The monovalent as a 2- given

ays d

ays

d 10

- 75- OR ays

d - x 7

ays 10 ays - d d

daily 7

x 7 14 -

- Erythromycin x 5

Ceftriaxone

x 10 OR

ays ays d

2 doses d ays

PO div 2 doses div PO d

PO div 3 doses div PO

x 3

Regimen PO div 3 doses div PO IV or PO div or 4 dosesx10 IV /day

IV div PO

/day PO div 4 doses especially for patients with with patients for 4 dosesespecially div PO

POx 5 /kg /day /day ays /day /day d /50mg 50mg/kg - 10

35 15mg/kg 30mg/kg

30mg/kg 6mg/kg/day 10mg/kg IV x 14 IV

/day 40mg/kg PO div 4 dosesx5 div PO

GASTROINTESTINAL AND OTHER INTRAABDOMINAL INFECTIONS /day trimoxazole - /day 100mg/kg Azithromycin 40mg/kg Metronidazole Metronidazole Co OralHydration Metronidazole Vancomycin Ciprofloxacin Azithromycin severe disease severe

Salmonella

associated associated -

s old, s old, 3 unformed 3 unformed

< ( ntyphoidal ntyphoidal Etiology histolytica

symptomatology) stools/day; minimal associated associated minimal stools/day; Gastroenteritis (infectious diarrhea) in Adults diarrhea) (infectious Gastroenteritis Diarrhea Mild Cyclospora Entamoeba Giardia children immunocompromised malnourished and malnourished Campylobacter nth mo <6 infants Suspected Suspected in diarrhea of severe setting the in or with prolonged symptoms symptoms prolonged with or Suspected antibiotic Suspected as disease severe presenting colitis National Antibiotic Guidelines

Comments

Try to make specific diagnosis, especially in in especially diagnosis, specific make to Try systemic or severe diarrhea with patients symptoms.

ays d 500mg 500mg OR 10

Levofloxacin Levofloxacin ays

d Tetracycline

OR 500mg PO q24h for 3 q24h for PO 500mg OR

of asciticfluid IV div 4 or 6 doses div IV

- 7 x tid PO 750mg

500-

2 doses

- ) ays 500mg PO bid x 3 x bid PO 500mg Azithromycin Azithromycin 500mg PO 500mg q12h d

Regimen 300mg x 1 dose x1 300mg 200mg/kg/d

OR x 3 IV div 1

ays Metronidazole Metronidazole d

5 Ciprofloxacin

Ciprofloxacin Ciprofloxacin

Cefotaxime Doxycycline Doxycycline

2g PO dailyPO 2g : :

ay 100mg/kg/d /μ neutrophils 250 ≥ and fever, histolytica: GASTROINTESTINAL AND OTHERINTRAABDOMINAL INFECTIONS ays therapy: d

(preferredfor Campylobacter 3

Tinidazole x

ays Shigella species: Shigella d e cholera Vibrio OR Specific therapy: Specific Ceftriaxone Empiric q24h x 3- PO 500mg Entamoeba qid pneumoniae S. Oral or Parenteral Hydration or Parenteral Oral

50%; 50%; -

40%), - toxin toxin (30

(Toxin (Toxin

(25 Salmonella

(Toxin (Toxin

4 unformed 4 unformed , -

(3 sp.

4%), Group A - (enterotoxigenic, (enterotoxigenic,

Etiology oxytoca K. Cryptosporidium

Shigella , Giardia lamblia,E.

S. pneumoniae S.

E. coli : C. jejuni,C. difficile , Parasitic: producer) - Shiga enteroaggregative, producing) Staphylococci Pediatric E.coli common), most Characterized by a patient with cirrhosis, ascites, ascites, cirrhosis, with patient bya Characterized Primary spontaneous bacterial peritonitis (SBP) peritonitis bacterial spontaneous Primary histolytica sp. cytes) leuko fecal or Bacterial: Severe Diarrhea (≥ 6 unformed unformed 6 (≥ Diarrhea Severe blood tenesmus, fever, ± stools/day symptoms) Moderate Diarrhea Diarrhea Moderate systemic orwithout with stools/day; positive)

National Antibiotic Guidelines

81 luid

may cause bile sludge sludge cause bile may Comments

Ceftriaxone

in patients with jaundice or cirrhosis. Maintain Maintain cirrhosis. or jaundice with patients in surgical Do balance. and electrolyte fluid as soon as antimicrobials Start consult. ally.medic managed Generally possible. adjunctive the no use in have Probiotics treatment. Perform analysis (check bleeding parameters parameters (check bleeding analysis Perform f of peritoneal culture and stain Gram first), secondary from primary distinguish to peritonitis. IV - x

x -

OR 4.5g IV 4.5g

2doses

- 6 doses - Ampicillin ays 200,000

/day 7.5mg/kg Ciprofloxacin - OR

3 2g IV2g q24h OR IV div 1

IV div 4 OR tazobactam tazobactam

- -

PO ays Penicillin G d threatening infection) infection) threatening -

14 Gentamicin Ceftriaxone

species (e.g., ESBL)] (e.g., species

Piperacillin /day 100mg/kg

400mg q12h x 7 PO 200mg/kg/day OR

: aqueous : 400mg/dose OR div 4 doses (ampicillin component) 4 doses (ampicillin div Regimen

ays Klebsiella d /day x 7 Ceftriaxone

3g IV q6h IV 3g Cefotaxime Norfloxacin

( :

2g IV q8h (q4h, if life if (q4h, q8h IV 2g E. coli, Norfloxacin

WITH or or WITH WITHOUT OR Monotherapy with Piperacillinwith Monotherapy S. pneumoniae

IV in 6 div doses x 10- doses x div 6 in IV

200mg/kg - OR IV div 3 doses (piperacillin component) component) 3 doses (piperacillin div IV

epends on clinical course of the patient. the of course clinical epends on PO 1g IV q8h IV 1g 1g IV1g daily

of SBP: of 1g IV q24h IV 1g 100

sulbactam GASTROINTESTINAL AND OTHER INTRAABDOMINAL INFECTIONS

- Unclear. Treat at 5 days and perhaps longer if documented documented if 5longer at and perhaps days Treat Unclear. Resistant Resistant [ hour infusion of 4.5g q8h) q8h) 4.5g of infusion hour sensitive sensitive

- to 3 weeks 3 weeks to to 3 weeks 3 weeks to Cefotaxime

negative bacilli: negative - ays ays d d line:

: uration st D D . bacteremia Meropenem 10 10 2nd line: q6h (or 4- q6h (or Ertapenem Gram /day 300mg/kg Prophylaxis Prophylaxis ose 500 mg/d sulbactam 1 Ampicillin cirrhosis with Patients Ceftriaxone Penicillin ay U/kg/d 300,000 doses) div 3 in

, sp. , S. ,

Enterococci eported , r Enterococcus Etiology

sp. e pneumonia

Enterobacteriaceae

lactamase (ESBL) positive positive (ESBL) lactamase Low protein ascites (

• Anaerobes, Extended spectrum spectrum Extended Anaerobes, - beta Klebsiella Prophylaxis of SBP of Prophylaxis Patients with cirrhosis: Variceal or or Variceal cirrhosis: with Patients bleeding GI upper Antibiotic Prophylaxis Antibiotic Adult: , pneumoniae Streptococcus Klebsiella National Antibiotic Guidelines

Comments

related infections and peritonitis in and peritonitis infections related - drainage procedure if a limited number of large of number large a limited if procedure drainage shown. be can abscesses Patient may require either immediate surgery surgery immediate either require may Patient to and contamination of source the control to and intestinal blood tissue, necrotic remove or a cavity al peritone the from contents

Meropenem but the the but

Cefotaxime

OR ays d PLUS azobactam

t 10 -

Piperacillin

Until liver transplantation, death, death, transplantation, liver Until IV div div 3 doses IV

Regimen ) /day (piperacillin component) component) (piperacillin for SBP: for

6 doses - 40mg/kg - IV div 3 doses div IV 22.5

IV div 3 doses div IV IV div 4

rophylaxis Antibiotics are generally given for 5- for given generally are Antibiotics GASTROINTESTINAL AND OTHERINTRAABDOMINAL INFECTIONS

/day 60mg/kg uration of P of uration Metronidazole 30- DURATION: clinical patient’s the is treatment antibiotic of duration for basis primary course. /day 300mg/kg resolution of ascites or improvement in liver function to a compensated tocompensated a function in liver improvement or ascites of resolution state. ( /day 200mg/kg D

fragilis E. coli , ,

recommendations based on the Consensus Guidelines for Prevention and Treatment of Catheter of Treatment and Prevention for Guidelines Consensus the based on recommendations Etiology Enterococcus seudomonas bilirubin > 3 mg/dL) bilirubin

associated peritonitis Children in peritonitis associated associated peritonitis associated Peptostreptococcus - - Prior episode of SBP of episode Prior Pugh score > 9 points with with 9 points > score Pugh serum dysfunction renal and/or > mg/dL, 1.2 creatinine (serum serum and/or 25 mg/dL > BUN mEq/L) 130 < sodium Advanced liver failure (Child failure liver Advanced

• •

pediatric patients receiving peritoneal dialysis (2012 update): (2012 dialysis peritoneal receiving patients pediatric CAPD the are The following Infectious complication of chronic ambulatory peritoneal dialysis (CAPD) dialysis peritoneal ambulatory chronic of complication Infectious CAPD group, group, Usually polymicrobial consisting of of consisting polymicrobial Usually Gram facultative and anaerobes Secondary peritonitis peritonitis Secondary Bacteroides bacilli: negative Klebsiella, P aeruginosa,

National Antibiotic Guidelines

83 - negative flora is is flora negative -

cefepime as empiric as empiric cefepime adding drugs to dialysis dialysis to drugs adding Comments

lactam antibiotics should be administered be administered should antibiotics lactam - seen on Gram yeast if only an antifungal Add stain A positive Gram stain will help guide initial guide initial help will stain Gram positive A Gram polymicrobic If therapy. catheter of possibility consider cultured, induced bowel perforation, and/or concomitant concomitant and/or perforation, bowel induced dead bowel). (e.g., pathology GI underlying abdominal to always limited almost Infection rare. is bacteremia complicating cavity; by usually Treated documented, or is is likely bacteremia if fluid; treatvia IV route.

PLUS

route. Beta

400mg IV IV 400mg and at least 50% of the WBCs are polymorphonuclear are polymorphonuclear WBCs of the 50% least and at 3 Meropenem

4 doses - OR

Ciprofloxacin

3g loading dose loading 3g

8h Regimen IV or intraperitoneal in3 duration of of duration for basis primary the but

IV div 3 doses div IV Ceftazidime 2g IV q6- IV 2g

effluent WBC count > > WBC count 100/mm effluent - 2g IP q24h or q48h q24h or 2g IP IP 2g 1 ays

/day OR d 20mg/kg IV q24h IV 20mg/kg 12h 15- –

is the patient’s clinical course. clinical is the patient’s 60mg/kg - /day 7.5mg/kg Aztreonam - 45 fluid. dialysis the to added

3 enerally, 10 enerally, GASTROINTESTINAL AND OTHER INTRAABDOMINAL INFECTIONS 2g IV q8 IV 2g G OR

Amikacin

OR management.

: uration therapy antibiotic q12h D Vancomycin Gentamicin Vancomycin Cefepime 1- then (IP), intraperitoneal q8h IV 1g

or co-

, related peritonitis can be made if the if made can be peritonitis related

30%) -

Acinetobacter (20

(0.1%) (6%), 45%), Etiology - recommends ISPD the although therapy antibiotic empiric of selection guide should patterns susceptibility antibiotic specific - (30

associated peritonitis Adults in peritonitis associated - positive cocci (45%), (45%), cocci positive (15%), bacilli negative positive organisms, organisms, positive - - -

treatment. Refer to a specialist f ato specialist Refer treatment. Center continuously. Antibiotics for the treatment of bacterial peritonitis should be administered by the intraperitoneal bythe administered be should peritonitis bacterial of the treatment for Antibiotics Empiric diagnosis of of PD diagnosis Empiric be cultured. should and sediment centrifuged be should Effluent leukocytes.

• Enterobacteriaceae Pseudomonas (4%) • tuberculosis M. Mixture (1%),Fungi (2%), Gram CAPD Gram coagulase negative staphylococci, staphylococci, negative coagulase aureus S. Gram • National Antibiotic Guidelines

Comments

High cure rate is achieved with VP shunt shunt VP achieved with is rate cure High removal

30-

IV div of the the of

4 doses -

Meropenem

dose series at a minimum age of 12 months. A second dose is given given is second dose A age months. 12 a minimum of at dose series /day 200mg/kg OR

IV div 1 or doses 2 div IV

Cefotaxime div 3 div doses IV doses 1 monthdoses apart 1

Regimen IV or intraperitoneal div 3 2 but the primary basis for duration for basis primary the but

– is the patient’s clinical course. clinical patient’s the is

/day100mg/kg IM single dose single IM

ays /day IM L

d recommended L between 6 & 12 months after initiation of primary course is recommended to ensure long term term long ensure to recommended is course of primary initiation after 12 months 6 & between

/day 300mg/kg 60mg/kg - div 3 doses div : infections negative - Ceftriaxone

45 IV

200-

enerally, 10 enerally, GASTROINTESTINAL AND OTHERINTRAABDOMINAL INFECTIONS G

forGram 1440 ELISA units/m ELISA 1440 720 ELISA units/m 720 ELISA

Booster dose Booster vaccine A Hepatitis Monovalent antibody titers. antibody - - 6 doses OR : uration

patient’s antibiotic treatment antibiotic patient’s ay 60mg/kg/d D • Ceftazidime 4 at least 6 months from the first dose. first the from months 6 least at No antiviral treatment is as a 2- intramuscularly is given vaccine A Hepatitis measures supportive Give is recommended. treatment antiviral No A vaccination: Hepatitis exposure, of 2 weeks within If • Vancomycin PLUS

Etiology

peritoneal shunt peritonitis shunt peritoneal positive/negative positive/negative - - negative bacilli negative - HepatitisA inAdults HepatitisA inChildren HepatitisA Coagulase Staphylococci Ventriculo Gram

National Antibiotic Guidelines

85 of birth

ours h

Comments

hours of life. HBIG HBIG be should life. of hours

of life. ours 2 kg, administer HBV within 12 within HBV administer 2 kg, h ) within 12 > L

dose was received at birth. at received was dose

) mothers and medically stable, the first dose of HBV may be given at 30 days of daysof 30 be given may at dose HBV of the first stable, and medically ) mothers -

Regimen might be preferred over Hepatitis A vaccination among seronegative individuals with with individuals seronegative among A vaccination Hepatitis over be preferred might last dose was given at age < 24 weeks. age < at given dose was last

. fatigue, nausea, anorexia, myalgias, arthralgias, asthenia, weight loss (except where ascites). where (except loss weight asthenia, arthralgias, myalgias, anorexia, nausea, fatigue, GASTROINTESTINAL AND OTHER INTRAABDOMINAL INFECTIONS immediately available. not immediately age, if daysof 7 than later not administered For preterm infants, if born to HBsAg ( to HBsAg born if infants, preterm For dose of Another series. 3 dose of the primary aspart cancounted be and this weight, of regardless age chronological 1st thosewhose 2 kg < for needed is HBV Refer to a to specialist Refer The of life. hours 12 first orthe within birth at given dose is The first intramuscularly. is given vaccine B Hepatitis Another weeks. age 24 than earlier not is dose administered final The 4 weeks. betweendoses is interval minimum the needed if dose is (0.5m and HBIG HBV administer mothers, HBsAg born (+) to infants For is weight birth if status, HBsAg unknown with mothers born to infants For age. than7 days of not later HBIG administer (+), HBsAg If possible. as assoon status HBsAg mother’s and determine 12 HBV within to addition in HBIG of administer kg, <2 weight birth with If A single dose of immunoglobulin 0.02mL/kg IM is protective if administered within 2 weeks of exposure but is not locally not locally is but exposure of 2 weeks within if administered protective is IM 0.02mL/kg immunoglobulin of dose single A Immunoglobulin available. disease. liver underlying significant

Etiology

HepatitisB inChildren HepatitisB virus include complaints common symptomatic, When elevation transaminase or stage and disease symptoms between correlation poor is There HepatitisB asymptomatic. areusually (HBV) B Hepatitis with Patients National Antibiotic Guidelines

ascites).

Comments 3 doses IM at 0,1,6 months at IM 3 doses 0,1,6

–

6 months to observe spontaneous spontaneous observe 6 months to

(20μg/mL recombinant) recombinant) (20μg/mL

B months 0,1,6 at doses 3 IM (20μg/mL)

(720 ELISA units) and units) ELISA (720

. Regimen

. Vaccine B Hepatitis Recombinant Combined Hepatitis A Hepatitis Combined

GASTROINTESTINAL AND OTHERINTRAABDOMINAL INFECTIONS

negative. negative. to HBeAg+ from seroconversion Vaccination: recommended referral Specialist effective. not globulin serum immune prophylaxis; recommended No Referral to a specialist is recommended for management of hepatitis cases. hepatitis of management for recommended is a specialist to Referral a to specialist Refer (ALT liverenzymes elevated DNA), (HBV load viral HBV status, HBeAg treatment: for key indicators are The following 3- for deferred typically is treatment patients, For HBeAg+ cirrhosis. level),

transaminases).

single or multiple abscesses on abdominal ultrasound or or CT ultrasound on abdominal abscesses or multiple single

Etiology

f persons with acute infection progress to chronic HCV. chronic to progress infection acute with of persons 85% Fever, right upper quadrant tenderness quadrant upper right Fever, with consistent Findings Liver Abscess Liver 75- HepatitisC virus When symptomatic, common complaints include fatigue, nausea, anorexia, myalgias, arthralgias, asthenia, weight loss (except if (except with loss weight asthenia, arthralgias, myalgias, anorexia, nausea, fatigue, include complaints common symptomatic, When failure. hepatic with associated rarely days to weeks; in abates usually symptomatic, If Usually asymptomatic (elevated asymptomatic Usually HepatitisC HepatitisB inAdults

National Antibiotic Guidelines

87 , MRSA ) are) - onidazole may cause bile bile cause may

Metr azobactam t Carbapenem

Comments

(or other

- Piperacillin Ertapenem alone and active sufficiently If MRSA is suspected, start on anti on start suspected, MRSA is If of treatment on to section (refer regimen MRSA infections). Ceftriaxone cirrhosis. or jaundice with patients in sludge done be should for amebiasis tests Serological mixed or anaerobic For patients. all on infections be discontinued. may

6h IV nd

30- PLUS (2 8h 3 weeks 3 weeks Ceftriaxone - [

4.5g IV q4- 4.5g IV

Levofloxacin OR

Metronidazole ) for) 2 ) /day 300mg/kg

ay ay OR Metronidazole

: PLUS 750mg IV/PO tid x 10 x tid IV/PO 750mg

) 16g/d azobactam - t or 500mg PO q6- PO 500mg or ay /d 2.25g IV div 4 doses (ampicillin 4 doses (ampicillin div IV 9 -

azobactam

t q8h 4g/d

/day - Max: suchas Diloxanide cides : 0.75:

1g IV1g q24h) : 2 :

div div

ays E. histolytica d Max ( - Piperacillin Max Regimen Metronidazole ] 6 weeks

x 10 200mg/kg - - Piperacillin

bacterial versus amoebic liver abscess: liver versus amoebic bacterial em Ertapen 100

OR 2 doses ( 2 doses - 400mg IV q12h OR 750mg PO PO 750mg OR q12h IV 400mg /day IV /day 40mg/kg Intraluminal amoebi Intraluminal IV div 3 doses div IV

2g q24h IV OR IV q24h 2g 30- - IV in1

1 IV div 3 doses div IV Sulbactam GASTROINTESTINAL AND OTHER INTRAABDOMINAL INFECTIONS -

Ciprofloxacin

/day 50mg/kg ays Ceftriaxone If amoeba serology is positive: serology amoeba If OR q24h OR PO/IV 750mg FOLLOWED BY infection. luminal to cure agent) line /day 50mg/kg div 3 doses (piperacillin component) ( component) 3 doses (piperacillin div 30- then shift to oral to complete 4- complete to oral to shift then to secondary abscess hepatic For ( Pending determination of of determination Pending Metronidazole d Ampicillin 8g) (Max: component) /day 100mg/kg

Klebsiella

and

esp

Etiology

histolytica . canis

Toxocara (Lemierre's) sp.) sp. Bacteroides sp. Enterococcus E. histolytica Fusobacteriumnecrophorum Enterobacteriaceae ( Enterobacteriaceae Liver Abscess in Adults in Abscess Liver In developing countries, may may countries, developing In consider K. pneumoniae, K. organisms Anaerobic E. coli Salmonella 50% polymicrobial 50% aureus S. sp. Streptococcus Liver Abscess in Children in Abscess Liver National Antibiotic Guidelines

i Comments baumanni

acalculouscholecystitis in over 95% of 95% in over acalculouscholecystitis

Laparoscopic cholecystectomy is the most most the is cholecystectomy Laparoscopic calculous acute for treatment surgical common or when options treatment Other cases. pediatric not is cholecystectomy open or laparoscopic cholecystostomy. include feasible

x 14- 6 doses - ays div 4 doses div d

21 IV div 4

x 14-

IV div 3 doses div IV appendix, ruptured diverticula, ischemic bowel, leaking surgical surgical leaking bowel, ischemic diverticula, ruptured appendix, /day 200mg/kg

3 doses (piperacillin div IV

/day 200mg/kg 100-

div 3 doses div /day /day 3.75mg/kg Regimen sulbactam - Cefotaxime

300mg/kg

/day 22.5mg/kg Gentamicin 15-

Ampicillin

tazobactam OR

- pneumoniae, Pseudomonas aeruginosa, Enterobacter cloacae, Acinetobacter cloacae, Enterobacter aeruginosa, Pseudomonas pneumoniae, GASTROINTESTINAL AND OTHERINTRAABDOMINAL INFECTIONS Amikacin

OR ays (ampicillin component) OR component) (ampicillin d Piperacillin component) or WITH WITHOUT ,

, abdominal infections abdominal -

Klebsiella coli, Escherichia Abdominal Infections Abdominal abdominal abscess or other like conditions. like other or abscess abdominal - s formation or or absces s formation either with associated space and is peritoneal the into origin of viscus hollow the extendsbeyond infection abdominal cholecystitis is is cholecystitis

Leptospirosis Leptospirosis Streptococci

Etiology

negative bacilli (like (like bacilli negative - ). Enterococcus gutluminal flora (E. coli,Klebsiella . interrogans for shouldcover therapy Antibiotic ) and ) Salmonella Clinical Setting Common pathogens: pathogens: Common intra complicated Biliary ruptured bowel perforation, due to flora by bowel cavity peritoneal of Contamination - intra anastomosis, peritonitis. Complicated Intra Complicated - intra Complicated caused by an infection secondary to to secondary infection an caused by and B A Groups Acute acalculous Acute usually and children in uncommon Gallbladder Infection Gallbladder Gram

National Antibiotic Guidelines

gallbladder gallbladder

established infection infection established 7 days, unless it is is it unless 7 days, Comments

Antimicrobial therapy of of therapy Antimicrobial to 4- limited be should control. source adequate achieve to difficult been have not therapy of durations Longer outcome. improved with associated Obtain surgical consult for possible possible for consult surgical Obtain cholecystectomy undergoing Patients removal. have should cholecystitis acute for 24 within discontinued therapy antimicrobial infection of evidence is there unless hours of thegallbladder. wall the outside -

1 12h 2g IV2g

400mg 400mg 400mg 400mg 1g IV IV 1g

2g IV q8-

Ceftriaxone

Cefepime

OR Meropenem OR Ciprofloxacin

Ciprofloxacin

( Ciprofloxacin

Cefepime OR

OR 1g IV q24h IV 1g

OR PLUS PLUS PLUS PLUS 8h -

1.5g q8h IV

12h 12h 12h 12h 750mg IV q24h IV 750mg 4.5g IV q6h 4.5g 4.5g IV q6h 4.5g

2g IV q6 IV 2g Ertapenem

Regimen OR 1.5g IV q8h OR 1.5g IV Cefuroxime Cefuroxime 750mg IV q24h IV 750mg 750mg IV q24h IV 750mg

500mg IV q8- IV 500mg 500mg IV q8- IV 500mg q8- IV 500mg q8- IV 500mg OR OR azobactam 1g IV q8h IV 1g t tazobactam tazobactam

- - Levofloxacin

1 Cefotaxime 2g q6h IV

OR OR 2g IV q8h IV 2g 2g IV q8h IV 2g Levofloxacin 24h Levofloxacin - -

GASTROINTESTINAL AND OTHER INTRAABDOMINAL INFECTIONS 1 1 24h

Metronidazole Metronidazole Metronidazole Metronidazole Meropenem Cefoxitin Piperacillin Piperacillin

line: line: line: line: 12h) line: line: line: line:

- q12 IV 2g - nd st nd st nd st st nd 2g IV q12- IV 2g q8- 1 2 1 2 q12h OR IV 1 q8h 2 Cefazolin 1 1 2 400mg IV q12h IV 400mg q12h OR IV Cefazolin

abdominal infections abdominal

- - :

severe severe moderate moderate

- to Etiology associated biliary biliary associated acquired acute acute acquired acquired acute acute acquired - - is of severe physiologic physiologic of severe is moderate severity moderate moderate severity moderate - - biliary complicated intra complicated biliary - to to - - ge, or immunocompromised state immunocompromised or ge, a physiologic disturbance, advanced advanced disturbance, physiologic High risk orseverity: risk High perforated or abscessed or perforated of infections other and appendicitis mild Extra Mild – care Health any severity of infection any severity of entericanastamosis Acute cholangitis following bilio following cholangitis Acute Community cholecystit disturbance, advanced age, or or age, advanced disturbance, state immunocompromised Community - ofmild cholecystitis severity National Antibiotic Guidelines

ay assist in in ayassist Comments ed until vital signs and GI and GI signs vital until ed

Current consensus is that use of prophylactic prophylactic use of that consensusis Current but pancreatitis, in advisable not is antibiotics clinical when employed be should they that necrosis. pancreatic toinfected point factors more or of 30% involving necrosis Those with ofdeveloping risk at greatest are pancreas the infection.

LUS P

1g IV1g q8h

amination by diversion or resection, and restore anatomic and anatomic and restore resection, or by diversion amination Ciprofloxacin

abdominal infection. abdominal

OR ileus. Some centers continue antibiotics until the serum procalcitonin procalcitonin serum the until antibiotics continue centers Some ileus. 750mg IV q24h IV 750mg

Meropenem

2g IV q8h q8h IV 2g

6h -

Levofloxacin 750mg IV q24h IV 750mg

Regimen OR 12h Ceftazidime

4.5g IV q4 4.5g

OR Levofloxacin 12h

- in the area of necrosis, rising inflammatory markers or persistent fever may be suspected of having having of suspected be may fever persistent or markers inflammatory rising necrosis, of area the in OR 500mg IV q8– IV 500mg 400mg IV q12h IV 400mg

azobactam t - GASTROINTESTINAL AND OTHERINTRAABDOMINAL INFECTIONS

2g IV q8 IV 2g

or has decreased by 90% from its peak concentration. peakconcentration. its from by 90% or has decreased

L Piperacillin Ciprofloxacin Metronidazole Cefepime q12h IV 400mg mg/m

Enterococcus

, Etiology , Candida Candida , Anaerobes inuity had returned (mean of 8 days). All patients had "source control". Normalization of serum procalcitonin concentration m concentration procalcitonin serum of Normalization control". had "source patients All 8 days). of (mean had returned inuity <0.25 is concentration serum Severe peritonitis: need source control and resolution of fever, leukocytosis and leukocytosis fever, of and resolution control source need peritonitis: Severe cont Mild or moderate peritonitis: clinical trial found comparable clinical outcomes in patients treated for 4 days4 treat for vs those treated patients in outcomes clinical found comparable trial clinical peritonitis: or moderate Mild customizing the duration of of therapy. duration the customizing Necrotizing pancreatitis, infected pseudocyst or pancreatic abscess pancreatic or pseudocyst infected pancreatitis, Necrotizing -

S. aureus, Staphylococcus Staphylococcus aureus, S. • •

An appropriate source control procedure to drain infected foci, control ongoing peritoneal cont peritoneal ongoing control foci, infected to drain procedure control source appropriate An - intra with patients all nearly for recommended is feasible extent the to function physiological epidermidis, epidermidis, sp. sp., Enterobacteriaceae infected pancreatic necrosis and would be candidates for antibiotic therapy. antibiotic for candidates be and would necrosis pancreatic infected Post Acute Pancreatitis Acute gas develop who pancreatitis necrotizing with Patients Duration of therapy is variable and clinical trial data, especially for severe disease is sparse: disease severe for especially data, trial and clinical is variable of therapy Duration

National Antibiotic Guidelines

91 91

1324. hospitalized children. Philipp J Philipp children. hospitalized reatment of legionella of legionella reatment

relative importance of various various of importance relative

53.

. Philadelphia: Elsevier; 2015. Elsevier; Philadelphia: The Asian perspective, Annals of Medicine and Surgery 3 (2014) 85- (2014) 3 and Surgery of Medicine Annals perspective, The Asian

Infect Dis 1990;19(2): 51- 1990;19(2): Dis Infect ladelphia: Elsevier; 2015. 2015. Elsevier; ladelphia: 164. ildren: Guidelines by the Surgical Infection Society and Society Infection Surgical the by Guidelines and ildren: Ch Adults in Infection abdominal //webedition.sanfordguide.com/ based study in urban Philippines. SEAMIC Publication (1987). Publication SEAMIC Philippines. urban basedin study - abdominal infections in in adults: infections abdominal

GASTROINTESTINAL AND OTHER INTRAABDOMINAL INFECTIONS

205.

The Sanford Guide to Antimicrobial Therapy 2016. Available at: http: at: Available Therapy 2016. to Antimicrobial Guide The Sanford Manila: Philippine Foundation for Vaccination; 2012. Vaccination; for Foundation Philippine Manila: in of diarrhea Etiology Tupasi T. Z, Forbes E, Sanvictores E, Trajano R, C, Ang Mate J, F, Leano M, Geronimo Saniel M, Lucero 1984. Dis Infect Microbiol the t for fluoroquinolones versus azithromycin of analysis Retrospective JM. Pogue Alaniz C, AW, Crowley RE, Rarus JL, Nagel - 39:204 2014; PT. pneumonia. 2012. Filipinos for Immunization Adult on Handbook Diseases. Infectious and biology Micro for Society Philippine and the Vaccination for Foundation Philippine A. The Balis J, Geronimo J, Villanueva L,R, Mat Sombrero B, Trajano Leano F, N, Salazar R, O, Monzon Moriles M, Saniel hospital a diarrhea: acute of etiology the in enteropathogen - Intra Complicated of Management and Diagnosis al. et JS, Solomkin - 2010;50(2):133 Dis. Infect Clin America. of Society Diseases Infectious the r Inc, 2016. Inc, r Elsevie Pennsylvania: Philadelphia, 20thedition, Pediatrics, of Textbook Nelson N. J, Schor Geme St. B, Stanton RM, Kliegman - intra of complicated management Antibiotic al. et A, Kurup Cherry J, et al. Feigin and Cherry's Textbook of Pediatric Infectious Diseases, 7th Edition. Edition. 7th Diseases, Infectious Pediatric of Textbook and Cherry's Feigin al. et J, Cherry Phi 2015. edition, 20th Pediatrics, of Textbook Nelson’s et al. RM, Kliegman National Antibiotic Guidelines

REFERENCES JMicrobiol Philipp iarrheas. d of epidemiology and M. Saniel Etiology C, Carlos 2014. Inc., Elsevier iladelphia: Ph Diseases. Infectious Pediatric of Textbook and Cherry's PJ. Feigin Hotez WJ, Steinbach SL, Kaplan GJ, Harrison JD, Cherry 2014 March Organization; Health rld Geneva: Wo Booklet. Chart Illness Childhood of Management Integrated - 60:1310 014; JHepatol2 2013. Conference Special EASL the based on statement position A in cirrhosis; infections Bacterial al. et R, Jalan

related infections and peritonitis in pediatric patients receiving peritoneal peritoneal receiving patients inpediatric peritonitis and infections related -

6 8 GASTROINTESTINAL AND OTHERINTRAABDOMINAL INFECTIONS

- S32 Suppl2: 2012 Jun;32 Int. Dial Perit update. 2012 dialysis: Warady BA, et al. Consensus guidelines for the prevention and treatment of catheter of and treatment prevention the for guidelines Consensus al. et BA, Warady National Antibiotic Guidelines

steroid -

4 weeks. Antibiotic alone alone Antibiotic 4 weeks.

Comments warm compresses, gentle lid lid gentle compresses, warm

The decision to use an antibiotic use an to The decision call dependjudgment the on will combination inflammation of on thedegree physician the of Avoid eyeliner, mascara, false eyelashes and eyelashes false mascara, eyeliner, Avoid extensions. eyelash about education patient involves Treatment term long need for and chronicity disease regular hygiene with to lid commitment of application washing. lid and massage 3 months. 6 to for recurrences prevent to Topical antibiotic steroid combination during during combination steroid antibiotic Topical 2- for phase acute the Apply Apply

(50:50 mixture) mixture) (50:50

100mg PO bid x 2 weeksx2 bid and PO 100mg

) continuously using cotton, gauze or face towel over the affected area for for area over the affected towel face gauze or cotton, using continuously 45ºC) Regimen 150mg/kg PO div q6h div PO 150mg/kg - OCULAR INFECTIONS 100

- (40 compress moist Warm

Cloxacillin Usually, topical antibiotic ointment of no benefit of ointment antibiotic topical Usually,

Topical antibiotics may provide symptomatic relief. symptomatic provide may antibiotics Topical

15 minutes; may repeat as often as necessary. as often may repeat minutes; 15 . eyes dry associated with if tears artificial No antibiotic. 10- Pediatric: q24h using a clean washcloth, gauze pad, or cotton swab. cotton or gauze pad, washcloth, a clean using q24h Pediatric: Adult: Doxycycline rosacea: acne associated If then q24h. q24h. then water warm and baby shampoo carewith margin lid Do

superficial superficial

S. epidermidis S. Etiology

and

of the meibomian glands glands meibomian of the

Infection . meibomianitis called also and is Internal hordeolum Internal sebaceous gland (eyelash follicle) (eyelash gland sebaceous External hordeolum hordeolum External of the infection External aureus S. Hordeolum (Stye) Hordeolum S. aureus aureus S. Blepharitis include but may unclear, Etiology well as associated seborrhea, seborrhea, as associated well eye dry rosacea, National Antibiotic Guidelines

OCULAR INFECTIONS

94 S.

. 57%. Orbital cellulitis is at

Comments

Oxacillin showed increased resistance of of resistance increased showed

Oxacillin Incision and curettage for chalazion. chalazion. for and curettage Incision to

a serious infection with risk of cavernous sinus sinus of cavernous risk with infection a serious coverage MRSA with Antibiotics thrombosis. Forconfirmed started. promptly be should MSSA, shift to aureus involved. Incision and drainage if with pointing pointing with if and drainage Incision involved. abscess. Rarely chronic. or te, subacu be acute, Can need Incision may and spontaneously drain . culture with and Drainage life and potentially serious is cellulitis Orbital for specimen obtain to best is It threatening. to treatment prior testing and sensitivity culture is consultation Surgical initiation. recommended. 2017 ARSP )

)

IV/POin PLUS

4 times a 4 doses - - 0mgPO 2 tabs

80 / IV in3

] 160 hot packs hot

ay 30mg/kg/d

PLUS

Tobramycin) or topical ay 4g/d 2 doses(Max:

- 600mg PO bid bid PO 600mg

IV in 4 div doses (Max: 4g/d (Max: doses div 4 in IV q12h Dexamethasone3 )

- trimoxazole - ay 300mg/kg/d ay ay) 4g/d doses (Max: in 4 div IV

IV in1 Co dose

Metronidazole 240-

Regimen ay) 4g/d div4 doses (Max: in IV Linezolid 500mg PO q6h PO 500mg ADD

60mg/kg/d ] ] Levofloxacin - 10mg/kg/ OCULAR INFECTIONS

250- : 45 associated:

ay mg/kg/d 60 OR rs acquired: acquired: ) ay 100mg/kg/d - tazobactam 30mg/kg/day in 2 div doses (Max: 1.5g PO PO 1.5g div 2 doses (Max: in 30mg/kg/day - 45- ay 60mg/kg/d 20- 45-

s to <5 yea <5 s to steroidointment (Tobramycin Vancomycin - [ nth

Piperacillin Ceftriaxone ay) 16g piperacillin/d (Max: component) acillin /800mg IV daily IV /800mg Vancomycin

[ line:

st Ciprofloxacin For children with serious allergy to PCN and/or cephalosporins: and/or PCN to serious allergy with children For (piper PLUS OR If with odontogenic source, odontogenic with If Vancomycin ≥6 mo For MRSA, hospital MRSA, For PLUS ay) 4g/d doses (Max: 4 div bid day. 1 Adults: Cloxacillin MSSA: For ForMRSA, community - daily Topicalantibiotic ointment (Erythromycin, [ antibiotic

Streptococci

Etiology

S. aureus, S. aureus, , including, methicillin

streptococcus hemolytic : - , Anaerobes (odontogenic (odontogenic Anaerobes , trauma) - b Aeromonas Aeromonas causes: Uncommon aeruginosa, P. hydrophila, influenzae H. corrodens, Eikenella type bacilli negative Gram source), (post

catarrhalis Grp A, B M. pneumoniae, S. pyogenes, S. or Pediatric Orbital Cellulitis S. aureus S. strains and resistant sensitive

National Antibiotic Guidelines

95 ment in in ment

Comments 36 hours. 36 -

ENT is required. Surgical debridement is is debridement Surgical required. is ENT medical if abscesses or with warranted an improve to to lead fails management thefirst 24 Close consultation with ophthalmology and /or and /or ophthalmology with consultation Close

)

600mg IV q8h IV 600mg 4.5g IV IV q8h 4.5g

ays d

4 doses (Max: 2g/day 4 doses(Max: 1g IV q12h IV 1g - 1g IV q12h IV 1g 14 -

tazobactam Clindamycin Clindamycin - IV in3

600mg IV q12h 600mgIV PLUS Ceftriaxone Regimen 12h) 12h) Metronidazole Piperacillin (

q24h (Max: 500mg) (Max: q24h Linezolid

, IV in 3 doses3 in IV IV in 2 doses2 in IV OCULAR INFECTIONS 500mg PO tid x 10 tid PO 500mg

ay 200mg/kg/d

ADD depending on clinical response on clinical depending dose

100-

ays intolerant ocular motion; CT with mucosal swelling but no fluid collection. no collection. but fluid swelling mucosal with CT motion; ocular 400mg IV q8- IV 400mg 1g IV q12h PLUS IV 1g

14 d 14 amoxiclav -

- ay 1200mg/d ay 30mg/kg/d considered:

10 mg/kg/ 10

7 IV:

: is Linezolid Co

Cefotaxime : ears line:

Vancomycin nd , source odontogenic f f If MRSA is not considered: not MRSA is If <12 y <12 For serious allergy to penicillins and/or cephalosporins: cephalosporins: and/or topenicillins allergy serious For If MRSA MRSA If Vancomycin Stage I: Stage Stage – II Ciprofloxacin I I : years ≥12 PLUS Duration: ≥ 5 years 5 ≥ 2

trauma), trauma), -

(GroupA),

bacilli(post (severe (severe sp.

Etiology sp. ophthalmoplegia with visual loss; CT with proptosis, abscess formation and periosteal rupture. and periosteal formation abscess proptosis, with CT loss; visual with ophthalmoplegia involved. muscles extraocular displacement, be glo abscess, subperiosteal CT loss, visual occasional

- extra limited proptosis, chemosis, edema,

negative negative

- neutropenia, HIV) neutropenia, Gram Mucormycosis (in patients with with patients (in Mucormycosis Invasive ketoacidosis), diabetic Aspergillus S. pneumoniae, H. influenzae, M. M. influenzae, H. pneumoniae, S. Anaerobes S. aureus, catarrhalis, source), (odontogenic Streptococcus Stage IV: Stage Stage II: Stage III: Adult: normal. CT swelling; lid anterior Stagecellulitis, preseptal I: National Antibiotic Guidelines

Comments of granules and local irrigation with an with irrigation and local granules of

Ophthalmologic consultation is needed and is consultation Ophthalmologic studies culture do to be required may surgery (todetect MRSA). Empiric systemicantibiotic aspirate, ofthe stain Gram based on is therapy infection, of the severity child, the age of Adjust tions. complica of and type presence results. on culture based therapy of cases in considered be may Hospitalization associated with infection bacterial suppurative

500

or daily)

Cefepime Cefepime

trimoxazole 15- 6 weeks if if 6 weeks - PLUS Cephalexin negative negative

- Co

doses 400mg IV q12h IV 400mg

(if Gram

2g IV q24h OR IV 2g Vancomycin Vancomycin

4 div

in IV

500 to 750 mg IV or PO or PO IV mg 750 500 to ay 875mg PO bid bid PO 875mg 3 div doses3 div Ciprofloxacin Ciprofloxacin ( Regimen in Ceftriaxone Ceftriaxone

PLUS OCULAR INFECTIONS PLUS 40mg/kg/d

amoxiclav depending on clinical response; 4- response; on clinical depending Levofloxacin Levofloxacin - 12h Co -

ays

d OR 1g IV q12h q12h IV 1g 21 bid PO tablets IV q8 ay 100mg/kg/d

ild infection limited to lacrimal sac and lid: lacrimal to limited infection ild 2

10-

Vancomycin

For m For

bone changes are suggestive of osteomyelitis. of suggestive are changes bone Withsigns or symptoms oforbital cellulitis: Duration: ay 20mg/kg/d 2g IV q6h if pseudomonal infection is suspected is infection pseudomonal if q6h IV 2g dacryocystitis is entertained). is dacryocystitis Adult: 500mg PO qid qid PO 500mg Pediatric: Ceftazidime 160/800mg Apply hot packs to punctal area qid. Referral to ophthalmologist for removal for ophthalmologist to Referral qid. area punctal packs to hot Apply solution. antibiotic Vancomycin Vancomycin OR bid PO 750 mg to

- ue to obstruction of the lacrimal duct. the lacrimal of obstruction to ue sp., . ; d ; S.

Alpha

Arachnia

Nocardia , Etiology , Staphylococci, Staphylococci, , (all rare)

sp. Enterobacteriaceae aeruginosa, S. viridans, viridans, S. aeruginosa, epidermidis, S. aureus epidermidis, S dacryocystitis: Chronic P. influenzae, H. pneumoniae, hemolytic streptococci, hemolytic Acute dacryocystitis: dacryocystitis: Acute Dacryocystitis (Lacrimal Sac) (Lacrimal Dacryocystitis chronic or be acute Can

Streptococci; rarely rarely Streptococci; Candida Actinomyces Canaliculitis (Lacrimal apparatus) (Lacrimal Canaliculitis fusobacterium

National Antibiotic Guidelines

97 x 1

ointment0.5% Chlamydia trachomatis

Comments viral therapy under the direction of of direction the under therapy viral rythromycin rythromycin - E consultis advised. the Treat detection. by antigen Diagnosed No topical partners. and sexual mother needed. is treatment anti Topical ophthalmologist an lacrimal gland abscess. Oral agents may may be agents Oral abscess. gland lacrimal cases. severe less used for Hyperpurulentdischarge is observed. Treat neonate forconcomitant treatment inadequate.Topical is Ophthalmologic infection.Treat themother and sexualpartner.

2g IV q8h

Cefazolin

ays OR d

x 1 application

ays d

8x/day - 2g IV q6h q6h 2g IV

6 Regimen 1% ointment 1% Oxacillin

) OCULAR INFECTIONS 20mg/kg PO q24h x 3 PO 20mg/kg baseor ethylsuccinate syrup12.5mg/kg xq6h 14

Ciprofloxacin delivery ays - etracycline etracycline 50mg/kg IV x 1 dose not exceed 125mg x 1 dose not to IV 50mg/kg d - T

25 14

OR 7 60mg/kg/day IV div q8h x 14 q8h x div IV 60mg/kg/day

Azithromycin Erythromycin , Gentamicin

line: line:

nd ays st Irrigate conjunctiva with saline to remove discharge as often as needed asoften discharge to remove saline with conjunctiva Irrigate Aciclovir Ceftriaxone Topical 1 d No antibiotic. Chemical conjunctivitis is rare since usual prophylaxis involves use of of use involves prophylaxis usual since rare is conjunctivitis Chemical antibiotic. No application 2 Documented MSSA infection: MSSA Documented Duration:

by day of onset post onset byday of

(

types types

delivery) -

Etiology N.gonorrhoeae

Herpes simplex Herpes Chlamydia trachomatis Chlamydia daypost

: st 16 10: (1 - -

1, 2 Days 2 Days

Days 3 Days

Days 2 to 4: to 2 Days Day 1: Day nitrate silver to due chemical prophylaxis Conjunctivitis of the Newborn of the Newborn Conjunctivitis Conjunctivitis National Antibiotic Guidelines

98 steroid is is steroid -

14 days in daysin 14 - . Remove Remove .

with saline. with offer the best spectrum of of spectrum best the offer 4 hours for 7 for 4 hours - Comments limiting,topical antibiotic - contact lens wearers contact for those with poor compliance, and those in in those and compliance, poor with those

Ophthalmology consult recommended recommended consult Ophthalmology perforation. corneal to progress can it because to remove saline with conjunctiva Irrigate Ointment is preferred over drops for children, children, for drops over preferred is Ointment in eye to administer difficult is it whom vision blur ointments However, medications. administered. theafter dose is 20 minutes for Fluoroquinolones preferred the is It therapy. empiric for activity agent by irrigating discharge one to two drops every 3 drops every two one to

OR ays

7 -

steroid drops steroid -

Erythromycin

OR 2 drops qid x 5 qid 2 drops

e to be referred). be e to

ays d

Regimen PLUS 7 Tobramycin

Levofloxacin

OR OCULAR INFECTIONS

qid x 5- qid - 1 drop tid Consider short course topical antibiotic topical course short Consider 1g IV/IM x 1 dose IV/IM 1g

Levofloxacin Tobramycin

given to those with severe symptoms marked swelling and with membrane formation which can lead to permanent permanent to can lead which formation membrane and with swelling marked severe symptoms with those to given hav cases (these scarring conjunctival Ceftriaxone Highly contagious. If symptomatic, artificial tears may help. If with ocular pain and photophobia, suspect keratitis (rare). (rare). keratitis suspect photophobia, and pain ocular with If help. may tears artificial symptomatic, If contagious. Highly self is conjunctivitis adenoviral Although as needed. as often resses comp moist Cold drops: Eye cases with severe inflammation, membranes or epithelial defects. epithelial or membranes inflammation, severe caseswith drops: Eye acid Fusidic No antibiotic

7 in children 7 in

infection) - gonococcal) conjunctivitis gonococcal)

Etiology

(presumptive co (presumptive trachomatis Chlamydia Gonococcal Conjunctivitis Gonococcal gonorrhoeae N. H. influenzae, influenzae, H. sp. Moraxella S. aureus, S. pneumoniae, S. pneumoniae, aureus, S. S. viridans Bacterial (non Bacterial Viral Conjunctivitis (Pink eye) (Pink Conjunctivitis Viral 3 and Adenovirus

National Antibiotic Guidelines

recurwithin 1

) 30% Comments Thirty percent ( percent Thirty . Oral antiviral drugs are not necessary. not drugs are antiviral Oral . ear Obtain specimen for Gram stain and culture and culture stain Gram for specimen Obtain accordingly. treatment adjust and studies discharge as often as needed. Test patient for for patient Test as needed. as often discharge sex partner. Treat and syphilis. HIV so prompt threatening sight and often Serious for essential is consultation ophthalmologic adjunctive and antimicrobial, diagnosis, therapy. y until

from

ay infection infection OR - co ours

day to lesions on day to lesions 1g PO tid PO1g tid

Erythromycin x/ 3

- Chlamydia OR 2 drops q4h 2 drops

Valaciclovir ointment 2

ays d ays Tobramycin 3% ophthalmic ointment, 5x/d ointment, ophthalmic 3%

d Regimen eye drops 1- eye drops OR x 10 and older with recurrent infections (>2x a year), (>2x year), a infections recurrent with and older day OCULAR INFECTIONS

Aciclovir 10mg/kg IV (most effective within 72 within effective (most IV 10mg/kg ears Dexamethasone 500mg PO tid OR 500mg tid PO

symptoms of resolution 3 until or weeks Tobramycin 1g PO x 1 dose for presumptive presumptive PO1g for x 1 dose Levofloxacin

0.15% or or 0.15%

800mg PO 800mg 5x/ 400mg bid for 12 months may be given to prevent prevent to be given may 12 months bid for 400mg

Aciclovir

Topical Topical Famciclovir negative: - Tobramycin

- For those aged 12 aged those For ointment qid x 2- qid ointment Adult: Apply lesions. lid of resolution until eyelids the Pediatric: Gram Pediatric: vesicles) of appearance Aciclovir Ganciclovir x7 thentid heals, ulcer corneal Aciclovir Azithromycin PLUS recurrences.

thalmicus

1 and 2

Etiology

S. aureus, S. pneumoniae, S. S. S. pneumoniae, aureus, S. sp., Haemophilus pyogenes, Acute bacterial keratitis (no comorbidity) (no keratitis bacterial Acute virus zoster Varicella Varicella zoster op zoster Varicella Herpes simplex Herpes Keratitis Keratitis Herpes

National Antibiotic Guidelines

100 reatening reatening th

Comments

rompt consultation with an with consultation rompt P

Referral to ophthalmologist is is ophthalmologist to Referral recommended. use. lens contact Discontinue ophthalmologist is essential. essential. is ophthalmologist Topical steroids are never used in isolation. isolation. used in are never steroids Topical eye. the patch NEVER - a vision be can keratitis Bacterial . disease and other and other 72h then taper taper 72h then 0.5% eye drops 0.5%

2 drops qh x 24h then taper taper x24h then qh 2 drops

Levofloxacin 0.5% eye drops 0.5% OR

Regimen 0.5% eye drops 0.5% aeruginosa Pseudomonas

. Givedrop 1 - qh x 24 . solution . OCULAR INFECTIONS Levofloxacin % % eye drops 0.3% 3 0.

Levofloxacin 0.3% ophthalmic solution 1- solution ophthalmic 0.3% positive: positive: -

use

Gram bacteria. enteric negative positive: positive:

- - Tobramycin OR based on clinical response on clinical based Pediatric: Tobramycin response. based on clinical Adult: Ciprofloxacin Gram Consider systemic antibiotic for large (>6 mm) corneal ulcer, corneal corneal ulcer, corneal (>6 mm) large for antibiotic systemic Consider due to or scleritis perforation ophthalmologist to Refer Gram Adult:

S. aureus, S. aureus, S.

P. aeruginosa, aeruginosa, P.

Etiology , Enterobacteriaceae

Keratitis secondary to contact lens contact secondary to Keratitis P. aeruginosa P. Bacterial Bacterial

Dry cornea/diabetes, cornea/diabetes, Dry immunosuppression: pyogenes, epidermidis, S. pneumoniae, S. S. S. pneumoniae, epidermidis, sp. Listeria Also for children: children: for Also spp. Moraxella

National Antibiotic Guidelines

101

. retinal

Comments Topical cycloplegic (atropine (atropine cycloplegic Topical

ngal agents. ngal fu - mount and cultures. Empiric therapy is not recommended for for recommended isnot therapy Empiric mount and cultures. Treatment regimen is as for extrapulmonary tuberculosis (see (see tuberculosis as extrapulmonary is for regimen Treatment Use of powdered Itraconazole for topical use is not topical for Itraconazole of Use powdered

associated with trauma or soft contact lens use. NEVER patch the the patch NEVER use. lens contact soft or trauma with associated spectrum antibiotics to prevent secondary bacterial infection. Avoid Avoid infection. secondary bacterial prevent to antibiotics spectrum

identify organism from corneal scrapings. NEVER give topical steroid. NEVER NEVER steroid. topical give NEVER scrapings. corneal from organism identify

Regimen

- to vitreo referral Immediate essential. is of antimicrobials administration Intravitreal Corneal infection usually usually infection Corneal therapy. of course Prolonged Obtain specimen for fungal wet wet fungal for specimen Obtain . . . . OCULAR INFECTIONS

Lasik surgery) Lasik -

ocally usually due to penetrating or perforating globe injury by pointed material e.g. BBQ stick, walis tingting, wires tingting, walis stick, e.g. BBQ material bypointed injury globe perforating or penetrating due to usually ocally recommended. patch the eye. Daily debridement is advised to enhance penetration ofanti enhance penetration to advised is debridement Daily eye. the patch sulfate 1%) one drop 3 times a day until free of pain. of until free a day one droptimes 3 1%) sulfate surgeon. L ophthalmologist to Refer te 1%) one drop 3 times a day until free of pain. free until a day times 3 one drop 1%) te sulfa (atropine cycloplegic Topical steroids. and subconjunctival topical ophthalmologist to Refer ). Tuberculosis on Guidelines National fungal keratitis. It is importantto try to ophthalmologist to Refer - broad Topical use. lens contact Discontinue eye. Refer to ophthalmologist to Refer

or other other or

Bacillus cereus Bacillus

moniae

or other other or tuberculous Mycobacterial (Post Mycobacterial tuberculous - Etiology N. meningitidis. (rare),

negative organisms, organisms, negative - Candida sp. Candida (heroin use) (heroin streptococci, streptococci, Endophthalmitis, Hematogenous Endophthalmitis, pneumoniae S. Endophthalmitis M. abscessus, M. massiliense M. abscessus, M. Keratitis,Non chelonae, Mycobacterium Acanthamoeba sp. Acanthamoeba K. pneu aureus, S. Gram Keratitis, Protozoan Keratitis, Fungal keratitis Fungal Candida Fusarium, Aspergillus, National Antibiotic Guidelines

102

Comments

susceptible isolates, isolates, susceptible . -

f only light perception or worse, perform perform worse, or perception light only f with or without macular involvement and with with and involvement macular without or with byan determined be should vitritis) without or ophthalmologist decrease to be considered should Vitrectomy the allow and to organisms of burden the are abscesses that fungal of removal agents. antifungal systemic to inaccessible flucanozole For voriconazole. over preferred is fluconazole Immediate ophthalmologic consult is needed. needed. is consult ophthalmologic Immediate I of removal require May vitrectomy. immediate material. lens (chorioretinitis infection ocular of The extent

- 800mg (6 800mg -

loading dose, then 400 then dose, loading

400mg IV bid for 2 doses loading dose 2 doses loading for bid IV 400mg Regimen

. . . . OCULAR INFECTIONS

Voriconazole

OR 800mg PO (12mg/kg) PO 800mg

(6mg/kg), then 300mg (4mg/kg) IV/PO bid IV/PO (4mg/kg) 300mg then (6mg/kg), Refer to ophthalmologist to Refer ophthalmologist to Refer Fluconazole ) /day 12mg/kg ophthalmologist to Refer Refer to ophthalmologist to Refer

- -

negative negative cataract surgery cataract

- (rare), Fungi (rare),

Candida Gram-

/voriconazole /voriconazole aureus - -

Etiology S.epidermidis,

sp. sp.

Candida albicans Candida uconazole fluconazole bacilli, chronic: grade, Low With macular involvement macular With For For isolates resistant Forfl isolates susceptible Candida Chorioretinitis without vitritis Endogenous: occurs in ~15% of patients with candidemia with of patients ~15% in occurs Endogenous: injury. traumatic or surgery ocular following occurs Exogenous: Endophthalmitis, Propionibacterium acnes, S. S. acnes, Propionibacterium S. epidermidis, Enterococcus sp., Enterococcus Early, acute: Early, sp ., Streptococcus aureus, S. Endophthalmitis, Post Endophthalmitis,

National Antibiotic Guidelines

103 -

Comments

Ophthalmology consult imperative. consult Ophthalmology

OR vasculitis and uveitis; frequently results in retinal retinal in results frequently uveitis; and vasculitis

ay 5x/d PO 800mg

until disease stabilizes, then then stabilizes, disease until

500mg tid PO

ays

10 - Regimen delay in wound closure, intraocular foreign body). foreign intraocular closure, wound in delay Famciclovir ours

h . . 6 weeks with Aciclovir with 6 weeks OCULAR INFECTIONS

12mg/kg IV q8h x 7 12mg/kgIV 1g PO1g OR tid -

ophthalmologist

efer to ophthalmologist. ophthalmologist. to efer Valaciclovir retroviral therapy (ART). ART should not be delayed owing to concern of IRIS. of concern to owing not be delayed should ART (ART). therapy retroviral Watch for Immune Reconstitution Inflammatory Syndrome (IRIS) (e.g., Immune Recovery Uveitis) in those on anti those in Uveitis) Recovery Immune (e.g., (IRIS) Syndrome Inflammatory Reconstitution Immune for Watch Aciclovir a min of for therapy oral Refer to Refer to ophthalmologist to Refer injuries risk in high antibiotics intravitreal + systemic of administration prophylactic Consider necessary. often Vitrectomy >24 contamination, (soil R

Treatment Recommendations for Adult Inpatients. Available at: at: Available Inpatients. Adult for Recommendations Treatment Gram s, 2016. 2016.

traumatic di

Herpes Herpes

Etiology Begins unilaterally but may involve the other eye (up to 50% ofcases). 50% to (up eye other the involve but may unilaterally Begins

zoster virus, virus, zoster

- http://www.hopkinsmedicine.org/amp/guidelines/antibiotic_guidelines.pdf Cytomegalovirus (CMV) Cytomegalovirus Retinitis,Cytomegalovirus (HIV/AIDS) simplex Varicella Vision loss, usually in immunocompetent individuals, which progresses rapidly with retinal necrosis, necrosis, retinal with rapidly progresses which individuals, immunocompetent in usually loss, Vision detachment. Retinitis Necrosis Retinal Acute Bacillus sp., S.epidermi sp., Bacillus Fungi Streptococci, bacilli, negative Endophthalmitis, Post Endophthalmitis, Chorioretinitis withvitritis (Endophthalmitis) National Antibiotic Guidelines

REFERENCES 2015- Guidelines Antibiotic

104

- Aureus Staphylococcus Resistant Resistant -

Infected Adults and Adolescents. Available at: http://aidsinfo.nih.gov/guidelines. at: Available and Adolescents. Adults Infected -

38. OCULAR INFECTIONS Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis Dis Infect Clin America. of Society Diseases Infectious 2016 bythe Update Candidiasis: of Management

2019 11, onMarch summary.pdf -

50. content/uploads/2018/07/2017_annual report content/uploads/2018/07/2017_annual – 52;1 2011: Dis Infect Clin and Children. Adults in Infections e1– 2016;62(4): The Sanford Guide to Antimicrobial Therapy 2014. Available at: http://webedition.sanfordguide.com/. at: Available Therapy2014. to Antimicrobial Guide The Sanford

Guidelines for Prevention and Treatment of Opportunistic Infections in HIV in Infections Opportunistic of and Treatment Prevention for Guidelines m.ph/wp http://arsp.co at Accessed 2017 ManilaPhilippines Report, Summary 2017 Data Program Surveillance Resistance Antimicrobial nical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin of Treatment the for America of DiseasesSociety Infectious Liu by the C, etGuidelines al. Cli Practice nical Pappas P, et al. Clinical Practice Guideline for the for Guideline Practice Clinical al. et P, Pappas National Antibiotic Guidelines

105

Comments

and is rare after Group C/G infection. The rationale for therapy is to eradicate toeradicate is therapy for rationale The infection. C/G Group rare after and is

infection, Regimen Streptococcus (GAS) pharyngitis. (GAS) Streptococcus

UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER

S. pyogenes S.

follows Group A follows urative phlebitis are also potential complications. potential also are phlebitis urative

–

ACT INFECTIONS ACT

Tonsillitis r r Etiology old years <7 children in glomerulonephritis streptococcal o - Post PANDAS or infection, Streptococcus A Group with associated disorder neuropsychiatric autoimmune Pediatric Acute rheumatic fever (ARF) (ARF) fever rheumatic Acute symptom onset. symptom and supp abscess Peritonsillar vention, start treatment within 9 daysof within treatment start vention, Forpre 0.2%. to 2.8% from ARF of rate the decreases G penicillin Benzathine ARF. and prevent GAS

Associated cough, rhinorrhea, hoarseness and/or oral ulcers suggest a viral etiology suggestviral a ulcers oral and/or hoarseness rhinorrhea, cough, Associated A diagnose Group to be used may Test Strep The Rapid include: GAS pharyngitis of Complications − − − −

• • • Pharyngitis Pharyngitis erythematous diffuse or Exudative National Antibiotic Guidelines

UPPER RESPIRATORY TR RESPIRATORY UPPER

106 - Co

and produces a non- produces is not not recommended. is are not effective. effective. not are 1 hour before or 2 hours or 1 before hour Comments

mpicillin A

tetracyclines

amoxiclav should be given on an empty an empty on given be should aken ,

or - he future use penicillins. of future he Co after a meal. In throat infections caused by caused infections throat meal. a In after mononucleosis), (infectious virus Barr Epstein Amoxicillin Penicillin V by impaired is absorption its because stomach To be t food. fluoroquinolones to macrolides has macrolides pyogenes to S. of Resistance reported. been ALERT! allergic maculopapular rash, which does not doesnot which rash, maculopapular allergic t preclude trimoxazole

OR PO

ays 500mg x 500mg ays d d OR MU IM x 1

Clindamycin ay) 1g/d (Max: 12h (Max: 12h (Max: ays

ays 1.2 d

d 50mg/kg/day q8- q6h 500mg q12h or or q12h 500mg

ays 25-

div div d div div Azithromycin

PO 12h x 10 PO PO div q12h x10 q12h div PO OR ) x10 ) Penicillin G

or 500mg PO qd x 3 PO 500mg or ays Penicillin V

d Penicillin V ays

d ays

OR or d /day 50mg/kg PO 500mg q12h x 10

/day 40mg/kg 400mg PO q6- PO 400mg Regimen /day 15mg/kg Benzathine Benzathine

PO x 5

OR he primary choice is a macrolide, such as: a macrolide, is choice primary he q8h (Max: 1.8g/d q8h (Max: The primary choice is a macrolide, such as: macrolide, a choice is The primary t UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER ays div div d

mg/kg/day

PO thylsuccinate 250mg PO q12h x 10 q12h PO 250mg e ethylsuccinate 12 Clarithromycin Clarithromycin ays ays

d d

Amoxicillin trihydrate trihydrate Amoxicillin Amoxicillintrihydrate Phenoxymethylpenicillin Phenoxymethylpenicillin

ays

d line: line: q6h x 10 /day 30mg/kg line: line:

st nd st nd 20- Adult: Alternative to the macrolides for severe penicillin allergy: penicillin severe for macrolides to the Alternative Azithromycin Azithromycin dose 2 x 10 250mg PO q6h x10 q6h PO 250mg If withIf Penicillin allergy: withIf Penicillin allergy: ) x 10 ay) 1g/d 2 div div 1 dose and then 250mg PO qd x4 qd PO 250mg 1 dose and then Erythromycin 1 Erythromycin Pediatric: 1 Clarithromycin

;

streptococci

Etiology

Group A, C, G A, Group Fusobacterium studies) (in

National Antibiotic Guidelines

107 ,

ephalosporins c

: binding proteins. proteins. binding Comments enicillin does not effectively does effectively not enicillin epithelial cells, this internalization internalization this cells, epithelial P

GAS is able to enter the epithelial cells, and cells, epithelial enter the to able is GAS presence the with associated is internalization - fibronectin certain of Because penetrate antibiotic despite persistence to contribute may pharyngitis, casesof persistent In therapy. include options antibiotic

div div OR PO ays d Clindamycin

/day kg/day : 50mg/kg/day 25-

50mg/ PO div q12h x10 q12h div PO

Penicillin V

ay d OR

Regimen streptococcal infection. streptococcal 20mg/kg/ ays ays

d d trihydrate Amoxicillin

UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER OR 8h x108h days 10 x

Phenoxymethylpenicillin ) x 10 x ay) 1g/d (Max: q6h 450mg PO q6- PO 450mg div div amoxiclav Cefuroxime axetil line: Cefuroxime 12h line: -

st nd 2 q8- PO Co Pediatric: 1 Alternative to the macrolides for severe penicillin allergy penicillin severe for macrolides to the Alternative 300-

Streptococci (GAS) infection is difficult to distinguish from GAS carriage with repeated viral pharyngitis. viral repeated carriage with GAS from distinguish to difficult is infection (GAS) Streptococci

Etiology treptococci S the occurrence of of occurrence the decrease to not recommended is Tonsillectomy A Group Recurrent pharyngitis Recurrent A Group True National Antibiotic Guidelines

108 wever, azalides azalides on which which on

. Ho Clindamycin Comments and

, , macrolides including including macrolides , s opinion expert varied

are amoxiclav - zithromycin) o A therapy is most appropriate. most is therapy there there c (

ays ays

d d

0mL, ays d /5mL(70mL); PO div q8h div PO /5mL (6

/5mL /5mL /5mL /5mL (30mL,70mL) 500mgq12h or250mg

/day ays d 500mg PO q12hx 10 PO q12h x10 q12h PO

45mg/kg/day PO div q12h div PO 45mg/kg/day

ay 40mg/kg - 25-

PenicillinV

500mg/125mg PO q12h x 10 q12h PO 500mg/125mg 20 1g/d

or OR

Regimen ays ays d d Clavulanate Potassium Potassiumclavulanate - 500mg

Clavulanate Potassium Potassiumclavulanate dosing:

mg UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER Surgical drainage is required in treatment. in required is drainage Surgical axetil trihydrate Amoxicillin

31mg 62.5 / / 57mg / / 28.5mg / 28.5mg OR

ays d

Cefuroxime Phenoxymethylpenicillin Amoxicillin Amoxicillin

Amoxicillin Amoxicillin ); ); ,60mL

: >40 kg: and >40 and older 3 months 500mg/125mg PO q12h x10 q12h PO 500mg/125mg amoxiclav line: line: -

st nd 30mL 100mL) Co 2 125mg ( 250mg (amoxicillin component) x 10 component) (amoxicillin Adult 1 PO q6h10x For 3 months and older and <40 kg: and <40 and older months 3 For x 10 component) (amoxicillin For dosing: BID for Preparations PNF 200mg 400mg TID for Preparations PNF

Etiology . pharyngitis exudative of complication a serious Sometimes Peritonsillar abscess (Quinsy) Peritonsillar

National Antibiotic Guidelines

109 ,

are best avoided (not (not avoided best are Comments is resistant to macrolides to resistant is

macrolides

lactamase production by oral anaerobes. byoral production lactamase recommended). There are some reports of reports some are There recommended). beta

Fusobacterium hence,

q6- (ampicillin 8h 500mg IV/PO IV/PO 500mg - div div Metronidazole q6h IV q8h (amoxicillin q8h (amoxicillin div div

(amoxicillin component) component) (amoxicillin div div (ampicillin component) component) (ampicillin PLUS

PO IV/IM 900mg IV q6 IV 900mg

- 24h

Metronidazole Metronidazole /day 5g/day 600

12g/day - 6 /day 100mg/kg Regimen /day 40mg/kg - 750mg 75mg/kg IV q12- IV 75mg/kg /day 40mg/kg Clindamycin Clindamycin UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER

Sulbactam Sulbactam sulbactam sulbactam - - ay) sulbactam/d 4g ays ays amoxiclav amoxiclav d - - d

Co Co ) IV q6h IV ay) 4 g/d (Max: (Max: x 10

q6h : Ampicillin Ampicillin q8h

div div

: div div 2g IV q24h PLUS IV 2g line: Ceftriaxone 50- line: Ceftriaxone 8h line: line:

st nd st nd component) x 10 component) 2 component) component) PO 2 q6- ay 30mg/kg/d withIf Penicillin allergy: to down Step IV/IM to down Step Adult 1 withIf Penicillin allergy: Pediatric 1

(44%)

group

Etiology reptococci (33%), Group (33%), reptococci Fusobacterium necrophorum Fusobacterium St A Group (9%), Streptococci C/G anginosus Streptococcus National Antibiotic Guidelines

110 If

- care

been reported reported been

treatment.

RSA has S. aureus (MRSA) aureus S. is Comments acquired M acquired - resistant resistant of risk factors for health for factors risk of - , current hospitalization for 5 days for or hospitalization current ,

should be guided by be guided should therapy antibiotic munity ure. days is recommended. is ancomycin associated pneumonia, immunosuppressive immunosuppressive pneumonia, associated prolonged or recent therapy, and/or disease or stay antibiotics, to exposure hospitalization, or Clindamycin care unit), an intensive in V Com more, high frequency of antibiotic resistance in in resistance antibiotic of frequency high more, unit, hospital in the specific or community the presence These factors. risk identified without children in superficial of predominance a caseshave abscesses, subcutaneous including infections, Step infections. skin recurrent and cellulitis, down cult Surgical drainage is required in in is required drainage Surgical methicillin preceding the in therapy (antibiotic suspected 90

PLUS q6h PLUS q8h (Max: (amoxicillin q12h div ays (Max: d div div ays (ampicillin div div q8h d V

I ays x 7

Metronidazole IV/IM 7 d

PO q8h (amoxicillin q8h (amoxicillin div div q6h PLUS 24h div div PO q8h PO div div PO ays

PLUS d

at least at q12- PO

at least 7 least at ays

IV/IM

for d div div

for /day 150mg/kg ay 1.5g/d /day 100mg/kg IV /day 30mg/kg 14 q6h at least 7

q6h 500mg PO bid bid PO 500mg 20- ay 50mg/kg/d

div div 12g/day for -

div div 6 30- IV - 750mg /day 40mg/kg Regimen IV ays axetil axetil d

sulbactam sulbactam

- /day 75mg/kg UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER

50- 2g IV q24h x 10- q24h x IV 2g sulbactam sulbactam amoxiclav amoxiclav - - - 750mg IV q8h 750mg Na Cefuroxime

Cefuroxime Na 100- Na Cefuroxime at 7 least Cefuroxime Co for OR OR

ay) 4g/d (Max:

Ceftriaxone : Ampicillin Ampicillinsepsis

: line: Ceftriaxone line: line: line:

ay) 4g/d Metronidazole to down Step component) component) /day 30mg/kg Metronidazole Cefuroxime to down Step q8h PO 500mg Metronidazole component) component) to down Step to down Step Step down to Co to down Step nd nd st st 2 − − 2 − − (ampicillin component) (ampicillin − component) ay) 4g/d Adult /day 30mg/kg Metronidazole 500mg IV q8h IV 500mg 1 Pediatric 1

S. aureus; S. aureus;

Etiology

Streptococcus spp.; Bacteroides Bacteroides spp.; Streptococcus spp. Deep Neck Abscess/ Retropharyngeal Abscess Retropharyngeal Abscess/ Neck Deep Polymicrobial;

National Antibiotic Guidelines

111

and

up cultures are are cultures up -

should be given for an for given be should 6 years before school school before 6 years

Comments

Benzathine Penicillin G 600,000 G Penicillin Benzathine

Erythromycin <30 kg: <30 IM x 1 dose x1 IM W B U Antibiotics decrease toxin production toxin decrease Antibiotics is Penicillin organisms. of spread decrease of the Eradication . Erythromycin to superior 24 hours documented be should organism consecutive by2 treatment completing after specimens pharyngeal from cultures negative follow If apart. hours 24 taken positive, 10 days. additional state: carrier of Treatment

div div

days ) q6h MU ) IMq12h /kg/day IVq6h or

/day 50mg/kg

40- olation. is in be placed should Patients media) (special cultures pharyngeal and nasal Obtain Persons recovering from diphtheria should begin or complete active active complete or should begin diphtheria from recovering Persons in available is toxoid diphtheria containing Vaccine immunization. 0.5mL at a dose of given is It pertussis. and tetanus with combination on doses5 given include should immunization pediatric Routine IM. a is there (provided months 12 14 weeks, 10 weeks, ages 6 weeks, dose and 4- 3) from of 6 months interval minimum entry.

ays 50mg/kg/day POq6h x14 - • • • d

250mg PO q6h x14 q6h PO 250mg 25

) IVay) 2g/d div (Max:

/kg IV q12h (Max:1.2 x 14 /kg/day (Max: 1.2 MU U U

IV 100,000to 150,000 U q6h Regimen ethylsuccinate 50,000 50,000

/day 50mg/kg 40- 500mg 500mg UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER is necessary. is

DOH ay) 2g/d (Max: Erythromycin C. diphtheriae. C. ays

Erythromycin :

Penicillin crystalline G

PenicillinG crystalline to down

x 14

: line: Erythromycin line: ays line:

line:

d Step downStep to Phenoxymethylpenicillin q6h Step Phenoxymethylpenicillin Phenoxymethylpenicillin to down Step

nd st nd st 2 Adult Procainepenicillin 25,000 to50,000 − − 2 Pediatric 1 1 −

(animal to C. (human to human), human), (human to

Etiology

and ours aftercompleting antibiotics arenegative for Observe standardObserve anddroplet precautions (respiratorydroplet isolation) for Ensure adequate airway. Perform cardiac assessment. cardiac Perform airway. adequate Ensure discharge. before toxoid diphtheria Administer accordingly. and treat contacts Culture Supportive treatment is critical in management. Antibiotics are not the the are not Antibiotics in management. critical is treatment Supportive patients patients andcarriers 2until cultures fromboth nose and collected throat 24 h mainstay of treatment. of mainstay Intensive surveillance and immediate notification to to notification and immediate surveillance Intensive

• • • • • • ulcerans C. C. diphtheriae C. Membranous pharyngitis due to diphtheria due to pharyngitis Membranous pseudotuberculosis human, rare) human, National Antibiotic Guidelines

112 IM

MU viruses viruses

PO q6h x q6h x PO

1.2 1.2 ECHO

5, 50mg/kg/day 50mg/kg/day

40- Comments zathine Penicillin G G Penicillin zathine Ben

Erythromycin BW >30 kg: >30 BW oral or 10days be to suspected pharyngitis vesicular For - B1 A9, coxsackie caused by and enterovirus, antiviral therapy is not is therapy antiviral and enterovirus, recommended. is therapy Supportive needed. host, in immunocompetent infections mild For recommended. is therapy supportive

10 -

500mg 500mg ay

q12h x1 q12h

5mg/kg 5mg/kg

Valaciclovir ay

500mg PO q6h x7 q6h PO 500mg ay

OR d : ears y

infusion IV 3h

ays days d : 4g/d: ears as1 x 5 q12h x 1 x q12h

ays ay d Regimen >12 bid x 7 bid ethylsuccinate

PO UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER Children >12 y >12 Children

10mg/kg 10mg/kg : 4g/d: ears : y q8h x 7- 500mg

ay 400mg 5x/d PO

ears y

Erythromycin

Valaciclovir Aciclovir

: : ays d Aciclovir Valaciclovir

: :

Valaciclovir

ays

Adult Recurrent herpes labialis: herpes Recurrent Pediatric For HSV 1 and 2 in immunocompromised host: 2 in and 1 immunocompromised HSV For Pediatric <12 x 7 bid Adult Step down to to down Step d OR .

5 -

Etiology tender cervical lymph nodes cervical tender

viruses (multiple types); types); (multiple viruses iae. petech palatal exudates, swallowing, difficulty throat, sore erythema, pharyngeal findings, Systemic absent: possibly or Mild ulcerative stomatitis. ulcerative conjunctivitis, colds, cough, Hoarseness, present: Consistently NO

• • • CHO CHO Coxsackie A9, B1 A9, Coxsackie E Herpes simplex 71; Enterovirus virus (HSV)1, 2 Associated signs and symptoms: and signs Associated Vesicular, ulcerative pharyngitis (viral) pharyngitis ulcerative Vesicular, years <3 patients in common More

National Antibiotic Guidelines

113 and

efpodoxime

C ,

efixime Comments C , may be used in pediatric pediatric be used in may

are not effective for pharyngeal pharyngeal for not are effective efuroxime Spectinomycin C infections. gonococcal Clindamycin allergy. penicillin with patients

/day

PO div div PO MU (ampicillin tazobactam 24 -

. PLUS 24h /day 40mg/kg div q6h IV/IM q6h IV/IM div Piperacillin

Penicillin G 2nd or 3rd generation 3rd generation 2nd or

1g loading loading 1g Metronidazole (

ay) 4g/d (Max: OR OR

q6h IV div q12- div IV PLUS

250mg IM x 1 dose x IM 250mg amoxiclav amoxiclav

- div div 6h 3g IV q6h IV 3g q4- /day 100mg/kg

Regimen IV/PO

>45 kg: >45 div 900mg IV q8h OR IV 900mg IV /day 75mg/kg UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER

600-

sulbactam sulbactam - Step down to Co to down Step -

THEN 0.5g IV q6h or 1g IV q12h IV 1g q6h or IV 0.5g

ays

Ceftriaxone

d Ampicillin : : 125mg IM x 1 dose; IM 125mg Ampicillin Clindamycin

250mg IM x 1 dose IM 250mg Ceftriaxone

THEN : : 50- line: Ceftriaxone line: line: line:

st nd st nd component) component) q8h x 10 2 2 dose Adult by continuous infusion or or infusion bycontinuous /day 30mg/kg Metronidazole 4.5g IV q6h or 4h infusion of 3.375g q8h 3.375g 4h of q6h or infusion IV 4.5g Pediatric 1 1 Pediatric kg: <45 Adult of patients require intubation. require patients of

third

robes robes Anae

Etiology (which outnumber aerobes 10:1) aerobes outnumber (which Streptococcus sp. Streptococcus Complications include infection of the carotid (with possible rupture) and jugular vein phlebitis jugular and rupture) possible (with carotid of the infection include Complications including: Polymicrobial, Closely monitor the airway; one the airway; monitor Closely drainage. surgical Perform abscess. the identify orscanto MRI CT Perform Parapharyngeal Space Infection; Peritonsillar Abscess Peritonsillar Infection; Space Parapharyngeal bones) fish toothpicks, (e.g., bodies or foreign extractions, dental hygiene, poor dental be due to May Gonococcal pharyngitis Gonococcal gonorrhoeae N. National Antibiotic Guidelines

114

resistant resistant - . ancomycin V

usobacterium F

due to Comments If not a complication of notcomplication a If

. Avoid in patients with with patients in Avoid . ears y is generally not recommended recommended not generally is

Note:

of 4 weeks in between doses. of 4 weeksbetween in

using using aureus Staphylococcus Levofloxacin <18 patients in that drugs with or prolongation QT of history Avoid macrolides Avoid resistance. jugular an internal is there if and pharyngitis, line, treat empirically formethicillin

15 months. 15

ays ays d d 10 daily IV 2g x 10 x 7- q6h

Metronidazole

iv 24h d

. IV PLUS q12-

Ceftriaxone Ceftriaxone iv occur

PLUS 1g IV q24h q24h IV 1g

4.5g IV q8h q8h IV 4.5g /day 100mg/kg

Regimen 2 months apart. Booster dose at 12- dose at Booster apart. 2 months ays) upper airway obstruction, especially in pediatrics. especially obstruction, airway upper d 900mg IV q8h IV 900mg

/day IV /day 100mg/kg UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER 600- . 18 months dose at Booster apart. 2 months 50- Ceftriaxone Sulbactam 500mg PO/IV q8h 500mgPO/IV

- tazobactam - at7 least threatening threatening - , e.g.,,

Erosion into the carotid artery can artery carotid the into Erosion Ampicillin Clindamycin :

Ceftriaxone Ceftriaxone Piperacillin

Metronidazole Metronidazole line: line: line:

line:

nd nd st st not recommended. 2 2 OR Pediatric 1 cephalosporins q8h for IV 500mg 1

in the

59 months, give only 1 dose. only give months, 59 11 months: Primary series of 2 doses, 1- 2 doses, of series Primary 11 months: b; b immunization is recommended, given IM at a minimum age of 6 weeks with a minimum interval interval minimum a age of with 6 weeks minimum a at IM given recommended, is b immunization

in 1936;other ype type type Etiology

ween 12- ween pneumoniae S. H. influenzae H. If given between 7- between given If bet given If H. influenzae t influenzae H. 3 1- of doses, series Primary weeks6 months: 6 to between given If Have tracheostomy set “at bedside.” “at set tracheostomy Have and is controversial is steroids of Use Acute Epiglottitis life with present May hospitalization. urgent Requires Fusobacterium Fusobacteriumnecrophorum vastmajority. Lemierredescribed Pulmonary and systemic emboli are common. are emboli systemic and Pulmonary anaerobes and Gram (+) cocciare lesscommon etiologies of suppurativephlebitis postpharyngitis. Jugular Vein Suppurative Phlebitis (Lemierre’s Syndrome) (Lemierre’s Phlebitis Suppurative Vein Jugular

National Antibiotic Guidelines

115 has M.catarrhalis if Clindamycin ever and ever

rythromycin and and ) bacteria and may )bacteria E

Comments onsiderations should be should onsiderations rythromycin E drug therapy for ABRS is is ABRS for therapy drug 2) still symptomatic after 10 days with no days with 10 after symptomatic still 2)

purulent nasal discharge or facial pain for >3 >3 pain for facial or discharge nasal purulent days; prolong QT interval. Tendon rupture can occur occur can rupture Tendon interval. QT prolong therapy. after or during are sinusitis bacterial for Antibiotics f high 1) with if: recommended a after worsen or 3)symptoms antibiotic; 5 days and had lasted that illness viral typical initially improved. The use of H. influenzae H.influenzae for cover not - assingle its On own, controversial. for true holds The same usedempirically. with this up for makes it however, clindamycin; anaerobic against added coverage the Thesec bacteria. poor coverage for Gram ( Gram for coverage poor

900mg 900mg

ays : d 14

ays /5mL(70mL); d /5mL /5mL (30mL,70mL)

ays x 10- d

600- Clindamycin

q12h x min 10 x min ays

d L PLUS amoxiclav (ES 600) (ES amoxiclav div q12h div - 10

Co div q12h div

in 5 m 5 in

14 days14 L Regimen div q12h x min 10 q12h x min div Clavulanate Potassium ay 50mg/kg/d Potassiumclavulanate /day 15mg/kg 45- UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER 9mg/5m - 7 x q24h IV 2g /day 30mg/kg q12h x 10- q12h

/ 57mg / 28.5mg / 28.5mg

div ays ay 30mg/kg/d

d PO 10 . 600mg/42 amoxiclav amoxiclav

- -

Co 750mg IV q24h IV 750mg Levofloxacin /d Co Ceftriaxone Clarithromycin

Amoxicillin g Amoxicillin k

: Cefuroxime line: line:

8h IV x7- IV 8h line: line:

st nd st nd Type 2: Cefuroxime 2: Type allergy: penicillin severe with patients pediatric For 1: Type OR Amoxicillin PNF Preparation for HIGH DOSE HIGH for Preparation PNF 2 400mg PNF Preparations for BID dosing: BID for Preparations PNF 200mg 90mg/ Pediatric: 1 Adult 1 q6- 2

; H.; influenzae; M. e Etiology

; Anaerobic Anaerobic ; S. aureus catarrhalis; streptococcal other Some bacteria; species Acute bacterial rhinosinusitis (ABRS) rhinosinusitis bacterial Acute pneumonia S. Rhinosinusitis National Antibiotic Guidelines

116 and they they

L as serious serious -

Co s 600 risk ES- are generally generally are

the The 200mg/5m

because of increasing increasing of because

amoxiclav in pediatric patients patients in pediatric - Comments Co 600 suspension should not be be not should suspension

Fluoroquinolones ES- L trimoxazole - Co substituted with with substituted resistance. resistance. because recommended not taken into account when prescribing these these prescribing when account into taken antibiotics. Avoid peripheral (tendinopathy, effects side interval) QT of prolongation and thy, neuropa benefits. the outweigh 400mg/5m interchangeable. not are NOTE: Data not available for use of use for available not Data NOTE: amoxiclav . more 40kg and weighing

or bid ays d

adults only only adults

500mg 500mg

POx 5

axetil

875mg/125mg PO PO 875mg/125mg

/day ays

ays 500mg

ays 7 d

amoxiclav amoxiclav 7 - Cefuroxime

q12h x5- q12h Co

Regimen PO OR Levofloxacin

TID UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER ays 1g 500mg bid x 5- bid 500mg

10 -

IVx 7

mild/moderate disease: mild/moderate 7 days 100mg bid x 5- bid 100mg Doxycycline Amoxicillin Cefuroxime 100mg 100mg Doxycycline

ays d /day

: 10 line or severe or disease:line line or or line

st nd allergy (adult): penicillin severe with patients For q12h x5- q12h 2nd line: Type 2: Type 2: 750mg

Type 1: Type 1: 1 x 7- 2 Adult line: 1st

diabetes mellitus with acute ketoacidosis; neutropenia; deferoxamine therapy – therapy deferoxamine neutropenia; acute ketoacidosis; with mellitus diabetes

; H.; influenzae; M. e Etiology Mucormycosis: ; Anaerobic Anaerobic ; S. aureus catarrhalis; streptococcal other Some bacteria; diagnostic consider species; tap/aspirate Acute sinusitis (clinical failure after 3 adults in after days) failure (clinical sinusitis Acute pneumonia S.

National Antibiotic Guidelines

117 is

prophylaxis prophylaxis ) is not included is ) % for 72%

salvage protocol salvage usitis occurs in <10%. <10%. in occurs usitis angle branching. angle ray“sinusitis” (fluid in - oriconazole -

Comments lipid complex monotherapy monotherapy complex lipid .

(not in the PNF inthe (not B uld increase suspicion. Palatal Palatal suspicion. increase uld osaconazole approved indications for for indications approved - p ccess rate against success rate

. therapy combination echinocandin week, bacterial sin bacterial week,

1 37%

rolonged use of v use of rolonged from 60% 80%60% to from P predisposes to mucormycosis infections. mucormycosis to predisposes . Complete or partial response partial or Complete . posaconazole rateswith - polyene Posaconazole After 7 days of nasotracheal or nasogastric nasogastric or 7nasotracheal days of After have X 95% tubes, 38% only puncture on transnasal but sinuses), requiring For patients positive. culture tube nasotracheal with ventilation mechanical for> Amphotericin Amphotericin has FDA the in in diameter and right diameter in

Vancomycin Liposomal

ADD OR 8h

- IV

variation with hyphae septated ay

4.5g IV q6 4.5g suspected: suspected:

- non like, Regimen

1.5mg/kg/d - 1

mg PO bid with meals. If NPO, NPO, qid 200mg If meals. with bid PO 400mg B UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER 1) resolution of clinical signs and symptoms of of symptoms and signs of clinical 1) resolution

: S. aureus is aureus S. tazobactam - ay IV 10mg/kg/d - 5

30mg/kg IV followed by 15mg/kg IV q8h or q12h q8h or IV by 15mg/kg followed IV 30mg/kg 1g IV q8h B resistant resistant -

based on response 2) resolution or stabilization of radiographic abnormalities; abnormalities; of radiographic stabilization or 2) resolution Amphotericin Amphotericin

; Piperacillin dose 25-

Meropenem

line:

st f methicillinf Posaconazole immunosuppression. of underlying resolution 3) AND on those for prophylaxis secondary be used for may therapy. immunosuppressive loading loading Duration: Duration: until therapy Continue infection Posaconazole 2nd line: I Amphotericin Amphotericin 1 OR 1st line: 1st

. E

Aspergillus

18% Staphylococcus Staphylococcus Etiology . (mucor),. ) in) 35%,Polymicrobial in common) in 47% of cases, cases, 47% of in common)

Pseudomonas, Acinetobacter, Acinetobacter, Pseudomonas, 80%, Yeasts in Yeasts 80%, aureus Gram negative bacilli bacilli negative Gram ( Acute sinusitis in adult hospitalized patients with nasotracheal or nasogastric intubation nasogastric or nasotracheal with patients hospitalized adult in sinusitis Acute coli ( positive Gram Rhizopus sp Rhizopus Diabetics are predisposed to mucormycosis due to microangiopathy and ketoacidosis. microangiopathy due to mucormycosis to predisposed are Diabetics growth. fungal stimulates as iron mucormycosis, to predisposes also overload Iron Rapidly fatal without treatment. without fatal Rapidly - wide ribbon revealing isolates, culture tissue of by stain is Diagnosis Early diagnosis is key to treatment success. Symptoms suggestive of fungal sinusitis (or lateral facial pain or numbness) sho numbness) pain or facial lateral (or sinusitis fungal of suggestive Symptoms success. treatment key to is diagnosis Early mucor. suggests patients diabetic or immunocompromised in blindness unilateral and eschars black and/or ulcers National Antibiotic Guidelines

118 -

shampoo plus medium plus shampoo Comments

Functional endoscopic sinus surgery surgery sinus endoscopic Functional

May need fluconazole if yeast cells seen on cells yeast if fluconazole need May aspirate. of sinus stain Gram

- 30mg/kg IV IV 30mg/kg

loading dose 25 loading

Otolaryngology consultation is recommended. is consultation Otolaryngology

. Culture and sensitivity testing is important. is testing sensitivity and Culture suspected. Perform CT scan of the maxillary bone if an odontogenic source is is source an odontogenic if bone scan of CT the maxillary Perform

Adjuvant therapy includes nasal saline washes (twice daily per nostril), per nostril), daily (twice washes saline nasal includes therapy Adjuvant Vancomycin

PLUS Regimen with failed, extensive, prolonged, and adequate medical management. medical and adequate prolonged, extensive, failed, with loading dose 25- loading Vancomycin or q12h or

UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER q8h

2g IV q8h q8h IV 2g

IV inflammatory agents, and topical (intranasal) corticosteroids. (intranasal) topical and agents, inflammatory -

Treatment of choice should be based on factors such as patient allergy, risk of ototoxicity, bacterial bacterial ototoxicity, of risk allergy, as patient such be based on factors should choice of Treatment

2g IV q12h IV PLUS2g Evaluate children for allergy. for children Evaluate

Ceftazidime : line:

. scan changes CT nd No persuasive evidence of benefit from antibiotics from benefit of evidence persuasive No but the agents, selected appropriately 10 3 6 orto with up weeks to for therapy antibiotic with usually is Treatment currently not and unproven CRS is for agents antifungal of The benefit controversial. approachis this of efficacy recommended. Pediatric anti antihistamines, children for considered can be 2 q12h OR q8h or IV by 15mg/kg followed IV 30mg/kg by 15mg/kg followed Cefepime

with or ing acute acute ing

solution (e.g., triamcinolone 0.1%) triamcinolone (e.g., solution

Etiology

resistance, availability, cost, and dosing schedule. dosing and cost, availability, resistance, Usually secondary to chronic seborrhea. Control seborrhea with dandruff shampoo containing selenium sulphide OR ketoconazole ketoconazole OR sulphide selenium containing shampoo dandruff with seborrhea Control seborrhea. chronic to secondary Usually steroid potency Otitis externa Otitis Otitis Multifactorial, e.g., damage to the damage the to e.g., Multifactorial, dur complex ostiomeatal PLUS mucopurulence on endoscopy or or on endoscopy mucopurulence PLUS suspected is allergy if may tested be levels IgE Serum allergy disease; bacterial occult polyps; without and/or immunodeficiency; (periodontitis disease odontogenic teeth) maxillary in Symptoms > 6 weeks > Symptoms smell of sense decreased or pain facial blockage, drainage, as Defined Chronic rhinosinusitis (CRS) rhinosinusitis Chronic

National Antibiotic Guidelines

- 119 4 crucial in in crucial

alcohol alcohol

are until clinical clinical until

inflammatory agents, inflammatory -

ck if edema prevents drug prevents edema ckif Comments may be instilled in the external external the in be instilled may A white vinegar + isopropyl + vinegar white A if bone is involved. Treat involved. bone is if (1:1)

solution solution proper restore to swimming after canal ear water. dry residual to and pH acidic at least for is prolonged of therapy Duration 6 weeks Do not use neomycin drops if the tympanic tympanic the if drops use neomycin not Do otitis chronic For punctured. is membrane months), >3 to 6 weeks (symptoms externa and debridement involves treatment anti topical of application corticosteroids. e.g., hygiene ear dry and Debridement removal with cleaning Thorough otomycosis. Assess warranted. is debris fungal matted of because membrane oftympanic perforation for canal of the Clean ototoxic. are antifungals Place wi a detritus. delivery.

ays

ays 14 d -

14 12h up to 10 to 12h up

- 12h up to 10- to 12h up ays

x 7

3 q8 drops -

uidelines). 3 drops q8- Regimen after cessation of symptoms. of cessation after

IMCI G ays d

solution 2- solution 1% solution 1%

UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER

or 3 ear drops ear

1% may be used and is well tolerated (as (as tolerated well be used and is may

ays Debridement is usually required. Rule out osteomyelitis with a CT or MRI scan. If bone is involved, involved, bone is If or scan. CT a with MRI out osteomyelitis Rule required. usually is Debridement

d 10 5 drops bid in the affected ear affected the in 5 drops bid -

bid drops 10

Clotrimazole Ofloxacin

recommendation no : : :

: : ears ay drops/d 10 drops ear Ofloxacin Clotrimazole

: ears : y : y ear Gentian violet Gentian

12 1 - Adult : Duration >12 1 Pediatric Pediatric OR WHO by the recommended Adult Pediatric <

in >95%; in

Etiology 6weeks. -

treat for4 aeruginosa P. sedimentation rates are typical. are rates sedimentation erythrocyte high Very Necrotizing otitis externa otitis Necrotizing Actinomyces spp.; Phycomycetes spp.; Actinomyces Aspergillus; Candida spp.; spp.; Candida Aspergillus; Fungal otitis externa / otomycosis / externa otitis Fungal Usually secondary to seborrhea seborrhea to secondary Usually (chronic) National Antibiotic Guidelines

120

Comments may be instilled in the external external the in be instilled may ) :1 1 (

10 days. A white vinegar + rubbing alcohol alcohol rubbing + vinegar white A days. 10 ear canal after swimming to restore proper proper restore to swimming after canal ear residual dry and to ear canal the to pH acidic water. solution Ointments should not be used in the ear. ear. Do the in used be not should Ointments the tympanic if drops use neomycin not surgical Perform punctured. is membrane water in head submerging Avoid debridement. x 7- and radiographical improvement has been hasbeen improvement and radiographical or canal ear the from cultures Obtain achieved. from Treatment debridement. surgical from by antibiotic guided be should etiologies other neomycin use not Do results. susceptibility . ruptured is membrane the tympanic if drops pain. severe for analgesics Give

q8h

div div

ays IV d q8h WITH OR WITHOUT OR WITH

x 7

h 6h div div q

ay 2x/d /day 4.5g IV 4.5g /day 300mg/kg 4.5g IV q8 IV 4.5g

after cessation of symptoms. of cessation after Regimen

daily ays 150mg/kg - d

day UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER day in the affected ear affected the day in tazobactam tazobactam tazobactam 100 tazobactam

or 3 2x/ ear drops ear 2x/

ays Amikacin

d OR 10 5 drops 5 drops -

10 drops drops 10

Ofloxacin - Piperacillin - Piperacillin

recommendation no Ceftazidime :

: : ears - 1 drops 10 drops ear Ofloxacin

: ears : y : y ear

12 - Adult : Duration >12 1 Gentamicin Gentamicin

Adult Pediatric <1 1st line: line: 1st 2nd line: - Piperacillin line: 1st 2nd line: in

in 8% in in 11%; S. aureus S. aureus

in 46%; Etiology Pseudomonas sp. sp. Pseudomonas 11%; 11%; Candida 2%; in Anaerobes psoriasis and dermatitis; contact (earphones); devices by occlusive be caused also May epidermidis S. Acute diffuse otitis externa / swimmer’s ear swimmer’s / externa otitis diffuse Acute P. aeruginosa, Proteus mirabilis Proteus aeruginosa, P. patients pediatric

National Antibiotic Guidelines

121 H. M. or als. There There als. 5% are resistant areresistant 5%

resolution occurred occurred resolution are are S. pneumoniae S. pneumoniae S. pneumoniae

weeks in between inweeks between and 0- Comments has a high failure rate if if rate failure high has a resistant

Macrolide resistance of S. of resistance Macrolide Clindamycin reported. been has Spontaneous macrolides macrolides

. trimoxazole - . . penicillins

pneumoniae pneumoniae and influenzae H. against effective not is catarrhalis . Up to 50% of 50% of to Up . influenzae to resistant Co - drug is etiology to

ype t days

7 -

: 5 : ears inflammatory inflammatory y

- >5 PO q12h PO ays; Haemophilus influenzae influenzae Haemophilus

PO div q12h div PO : 7: d ears

5 - Regimen 2

ay 90mg/kg/d UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER 80- ay 15mg/kg/d Clarithromycin

in the prior month in the prior

: : 10 days; ears y

dose.

2nd line: anaphylaxis: With agents, e.g., corticosteroids. e.g., agents, : Duration No antibiotic use antibiotic No Pediatric Amoxicillin line: 1st For chronic otitis externa (symptoms 6 weeks to >3 months), treatment treatment months), >3 to 6 weeks (symptoms externa otitis chronic For anti of topical and application debridement involves

15 months, with an interval of 6 months after the 3rd dose. the 3rd after months 6 of aninterval with months, 15

lactam drugs: lactam cephalosporin oral give may effective rash,

- beta

if withif 2 years old with no fever and ear pain with a negative or questionable exam, consider analgesic treatment without antimicrobi without treatment analgesic consider exam, questionable or negative a with pain and ear no fever with old 2 years Bacterial pathogens pathogens Bacterial

Etiology hylaxis), avoid cephalosporins cephalosporins avoid anaphylaxis), (e.g., allergy mediated - b conjugate vaccine is given IM in children aged at least 6 weeks. Primary vaccination involves 3 doses with an interval of 4 of an interval with 3 doses involves vaccination Primary 6 weeks. at aged least children in IM given is vaccine b conjugate in 49%; 49%; pneumoniae in S.

IgE

patients allergic to allergic patients with

may be favorable results in mostly afebrile patients with waiting for 48 hours before deciding to use antibiotics. use to before deciding hours 48 for waiting with patients afebrile mostly in results be favorable may For in 28%. in infections: infections: in29%; influenzae H. catarrhalis M. account for 85% of middle ear ear of middle 85% for account doses. Booster is given at age 12- age at given is Booster doses. above patients For Influenzae ear infections. ear Viruses cause up to 6% of middle of middle 6% up to cause Viruses • If history unclear or unclear history If • doses. Booster is given 6 months after the 3rd after 6 months given is Booster doses. • If terval of 4 weeks in between between ofin 4 weeks terval in an doses 3 with involves vaccination Primary 6 weeks. aged least at children in IM given is vaccine conjugate Pneumococcal Acute otitis media (AOM) media otitis Acute and disease pneumococcal invasive against immunization includes Prevention National Antibiotic Guidelines

122 ,

14 S. and line agent line - H. M. catarrhalis tympanostomy tympanostomy

S. pneumoniae S. pneumoniae .

amoxiclav - are usually also also usually are Co

80% resolve within 2- within resolve 80%

tesis or myringotomy may may myringotomy or tesis ,

Comments not active against against not active responsive to antimicrobial antimicrobial to responsive does not require retreatment. retreatment. require not does is . indamycin 3 months after therapy is is therapy 3 months after

M.catarrhalis

(overall - may be may usedfirst asa Cl Macrolides or C and/or if with severe otalgia. If If otalgia. severe with if and/or C inadequate. or pediatric patients: pediatric or days). For severe disease, appropriate appropriate disease, severe For days). but 5 days unclear, is of treatment duration be may F resistant to to resistant expected and expected Clindamycin influenzae in 90% of patients infected with with infected patients of 90% in with and 10% , H. influenzae with 50% Ceftriaxone a of Placement necessary. be at Adenoidectomy for some. option an is tube future decreases tubes of tympanostomy time ear middle Persistent AOM. for hospitalization 2 for effusion pneumoniae pneumoniae high with presents child the onset, atthe if º >39 fever non- is infection tympanocen therapy, resistant to to resistant

/day ays d x 7 ays d

mg/kg 7

- : q12h

using using

div div ays d : 5 : ears y

) ears <40 kg <40

q12h y

>5 ay BW >2 (

1g/day ays;

and ays ays

ays

d d (high dose) (high

d : 7: d amoxiclav (ES 600) (ES amoxiclav

old 7 -

- 5 - 500mg 30mg/kg/d 875mg/125mg PO q12h x 10 PO 875mg/125mg

ays

Co ears

x d

y ;

750mg PO q24h x 5 PO 750mg 5 - Regimen IM/IVx 3 2 IV/IM x 3 axetil axetil axetil

s old) ≥3 months ≥3 ear amoxiclav -

for UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER y

/day 2g/day 1g q8h x10 q8h 1g

Co <2 ( : Levofloxacin Levofloxacin

Cefuroxime Cefuroxime

ays : : 10 days; ears d y

amoxiclav -

Ceftriaxone

OR : line: ay 50mg/kg/d Ceftriaxone : allergy penicillin ith

line:

w ays st

preparation /5mL 600/42.9mg PNF Preparation for HIGH DOSE HIGH for Preparation PNF Adult OR d 2nd allergy penicillin No No anaphylaxis: No 1st line: Amoxicillinline: 1st If anaphylaxis: With 1 q12h x 10 div No anaphylaxis: No : Duration

S. pneumoniae

Etiology

resistant - Drug Acute otitis media (clinical failure after 3 days) days) 3 after failure (clinical media otitis Acute positive. - are virus 63% and year, per AOM In children aged 6 months to 3 aged 6 months to children In be may of episodes 2 there years,

National Antibiotic Guidelines

123

S. resistant resistant

high dose high no change in ear pain, pain, ear changein no

Comments amoxiclav -

Co acute otitis media. otitis acute w culture. - penicillin for successful reported pneumoniae Definition offailure: otorrhea or membrane tympanic bulging fever, will Tympanocentesis daysof 3 therapy. after allo

on all cases of CSOM with suppurative complications. suppurative with CSOM cases of on all rs old

ays ea d y

s with mild or mild s with OR

<2 ( ear y

purulent meningitis, or brain abscess. or brain meningitis, purulent ays >2 ( d div q12h div Give quinolone ear ear quinolone Give

ays x d

7 -

5 L

ays q12h x d

; div div be performed must Surgery

in 5 m 5 in ays

d L Regimen IMx 3 PO 750mg PO bid x 5 bid PO 750mg Levofloxacin

UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER Diagnosis is by CT or MRI scan. MRI or byCT is Diagnosis 9mg/5m

. 15mg/kg/day Cefuroxime

600mg/42

disease)

ay 50mg/kg/d Ceftriaxone /day 30mg/kg Cefuroxime line:

nd 2 moderate moderate OR vere symptoms regardless of age) of regardless symptoms severe Mild penicillin allergy: 50mg/kg IM/IV x3 IM/IV 50mg/kg Ceftriaxone be done. should drying and cleansing ear Daily days.5 for tid drops Amoxicillin OR allergy: penicillin Severe

Etiology Bacteroides; Bacteroides; P. aeruginosa; E. coli; S. coli; E. aeruginosa; P. : Usually a complication of acute otitis media. Obtain cultures. Obtain media. otitis acute of a complication Usually thrombophlebitis, sinus lateral suppurative suchas osteomyelitis, complications, Look for Propionibacterium mastoiditis Acute Peptostreptococcus; Peptostreptococcus; mirabilis; Klebsiella sp Aerobic Proteus pyogenes; S. aureus; Aural toilet is an essential part of the treatment of CSOM in all in patients. of CSOM treatment of the part an essential is toilet Aural Chronic suppurative otitis media (CSOM) media otitis suppurative Chronic : Anaerobic National Antibiotic Guidelines

124

Comments ith topical antimicrobials. Do not antimicrobials. topical ith

cultures. obtain debridement, Surgical the on depends group pediatric in Treatment response. patient’s Antibiotic treatment as in acute otitis media if if media otitis acute as in treatment Antibiotic Systemic exacerbation. acute is there to given be routinely not should antibiotics or in alone CSOM either with patients w combination membrane the tympanic if drops use neomycin ruptured. is

150 IV

1g IV 1g IV

PLUS Topical Topical

tazobactam q6h - nded. Oxacillin

(dose to achieve achieve to (dose div div Meropenem

PLUS daily

/day

is recomme is Piperacillin

q12h are suspected, surgical surgical suspected, are

. ay 150mg/kg/d Cefepime div

750mg IV IV 750mg Vancomycin ENT IV q6h IV PLUS IV

300mg/kg div Pseudomonas sp: Pseudomonas q8h /day Regimen

div div of chronic otitis media otitis chronic of IV Consult with with Consult

Levofloxacin

20mcg/mL) 20mcg/mL) .

resistant resistant - UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER 100mg/kg tazobactam tazobactam OR

Staphylococcus spp Staphylococcus /day 60mg/kg q6h

- 45 div and and

2g IV daily2g IV

Piperacillin Ceftriaxone then canal, auditory the of ent

exacerbation Acute : : Obtain cultures, then empiric therapy for the first episode: episode: first the for therapy empiric then cultures, Obtain Culture ear drainage. May need surgical debridement. debridement. surgical need May drainage. ear Culture

: :

Vancomycin line: line:

Pseudomonas Pseudomonas nd st Adult If If OR 15- of levels trough serum q6h IV 3.375g caused by a multidrugIf suspected: is extension intracranial If q8h Adult Ceftriaxone fluoroquinolone ear drops ear fluoroquinolone debridem given. be q8h should Pediatric /day 7.5mg/kg Gentamicin Pediatric /day 200mg/kg 1 2

Etiology S. pneumoniae; S. S. pneumoniae; S.

S. pneumoniae; S. pyogenes; S. S. pyogenes; S. pneumoniae; S. M influenzae; H. aureus; Chronic or recurrent mastoiditis or recurrent Chronic If secondary to otitis media: otitis to secondary If Fungi P. aeruginosa; catarrhalis; aeruginosa; S. S. aeruginosa; P. aureus; pneumoniae M. catarrhalis; P. aeruginosa catarrhalis; M. 1st episode: 1st H. influenzae; aureus; S. pyogenes; Consult an otorhinolaryngologist (ENT) for possible mastoidectomy. possible for (ENT) otorhinolaryngologist an Consult

National Antibiotic Guidelines

125

Comments

Regimen UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER See recommendations for membranous pharyngitis due to diphtheria. to due pharyngitis membranous for recommendations See

Antibiotics are not indicated in viral laryngitis. viral in notindicated are Antibiotics

Etiology n Developing Countries (Pediatrics) Countries nDeveloping

Laryngitis Viral(90 %) Diphtheria Diphtheria National Antibiotic Guidelines

126

inical practice guideline for for guideline practice inical Symptoms? Grand Rounds Rounds Grand Symptoms? - http://arsp.com.ph/arsp from:

th underlying eardrum eardrum underlying th value care from the American the American from care value -

high

2766.

34. 10.1056/ NEJMcp1601749 10.1056/

70. DOI:

- doi:10.7326/M16 208.

Clinical Practice Guideline (Update): Adult Sinusitis. Head and Head Sinusitis. Adult (Update): Guideline Practice Clinical . 30th ed. Elk Grove Village, IL: American Academy of Pediatrics. of Academy IL: American Village, Grove Elk ed. 30th . e112. . 7th ed. Philadelphia, PA: Saunders. PA: Philadelphia, ed. 7th . Diseases

- 164:425 , Medicine Internal Annals of (3):CD004783. doi: doi: (3):CD004783. Review Systematic of Database Cochrane Head and Neck Surgery. Surgery. Neck and Head hns Hopkins University Hospital. University hns Hopkins ed. Philadelphia, PA: Elsevier. PA: Philadelphia, ed.

th UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER , 166, 201- 166, , Medicine Internal Annalsof , 54: e72 - 54: , Disease Infectious Clinical

Retrieved Report. Summary 2015 Data Program: Surveillance Resistance Antimicrobial

Systematic Review. Issue 1. Art. No.: CD005608. DOI: 10.1002/14651858. CD005608 10.1002/14651858. DOI: CD005608. No.: Art. 1. Issue Review. Systematic

. Pasig City: Philippine Society of Otolaryngology – of Otolaryngology Society Philippine City: Pasig . Sinusitis for Guideline Practice Clinical (2006). rgery. Su and Neck Head

Red Book: Report of the Committee on Infectious Diseases on Infectious Committee of the Report Book: Red S39.

Feigin and Cherry's Textbook of Pediatric Infectious Infectious Pediatric of Textbook and Cherry's Feigin -

2015/ - report

- summary Head and Neck Surgery. and Neck Head - data 10.1002/14651858.CD004783.pub4. .152Surgery Neck (2S):S1 trol and Prevention. Prevention. and trol Con Disease for Centers and the Physicians of College l Center.l Medica Deaconess Israel Both from Discussion of Cochrane Database perforations. . and adults children in rhinosinusitis bacterial acute - 375:962 Medicine, of Journal England The New Adults. in Sinusitis Acute al. (2016). et RM Rosenfeld Research Institute for Tropical Medicine. Medicine. Tropical for Institute Research Reveiz L, Cardona AF. (2013). Antibiotics for acute laryngitis in adults. inadults. acute laryngitis for Antibiotics (2013). AF. Cardona L, Reveiz n Academy of Otolaryngology – Otolaryngology Academyn of America al. (2015). et RM Rosenfeld Kimberlin, DW et al., ed. (2015). (2015). ed. DW et al., Kimberlin, . 20. Pediatrics of n Textbook Nelso (2016) eteds. al., RM, Kliegman Mandell LA, et al. (2015). Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Disease, 8th edition. edition. 8th Disease, Infectious of and Practice Principles and Bennett’s Douglas, Mandell, al. (2015). et LA, Mandell – of Otolaryngology Society Philippine Respiratory Upper Persistent with Patient to This Antibiotics Prescribe We Should (2017) HS. Gold, DM, Brockmeyer, H, Libman, Macfadyen CA, Acuin JM, Gamble CL. (2006). Systemic antibiotics versus topical treatments for chronically discharging ears wi ears discharging chronically for treatments topical versus antibiotics Systemic CL. (2006). Gamble JM, Acuin CA, Macfadyen Harris AM, Hicks LA, Qaseem A. (2016). Appropriate antibiotic use for acute respiratory tract infection in adults: advice for advice in adults: infection tract respiratory acute use for antibiotic Appropriate (2016). A. Qaseem LA, Hicks AM, Harris Chow AW, BenningerMS, Brook I,Brozek JL,Goldstein EJ,Hicks LA, et al. (2012). Infectious Diseases Society of America. IDSA cl IDSA America. of Society Diseases Infectious al. (2012). et LA, EJ,Hicks JL,Goldstein Brook I,Brozek BenningerMS, AW, Chow

REFERENCES Baltimore,. Guide ABX Hopkins Johns ed. (2015) JG, MD:Jo Bartlett National Antibiotic Guidelines

Cherry JD, et al., eds. (2014). (2014). eds. al., et JD, Cherry 127

// webedition.sanfordguide.com // UPPER RESPIRATORY TRACT INFECTIONS TRACT RESPIRATORY UPPER

National Antibiotic Guidelines

The Sanford Guide to Antimicrobial Therapy 2015. Available at: http: at: Available Therapy2015. to Antimicrobial Guide The Sanford

128 - X

should only be only should

tinely recommended due to to due tinely recommended Comments

. is a humanized mouse humanizedmouse a is s ofs bronchiolitis and bronchitis. ) is not rou not is

RSVof 10.6% accounts for etiologie 82% among high risk infants (e.g., those (e.g., infants high among risk 82% Chlamydia Purulent sputum alone not an indication for for an indication not alone sputum Purulent 2 for last Expect to cough therapy. antibiotic get chest a or rigors, fever is there If weeks. Ribavirin controlled of absence toxicity, cost, high the Ribavirin Aerosolized data. SPAG 2. with administered Palivizumab of prevention the for antibody monoclonal by rates n hospitalizatio reducing bronchiolitis, 39- lung chronic disease, heart congenital with It is weeks). <32 birth preterm or disease, 30 onceevery IM 15mg/kg of dose a at given 5 months. of a maximum for days,

(formerly 5

Chlamydophila Chlamydophila or Antibiotics not indicated indicated not Antibiotics

20 hours daily for 3- for daily hours 20

for severe disease (e.g., requiring requiring (e.g., disease severe for

Mycoplasma Mycoplasma Regimen is not available in the Philippines. the in not available is

Ribavirin

LOWER RESPIRATORYTRACT INFECTIONS

particle aerosol generator (SPAG) 2 via via 2 (SPAG) generator aerosol particle Antibiotics are indicated only with associated associated with only are indicated Antibiotics

) rs old) rs ea ears y y

(<5 (<5

there is evidence of secondary bacterial infection. infection. bacterial secondary of evidence is there Antibiotics are not indicated. arenot Antibiotics

: . Aerosolized RibavirinAerosolized ays. forchronic obstructivepulmonary disease, 7.2% forasthma and 5.4% for congestive heart failure inpatients >65 yearsof unless unless hydration, includes which care, supportive is therapy of The mainstay oxygen if supplemental use of and saturation oxygen of measurement needed. Adult For infants hospitalized with RSV bronchiolitis: RSV with hospitalized infants For d , Group A A Group , S. pneumoniae culture for on throat heavygrowth or sinusitis Pediatric: in 20mg/mL of a at concentration Administer ventilation). mechanical by small water sterile over 18- for administration aerosol continuous Pediatric ACT INFECTIONSACT

(most

Etiology Adenovirus Adenovirus

: ears y

<2 common) Acute Bronchitis Acute to done be diagnose may test reaction chain polymerase swab throat A metapneumovirus Human RSV in 50%; Parainfluenza in 25%; 25%; in Parainfluenza 50%; in RSV hospitalizations forpneumonia, 11.4% age. RSVcaused 11%of clinically important respiratory illnesses in military recruits. Thereis a need forsurveillance for Bronchiolitis / Wheezy Bronchitis (Expiratory Wheezing) (Expiratory Bronchitis / Wheezy Bronchiolitis syncytialtheetiology; important most (RSV) isuses Respiratory virus diagnosis detection rapid antigen methods. adults, In

LOWER RESPIRATORY TR RESPIRATORY LOWER National Antibiotic Guidelines

129

500mg

2 weeks). -

tussive emesis or or emesis tussive

500mg PO qid 14 qid PO 500mg - 500mg PO bid bid x 7 PO 500mg 160/800mg PO x PO bid 160/800mg if post if Azithromycin

1, then 250mg q24h on q24h 250mg then 1, is documented, prefer prefer documented, is

Comments over macrolides due to due to macrolides over Erythromycin trimoxazole

- increased is Co Clarithromycin OR

5 - Mycoplasma Mycoplasma OR OR 2 ntibody titres. ntibody outbreak setting, the likelihood of of the likelihood setting, outbreak ays x1 dosex1 on day d

ays ays ays d d d (adults and children): (adults PO 14 ray. If Doxycycline resistance. macrolide increasing in pertussis eliminate or abort may Treatment the shorten does not but stage, catarrhal the at aimed is Treatment stage. paroxysmal In the carriage. nasopharyngeal of eradication non- pertussis inspiratory whoop is is whoop present. inspiratory contacts household of prophylaxis Pertussis

toxin a toxin -

4 weeks); and 3) convalescence (1 and 3) convalescence 4 weeks);

- ays OR ays d 5 d

- 2 (Max: 1 ays d q24h for 5 for q24h trimoxazole in 4 div doses div 4 in - ays d Co ay 5mg/kg/d 1 then 500mg PO x 7 PO 500mg bid 14 OR ays g q24h on daysg q24h in 2 div doses x 14 div 2 in d

ay 10mg/kg/d ay 40mg/kg/d

.25 PO on day PO ay

1 7.5mg/kg PO q12h x7 q12h PO 7.5mg/kg

div q6h x7- q6h div in 4 div doses x 14 div 4 in

there is no improvement in 1 week. week. 1 in no improvement is there

Clarithromycin estolate Regimen when 2 weeks); 2) paroxysmal coughing (2 coughing 2) paroxysmal 2 weeks);

- OR 8/40mg/kg/d Azithromycin

ay 10mg/kg/d

; or; ays ay 40mg/kg/d ay 40mg/kg/d d 500mg PO qid x14 qid PO 500mg LOWER RESPIRATORY TRACT INFECTIONS Clarithromycin

500mg PO on day PO 500mg base OR

Erythromycin

trimoxazole estolate - . bronchodilators inhaled ays OR

H.influenzae - d Azithromycin Co

: 6 months up to s:

Erythromycin

: OR ) nth nth Azithromycin Antibiotics are usually not indicated. not areusually Antibiotics

OR : :

Erythromycin

6 ays ays Adult ay 2g/d OR ay) 1g/d (Max: PO q24h x 4 q24h x PO > d 160/800mg PO bid x14 bid PO 160/800mg d Pediatric <1 mo Erythromycin Streptococci, Streptococci, . symptomatic is treatment Otherwise, Adult +/ Antitussive

esents as 3 stages: 1) catarrhal (1 catarrhal 1) stages: as 3 esents pr

Usually

and

Chlamydophyla

Etiology parapertussis B. in 5%; in 5% Respiratory syncytial syncytial Respiratory

nasal drip nasal - ears y

5 - 2. Gastroesophageal reflux Gastroesophageal 2. Asthma 1. Post 3. following: Differential diagnoses include the the include diagnoses Differential occasionally, occasionally, Diagnosis is made through polymerase chain reaction on nasopharyngeal secretions or increased pertussis increased or secretions nasopharyngeal on reaction chain polymerase through made is Diagnosis pertussis Bordetella Pertussis (whooping cough) (whooping Pertussis Adolescents andadults: pneumoniae 2 Human 3 virus; Parainfluenza virus; metapneumovirus pneumoniae infection Chlamydophila 5. infection Mycoplasma 4. National Antibiotic Guidelines

130

acquired - rimantidine

and

Comments Amantadine

) Resistant to to Resistant (100% The role of antimicrobial therapy is debated is therapy antimicrobial of The role study a recent but diseases, severe even for of value shows patients 80,000 over on hospitalized patients in therapy antimicrobial disease. severe with

OR invasive positive pressure ventilation pressure positive invasive Azithromycin Doxycycline

OR , and Haemophilusand influenzae .Prevention , includesannual vaccination.

500mg PO bid bid PO 500mg

ays

500mg tid tid 500mg

875/125mg bid OR bid 875/125mg

PO 500mg bid Regimen ray, especially if febrile and/or with low oxygen saturation; (2) inhaled anticholinergic anticholinergic inhaled (2) low with oxygen saturation; and/or febrile if especially ray, - Clarithromycin

Amoxicillin

X LOWER RESPIRATORYTRACT INFECTIONS ays

amoxiclav OR

- Streptococcuspneumoniae d

, Cefuroxime Co s old: 3mg/kg bid x 5 bid 3mg/kg old: s

ays

ays d . antibiotics oral tolerate cannot the patient be used if only should antibiotics IV invasive. d nth OR

500mg PO q24h PO 500mg 10 -

Oseltamivir

: 5 : 11 mo 11 : - infections: ks ee Levofloxacin Severe Severe 2 w 5 x bid 30mg ≤15kg: 100mg PO bid bid PO 100mg x3 q24h 500mg Duration (1) who: COPD of with exacerbations patients to be given should Antibiotics states: 2015 Update COPD The GOLD the of two have (2) purulence); and sputum volume, sputum dysp nea, in (increase symptoms cardinal have three ventilation, mechanical requires or (3) symptoms; the two of one is purulence sputum increased if symptoms, cardinal non- or invasive Pediatric Mild Moderate infections: Moderate Mild Staphylococcusaureus

in 5%,

H. in <1% in

smokers with chronic obstructive pulmonary disease. Tobacco use and air pollution contribute to ABECB. contribute pollution use and air Tobacco disease. pulmonary obstructive chronic with smokers

b Moraxella Moraxella 50%, 50%, - Etiology and

is controversial is

resistantand susceptible a

- a methicillin Influenza Influenza Influenz Fever,cough, myalgia during influenzaseason. Complicationsinclude influenzapneumonia and secondary bacterial pneumonia due tocommunity e pneumonia Mycoplasma Viruses in 20% in Viruses e pneumonia Chlamydophila Management of severe ABECB includes: (1) consider a chest consider (1) includes: ABECB severe of Management non- (5) and cessation; (4) tobacco 2 weeks; over taper corticosteroid; oral (3) bronchodilator; catarrhalis Almost always in in always Almost volume. and sputum viscosity/purulence sputum dyspnea, by increased characterized is ABECB Severe Acute bacterial exacerbation of chronic bronchitis (ABECB), adult (ABECB), bronchitis chronic of exacerbation bacterial Acute , S.pneumoniae of The role and , influenzae

National Antibiotic Guidelines

131

improved improved

ly increase increase ly

)

, etc. Comments decreases the number of of number the decreases

induced QTc prolongation, liver liver prolongation, QTc induced Cladosporium s).Airway colonization isassociated with , . tolerance exercise and function lung Itraconazole with corticosteroids requiring exacerbations , markers immunological improved Higher rates of macrolide resistance in in resistance of macrolide rates Higher potential may flora oropharyngeal from deaths cardiovascular of risk the - macrolide loss . orhearing toxicity,

Alternaria

OR Itraconazole Itraconazole

ays d

500mg PO bid bid PO 500mg

otherdematiaceous species ( 10

.or days

dyskinetic cilia, tobacco,or prior severe or recurrent necrotizingbronchitis (e.g.,

spp

Regimen ays ays d d

Erythromycin

Aspergillus LOWER RESPIRATORY TRACT INFECTIONS ays d 500mg PO q24h x 7 PO 500mg

75mg PO bid x 5 x 75mgbid PO

250mg q24h x1 year q24h 250mg

) Levofloxacin Oseltamivir

: : Adult exacerbation: of Prevention aspergillosis: bronchopulmonary allergic of Treatment longer. or x16 weeks bid PO 200mg >15kg to 23kg: 45mg bid x 5 bid 45mg 23kg: to >15kg x 5 bid 60mg 40kg: to >23kg 5 x bid 75mg >40kg: Adult Azithromycin bronchopulmonary allergic with associated attacks asthma Acute corticosteroids. with treated is aspergillosis

and

) A. flavus treatment screeningincludes baseline liver function electrocardiogram, tests, hearing test, sputumand culture to exclude cobacterialmy disease. - Aspergillus fumigatus fumigatus Aspergillus Etiology (rarely

luenzae; P. aeruginosa; S. S. P. aeruginosa; luenzae; Aspergillosis; Aspergillosis; common); (most others. Allergic bronchopulmonaryaspergillosis (clinical manifestation: wheezing,pulmonary infiltrates, bronchiectasis,and fibrosi increaseblood eosinophils, increaselgE levels andisolation of H.inf pneumoniae May be May caused byobstruction, decreased immunoglobulins,cystic fibrosis, pertussis).Pre Acute bacterial exacerbation (bronchiectasis exacerbation bacterial Acute National Antibiotic Guidelines

132

and

- 4 weeks

Amoxicillin 15, with an interval an interval with 15, dose. every doses 3 includes on Comments 600mg /42.9mg/5mL in 5 mL in /42.9mg/5mL 600mg

Amoxicillin Primary vaccinati Primary the after 6 months and a booster, 4 weeks dose. 3rd 3 doses every includes vaccination and a booster dose at 12- dose at and a booster the3rd after 6 months of Pneumococcal Conjugate Vaccine given IM. IM. given Vaccine Conjugate Pneumococcal Primary IM. given Vaccine Conjugate Hib

Equal efficacy between oral oral between efficacy Equal tolerated. is feeding if penicillin IV DOSE Co ofHIGH Preparations PNF (14:1) BID dosing 600) for (ES amoxiclav Immunize at 6 weeks of age 6 of at weeks Immunize • •

) e influenza H. or - IV infusion infusion (amoxicillin

6h typeable typeable 100,000 -

1 then 1 then div q4- div ay IV 60 min 60 Azithromycin Azithromycin 90mg/kg/dayq12h PO x5 Penicillin G

- PO on d PO 80

:1 preparations) 14:1 OR

ay K. pneumoniae Non, K. 500/125mg PO q8h (Max: ay 2g/d q8h (Max: PO 500/125mg , PO div q12h div PO /day U/kg 400,000 Regimen infusion over 15- over infusion IV div q6h div IV Amoxicillin

6h or 10mg/kg/d or S. aureus

/day : : macrolide consider IV amoxiclav , LOWER RESPIRATORYTRACT INFECTIONS - ays /day 15mg/kg Amikacin Aminoglycoside - 250,000

div q4- div d Co

/day 30mg/kg 30%,

90mg/kg PO div q12h ( q12h div PO 90mg/kg IV 20- 200mg/kg 80- - POx 3

/day 5mg/kg Amoxicillin

100

60 min PLUS min 60 g/day type b in 10%in b type Cefuroxime Cefuroxime amoxiclav

- ays Gentamicin

If allergicIf to 10mg/k For severe infections: severe For vaccination: Hib complete with If d history: orvaccination unknown lete incomp or vaccination Hib no with If Co component) kg: >40 children For OR Ampicillin /day U/kg 250,000 15- over -

H.influenzae s),≥40 No or ≤35/min ≤35/min nth - 50%, 50%, -

12mo - severe): severe): - in 30% in bacilli, Group B Group B bacilli,

), ≥30 ), ears Etiology Acquired Pneumonia (CAP) in Infants and Children up to 5 up to years Children and in Infants (CAP) Pneumonia Acquired Acquired Pneumonia (CAP) in Neonates in (CAP) Pneumonia Acquired

- - 5y -

≥60/min (3 - negative - ) ears pallor; awake; no signs of no of awake; signs pallor;

(>5 y ≤50/min (1 mild dehydration; no malnutrition; no malnutrition; dehydration; mild no respiratory failure; respiratoryrate of ≥50 pneumoniae S. (non PCAP A/B Community Streptococci Community Gram Pneumonias and Infections of Parenchyma Lung of the and Infections Pneumonias

National Antibiotic Guidelines

133

4 weeks). 4 weeks).

3 days after 3 days after -

, intact GI absorption GI , intact Comments

with ed for more severe disease (pleural (pleural disease severe more for ed Responding to initial treatment initial to Responding feed to Able extrapulmonary pulmonary/ from Free complications

1. 2. 3. Switch from IV to oral form2 are: who patients in of treatment initiation Although the total course of therapy is usually usually is therapy of course total the Although pneumonia, uncomplicated days for 10 7 to be 2 tomay weeks 3 of courses longer requir abscesses). pulmonary or empyema

ritative and nonproductive (lasting for for 2- (lasting and nonproductive ritative IV div history:

div PO PO div

/day /day IV div q12h div IV amoxiclav

Cefuroxime

15mg/kg OR

200,000 U/kg 200,000

/day 100mg/kg

72h): IV q6h IV div

IV div q6h div IV , admitay, for 90mg/kg/d IV antibiotics.

Penicillin G Clarithromycin Clarithromycin

, shiftay, 90mg/kg/d to Co Regimen 80- Ceftriaxone

OR 80- . 5 - OR

2 ). LOWER RESPIRATORY TRACT INFECTIONS /day 100mg/kg

ays 200mg/kg/day ears amoxiclav amoxiclav

- y

div PO q12h (amoxicillin component). q12h (amoxicillin PO div Co Amoxicillin IV div q8h div IV efer for antibiotic guidance. antibiotic for efer

PO on d PO . R .

sulbactam

- ays ay d Ampicillin

- (48 treatment initial to responsive OR /day 90mg/kg on started If If started on on started If macrolide. an oral adding consider also May Consider other diagnosis other Consider Clinical presentation may be indistinguishable from viral pneumonia. Complaints are related to slowly progressive progressive slowly to are related Complaints pneumonia. viral from indistinguishable be may presentation Clinical

non-

ears >35/min), (>5

/day 100mg/kg • orvaccination unknown incomplete or vaccination Hib no with If If If • Hib vaccination: complete with If q6h Ampicillin 5mg/kg/d x7 q12h • • y

5 -

s), subcostal head retractions, bobbing,cyanosis, grunting, apnea; respiratory rate

dmit to critical unit care critical to dmit nth a Severe dehydration;severe malnutrition; with pallor;lethargic/ stuporous/in coma (+

and s), >50/min s), (1

Moderate Moderate 12 - nth Etiology ),5 years >35/min (>5 12mo - - ≤70/min (3 ); NO grunting; apnea. NO grunting; NO ); ears y Refer to Specialist to Refer >50/min(1 >70/min (3 Physical examination may show rales, rhonchi, and wheezes in the context of a child who does not appear ill (“walking pneumon ia”). (“walking ill appear not does who child a of context the in wheezes and rhonchi, rales, show may examination Physical systemic symptoms over 3 to 7 days, with malaise, pharyngitis, and headache, followed by cough that is ir is that by cough followed headache, and pharyngitis, malaise, with days, 7 to 3 over symptoms systemic Children (>5 years) years) adolescents: and (>5 Children supraclavicular/intercostal/ PCAPD (very severe): PCAP C (severe): (severe): PCAP C malnutrition; moderate dehydration; withpallor; irritable (+intercostal/ head retractions, subcostal rate respiratory cyanosis); bobbing, - >60 of National Antibiotic Guidelines

134 line -

drugresistant -

arepotential second uncontrolled diabetes

Comments tuberculosisand not recommendedas first line treatment option forlow CAP.risk Sputum Gram stain stain andculture isnot ssary.nece Treatment choices when atypical pathogens pathogens atypical when choices Treatment suspected. are Fluoroquinolones pulmonary theofagents treatment for tuberculosis,particularly for multi

IV, unstabledisease,onIV, coronary artery failure renal -

OR conditions morbid

PO on day PO ays d OR

Azithromycin 500mg PO 500mg daily

using if ays X ray: localized infiltrates; no evidence of pleural effusion pleural of no evidence infiltrates; localized ray: X x 10

OR ays 14 d -

dialysis,uncompensated COPD,decompensated disease.liver Unstable/Decompensatedcomorbid condition: mellitus,active malignancies,neurologic disease in evolution,congestive heartfailure class II 1g PO bid OR bid PO 1g aspiration suspected No co- stable or No Chest 5

- • • • • x 10

div q12h div

ay 10mg/kg/d or

or 3 8h 1g PO tid - Azithromycin ays 500mg PO bid bid PO 500mg

- ays d

amoxiclav 7

- div q6 div - 5 Regimen - Co 2

PO POx 3

Amoxicillin

/day LOWER RESPIRATORYTRACT INFECTIONS Clarithromycin 500mg PO bid bid PO 500mg

500mg PO bid +/ 500mg bid PO

PO on days PO OR /day15mg/kg suspension

>90mmHg, >90mmHg,

50mg/kg

/day 10mg/kg morbidillness: S. pneumoniae5 : S.

axetil morbid illness: morbid

- For

Clarithromycin

were reported as werereported isolates) 2 (only and 0.7% breakpoint meningitis using Penicillin to were resistant 11% (302), tested

<125/min, SBP <125/min, ay 5mg/kg/d then Azithromycin With stable co- stable With Without co Without dailyPO 500mg Cefuroxime Azithromycin Erythromycin Clarithromycin Duration: Duration: OR

<40˚C)

isolates meningitis breakpoints. meningitis

>36˚C or >36˚C <30/min, PR

bacilli morbid morbid

respiratory respiratory

negative Etiology - Acquired Pneumonia (CAP) in Adults in (CAP) Pneumonia Acquired

- ray: multilobar infiltrates; pleural effusion - risk CAP: risk - resistant usingnon- resistant - Temp >60mmHg,

risk CAP: risk - pneumoniae S. aspiration Suspected Altered mental state of acute onset acute state of mental Altered Chest X Chest Unstable Vital Signs:RR>30/min, PR >125/min,Temp <36˚C or >40˚C DBP Stable vital signs (RR signs vital Stable No altered mental state of acute onset acute of state mental altered No

illness) (among those with co- with those (among • • • • Moderate Potential pathogens: Potential C. influenzae, H. pneumoniae, catarrhalis M. pneumoniae, For For penicillin Enteric Gram Low • Community S. pneumoniae, M. pneumoniae, C. C. pneumoniae, M. pneumoniae, S. e pneumonia •

National Antibiotic Guidelines

135 can

negative negative -

or use an oral or useoral an

Gram

eeks Fluoroquinolones Comments is not recommended. recommended. not is

biological data, biological and

for at least 2w at least for , monotherapy with with , monotherapy Fluoroquinolones

mechanical ventilation mechanical increasing resistance of

empyema. necrotizing or cavitary infiltrates cavitary or necrotizing requirement for intensive care unit unit care intensive for requirement

mg/d • • • cause prolongationcause of QT interval.Caution should be taken especiallyin elderly with cardiovasculardiseases. Shift fromIV to oral therapyonce thepatient is clinically improving. Empiric therapy for MRSA among hospitalized hospitalized among for MRSA therapy Empiric any in of indicated is severe CAP with patients conditions: following the Due to Due bacilli to Fluoroquinolone Azithromycin

P. OR 1.5g IV 1.5g

or 500mg PO

. Ertapenem odium

for azalides). A A azalides). for

OR Levofloxacin 4.5g IV q6h IV 4.5g S. aureus S. aureus

ays OR d for

5 Malnutrition >15 steroids use of Chronic • • Clarithromycin Clarithromycin daily

1g IV q8h) IV 1g

2g IV q24h IV 2g Cefuroxime

tazobactam OR

be given may daily daily 500mg IV IV 500mg Regimen Meropenem ays

d Ceftriaxone (

: stain and culture are are necessary and culture stain OR - Piperacillin

LOWER RESPIRATORY TRACT INFECTIONS ( 1.5g IV q6h 1.5g 750mg PO dailyPO 750mg 500mg IV IV 500mg 500mg PO dailyPO 500mg 2g IV q24h q24h IV 2g may be adequate (or 3- (or be adequate may 12h Gram ays Azithromycin ( d

bacteremia concomitant with ulbactam ulbactam 10 - if if s

P. aeruginosa P.

2g IV q8- IV 2g - 7 daily) PLUS

Ceftriaxone Ceftriaxone : P. aeruginosa

Levofloxacin Levofloxacin

Azithromycin Azithromycin Azithromycin Azithromycin OR OR : uration risk CAP plus any of the following: severe sepsis and septic shock or need for or shock sepsisseptic and severe the following: anyof plus CAP risk - longer duration of up 28 of to duration longer aeruginosa aeruginosa D 750mg IV IV 750mg bid bid Risk for No risk for for risk No q24h) IV Cefepime PLUS Ampicillin q8h PLUS

infections: S. (among (among ) bacilli) ; ) bacilli,) - , Anaerobes Anaerobes ,

S. S.

aspiration, infections with anaerobes should be considered. Choose antibiotics based on available micro available on based antibiotics Choose considered. be should anaerobes with infections aspiration, P. aeruginosa P. aeruginosa

Etiology Enteric Gram ( Gram Enteric

, Enteric, Gram (- therapy antibiotic spectrum risk CAP: risk - - broad Severe underlying bronchopulmonary disease bronchopulmonary underlying Severe History of chronic or prolonged (>7 days within the past month) use of useof month) past the days within (>7 or prolonged chronic of History

Anaerobes pneumophila, L. aeruginosa P. aureus, those with risk of aspiration), of aspiration), risk with those Potential Pathogens: Pathogens: Potential C. influenzae, H. pneumoniae, M. pneumoniae, M. pneumoniae, catarrhalis; • Risk factors for for factors Risk • Any of the clinical feature of Moderate of feature clinical the of Any High (among those with risk of of risk with those (among aspiration) Potential Pathogens: Potential C. influenzae, H. pneumoniae, M. pneumoniae, M. pneumoniae, catarrhalis For those at risk of of risk at those For sputum culture, Blood class. drug same the from agent Legionella pneumophila Legionella National Antibiotic Guidelines

136

ccording to ccording monotherapy for for monotherapy

Comments Clindamycin

or Linezolid Treatment should be modified a modified be should Treatment Use once available. results culture/sensitivity of a with associated evenif bacteremia, MRSA recommended. not is source, pulmonary and antibiotic systemic includes Treatment by guided be should Treatment drainage. results. culture

12h OR -

daily) q24h

daily IV Ceftriaxone Ceftriaxone

2g IV q8- 30mg/kg 30mg/kg 40mg/kg/day 40mg/kg/day 2g 600mg IV q12h IV 600mg Ampicillin 25- 15mg/kg IV IV 15mg/kg PLUS q24h infusion over over infusion q24h concomitant withif concomitant 750mg IV IV 750mg div q6h) div 8h Cefepime IV

Linezolid

Ceftriaxone Vancomycin Vancomycin min 30 OR ( Amikacin Amikacin

Vancomycin divPLUS q6h IV div q6- div IV OR OR

PLUS IV 12h Levofloxacin aeruginosa P. ( ADD ay IV ayIV 100mg/kg/d

30mg/kg/day 30mg/kg/day daily q8h Regimen 4.5g IV q6h IV 4.5g 50- div q6h) div

12h) PLUS

IV /day 40mg/kg . aureus or aureus . LOWER RESPIRATORYTRACT INFECTIONS 40mg/kg/day 40mg/kg/day 600mg 600mg 25- 7mg/kg IV IV 7mg/kg 20mg/kg IV q8- IV 20mg/kg - - q24h infusion over 10- over infusion q24h 5

IV tazobactam 1g IV1g q8h) Metronidazole Metronidazole Ceftriaxone Ceftriaxone -

ay 400mg IV q8- IV 400mg d 10 days may be adequate. A longer duration of up 28 to duration longer A adequate. be days10 may - 100 mg/kg/day

7 Vancomycin Vancomycin

( : Clindamycin Clindamycin Clindamycin Clindamycin Gentamicin (

: Piperacillin Meropenem ( line:

30 min PLUS min 30 100mg/kg/ line: line:

div q6h PLUS div

st st nd Ciprofloxacin , suspected pneumonia is MRSA If Adult OR sulbactam sulbactam 10- IV days may be given for S for be given days may bacteremia. 2 50- 1 Duration: Duration: Pediatric 1 PLUS OR 15 dose then loading

Etiology

pyogenes; H. influenzae H. pyogenes; Acute Empyema Acute S. S. pneumoniae; aureus; S. Empyema

National Antibiotic Guidelines

137

of appropriate antibiotics. appropriate of Comments ays d

Rule out the possibility of of tuberculosis. possibility the out Rule to failure with if intervention surgical Do 7 after improve

50- 3g IV IV 3g PLUS

- Ceftriaxone 12h 500mg IV q6h IV 500mg Ceftriaxone Metronidazole PLUS sulbactam - Ampicillin 8h

500mg IV q6h) IV 500mg 4.5g IV q8h (for mixed IV (for q8h 4.5g - q8 IV 15mg/kg PLUS min 30 Metronidazole Metronidazole

IV div q6- div IV 30 min PLUS min 30 Ampicillin

12h - IV q6h PLUS IV div tazobactam tazobactam Metronidazole Regimen - negative aerobes) negative - Vancomycin (

ay 40mg/kg/d OR

ay 40mg/kg/d LOWER RESPIRATORY TRACT INFECTIONS 15mg/kg IV q8 IV 15mg/kg 25- 2g IV q24h PLUS IV 2g

600mg IV q8h OR IV 600mg

q24h infusion over 10- over infusion q24h

Piperacillin

IV q24h infusion over 10- over infusion q24h OR IV resistant Gram resistant

IV div q6h div IV 2g IV2g PLUS q24h 6weeks 4 weeks based on clinical response to drainage and drainage to response on clinical based 4weeks - - 1.5g IV q6h IV ) 1.5g

4 2

Ceftriaxone Ceftriaxone Vancomycin

( Clindamycin ( :

q12h)

Clindamycin Clindamycin (

OR :

line: ay 100mg/kg/d

infections with with infections Duration: antimicrobial therapy antimicrobial Duration: Duration: or 1g IV or Ceftriaxone Vancomycin 2nd line: Refer to specialist. to Refer Pediatric line: 1st 50- q6h) 2 sulbactam ay 100mg/kg/d ay 30mg/kg/d Adult

respiratory respiratory

Etiology

Anaerobes of the upper the of Anaerobes Lung Abscess S. pneumoniae; aureus; S. Mycobacterium tuberculosis Mycobacterium tract Chronic Empyema Chronic organisms anaerobic Mostly National Antibiotic Guidelines

138

commended. Comments monotherapy for MRSA for monotherapy

Linezolid Use of of Use a with associated if even bacteremia, re not is source, pulmonary

- Co - 1g PO PO 1g

300 OR

1g PO bid PO 1g 600mg IV q12h 600mg

amoxiclav

- risk CAP in adults and and adults CAP in risk - Oral: Clindamycin 450mgPO tid amoxiclav Co bid

Linezolid

PLUS OR 3g IV 3g IV

4.5g IV 4.5g

IV q24h IV

12h 500mg IV IV 500mg 2g q24h IV IV q24h 2g 1g

Regimen negative infection infection negative - sulbactam - 600mg IV q8h IV q8h 600mg azobactam

2g IV q24h for for q24h 2g IV t - LOWER RESPIRATORYTRACT INFECTIONS

Ertapenem Ceftriaxone 15 mg/kg IV q8- IV mg/kg 15 Metronidazole 4 weeks, depending on clinical response; longer (up (up longer response; clinical on 4 depending weeks, - OR OR

Ampicillin

OR suspected Gram q6h Piperacillin q8h PLUS q6h Parenteral: Clindamycin Ceftriaxone

Up Up 3 to

Vancomycin 3 months) for abscess. lung for 3 months) - line: line:

nd st influenza 2 Duration: to 2 high or moderate for to recommendations Refer ADD 1 -

Gram ; ri lle i m pneumoniae Etiology

aureus; S. aureus; S. atients with active influenza or with history of influenza within 2 weeks of development of of CAP development of 2 weeks within of influenza history with or influenza active with patients as Defined Pneumonia with concomitant/post with Pneumonia Streptococcus Streptococcus Pneumonia, anaerobic or aspiration with or without abscess lung without with or aspiration or anaerobic Pneumonia, cocci; positive Gram Anaerobes; bacteria negative

National Antibiotic Guidelines

139 to negative bacilli bacilli negative -

Comments ter the 3rd day of admission 3rd day of admission the ter

For infections with MDR Gram with infections For of classes several to resistant highly are that on current be based should Choice the in pattern susceptibility antimicrobial empiric for recommendations The institution. based on national are here therapy data. resistance antimicrobial

s e disease and/ or therapy or and/ e disease

30 min 30 - Meropenem OR risk CAP in adults and adults CAP in risk - 5mg/kg/day IV) IV) 5mg/kg/day Home infusion therapy (including antibiotics) (including therapy infusion Home Chronic dialysis within 30 days within dialysis Chronic care wound Home pathogen MDR with member Family Residence in a nursing home or extended care facility care extended or home a nursing in Residence Immunosuppressiv

• • • • • • 8h for documented MRSA documented for 8h - div q6h div

IV q6 /day div q8h infused over 15 over q8h infused div Gentamicin Gentamicin

Regimen . Vancomycin /day add 300mg/kg

600mg IV q12h IV 600mg LOWER RESPIRATORY TRACT INFECTIONS ay 60mg/kg/d - 40 15mg/kg IV OR IV 15mg/kg associated pneumonia (VAP) in Children in (VAP) pneumonia associated 150mg/kg - - div q6h (120mg/kg/day q8h if with meningitis) 2- (Max: meningitis) with if q8h (120mg/kg/day q6h div

Linezolid

azobactam 100

is suspected, is -

OR Amikacin Amikacin

( Vancomycin

S. aureus S. aureus

If If infections infections /day 300mg/kg Ceftazidime Ceftazidime PLUS Piperacillin Refer to recommendations for moderate high or moderate for to recommendations Refer ADD

preceding 90 days preceding

the the

lactamase lactamase

producing producing -

Klebsiellaspp., E. Etiology for infection with MDR pathogens are: MDR with infection for

acquired pneumonia (HAP) and Ventilator and (HAP) pneumonia acquired - drug resistant (MDR) pathogens (MDR) drugresistant - Presence of risk factors for HCAP: for factors risk of Presence High frequency of antibiotic resistance in the community or in the specific in the specific or the community in resistance antibiotic of frequency High unit hospital Current hospitalization of 5 days or more daysor 5 of hospitalization Current Hospitalization for 2 days or more in the preceding 90 days the preceding 2 in more for days or Hospitalization Antimicrobial therapy in in therapy Antimicrobial

• • • • • and carbapenemase P. aeruginosa, K. pneumoniae K. aeruginosa, P. - beta spectrum (extended Risk factors Risk Multi spp.; Serratia marcesens Serratia spp.; P. aeruginosa, A. baumanii, K. baumanii, A. aeruginosa, P. pneumoniae; Proteus spp.; Enterobacter coli, S. aureus; S. pneumonia aureus; S. HAP in children is pneumonia (diagnosed by a combination of clinical, laboratory and imaging parameters) that occurs on or on af occurs that parameters) and imaging laboratory of clinical, by a combination pneumonia (diagnosed is children in HAP with day of event, of e date dayson th >2 calendar for ventilation on mechanical is patient the where pneumonia is children in VAP location. inpatient an before. day the or of the event date placeon the in was ventilator day 1 and the being placement ventilator Hospital National Antibiotic Guidelines

140

Comments negative bacilliin all empiric -

antimicrobial agents, referral to a specialist is is to a specialist referral agents, antimicrobial warranted. a to specialist. Refer HAP, and VAP suspected with patients In , P. aeruginosa aureus, S. for coverage include Gram and other regimens). to and culture blood GS/CS sputum Do of HAP. etiology determine own their generate should hospitals All be guided treatment empiric and antibiogram

or more after admission and not associated with with associated not and admission after more or OR ours OR lactam h

Linezolid 20mg/kg IV IV 20mg/kg beta OR 2g IV2g q8h

2g IVq8h

(ifwith

20mg/mL 20mg/mL

Cefepime

30mg/kg then 15- then 30mg/kg 2g IV q8h

OR OR Regimen Aztreonam 4.5g IV q6h 4.5g

4.5g IV q6h q6h IV 4.5g

LOWER RESPIRATORYTRACT INFECTIONS

100mg/kg/day q8h (150mg/kg/day q8h for q8h for (150mg/kg/day q8h 100mg/kg/day OR

loading dose of 25- dose of loading associated pneumonia (VAP) in Adults in (VAP) pneumonia associated -

: Prior IV antibiotic use within 90 days 90 use within antibiotic IV Prior HAP: in azobactam 1g IV q8h IV 1g azobactam 1g IV q8h t

Cefepime - -

) Vancomycin ay 12h with goal to target trough level to 15- level trough to target goal 12h with allergy) PLUS q8- Piperacillin Meropenem Piperacillin Meropenem q12h IV 600mg 4g/d ) Pseudomonas

, , cepacia

S. aureus S. Acinetobacter Acinetobacter Etiology resistant resistant strains),

acquired pneumonia (HAP) and Ventilator and (HAP) pneumonia acquired - MRSA factors increasing the likelihood of of the likelihood increasing factors MRSA Not athigh riskof mortality but with factors increasing the likelihood of the likelihood increasing factors Not at high risk of mortality and no mortality of high risk at Not Empiric Treatment for HAP for Treatment Empiric 48 and occurring admission of hospital time at the incubating as a not pneumonia defined is HAP Hospital Viral and fungal pathogens in immunocompromised hosts (patients on chronic immunosuppressants, solid immunosuppressants, chronic on (patients hosts immunocompromised pathogens in and fungal Viral recipients) transplant bone marrow and organ maltophilia,Burkholderia Methicillin Pseudomonas MRSA, MDRHAP, for Factor Risk Klebsiella Stenotrophomonas spp., ventilation

National Antibiotic Guidelines

141

is to beto is

escalated or or escalated

Colistin Carbapenem

Comments

20%, add coverage for MRSA. add for coverage 20%,

. discontinuation of therapy for both both HAP for therapy of discontinuation dified based on the culture and culture the based on dified ventilation used, referral to ID physician is required. required. is physician to ID referral used, to criteria clinical and levels procalcitonin Use guide and VAP is or unknown is rate MRSA hospital If 10- between resistance or MDR where MDR or resistance by the local distribution of pathogens and their their and pathogens of distribution local bythe susceptibilities. antimicrobial shouldbe de- therapy Antibiotic mo results. susceptibility show results culture If

OR OR OR 2g IV q8h q8h IV 2g

/day Linezolid Linezolid

20mg/kg IV IV 20mg/kg 20mg/kg IV IV 20mg/kg 20mg/kg IV q24h IV 20mg/kg OR OR 2g IV2g q8h 2g IV2g q8h IV2g q8h

15- 20mg/kg - 15 20mg/mL 20mg/mL 20mg/mL 20mg/mL Cefepime Cefepime Cefepime

Amikacin

2g IV q8h (if with allergy to allergy to with q8h (if IV 2g (forpenicillin allergy) 30mg/kg then 15- then 30mg/kg 30mg/kg then 15- then 30mg/kg

- beta allergy to with (if 2gq8h IV Amikacin OR OR OR

OR daily Regimen . High risk of pathogens in the ICU (25%) ICU the in of pathogens risk High .

Aztreonam

4.5g IV q6h 4.5g IV q6h 4.5g 4.5g IV q6h 4.5g

LOWER RESPIRATORY TRACT INFECTIONS OR 750mg IV IV 750mg loading dose of 25- dose of loading loading dose of 25- dose of loading 750mg IV daily daily IV 750mg

mechanical mechanical with associated and intubation endotracheal after azobactam azobactam azobactam 1g IV q8h Aztreonam OR IV 1g q8h Aztreonam or IV 1g 1g IV q8h IV 1g t t t

- - -

7 days but may be longer depending on clinical radiologic radiologic clinical on depending be longer 7 days butmay ours h

Levofloxacin Vancomycin Vancomycin Levofloxacin lactam) 12h with goal to target trough level to 15- level trough to target goal 12h with 12h with goal to target trough level to 15- level trough to target goal 12h with - beta lactam) PLUS q8- and laboratory improvement and laboratory Piperacillin Meropenem Piperacillin Meropenem PLUS q12h IV 600mg Piperacillin Meropenem PLUS PLUS q8- 600mg IV q12h IV 600mg Duration:

Need for for Need

Etiology Treatment VAP of Treatment >48 occurring aspneumonia defined is structural lung lung disease structural isk factors for MDR VAP for factors isk r ithrisk factors for MRDVAP pneumonia; septic shock septic pneumonia; ventilatory support due to support ventilatory With W No disease lung structural No Empiric VAP High risk of mortality and with risk risk and with mortality of risk High factor for MDR Mortality: for Risk High te renal replacement therapy therapy replacement renal te Acu VAP, ARDS VAP, preceding of time shockat 90 Septic days, use within IV antibiotic Prior MDR VAP: for Factors Risk prior to VAP onset VAP before onset, 5 days hospitalization At least National Antibiotic Guidelines

142 P.

is at high at P.

lactam is preferred. is lactam

only if organism is resistant resistant is organism if only Comments

lactams. - not not shock or septic in not in septic shock or at high risk of risk high at shock or septic in Meropenem to all otherbeta should be basedon upon antibiotic of Choice testing. susceptibility of results the be should monotherapy Aminoglycoside due to VAP/HAP with patients For avoided. aeruginosa of results and the whom death for for risk known, are testing susceptibility antibiotic a - beta with monotherapy For patients with HAP/VAP due to due to HAP/VAP with patients For aeruginosa testing antibiotic of results when death 2 using therapy use combination available, susceptible. is which theisolate to antibiotics Use

- 5

Amikacin Amikacin (

IV/PO div q8h q8h div IV/PO Cefepime Cefepime

OR div q6h ORdiv

OR PLUS

) ears IV 600 mg IV/PO q12h IV/PO 600 mg

OR 15mg/kg/day IV OR IV 15mg/kg/day Gentamicin

IV)] >12 y >12 750mg IV IV 750mg /day 30mg/kg

IV div q8h div IV div q6h with goal to target to target goal q6h with div

30mg/kg/day IV div q12h (Max: q12h (Max: div IV 30mg/kg/day Linezolid 2g q8h IV Amikacin ( or 20- /day

7mg/kg/day /day 300mg/kg -

IV 5 Linezolid

Regimen susceptibility testing and susceptibility of culture results the on be based should antibiotic of Choice

15mg/kg/day IV OR IV 15mg/kg/day OR [(Levofloxacin Cefepime 60mg/kg

IV div q8h (120mg/kg/day if with meningitis) meningitis) with if q8h (120mg/kg/day div IV - /day150mg/kg 4.5g q6h by extended infusion OR infusion by extended q6h 4.5g 40 LOWER RESPIRATORYTRACT INFECTIONS OR mg/kg 20 OR

100- tazobactam Ciprofloxacin [ Gentamicin Gentamicin 15-

q8h q8h 20mg/mL 20mg/mL Amikacin Amikacin (

OR OR

) 400mg IV q8h) PLUS q8h) IV 400mg div div

IV azobactam azobactam /day 60mg/kg 1g IV q8h IV 1g 2g IV2g q8h t

IV)] -

rs) or 600mg IV/PO q12h (age or 600mg IV/PO ears) 7 days but may be longer depending on clinical radiologic radiologic clinical on depending be longer 7 days butmay PLUS Vancomycin

Ceftazidime - Piperacillin [ ay 4g/d - Vancomycin

line: line:

st nd Adult: 2 /day 150mg/kg ay) 1.2g/d /day 7mg/kg ay 15mg/kg/d (Max: 2 Ciprofloxacin Meropenem Meropenem Adult: Pediatric: 1 Piperacillin Ceftazidime Duration: Duration: improvement and laboratory Pediatric: 15- to level trough y 12 to (up

S. aureus S.

Etiology : Patients Pediatric and Adult for Treatment Specific resistant resistant - P. aeruginosa P. Methicillin - Pathogen

National Antibiotic Guidelines

143 . is

in patients patients in

Meropenem

Colistin species that is is that species is preferred than preferred is

Rifampicin Comments species that is sensitive only to onlyto sensitive is that species of The combination species.

tigecycline. tigecycline. if use of ialist, Spec to Refer indicated. Consider patient specific factors such as factors specific patient Consider an choosing in and comorbidities allergies In patients with HAP/VAP caused by HAP/VAP with patients In Acinetobacter plus colistin IV use polymyxins, use adjunctive not Do Acinetobacter caused by not Do use colistin. to only sensitive due to HAP/VAP with patients in Tigecycline Acinetobacter and Meropenem colistin

MU - - 60

100-

sulbactam - Amikacin Amikacin ( IV) - Piperacillin

Imipenem h q8 2g

Amikacin ( sulbactam sulbactam Colistin 2g IV q6h for for q6h beta IV 2g IV) PLUS

Ampicillin

/day PLUS /day 5mg/kg

/kg Combine Combine

8h) 8h) IV div q8h IV :

Meropenem Meropenem Ampicillin Aztreonam IV div div q8h OR IV 7mg -

5 /day OR Regimen IV q8h PLUS IV Gentamicin Gentamicin IV div q6- div IV 2g

IV)]

ay LOWER RESPIRATORY TRACT INFECTIONS 1g IV q8h IV 1g initially to be followed 24 hours later by 4.5 later 24 hours be to followed initially 60mg/kg

/day 60mg/kg

Gentamicin Gentamicin

resistant strains: ( strains: resistant - 9 OR 7mg/kg/d IV div q6h (ampicillin component) OR component) (ampicillin q6h div IV IV div q6h div IV Meropenem

Colistin IV OR q8h div IV : ay 300mg/kg/d 5

Meropenem Meropenem

Meropenem Meropenem /day

: Meropenem

kg/day with Carbapenem line:

st 15mg/ Adult: q12h /day 200mg/kg tazobactam For For Specialist Refer to Acinetobacter: MDR For resistant Pan 100mg/kg Pan susceptible monotheraphy with with monotheraphy susceptible Pan Colistinto only sensitive strain MDR (colistimethate) q6h PLUS IV Pediatric 1 Gentamicin allergy lactam Pediatric: /day 15mg/kg

species Etiology Klebsiella pneumoniae Klebsiella Acinetobacter Acinetobacter National Antibiotic Guidelines

144

. Tazobactam -

strains are susceptible are susceptible strains

Piperacillin Comments , if with meningitis, increase increase meningitis, if with , and

particularly in septic patients septic in particularly

Achromobacter Meropenem Ceftazidime

to antibiotic. Consider prolonged infusion of of infusion prolonged Consider antibiotic. Carbapenem For q8h div 120mg/kg/day dose to Some

OR 1g q8h IV 1g q8h

Piperacillin

trimethoprim trimethoprim Amikacin ( OR (

8h ( - 750mg IV q24h IV 750mg Meropenem

12h IV)

OR /day

div q6- div

IV div q12h q12h div IV

PO 6h /day IV div div q8h PLUS IV 7mg/kg IV div div q8h IV Levofloxacin -

- q8 IV 4.5g

Regimen q8h div IV

30mg/kg 10mg/kg/dayq6 div PO - - 4.5g IV q8- 4.5g 8mg/kg/day

20 LOWER RESPIRATORYTRACT INFECTIONS

1g IV q8h IV 1g /day 60mg/kg

/day 60mg/kg

1g IV q24h q24h IV 1g Gentamicin

tazobactam 2g q24h OR IV producing organisms: organisms: producing

- . OR azobactam ay 300mg/kg/d t

trimoxazole

trimoxazole - -

Meropenem Co Ciprofloxacin Co Meropenem Ertapenem

Meropenem Piperacillin

Ceftriaxone

: : line: line: line: line: line: line: line:

line: line:

nd st nd st nd st nd st 2 2 component) Adult 1 - ESBL for Regimen component) component) Adult 15mg/kg/day IV IV 15mg/kg/day Refer to Specialist to Refer Pediatric: 1 1 Pediatric: 1 2 tazobactam Piperacillin 2

Klebsiella

resistant resistant - Etiology Burkholderia cepacia Burkholderia Achromobacter Carbapenem

National Antibiotic Guidelines

145

Comments

IV 1g IV IV 1g

PO div div PO /day 8mg/kg 20- div q12h div 100mg bid bid 100mg

PO q12h PO div

trimethoprim Piperacillin

trimethoprim /day 7mg/kg OR - 400mg IV q12h IV 400mg Meropenem Meropenem 5 8h (

- Meropenem Meropenem

/day 90mg/kg trimoxazole /day 4mg/kg - /day 8mg/kg OR

24 weeks. 24 Doxycycline Doxycycline Ciprofloxacin 8mg/kg bid bid ( 8mg/kg

- Co

IV div q8h q8h div IV ays

OR OR d Gentamicin 8h 14

amoxiclav /day PLUS - Ciprofloxacin IV div q8h OR div IV

PO div q12h (TMP component) x component) div (TMP q12h PO

daily daily

trimoxazole Doxycycline Doxycycline - ays

OR d Regimen trimoxazole Co

- OR 14 IV div q6- div IV

component) x 12- component) 10mg/kg/dayq6 div PO 150mg/kg - - 8

LOWER RESPIRATORY TRACT INFECTIONS /day 8mg/kg

100 2g IV q6h x 10- q6h IV 2g 1g IV q8h q8h IV 1g

/day 150mg/kg

625mg PO tid (for pregnant or sulfa allergy) sulfa or pregnant (for 625mg tid PO 5mg 5mg acid Folic

15mg/kg/day IV OR IV 15mg/kg/day component) component)

ays trimethoprim IV div q12h OR q12h div IV div IV q8h x 7- q8h x IV div /day 300mg/kg

PLUS d

trimoxazole

trimoxazole - 14

Ceftazidime Co Ceftazidime Ceftazidime Meropenem amoxiclav - Co Amikacin

amoxicillin Co line: line: line: 24 weeks 24 line: line: line:

st st nd st nd omponent) azobactam 12- Adult: component) component) OR Adult: /day 30mg/kg Followed by oral therapy: Co therapy: by oral Followed 2 /day 60mg/kg q8h ( PLUS q8h x 10- c Pediatric: 1 ( q12h div PO 1 2 t PLUS 1 Co use: regimens eradication Some

Etiology Burkholderia pseudomallei Burkholderia National Antibiotic Guidelines

146

Comments

2g q8h IV OR Amikacin Amikacin IV Ciprofloxacin Ciprofloxacin

Meropenem Meropenem

Amikacin Amikacin /day 7mg/kg - azobactam, azobactam, PLUS t 5 - OR Cefepime

24h IV IV 12h

/day 15mg/kg

Aminoglycosides div q8- div

or Gentamicin Gentamicin IV div q12- div IV IV div q8h PLUS IV

/day 5mg/kg /day 5mg/kg 4.5g IV q6h OR IV 4.5g

Amikacin Amikacin Regimen (

IV) 1g IV q24h IV 1g 8mg/kg/day PO div q12h OR div PO 8mg/kg/day

1g IV q8h IV 1g /day 150mg/kg LOWER RESPIRATORYTRACT INFECTIONS /day 60mg/kg /day 100mg/kg Gentamicin Gentamicin Gentamicin Gentamicin azobactam

t Fluoroquinolones

15mg/kg/day IV OR IV 15mg/kg/day - 500mg IV div q12h div IV

7mg/kg/day Ertapenem - trimoxazole IV div q8h PLUS div IV Strains: Choices include Piperacillininclude Choices Strains: 5 -

: 6 months for osteomyelitis and CNS infection, 3 months for monthsfor 3 and infection, CNS osteomyelitis for months 6 : Meropenem Meropenem Ceftriaxone Ceftriaxone Amikacin - Piperacillin

: Meropenem line:

/day 30mg/kg line:

st nd Adult 20- PLUS 2nd line: Co 2nd line: ESBL strains: strains: ESBL Gentamicin 15mg/kg/day IV OR IV 15mg/kg/day 2 , Cephalosporins /day 60mg/kg 15mg/kg/day IV OR IV 15mg/kg/day Adult: Pansensitive Pansensitive Pediatric: 100- Cefepime line: 1st OR Duration infections other Pediatric: 1

Etiology

Enterobacter Escherichia coli Escherichia

National Antibiotic Guidelines

147 - http://arsp.com.ph/arsp

Acquired Pneumonia. Acquired

2016 Update. Joint Statement of Statement Joint Update. 2016 by the Infectious Diseases Society of of Society Diseases bythe Infectious

ed. Elk Grove Village, IL: American Academy of Pediatrics. of Academy IL: American Village, Grove Elk ed.

http://www.hopkinsmedicine.org/amp/

. 30th. ed. 2015. ed. . Available at: Available .

th Adults Immunocompetent in Pneumonia Acquired - http://webedition.sanfordguide.com/

S72. LOWER RESPIRATORY TRACT INFECTIONS

ed. Available at: Available ed.

th - Community Pediatric of and Management Evaluation the in PAPP2012 Update

Retrieved from: from: Retrieved Report. Summary 2015 Data Program: Surveillance Resistance Antimicrobial

s Guideline Practice Clinical 2016 Pneumonia; associated and Ventilator acquired -

Treatment Recommendations for Adult Inpatients Adult for Recommendations Treatment Red Book: Report of the Committee on Infectious Diseases on Infectious Committee of the Report Book: Red

Thoracic Society. CID 2016:63 2016:63 CID Society. Thoracic . 7th ed. Philadelphia, PA: Saunders. PA: Philadelphia, ed. 7th . Diseases Infectious Pediatric of Textbook and Cherry's Feigin 2016. 2016. 2015/ - Antimicrobial Therapy 2016. 46 Therapy 2016. Antimicrobial r Tropical Medicine. Medicine. Tropical r report

American and the

- summary Quezon City: Philippine Academy of Pediatric Pulmonologists, Inc. Pulmonologists, Pediatric of Academy Philippine City: Quezon America PSMID, PCCP, PAFP and PCR. Manila: Philippine Society of Microbiology and Infectious Diseases Infectious and of Microbiology Society Philippine Manila: PAFPPCR. and PCCP, PSMID, - data /antibiotic_guidelines.pdf guidelines - S27 2): 44pplement (Su (2007) Dis. Clin al. Infect et LA, Mandell Inc. Pulmonologists, Pediatric of Academy Philippine fo Institute Research Mandell, Douglas and Bennett’s Principles and Practice of Infectious Diseases, 8 Diseases, Infectious of Practice and Principles Bennett’s and Douglas Mandell, Kimberlin, DW et al., ed. (2015). (2015). ed. DW et al., Kimberlin, National Antibiotic Guidelines

Task Force: Diagnosis, Empiric Management and Prevention of Community of Prevention and Management Empiric Diagnosis, Task Force: The Sanford Guide to Guide The Sanford Cherry JD, et al., eds. (2014). (2014). eds. al., et JD, Cherry REFERENCES - 2015 Guidelines Antibiotic Elsevier. PA: Philadelphia, ed. 20th . Pediatrics of Textbook Nelson (2016) eteds. al., RM, Kliegman Hospital with Adults of Management

148

antibiotic therapy therapy antibiotic

immunosuppression; immunosuppression;

3 days with oral oral 3 days with - Comments dities or dities ultiple sites of infection) or rapid or rapid infection) of sites ultiple is <5 cm in diameter. Oral Oral diameter. in cm <5 is

using parenteral agents (in absence of specific specific absence of (in agents parenteral using an agent select data and sensitivity culture up culture follow MRSA) against activity with should agents Systemic results. and sensitivity have who toxic, are who patients used in be have associated who or disease, sive exten cellulitis. MRSA against active antibiotic An the following: any of for recommended If no response after 2 no after response If and complications for look antibiotics, culture drainage: and Incision consider: Empiricblood. and abscess PEDIATRIC

- 4 - 4 doses

- )

)

IV/IMin 3

ay Cefazolin 4 doses - 150mgIV/IM in 3 in 3 - TISSUE INFECTIONS

100 ay) 6g/d (Max: 50mg/kg/d ay 3g/d (Max: doses ay 4g/d 4 doses(Max:

) in 3

ay) 2g/d doses4 (Max: in

ay 50mg/kg/d IV/IM inIV/IM IV/IM inIV/IM Regimen

ays

25- ay ay d

10 RIC SKIN SOFT AND - 5 ay 100mg/kg/d

Oxacillin : ay 100mg/kg/d eedle aspiration inadequate. is eedleaspiration N 50-

200mg/kg/d 150mg/kg/d - - ay 12 g/d (Max: 6 doses uration - PEDIAT 150 4 100 ay) 4 g/d 4 doses(Max: D

Cloxacillin Cephalexin

line:

st Infections Severe infections: 75- infections: Severe Severe 1 Oral : OR infections: to moderate Mild Parenteral Mildto moderate

INFECTIONS - the mainstay of therapy. of mainstay the is

cellulitis; presence of systemic inflammatory response syndrome (SIRS), such as temperature >38°C or <36°C, >24 tachypnea <36°C, >38°Cor suchtemperature as (SIRS), syndrome response inflammatory systemic presence of cellulitis;

(I&D)

abscesses. multiple and in diameter abscess in in cm >5 maybe effective I&D

Etiology associated MRSA is of of is MRSA associated Methicillin sensitive sensitive Methicillin : Methicillin resistant and drainage PLUS

, S. aureus S. (MSSA) effective for concern increasing management. breaths per minute, tachycardia >90 beats per minute, or white blood cell count >12,000 or <4000 cells/μL; associated comorbi associated cells/μL; <4000 or >12,000 count cell blood white or minute, per beats >90 tachycardia minute, per breaths alone. I&D sponse to of re lack phlebitis; septic associated hand and genitalia), face, (e.g., drain to difficult areas abscessage in of extremes (MRSA) - Community Antibiotic therapy is recommended for abscesses with the following conditions: severe or extensive disease (e.g., involving m involving (e.g., disease extensive or severe conditions: following the with abscesses for is recommended therapy Antibiotic of presence in progression May treat patients with I&D only and in outpatient setting if there is no diabetes or immunosuppression, and boil or abscess or and boil immunosuppression, or no diabetes is there if setting and inoutpatient only I&D with patients treat May therapy Incision Incision Skin Infections Skin furuncles boils, abscess, Skin

SKIN SOFT AND TISSUE National Antibiotic Guidelines

149 -

Comments

MRSA, particularly the the CA particularly MRSA, is not recommended for age <8 <8 age for recommended not is

which correlates with with whichcorrelates aureus S.

Those with SIRS and hypotension SIRS Those with aired host host aired imp markedly Those with or defenses, Patients with carbuncles or abscesses who who abscesses or carbuncles with Patients antibiotic recommended initial have failed MSSA against treatment

• • • Doxycycline clinical recent limited bacteriostatic; yrs.; experience. Some strains of of strains Some - Panton named a toxin produce MRSA, associated and are (PVL) leukocidin Valentin virulence a is PVL infections. severe with of factor PEDIATRIC

OR OR )

) in 3 doses in in 2 doses2 in

2 doses (Max: (Max: 2 doses - in 1

1200mg/day in 2 doses in 1200mg/day

ay) 1.8g/d 4doses (Max: - ay 2.7g/d 4 doses (Max: - ay 4mg/kg/d ≥12yrs.: ay 1200mg/d yrs.: ≥12 in 2 doses (TMP component) (Max: (Max: component) doses2 (TMP in doses 3 in 30mg/kg/day yrs.: <12 - ay 4 g/d doses4 in (Max: IV Regimen IV in3 POin 3

SKIN SOFT TISSUE AND INFECTIONS 10d ay) 1.2g/d (Max: Same -

: If patient and physician wish to attempt attempt to wish and physician patient If

ay 12mg/kg/d : 7 : - ay 40mg/kg/d ay 40mg/kg/d ay mg/kg/d 60 Doxycycline Linezolid 8

25- 30- 40- OR OR

uration

Linezolid decolonization: trimoxazole line

- Mild to moderate infections: infections: to moderate Mild ay 30mg/kg/d yrs.: <12 : infections to moderate Mild Severe infections: Same infections: Severe Severe infections Severe nd ay) 320mg/d ay) 200mg/d Co Parenteral Clindamycin For and is infections skin no active have should Patient decolonization. nose, e.g., sites, multiple culture to Need host. a healthy otherwise 2 Oral Clindamycin OR Vancomycin

Etiology (MSSA and(MSSA MRSA) S. aureus aureus S. as recurrent presenting infection in boils) (abscesses, furunculosis host. healthy otherwise an Treat as for furuncles and boils and furuncles for as Treat Recurrent furunculosis Recurrent National Antibiotic Guidelines

150

limited and no limited

Comments

treatment is indicated. indicated. is treatment and large in of cases therapy Systemic with multiple be treated should lesions Folliculitis is infectionof the hair follicle with the epidermis. in exudate purulent by caused always almost is folliculitis tub Hot self usually is , aeruginosa P. chronic recurrent furunculosis. Topical Topical furunculosis. recurrent chronic has 2 or patient if red conside is decolonization household other or year 1 in episodes more infection. develop members the for is recommended antibiotics Systemic and is not ONLY infection of active treatment decolonization. for recommended routinely tionof prepara intranasal Recommended local Some locally. available not is mupirocin nasal for mupirocin use topical experts decolonization.

PEDIATRIC ays

d -

OR % of filled bathtub or 13 or bathtub filled - evere infections) evere blinded controlled controlled blinded s

(

) infections moderate to ild ays m d TISSUE INFECTIONS (

4% or dilute bleach baths/6% baths/6% bleach or dilute 4% only culture missed 48 missed only culture - ay) 2g/d doses4 (Max: in

4 doses - Regimen in 3 the mainstay oftherapy. mainstay the 4 doses (Max: 4 ay) g/d 4 doses(Max: Chlorhexidine - SKIN SOFT AND 4% shower daily x 7 daily shower 4% are are in 3 ay 100mg/kg/d

50-

ay 50mg/kg/d 25- limiting; no therapy indicated. Hot packs for comfort. comfort. packs for Hot indicated. therapy no limiting; - ointment in anterior nares and under fingernails bid x 7 fingernails under and nares anterior in ointment etiology. staphylococcal if ointment

Topical antibiotic therapy for mild cases of folliculitis. Could use Could folliculitis. cases of mild for therapy antibiotic Topical ay 100mg/kg/d Cloxacillin

line: 75-

st or 1 Cephalexin trial. Intermittentbathing with self Usually and draining Incision Mupirocin throat, and inguinal area skin. Nares skin. area and inguinal throat, antibiotics. systemic Avoid individuals. colonized Mupirocin PLUS Chlorhexidine cupof ¼ with water warm of (tub baths bleach that indicates report One is as 15 minutes, for bleach) (household hypochlorite sodium 6% a modest Only bodywashes. shower chlorhexidine as use of effective - single randomized in a prospective, effect positive 3xa 15 minutes for water) of gallon 1 in 1 bleach or tsp water gallons aureus . S. of load reduce skin significantly to be used can week sodium hypochlorite (1/4 cup of bleach in in quarter a bleach cup of (1/4 hypochlorite sodium Oral:

(following

Etiology

(most common) (most (from exposure to to exposure (from aeruginosa P. swimming chlorinated inadequately tubs) hot and whirlpools pools, S. aureus aureus S. Aeromonashydrophila exposure) water Folliculitis

National Antibiotic Guidelines

151 Cloxacillin

Comments

). ). Cephalexin Penicillinase resistant antibiotics ( antibiotics resistant Penicillinase or

) PEDIATRIC

- ) for

) ) of the roof’s remnants. roof’s the of

ay ay epidermal junction to form fragile, thin roofed vesicopustules. vesicopustules. roofed thin fragile, to form junction epidermal - 4doses (Max: /d colored crusts on an erythematous base. on an erythematous crusts colored - g 6 doses (Max: - 1.8 ay) 2.7g/d 4 doses(Max: - 4doses (Max: 6 g/day - in 3 doses (Max: 4g/d doses(Max:

4 doses (Max: 4 doses (Max: - ay) 2g/d doses4 (Max: in

IV in4 200mg/kg/dayin 4

50mg/kg/dayIM/IV in3 in 3 150mg in3

- ay Regimen

forMSSA PO ay 40mg/kg/d

25- ays 150mg/kg/dayIM/IV in 4 doses (Max:4g/d ay d SKIN SOFT TISSUE AND INFECTIONS

Cefazolin Cefazolin 40mg

- 60mg/kg/d 100- 10 ay 100mg/kg/d -

- infections; 150- 30 OR 40 : 7 : 50-

ays

that produce a toxin that cleaves the dermal the cleaves that producetoxin a that 10 - Clindamycin

Oxacillin

: uration : 7 : if MRSA is MRSA if suspected

D ) severe for

, or both in combination. Impetigo begins as erythematous papules that that papules aserythematous begins Impetigo combination. or in , both aureus S. or streptococci hemolytic -

)for mild to moderate; 100 Clindamycin Cloxacillin

Vancomycin line:

line:

S. aureus aureus S.

uration nd st Oral: severe 2 ay 3g/d ay 12g/d Oral: Parenteral: for mild to moderate Parenteral OR D 1

S. aureus S. Etiology rming honey- rming fo discharge the dried with rupture, that pustules and vesicles into evolve rapidly These lesions may rupture, creating crusted, erythematous erosions, often surrounded by a collar a by surrounded often erosions, erythematous crusted, creating rupture, may These lesions by betabe caused can impetigo Nonbullous Bullous impetigo is caused by strains of of causedis bystrains impetigo Bullous Impetigo and ecthyma Impetigo nonbullous. or bullous can be either Impetigo Result of colonization of skin or or skin of colonization of Result of by strain mucosa Staphylococcal scalded skin syndrome skin scalded Staphylococcal producing an exfoliative toxin. toxin. an exfoliative producing MRSA. or be MSSA may Pathogen National Antibiotic Guidelines

152

markedly impaired impaired markedly

ons) if infection is is not infection if ons) , has , Comments unless cultures yield yield cultures unless ldren in hot, humid environments. environments. humid hot, in ldren infection manifests as “honey manifests infection

S. aureus S. Topicals can be used for patients with limited limited with patients for can be used Topicals those for and appropriate lesions of number no more impetigo, areas of localized mild, with infection an area of or impetigo of areas 3 than for indicated are antibiotics Oral cm. <5 infection of areas extensive more with patients lesi multiple with (those with or those worsening, is or resolving non- with and those symptoms; systemic members, family in multiple impetigo bullous teams. or athletic groups, care child PEDIATRIC

- - Co evere evere

s OR

for

) (Max: OR ay ) ay 2 doses - ild to moderate toild moderate 2% cream bid cream 2% in 1

for m recommended antibiotic treatment against MSSA against treatment antibiotic recommended TISSUE INFECTIONS

acid

day regimen with an agent active against against active an agent with day regimen ay) 4 g/d 4 doses(Max: - 4 doses 4 doses (Max: 1.8 g/d 1.8 4 doses(Max: - - iledinitial ay 4mg/kg/d - Fusidic Regimen

in 3 2

in 3 in 3

in 4 doses (Max: 12 g/d doses4 (Max: in in 2 doses (TMP component) (Max: (Max: component) doses2 (TMP in

and/or streptococci may be the cause. Lesions begin as vesicles that rupture, resulting in in resulting rupture, that asvesicles begin Lesions cause. the be may streptococci and/or OR ay ay and/or a and/or aureus S. whether identify help to recommended are and ecthyma impetigo s of SKIN SOFT AND patients who fa who patients S. aureus S. 40mg/k/d ays Doxycycline - ay 100mg/kg/d ay mg/kg/d 50 d 100mg/k/d ay 12mg/kg/d - 30 - ays ays

75- 8 25- OR 12 d d

- ointment 2% tid tid 2% ointment

7 7 or

: uration : uration : 7 : uration ) ay 200mg/d D infections D infections ) ay 320mg/d Mupirocin D Cloxacillin Cephalexin Clindamycin trimoxazole -

. hypotension and SIRS

has

sp. sp. or Etiology susceptible susceptible - Staphylococcus aureus aureus Staphylococcus

impetigo bullous resistant resistant Suspected or confirmed methicillin confirmed or Suspected impetigo bullous aureus Staphylococcus Methicillin Groupcauses A honey crust impetigo; common less are G C, B, Group oral penicillin is the recommended agent). recommended is the penicillin oral (when alone streptococci Streptococcus Gram stain and culture of the pus or exudates from skin lesion skin from exudates or pus of the culture and stain Gram be a 7- should impetigo ecthyma and for therapy Oral cause. the is GABHS nes pyoge Streptococcus edema. erythematous surrounding with often crusts, adherent with ulcers erythematous circular, chi in occurs frequently Most scarring. with heals ecthyma impetigo, Unlike (ecthyma). ulcers out” or “punched lesions crust” a consequence of neglected impetigo, and and impetigo, neglected of a consequence is Ecthyma An antibiotic active against MRSA is recommended for for recommended is MRSA against active antibiotic An defenses host

National Antibiotic Guidelines

153

associated MRSA MRSA associated -

Comments

cess of of abscess the from pyogenes) S. . Dual. infectionis rare.

) due to superficial superficial due to ) d’orange peau utaneous edema surrounding hair follicles follicles hair surrounding edema utaneous and causing skin dimpling because the follicles follicles because the dimpling skin and causing dermis. the underlying to tethered remain red between distinguish can clinically Usually, of skin inflamed demarcated indurated ( erysipelas aureus S. detection in helpful be may ultrasound Bedside doubt, in If abscess(es). aureus deep S. of Community both. for treat Erysipelas is an unusual type of streptococcal streptococcal of type an unusual is Erysipelas the and sometimes the skin involving infection elevated an is It membranes. mucous adjacent exhibiting sometimes lesion, erythematous may which fluid, yellowish with filled blebs rupture. after over crust spreading rapidly cause These infections and tenderness, swelling, erythema, of areas by accompanied sometimes warmth, the regional of and inflammation lymphangitis nodes. lymph orange an resemble may surface The skin ( peel c

PEDIATRIC

- OR

. evere

in 3 doses 3 in

in 3 doses3 in ay

OR fors OR

ay) 2 g/d

) ay

) ay ay

ay) 4g/d Max: Max: ay) 4g/d ild to moderate toild moderate ay) 6 g/d 3g/d : 4: g/d ay) g/d 1.5 150mg/kg/d Max: Max: - 50mg/kg/d - Max: Max: max form evere infections: evere Max: Max: Max: Max:

( 100 ( Cefazolin 25 Max: Max: 4 doses(

)

OR in 3 ay

ay ay 4 doses 4 doses ( - - Regimen IV in 4 doses4 in ( IV in 3 in 3 doses3 ( in 24 8 MU/d in 3 IV in 4 doses4 ( in IV patient therapy for less ill patients ill less for therapy patient

- Penicillin G SKIN SOFT TISSUE AND INFECTIONS Max: Max: Max: Max: ay 30mg/kg/d - 300,000 U/kg/d 300,000 150,000 U/kg/d 150,000

- - 25 )

ay 60mg/kg/d ay allergy penicillin with patients in except ay 50mg/kg/d ay 50mg/kg/d

ay 20mg/kg/d ay 100mg/kg/d 40- 25- 25-

in 4 doses4 ( in 200,000 doses6 ( in MU/d 100,000

75-

IV until afebrile; then may shift to oral agents as outpatient; oral oral asoutpatient; agents to oral shift may then afebrile; until IV Penicillin VK Penicillin Penicillin

line: line:

nd st ; infections infections agents are used also as out also used are agents Treat Vancomycin Cephalexin moderate Severe with s allergic or cephalosporin penicillin If Erythromycin 2 Oral: Amoxicillin 1 Oral: Parenteral: Mildto

(Groups (Groups

Etiology

A, B, C,G) Erysipelas pyogenes Streptococcus National Antibiotic Guidelines

154

like skin on the on the skin like

Staph.) israre. If an extremity.

is recommended and recommended is Comments

like on the face, must treat as if as if treat must on the face, like S. aureus S. aureus

is present, need incision and need incision present, is mimic can face the of erysipelas

- beta to due infection for therapy empiric unnecessary. likely is streptococci hemolytic Cellulitis refers to infection involving the the involving infection to refers Cellulitis For fats. and subcutaneous dermis deeper associated cellulitis (e.g., cellulitis, purulent the in exudate or drainage purulent with empiricabscess), a drainable of absence for therapy can mimic erysipelas; look for loculated loculated for look erysipelas; can mimic purulence. And (Strep. infection Mixed aureus S. spreading rapidly of onset Sudden drainage. - plaque tender edematous red host. healthy otherwise an in face aureus S. of erysipelas streptococcal - erysipelas If present. is MRSA ) PEDIATRIC

) - Max:

) for ) 6 doses - 5 daily (Max:

- 2 5 days; 5 days 4doses ( - ays

TISSUE INFECTIONS

50mg/kg/day in3 doses (Max: IV in 4 doses (Max: 4 ay g/d doses4 (Max: in IV

S. aureus Children≥6 months): 10mg/kg PO ( POin doses4 (Max: 2g/d ay

200mg/kg/dayIV/IM in4 40 mg/kg/dayPO in3

150mg in3 doses (Max: 6g/day - ay - Regimen 30 Cefazolin

in 3 doses3 in in 2 doses2 in ; 100 ;

OR ay mg/kg/d 60 150mg/kg/dayIV/IM in4 doses (Max: g/d4 ay ay) followed by 5mg/kgon d SKIN SOFT AND 40- Azithromycin or until the patient is afebrile for 3- for is afebrile patient the until or 100-

100 mg/kg/d - (same for mild, moderate and severe) moderate mild, (same for 50 ays bacteremic is patient if ays,longer Clindamycin Clindamycin

therapy to cover for for cover to therapy

d d 500 mg/d ay 1200mg/d ) forsevere ay 30mg/kg/d

ildto moderate OR 10 10 ay - -

Oxacillin

Max: ) Linezolid Vancomycin Empiric

1 ( : ay

) for m ) for ld to moderate infections;150 - Cloxacillin <12 yrs.: <12 yrs.: ≥12 line: Azithromycin line: line

: 7 : uration : 7 : uration st nd st for face: the involving erysipelas For 1.8 g/d D D severe 2 ay 3g/d 250 mg/day) (Max:12 g/d 1 1 Oral: Parenteral: for mi Ifallergic topenicillin: dayon

Etiology S. aureus (purulent) Most cases of cellulitis are are cellulitis casesof Most attributed to Cellulitis

National Antibiotic Guidelines

155

coverage for CAMRSA is is CAMRSA for coverage

Comments

Empiric

lactam therapy and may be considered be considered and may therapy lactam

purulent cellulitis is defined as cellulitis cellulitis as defined is cellulitis purulent - ommended in patients who do not respond respond not do who patients in ommended Those with markedly impaired host host impaired markedly Those with defenses and hypotension SIRS Those with Patients with carbuncles or abscesses who who abscesses or carbuncles with Patients antibiotic recommended initial have failed MSSA against treatment - beta

rec to toxicity. systemic with those in Non purulent of no evidence and skin intact with discharge. An antibiotic active against MRSA is is MRSA against active antibiotic An following: the for recommended • • •

PEDIATRIC

- OR ) Max: Max: ) for severe OR severe for ) 40 mg/kg/d40 ay

doses (Max: doses (Max: 20-

[ ]

4doses ( in 2 doses (amoxicillin doses2 (amoxicillin in 2 doses (Max: (Max: 2 doses - Staph

- 1.5g) IV in4 in 1 and

IV in3

ay 1.8g/d 4 doses(Max:

- Max: 4 doses for mild to moderate to moderate mild 4 doses for - Strep in 2 doses2 in formulation

in 3 ay 45mg/kg/d ld, moderate and severe infections) infections) and severe moderate ld, in 3 4:1

ay 4g/d 4 doses (Max: 25- - ay 4mg/kg/d [ in 2 doses (TMP component) (Max: (Max: component) doses2 (TMP in - or ay 60mg/kg/d Regimen 2 ] ) ay 40mg/kg/d in 3

40- in 3 doses in 25- ay 1200mg/d

SKIN SOFT TISSUE AND INFECTIONS ay 40mg/kg/d (same for mi for (same - ay 50mg/kg/d is recommended but should be individualized individualized be should but recommended is -

30 ay 1.75 g/d ay 12mg/kg/d 25 - ays Doxycycline therapy to cover both both cover to therapy 8

d formulation 7:1

Vancomycin ay 100mg/kg/d ay 30mg/kg/d

Max: Max:

OR 10 days is recommended but should be individualized on be individualized should but days10 recommended is 10 : Linezolid

- - Clindamycin

: OR : 7 : For suspected/confirmed MRSA suspected/confirmed For OR

ears : : Empiric: ) response clinical patient’s the Clindamycin Cephalexin

amoxiclav trimoxazole line line -

<12 y <12 : and adults years ≥12 : 7 : uration uration st nd Co ( component) 3 doses (amoxicillin in PO response clinical patient’s the of basis the Oral: ay) 320mg/d ay) 200mg/d Parenteral D ay) 2.7g/d ay 4g/d 1 Oral: 75- infections; ( component) D based 2 Co

hemolytic hemolytic -

purulent) - Etiology Usually caused by beta caused Usually C, G Group B, A, (e.g. streptococci MSSA and streptococci) Cellulitis (non National Antibiotic Guidelines

156 nst nst

). should not not should hemolytic hemolytic pithelialization

e Tetracycline -

or a

Doxycycline MRSA is desired, may desired, is MRSA - Comments and and t well not is streptococci hemolytic trimoxazole

lactam(e.g., Amoxicillin Co

- beta

- beta trimoxazole - MSSA Patients who have failed initial initial have failed who Patients agai treatment antibiotic recommended Those with markedly impaired host host impaired markedly Those with defenses Those with SIRS and hypotension SIRS Those with ome believe drug impairs re impairs drug believe ome

s An antibiotic active against MRSA is is MRSA against active antibiotic An following: the for recommended • • witha • initial the in agent as a single used be activity because their of cellulitis treatment against - beta both for coverage If defined. and CA streptococci combine combine Co

PEDIATRIC

- ild to OR for m

) severe for

ay 4 doses (Max: 2.7 2.7 4doses (Max:

) infections - in 3 doses (Max: 1.5 1.5 doses3 (Max: in ) ay g/d doses4 (Max:4 in in 4 doses (ampicillin doses4 (ampicillin in

in 3 doses (Max: 1.5 1.5 doses3 (Max: in 2 doses (Max: 200 2 doses(Max: IV in3 TISSUE INFECTIONS

IV in 4 doses (Max: ay) 4 g/d in4 doses (Max: IV

4 doses (Max: 1.8 g/day) 1.8 4 doses(Max:

in 1- to severe -

in 2 in doses

ay in 3 in 3 doses (Max: 3g/d doses3 (Max: in

ay mg/kg/d 50 in 2 doses (TMP component) (Max: (Max: component) 2 doses (TMP in ay ay 200mg/kg/d 25- mg/d ay mg/kg/d 50

Regimen moderate

ay mg/kg/d 40 cream (mixture of silver nitrate and sulfadiazine) sodium nitrate silver of (mixture cream ,

ay mg/kg/d 60 25-

ay 4 mg/kg/d 100- severe for

1200 25-

ay) 6g/d (Max: 3 doses in 150mg 2 40- SKIN SOFT AND ay 40mg/kg/d 50mg/kg/d -

is recommended but should be individualized individualized be should but recommended is 100- 30 Amoxicillin ay mg/kg/d 12 - 8 ays d sulbactam Amoxicillin 30 mg/kg/day in 3 doses in mg/kg/day 30 - (same formild

: PLUS 10

- Clindamycin Cefazolin Doxycycline

Vancomycin : :

the patient’s clinical response clinical patient’s the ears For suspected/confirmed MRSA suspected/confirmed For PLUS Silver sulfadiazine Silver

OR : )

] ) ) ) Clindamycin ay

trimoxazole Ampicillin Linezolid line : and adults years ≥12 <12 y <12 -

ay ay ay line:

: 7 : uration st nd Co g/d Parenteral mg/d based on D g/d OR Oral: Minor adverse effects: Sulfonamide allergy; Steven Johnson's Syndrome; Syndrome; Johnson's Steven allergy; Sulfonamide effects: adverse Minor of to due margination probably leukopenia; Transient and fibroblasts. keratinocytes to toxic is silver wound; burn the of [ ay) 320mg/d g/d 1 Parenteral ; infections moderate ay 200mg/kg/d infections; to moderate mild for ay) g/d (Max:8 component) 2 OR

positive positive

ram Etiology infected burns infected - Wide spectrum of potential potential of spectrum Wide G e.g., pathogens: Non

National Antibiotic Guidelines

157

tetanus tetanus

. These . Anti- : patients

Serratia silver silver 0.5% solution solution 0.5%

Enterococcus

Comments broad than than broad , and , >30% of BSA. Other Other of BSA. >30% Silvernitrate

who have failed initial recommended recommended initial failed have who

Those MSSA against treatment antibiotic Pediococcus Klebsiella pneumonia and pneumonia Klebsiella

, • Ideal care is in dedicated burn unit. unit. burn dedicated in is care Ideal is MRSA against active antibiotic An following the for recommended

Strep PEDIATRIC ,

- negative bacteria less less bacteria negative - 4 doses -

Micrococcus ) ), ), Enterobacter cloacae , Enterobacter ay , ay) 6g/d : 300mgIV/IM in 3 - E. coli 150mg IV/IM 3 in doses IV/IM 150mg Ceftazidime - S. aureus

90 3g/d (Max: 200 (Max

PLUS

) IV/IM inIV/IM inIV/IM Regimen ay (CONS and (CONS

toxic shock syndrome (TSS), suppurative phlebitis, pneumonia. phlebitis, suppurative (TSS), shock syndrome toxic ay ay Oxacillin Staph Staph Messy. Turns skin black. Activity vs Gram Activity black. skin Turns Messy.

SKIN SOFT TISSUE AND INFECTIONS

- S. aureus S.

150mg/kg/d 200mg/kg/d - - solution solution are ay) 12g/d (Max: 6 doses

cream. Hyponatremia and hypochloremia can occur. Rarely, Methemoglobinemia can occur can Methemoglobinemia Rarely, occur. can and hypochloremia Hyponatremia cream.

- . indicated is 100 4g/d 4 doses(Max: 150 4

, P. aeruginosa bacteria: negative -

antimicrobials Topical

ram G line: line: ation or injury. ation

st nd sulfadiazine prophylaxis Stage I (epidermis) and II A and B wounds (partial thickness, superficial and deep): superficial thickness, A (partial wounds and B and II (epidermis) I Stage Silvernitrate 1 Mildto moderate Severe WBCs in the wound rather than bone marrow suppression. Resolves spontaneously. Not facial burns for fear of eye of fear for burns facial Not spontaneously. Resolves suppression. marrow bone than wound the rather in WBCs irrit 2

o found more often in patients with more severe burns comorbidities. and severe more with in patients often o found more burns extensive with patients causes in common were aeruginosa P. esp. bacteria negative and MRSA were the most common causes of burn infections in patients with relatively small burns <30% of BSA. BSA. of <30% burns small relatively with inpatients infections burn of causes common the most were and MRSA aureus S. - als

is ) and ) Candida ram

bacter sp.; S. sp.; bacter Etiology Acinetobacter Acinetobacter negative bacilli, and bacilli, negative - epidermidis; E. faecalis;

ram G positive cocci, including including cocci, positive and G cocci positive positive organisms prevail in the early postburn period: period: postburn early the in prevail organisms positive - - -

S. pyogenes; Entero pyogenes; S. S. aureus; Fungi; aeruginosa P. (rare) coli; E. (rare). virus and Herpes complications of concern in critically ill burn patient ill critically in concern of complications Gram Gram . marcescens Gram ( by fungi replaced are then Burns with secondary infections secondary with Burns cocci, cocci, fungi. National Antibiotic Guidelines

158

. and if

ally itif Amikacin azobactam

Oxacillin

t -

instead of of instead Comments

Piperacillin or

soled footwear), ADD footwear), soled - Clindamycin pseudomonal agent. agent. pseudomonal - Those with markedly impaired host host impaired markedly Those with defenses Those with SIRS and hypotension SIRS Those with infection is highly considered considered highly is infection P. aeruginosa

anaerobes or MRSA are suspected. Any Any suspected. are MRSA or anaerobes especi deep infection, of evidence injury 72h after than more develops or persists is a strong children, in and particularly of an and addition exploration for indication anti If through nail with associated is wound (e.g. rubber Ceftazidime • of and management prevention to WHO Refer infection. wound Use •

for

PEDIATRIC OR )

- ) ) for ) for ) ) ay ay 150-

) for) mild 4g/d ay 6g/d

16 g/d16 ay

4 doses - 6 doses (Max: ay 1.5g/d - : ] evere in 3 ax

M for s ild to moderate moderate to ild 4 doses (Max: 6 ay) g/d 4 doses(Max: ay) 2.7g/d 4 doses (Max: for m ; infections severe TISSUE INFECTIONS )

ay) 6g/d

3 doses( ay 3g/d (Max: doses

for

IV in 4 doses4 (Max: in IV

in 3 div doses (Max: div 3 in

ay 300mg/kg/d ay ay 4g/d

240- 200mg/kg/dayIV/IM in4 Regimen for

300mg IV/IM in 3- IV/IM 300mg 3 doses(Max: 40mg/kg/day in 3- in 40mg/kg/day 60mg/kg/d - ay 120mg/kg/d SKIN SOFT AND 150mg IV/IM 3 in IV/IM 150mg 25- 40 150mg/kg/day4 doses(Max: IV/IM 4 g/d in

- 22.5mg/kg/day in 1- in 22.5mg/kg/day 60- -

90-

4 doses (piperacillin component) (Max: component) 4 doses(piperacillin - 100 azobactam 15 t - 150mg in 2- in 150mg in 3

100- 100mg in in 100mg 2 doses (Max:

Clindamycin Vancomycin Oxacillin ) forsevere

Meropenem evere evere Piperacillin line: line:

line:

nd nd st patients <6 months of age of months <6 patients , infections Cefepime ay 300mg/kg/d ay) 16g/d (Max: component) (piperacillin 2 PLUS Amikacin OR fors PLUS Ceftazidime - 200 infections; moderate to 12 g/d12 ay mildto moderate infections;150 - 2 PLUS [ 1

mixed mixed

Etiology

S. aureus, Streptococcus sp., Streptococcus aureus, S. flora Puncture wound Puncture

National Antibiotic Guidelines

159

: if if ram

patients resistant in resistant

has been used most most has been used Comments - Erythromycin are are

who have failed initial recommended recommended initial failed have who

antibiotic treatment against MSSA against treatment antibiotic S. aureus S. aureus Those vitro, may have inducible resistance to to resistance have inducible may vitro, using checks if lab make sure ; Clindamycin thelatter. Ciprofloxacin and adolescents and children in extensively and effective tolerated, be well to appears causearthropathy. to appear doesnot • defenses host impaired markedly with Those • and hypotension SIRS with Those • If indicated. is MRSA against active antibiotic An following the for recommended Debridement of wound may be indicated. be indicated. may wound of Debridement check G and sensitivity, culture Obtain stain. vaccine and Prophylaxis Tetanus Give PEDIATRIC

- OR

OR evere OR

)

for s :

ild to moderate to ild moderate amoxiclav ) infections - Co 40mg/kg/day POin 3 doses

- 3 doses (piperacillin 3 doses(piperacillin

) ay 2g/d doses4 (Max: in

PLUS to severe to

4 doses for m ay) 4 g/d (Max: 4 doses - infections evere - ay) 200mg/d (Max: 2 doses - Regimen 300mg in in 300mg in 3 in 3

fors in 1 in 2 doses2 in

moderate 240-

, SKIN SOFT TISSUE AND INFECTIONS ay 100mg/kg/d ild 4:1formulation: 50- 45mg/kg/day POin 2 doses (amoxicillincomponent)

30mg/kg/dayPO in 2 doses (Max:1.5g/d ay 25 - OR

ay 50mg/kg/d ay 4mg/kg/d ) - ay 1200mg/d 30mg/kg/day in 3 doses in 30mg/kg/day 20

ay 100mg/kg/d

2 azobactam ay t 25- -

75- (same for m for (same or suspected/confirmed MRSA or suspected/confirmed f Parenteral Cloxacillin negative bacilliis suspected: - <12 yrs.: <12 yrs.: ≥12 line: line: line:

nd st st If Gram Complicated, severe, febrile patient febrile severe, Complicated, (amoxicillincomponent) (Max:1.5g) for mild to moderateinfections Ciprofloxacin infections 2 ay) 16g/d (Max: component) Linezolid Cephalexin ; infections Doxycycline (Max:1.75g/d Piperacillin 7:1formulation: 1 Uncomplicated, mild or moderate, afebrile patient afebrile moderate, or mild Uncomplicated, 1

, trauma -

, (water (aerobic and and (aerobic . sp. species Etiology C. tetani , Enterobacteriaceae sp. Aeromonas (MSSA, MRSA), MRSA), (MSSA, anaerobic), anaerobic), dependent on nature of the trauma): the trauma): of on nature dependent aureus S. Wound infection, post infection, Wound Polymicrobic (microbial flora sp. Streptococcus Pseudomonas Pseudomonas , perfringens exposure), Acinetobacter National Antibiotic Guidelines

160 mised

Comments

positive organisms. positive - ram Surgical site infections require prompt and prompt require infections site Surgical incision. the surgical of opening wide for recommended is therapy Antimicrobial if infections site surgical incisional deep source if present, are sepsis of signs systemic incompletein immunocompro iscontrol or had clean have who patients In patients. cover should therapy antimicrobial operations, G

)

IV PEDIATRIC ay

- OR IV in

ay) doses 3 in IV ay 30mg/kg/d ay 60mg/kg/d ) forsevere

20- 4 doses (piperacillin 4 doses(piperacillin - 40-

4 doses (Max: 2.7g/d 4 doses(Max: in 3 -

doses (Max:1.8g/d ay TISSUE INFECTIONS

4 -

IV in3

IV in 2 in doses IV Ciprofloxacin ay

Vancomycin Vancomycin

) ay 30mg/kg/d yrs.: <12

60mg/kg/day IV in 4 div doses (Max: (Max: doses div 4 in IV 60mg/kg/day 300mg/kg/d Regimen ay - PLUS 40- PLUS 150

40mg/kg/d - 40mg/kg/day in3 - SKIN SOFT AND same same

in 3 doses3 in 25

12mg/kg/day in2 doses (TMP component) (Max: - GU tract surgery) tract GU 8 -

Vancomycin Vancomycin ay 6g/d (Max: doses 3 in 120mg/kg/day 60-

) 3 doses (Max: 1.2g/d 3 doses(Max: 1200mg/day in 2 doses in 1200mg/day PLUS PLUS ay 30mg/kg/d -

Linezolid Parenteral Clindamycin : Clindamycin

nem

: ) ay 1200mg/d adults: and yrs. ≥12 Severe infections: Severe in 2 in Mild to moderate infections: to moderate Mild Linezolid trimoxazole line: line:

line

line: - GI tract, non tract, GI

- st nd nd st ay 320mg/d 2 Co <12 yrs.: yrs.: <12 Merope infections and sepsis infection with severe patients Febrile 1 Afebrile patients with mild to moderate infections without sepsis without infections moderate to withmild patients Afebrile 1 Patients <6months of age: of <6months Patients ) ay 16g/d (Max: component) 2 ay) 4g/d doses (Max: 4 div . yrs ≥12 ay 4g/d OR

Streptococcus Streptococcus Etiology operative wound infection (non infection wound operative - kin flora, S. aureus, aureus, S. flora, kin sp. (Group A, B, C, G) Post S

National Antibiotic Guidelines

161

;

: patients : patients negative negative . ension -

nt against MSSA against nt Comments

positive andGram positive - who have failed initial recommended recommended initial failed have who who abscesses or carbuncles with

Gram Those antibiotictreatme host impaired markedly Those with or defenses Those treatment antibiotic initial have failed Those with SIRS and hypotension. SIRS Those with Those with markedly impaired host impaired markedly Those with or; defenses Those with SIRS and hypot SIRS Those with

• • •

An antibiotic active against MRSA is is MRSA against active antibiotic An following the for recommended • GI the on had procedures have who patients In cover should therapy antimicrobial tract, GU or both remove usually skin incision, with If organisms. and culture wound,obtain drain to sutures packwound. and sensitivity, is MRSA against active antibiotic An following the for recommended • •

) PEDIATRIC

- ay or

Vancomycin PLUS in 3 doses3 in

ay 300mg/kg/d ) ay 40mg/kg/d 20- IV in 3 doses3 in IV

150-

PLUS

4 doses (Max: 4g/d 4 doses(Max: - ay) 1.8g/d 4 doses (Max: - ay 300mg/kg/d

in 2 doses (TMP component) in 2 doses(TMP for adults; adults; for in 3

IV in3

240- ay

PO in 2 doses (amoxicillin 2 doses (amoxicillin in PO IV 4:1 formulation: 4:1 ay rs. 30 : mg/kg/d ay) 4 g/d 4 doses (Max:

- <6 months of age of months <6 ay 1.2g/d (Max: 3 doses Regimen -

OR ay) g/d :16 in 3 for <12 y <12

ay 12mg/kg/d ay 40mg/kg/d - 60mg/kg/d Max - 8 PLUS

4 doses (Max: 4g/d ay) (Max: 4 doses SKIN SOFT TISSUE AND INFECTIONS IV in 2 doses2 in IV - 30- 45

azobactam t ay 45mg/kg/d - ay amoxiclav

same - 30mg IV in 2 in 30mg IV

25-

IV in3 ay 30mg/kg/d Co 20-

trimoxazole -

1200 mg/d 1200

Clindamycin Vancomycin Co Piperacillin :

: 4 doses (Max: 16g/d ay) (Max: 4 doses Linezolid - line: line

ay 60mg/kg/d line: line:

st nd st nd Ciprofloxacin Metronidazole ay) 320mg/d (Max: 2 ( component) (piperacillin in 3 Severe infections: Severe 40- ≥12 yrs. ≥12 (Max: 1.5g) component) 3 doses (amoxicillin in PO If S. aureus (MRSA) is suspected PLUS: suspected is (MRSA) S. aureus If s: infection Severe ay) 1.75g/d (Max: component) Mild infections: Mild formulation: 7:1 1 1 2 OR infections: to moderate Mild

S. , Other,

Bacteroides Etiology (MSSA,MRSA), Coliform operative wound infection (GI tract or GU tract surgery) GUtract or (GI tract infection wound operative - kin flora, GI and vaginal flora, flora, and vaginal GI flora, kin species: e.g., B. fragilis e.g., species: aureus aureus E. coli, e.g., species: Post S bacteria anaerobic National Antibiotic Guidelines

162 5 -

Comments

Preemptive early antimicrobial therapy for 3 for therapy antimicrobial early Preemptive arewho patients for recommended days is

) in

) PEDIATRIC

)

OR ) PLUS )

] ay ) ay

) PLUS )

ay U/kg/d 300,000 in 4 doses (Max: doses4 (Max: in

ay 2.7g/d 4 doses(Max: 4 doses (Max: 4g/day 4 doses(Max: - - ay

TISSUE INFECTIONS

ay) 1.5g/d (Max: 3 doses ay 1.5g/d 3 doses(Max: - 200,000 - - ;

IV in3 IV in3 ay 12g/d 4 doses (Max: - IV in 3 doses (Max: 6g/d ) ay doses3 (Max: in IV IV in 3 doses (Max: 6g/d doses3 (Max: in IV ay 4g/d 4 doses (Max:

- ay 4g/d 4 doses (Max: - ay in 2 doses 2 in

IV in 1 or 2 doses (Max: 4g/d or1 doses 2 (Max: in IV IV in3

Regimen 150,000U/kg/d evere IV in3

- ay IV in3 fors ay 40mg/kg/d ay 60mg/kg/d

SKIN SOFT AND ay 120mg/kg/d 120mg/kg/d 25- in 3 doses3 in 40- -

100,000

ay 1200mg/d 22.5mg/kg IV/IM in 1 in IV/IM 22.5mg/kg 22.5mg/kg IV/IM in 1 in IV/IM 22.5mg/kg

60- 60

100mg/kg/d 15- 15- ay 200mg/kg/d ay 60mg/kg/d

ay 30mg/kg/d IV 40- 100-

for mild to moderate infections mild to moderate for

) Clindamycin Vancomycin

Penicillin G

Amikacin Amikacin Meropenem Meropenem ay

Ceftriaxone Linezolid [ line: line:

line: line:

st st nd nd

OR ay 30mg/kg/d yrs.: <12 adults: and yrs. ≥12 PLUS 2 Metronidazole Vancomycin 2 ay) 24MU/d (Max: 6 doses PLUS PLUS Cleaning, irrigation and debridement are most important. important. are most and debridement irrigation Cleaning, 1 PLUS 1 8MU/d OR Cefotaxime

negative negative

Gram , Anaerobes, Anaerobes, , Etiology nd Mammal Bite nd Mammal a , GABHS, GABHS, , Enterobacter Enterobacter

caviarum, M. fortuitum, M. - bite

at Bacteroides sp., Fusobacterium sp., sp., Fusobacterium sp., Bacteroides abscessus, Actinomyces, Actinomyces, abscessus, C aureus, S. species, Pasteurella Cat, Dog Dog Cat, otitidis Enterococcus Aspergillus, cancerogenus Nocardia asteroids, Nocardia enterics, enterics, S. aureus S. Wound infection, soil contaminated soil infection, Wound

National Antibiotic Guidelines

- 163

but no 0012.

e or patient presents presents patient e or Comments . Many strains strains Many . Clindamycin exposure prophylaxis and and prophylaxis exposure - 0012 pdf) 0012 and is resistant to Dicloxacillinto resistant is

morbidity (e.g., diabetes). (e.g., morbidity

- bserve for osteomyelitis. osteomyelitis. for bserve - page/ao2014 to Azithromycin susceptible appear post and tetanus rabies Consider data. clinical and vaccination. prophylaxis exposure Only 5% of dog bite wounds get infected. Treat Treat infected. bite dog get wounds of 5% Only is bite sever the if only withco post rabies For to2014- AO DOH refer vaccination, immunocompromised; are asplenic; have have asplenic; are immunocompromised; or preexisting have disease; liver advanced have area; the affected of edema resultant to the especially injuries, severe to moderate have may that have or injuries face; or hand capsule. joint or periosteum the penetrated empirically. treat and Culture O P. multocida Cephalexin (http://www.doh.gov.ph/sites/default/files/basic - )

)

PEDIATRIC

ay - OR

)

ay 40mg/kg/d ay 40mg/kg/d in 4 doses (Max: doses4 (Max: in

)

20- 20- ay )

4 doses (Max: 4doses (Max:

4 doses (Max: 4 doses(Max: ) - kg/day in 4 doses in kg/day 2 doses (Max: 200mg/d 2 doses(Max: ay 1g/d 2 doses (Max: in PO POin 3 -

POin 3 ay 200mg/kg/d

ay 2g/d doses4 (Max: in

formulation: ay 4g/d 4 doses(Max: infections for severe ay 2.7g/d 4 doses (Max: -

- PO in 2 doses (max 1g/day) 2 doses (max in PO 100- PO in 2 doses (amoxicillin 2 doses (amoxicillin in PO PO in 2 doses (amoxicillin 2 doses (amoxicillin in PO

4:1 4:1 4:1 formulation: 4:1

in 3 PO/IVin 1

Regimen IV in3 OR OR

ay 30mg/kg/d ay ay mg/kg/d 50

ay mg/kg/d 40 20-

Mild to moderate infections moderate to Mild ay 100mg/kg/d SKIN SOFT TISSUE AND INFECTIONS ( ild to moderate infections moderate to ild sulbactam

30- ay 30mg/kg/d - Erythromycin -

ay 45mg/kg/d ay 45mg/kg/d (m 50-

4mg/kg/d ay 30mg/kg/d 20 -

2 25- 25-

ay mg/kg/d 40 - amoxiclav Ampicillin -

amoxiclav Clindamycin Cloxacillin - Co for mild to moderate infections; 200mg/ infections; tomoderate mild for

) ) Co

to moderate infections: to moderate ay ay Metronidazole Doxycycline line: line:

line:

nd st nd If allergicIf toPenicillin: Mild Cefuroxime axetil Cefuroxime 2 /d (Max: 1.5g component) 3 doses (amoxicillin in PO 2 Parenteral: PO in 3 doses (amoxicillin component) (Max: 1.5g) component) 3 doses (amoxicillin in PO ay) or 25 1.8g/d OR axetil PLUS Cefuroxime ay) 1.75g/d (Max: component) 2g/d OR 1 formulation: 7:1 Oral: formulation: 7:1 ay) 1.75g/d (Max: component) 4g/d ay) 8g/d (Max: component) (ampicillin

Group Group 4, -

multocida

EF P. Etiology

Capnocytophaga sp., sp., Capnocytophaga

4, - Capnocytophaga sp. Capnocytophaga Fusobacterium sp., sp., Fusobacterium aureus, Bacteroides sp., sp., Bacteroides aureus, Dog bite bite Dog Staphylococcus canis, Pasteurella EF AStrep get infected, 80% infection develops within 24 h. h. 24 within develops infection National Antibiotic Guidelines

164 5

- borne . . Co on status. on

Sulbactam - fluoroquinolones Comments . Erythromycin beta lactamase inhibitor inhibitor lactamase beta

etanus immunizati etanus - and

Clindamycin, Nafcillin/Oxacillin, sp.: Susceptible to to Susceptible sp.: lactam

beta

ray would evaluate for fracture or foreign fracture for evaluate would ray - Clenched fist (and other hand) bite wounds wounds bite hand) other (and fist Clenched bone, joint, (e.g., deep infections for risk pose evaluation. careful and require sheath) tendon X - blood of transmitting risk Potential body. to Resistant Cefazolin, Cephalexin/ Metronidazole, trimoxazole pathogens if injury contaminated with another's another's with contaminated injury if pathogens t Review blood. 3– for therapy antimicrobial early Preemptive of therapy, duration bites, Infected For days. Cleaning, irrigation and debridement are most are most and debridement irrigation Cleaning, X or hand injuries, fist clenched For important. by inflicted bites For be obtained. should rays Gram- aerobic consider patients, hospitalized bacilli. negative Eikenella combinations, e.g., Ampicillin e.g., combinations, and

) PEDIATRIC

- 4 -

) ay

) in 3 doses3 in ay

PO in in 3 doses PO POin 3 ay 300mg/kg/d 150-

4 doses (Max: 4doses (Max:

- ay 4g/d 4 doses(Max: in 4 doses (Max: doses4 (Max: in -

in 3

IV in3 TISSUE INFECTIONS ay 40mg/kg/d

ay 40mg/kg/d

ay 300mg/kg/d -

ay for adults; adults; for

20- 30

240-

2 doses (Max: 200mg/d 2 doses(Max:

- IV

in 4 doses (ampicillin component) component) doses4 (ampicillin in ay 200mg/kg/d IV in 4 doses (Max: 4g/d doses4 in (Max: IV in 1 <6 months of age of months <6

Regimen 30mg/kg/d ay) g/d :16 ay ay ay 40mg/kg/d for ay kg/d 25- Max

Clindamycin

SKIN SOFT AND sulbactam or - azobactam t 4:1 formulation: 4:1 ) infections moderate to Mild

45mg/kg/d PO in 2 doses (amoxicillin component) component) 2 dosesin (amoxicillin PO 45mg/kg/d ( 4mg/kg/d - 20mg/kg/d

2 25- OR : 200mg/ :

) penicillin:

Metronidazole

to Ampicillin

: OR

amoxiclav

- Piperacillin

- :

) llergy y Co 4 doses (Max: 16g/day) (Max: 4 doses Doxycycline - line:

: 5 days5 : uration nd (amoxicillin component) (Max: 1.5g) 1.5g) (Max: component) (amoxicillin Parenteral (piperacillin component) ( component) (piperacillin in 3 Witha ay) 2.7g/d Severe infections Severe a 4g/d ay) 8g/d (Max: D 2 ay 1.75g/d (Max: 100- infections: to moderate Mild ay) 1.8g/d doses(Max: Severe infections: Severe OR 1stline Oral: formulation: 7:1

. sp.

(53%),

(29%), (100%), (100%),

Bacteroides sp. (41%),

epidermidis aureus aureus Etiology

sp. (15%),

Viridans streptococcus Viridans Staphylococcus Human bite bite Human Corynebacterium Eikenella Peptostreptococcus (82%), sp. Staphylococcus (26%)

National Antibiotic Guidelines

165

indicated for rat bites. rat for indicated Comments not not exposure prophylaxis and prophylaxis exposure -

for exploration, drainage and drainage exploration, for

e Incis and anaerobic aerobic (include debridement when proper drainage has been established, is is established, hasbeen drainage proper when abscess. localized or cellulitis daysfor 10 post Rabies is vaccination

in )

) PEDIATRIC

)

- ) - ay 2 ay

POin 4 doses - 4 doses (Max: 4doses (Max: (Max: 1.5g/d -

in 3 Doxycycline

ay 300,000U/kg/d

ay 40mg/kg/d ay in 4 doses (Max: doses4 (Max: in

OR 30- IV in3 ay 2g/d 4 doses(Max: - IV in 4 doses (Max: doses4 (Max: in IV

) - 200,000 ay 200mg/d 2 doses (Max:

- IV in 4 doses (Max: 4 g/d doses4 (Max: in IV

PO in 2 doses in PO POin 3 ay) 1.5g/d 3doses(Max: in

300mg/kg/d in 1

- ay ay Clindamycin ay 40mg/kg/d 240

ay 20mg/kg/d Regimen infections evere ay 150,000U/kg/d 25- OR or ay) 1.2g/d 3 doses(Max: fors -

60mg/kg/d ) 30mg/kg/d - ay 4mg/kg/d ay 50mg/kg/d - ay mg/kg/d 50 - SKIN SOFT TISSUE AND INFECTIONS 2 40

20 - 100,000 25-

azobactam IVin 2 t - ; infections to moderate days ay 200mg/d 2 doses (Max: - ild

14 ays

- infections evere d in 1

form

) Erythromycin Doxycycline Penicillin G Amoxicillin Vancomycin fors

: ay Piperacillin Ciprofloxacin ay 30mg/kg/d

; infections moderate to ild line: line: line: line: line

20-

ay 1.8g/d 4 doses(Max: : 3 : uration : 10: uration - st st nd st nd 2 ay 4mg/kg/d ay) 24MU/d 6 doses(Max: Rat bite fever bite Rat 8MU/d 2 form ay) 4g/d D 3 ay) 2.7g/d D 1 PLUS 1 PLUS or Prophylaxis 1

C, sp.:

Group A Group A

, MRSA) - Etiology Clostridium ,

(CA

streptococci Necrotizing fasciitis/gas gangrene fasciitis/gas Necrotizing aureus S. Spirillum minus, Streptobacillus Streptobacillus minus, Spirillum moniliformis Rat bite National Antibiotic Guidelines

166 S.

; stain of stain

: patients

scan and ultrasound scan and ultrasound

ray, CT scan may show gas show scan may CT ray, Comments - MRSA is now different and different now MRSA is - iled initial recommended recommended initial iled fa have who

was not associated with necrotizing necrotizing with associated not was

Those MSSA against treatment antibiotic

in involved tissue. Hyperbaric oxygen (HBO) is is (HBO) oxygen Hyperbaric tissue. involved in recommended. not • can cause the disease. disease. the can cause bya preceded is gas gangrene Usually X tissue. necrotic An antibiotic active against MRSA is is MRSA against active antibiotic An following the for recommended cultures if available in your setting) and resect and resect setting) in your available if cultures tissue. nonviable all plane fascial the into extends Infection with fat subcutaneous and muscle between Historically, fasciitis. necrotizing resulting contamination with surgery or wound traumatic spores. byClostridial by Gram made easily is Diagnosis aureus aureus fasciitis, but CA - for PEDIATRIC for )

- ) 300 for -

ay ) IV in3

40 ay 150

30- 6 doses - in 6 doses 6 in

ay 40mg/kg/d

IV/IM in 4 6h (Max: 12g/d (Max: 6h 25-

U/kg/d ay) 1.8g/d 4 doses(Max: Clindamycin ay) 12g/d 4 doses(Max: - evere infections; evere - or TISSUE INFECTIONS

in 3

for s ay 8MU/d doses4 (Max: in

) PLUS IV/IM in 4 doses (Max: 4g/d 4 doses(Max: in IV/IM IV div q4- div IV POin 3 for patients <6 months of of age. months <6 patients for

ay 300,000

ay ay ay 200mg/kg/d is recommended for treatment of of treatment for recommended is Regimen 16g/d U/kg/d : - 200,000 150- ay) 16g/d ay) 2.7g/d (Max: 4 doses ay 200mg/kg/d -

ay 40mg/kg/d SKIN SOFT AND ) 150mg/kg/d ay 150mg/kg/d infections evere - - 150,000 100-

30- IVin 3 ay) 1.8g/d 4doses (Max: - 100 for s

infections;

ays ) or) 100 d

: : (Max 4 doses - 100,000

POin 3 PLUS Clindamycin

Cefotaxime Oxacillin

: :

Clindamycin ay 40mg/kg/d line line

25-

; infections to moderate ild to moderate ild : 10: uration st nd ay 2.7g/d 4 doses(Max: D ay mg/kg/d m ay) 24MU/d (Max: or Penicillin and clostridial fasciitis necrotizing streptococcal A group documented myonecrosis Penicillin G PLUS severe ay 12g/d (Max: 1 m (piperacillin component) (Max component) (piperacillin 3- in mg/kg/d 2

C. - species) sp. sp.

Clostridium Etiology

(most common), common), (most is

negative bacilli (rare), Anaerobic Anaerobic (rare), bacilli negative bacteria (rarely (Group A and others), Gram others), and A (Group studies are also useful. Appropriate cultures (blood and abscess) should be obtained. be should abscess) and (blood cultures Appropriate useful. also are studies Streptococcus aureus, S. Magnetic resonance imaging (MRI) is the recommended imaging modality for establishing the diagnosis. Computed tomography (CT) tomography Computed diagnosis. the establishing for modality imaging is the recommended (MRI) imaging resonance Magnetic Pyomyosit perfringens septicum,C. tertium

National Antibiotic Guidelines

167 ion ion

negative - ollowing open Gram

arterial bone biopsy. Needle Needle biopsy. bone Comments ations can include involvement of the the of involvement can include ations

limited regional lymphadenitis. Disease Disease lymphadenitis. regional limited - . and hypotension SIRS Those with Those with markedly impaired host defenses; defenses; host impaired markedly with Those

bacilli should be addedbacilli infection in for immunocompromisedpatients or f trauma tothe muscles (aminoglycosides). Self manifest • • agentAn active against enteric wound moist use and tissue necrotic Debride ulcer; decubitus if pressure Remove dressing. for evaluate venous stasis; if leg elevate is there if revascularization or iodine not povidone Do use insufficiency. granulat damage may both chlorhexidine, is method Best and fibroblasts. tissue for specimen tissue deep obtained surgically is osteomyelitis If culture. and histology obtain also suspected, acceptable. is margin ulcer the from aspiration

PEDIATRIC in or

- for

)

ild to

Azithromycin

form ay 300mg/kg/d

) For patients <6 patients For ay ). ). 2 h 240-

4 doses (Max: 4doses (Max: - ay) 2.7g/d 4 doses (Max: uperficial infection - s IV in3

ay) 16g/d 4 doses(Max: in 3 doses (Max: 6g/d doses (Max: 3 in - in 3

for

azobactam in 3 ay) 1.5g/d 2 doses (Max: in PO

t ay) 4g/d 4 in doses (Max: IV - Regimen 1% cream 1% in 3 doses (Max: 3g/d doses3 (Max: in

ay 40mg/kg/d ay 40mg/kg/d ay 150mg/kg/d ay ay) 1.2g/d 3 doses(Max: 25- SKIN SOFT TISSUE AND INFECTIONS - 25- Piperacillin ay 30mg/kg/d

ay) 3g/d 3in doses(Max: IV 150mg ay 300mg/kg/d ay 60mg/kg/d 100-

20- 90 40- IV in2 150-

50mg/kg/d

ay) 6g/d 3 or 4 doses (Max: in IV 300mg 3weeks -

infections; infections; Clindamycin

Clindamycin ) 200- Lymphadenitis in immunocompromised patient: in immunocompromised Lymphadenitis Silver sulfadiazine Silver

: :

Ceftazidime Ciprofloxacin Vancomycin Cefazolin line

ay 30mg/kg/d line line:

4 doses (piperacillin component) (Max: ay 16g/d (Max: component) 4 doses (piperacillin : 2 : uration - st st nd evere 20- : 2nd line ay 2.7g/d PLUS to moderate: Mild Severe: OR months of age: of months 3 2 OR - 1.5 over infused be should g ≥1 doses Individual s D 1 1 infection: local Severe OR moderate

, aeruginosa P.

S. aureus S.

sp., Etiology henselae Cat scratch disease scratch Cat Bartonella Streptococcus Streptococcus Enterobacteriaceae, Decubitus ulcer Decubitus B. fragilis streptococci, Anaerobic National Antibiotic Guidelines

168

ised ised

6 months.

Comments and should not be used in those in used be not and should

failure have been reported in patients receiving receiving patients in reported have been failure Terbinafine disease. liver active or chronic with central nervous system, eyes and viscera viscera eyes and system, nervous central of duration The optimal spleen). and (liver, several be may but known not is therapy disease. systemic for weeks create centers than margins Redder capitis, Tinea to Opposed a ring. of impression topical with be cured often can infections these canbe therapy Systemic alone. therapy infection, refractory or severe for reserved orin immunocomprom infection, recurrent hepatic cases of but rare Serious patients. Complete resolution may take 2- take may resolution Complete 4 PEDIATRIC

- - 8

No therapy, as therapy, No

trimoxazole ay 250mg/d -

Rifampicin

OR OR >40 kg: >40 ) | | pigmentation. Rule out erythrasma. Rule pigmentation. TISSUE INFECTIONS -

1 (Max: 500mg/d) followed followed 500mg/d) 1 (Max: 4 weeks

ay , etc.) apply x2- apply bid etc.) , Ketoconazole

ay 125mg/d

Regimen 5 (Max: 250mg/d) ay 5 (Max: - 40 kg:40 2 SKIN SOFT AND

20- 1% cream for Tinea corporis, Tinea cruris, and cruris, Tinea Tinea corporis, for cream 1% 10mg/kg PO on d PO 10mg/kg , , Clotrimazole

| |

( ay 600mg/d 2 doses (Max: - 6mg/kg once a week x2- once a week 6mg/kg days ays days on - 3 ay) 320mg/d (Max: component) doses2 (TMP in in 1 10 -

Terbinafine

Lymphadenitis in immunocompetent patient: in immunocompetent Lymphadenitis Imidazoles Terbinafine

ay 62.5mg/d

line: line line:

: 7 : uration st nd nd the lymphadenitis spontaneously resolves. resolves. spontaneously lymphadenitis the Fluconazole 2 ay 12mg/kg/d D Topical: 2 1 pedis, Tinea plantar x 1 week;for bid apply pedis, Tinea interdigital 2 weeks. x bid apply weeks Systemic: kg: <20 Children ≥6 months: ≥6 Children /day by5mg/kg ay 20mg/kg/d

cruris (jock itch), Tinea pedis (athlete’s foot) (athlete’s pedis Tinea itch), (jock cruris

Etiology discolored skin with sharp borders commonly found on back, underarms, upper arms, chest, and neck. Skin may appear appear may Skin neck. and chest, arms, upper underarms, on back, found commonly borders sharp with skin discolored of patches with rash scaly Fine, hyper hypoor either Americans, African in skin; healthy surrounding than lighter Tinea versicolor (Pityriasis versicolor) (Pityriasis versicolor Tinea Trichophyton rubrum, T. T. rubrum, Trichophyton mentagrophytes, Epidermophytonfloccosum Tinea corporis, Tinea corporis, Tinea

National Antibiotic Guidelines

- 169 ; treat 100%) in in 100%)

extract): a meta extract):

T. tonsurans

re needed to needed to are rates up - Comments Senna alata Senna

and should not be used in those in used be not and should

Gnilo CM, 2016 unpublished) showed showed 2016 unpublished) CM, Gnilo at 50% Akapulco lotion was superior to superior was lotion Akapulco 50% at Durations of therapy are for for are therapy of Durations . M. canis for twice as long approximately for - (60 rates cure similar have agents All studies. clinical have failure hepatic cases of rare but Serious receiving patients in reported been Terbinafine disease. liver active or chronic with Akapulco lotion ( lotion Akapulco and RF, Genuino EJL, (Tababa analysis - Salud th cure (mycologic versicolor tinea for placebo to appears It activity). clinical in and decrease and thiosulfate sodium 25% as as effective be randomized larger but cream, ketoconazole trials with goodfollow findings. these confirm sharply often scaly patches raised, red, Itchy, defined.

PEDIATRIC

ays d

12 weeks (Max: 150 mg 150 mg (Max: weeks 12

PO in 2 doses x 7 in PO 20mg/kg/day hair until (c hild) - based dosing dosing based

- 6mg/kg x 1 dose, repeat in in 14 days repeat dose, x 1 6mg/kg prevention

- 3 2% shampoo daily for 3 days; days; 3 can use for shampoodaily 2% Regimen x 4 weeks PO every week x8- week every PO

ay 10mg/kg/d >2y;weight - SKIN SOFT TISSUE AND INFECTIONS 5 for a week maintenance/prevention 3 times for

Fluconazole

2.5% shampoo, daily application while bathing for 1 for bathing while application daily shampoo, 2.5% Ketoconazole

ay 5mg/kg/d ay 6mg/kg/d (microsize formulation) 10

1 dose x 2 weeks in PO 125mg

Itraconazole

Terbinafine

250mg PO inweeks x2 dose 1 PO 250mg 62.5mg PO in 1 dose x 2 weeks PO 62.5mg

line: line 40 kg:40 line: line:

3 times a week for for a week maintenance/ 3 times - nd st nd st 2 regrows. sulfide Selenium 2- can use 2 weeks, to disease: Extensive kg: >40 2 Itraconazole Fluconazole adults) for week every PO Griseofulvin 2 20- 1 kg: <20 1 disease: Limited

)

(North America;

Etiology Trichophyton tonsurans, tonsurans, Trichophyton Microsporumcanis Tinea capitis (ringworm capitis Tinea other species elsewhere) species other Malassezia furfur Malassezia National Antibiotic Guidelines

170 varicella varicella - decreased decreased

Aciclovir Comments

slowed development and reduced reduced and development slowed

duration of fever, time to healing, and healing, timeto of fever, duration symptoms. Aciclovir duration and reduced lesions new of number children. in disease of infection. ications (immunocompromised such as HIV, as HIV, such (immunocompromised ications PEDIATRIC risk patients. Susceptible children should receive receive should children Susceptible patients. risk

- - in high in

PO 4 PO in

Disseminated VZV disease/organ involvement disease/organ VZV Disseminated , 12y - 2

2 weeks. Safe for children age >2 months. Reapply to hands after handsafter to Reapply age >2 months. children for 2 Safe weeks. s Pruritus may persist for 2 weeks after mites are gone. are mites after 2 weeks for persist may Pruritus Antihistamines may help reduce itching. reduce help may Antihistamines can occu r. infections streptococcal Secondary ay 80mg/kg/d

• • • TISSUE INFECTIONS

(VZIG) (125 units/10 kg body weight IM up to a max of 625 units; minimum dose a to up IM units; max 625 of weight body kg (125 units/10 (VZIG) Child age Child

Aciclovir

Regimen 14 h. Repeat in 1- in Repeat h. 14 no treatment no

Apply to entire skin from chin down to and including toes and under fingernails and toenails. toenails. and fingernails and under toes to down chin including and skin from entire to Apply SKIN SOFT AND : ter of any specific lot of IGIV is uncertain because IGIV is not tested routinely for IGIV anti IGIV for routinely not tested is IGIV because uncertain is of IGIV lot of any specific ter

- re prevent to linens and dry Wash contacts. close Treat

exposure prophylaxis to varicella is 400 mg/kg, administered once IV. If varicella develops, initiate initiate develops, varicella If once IV. administered mg/kg, 400 is varicella to prophylaxis exposure . Some would treat presumptively with aciclovir with presumptively would treat Some . - 5% cream 5%

immuneglobulin zoster

- moderate disease: moderate aciclovir exposure prophylaxis in susceptible persons at greater risk for for compl risk greater at persons susceptible in prophylaxis exposure - For patients at increased risk of moderate or severe varicella; chronic chronic varicella; severe or moderate of risk at increased patients For diseases: pulmonary or cutaneous May require 30 g. Leave 30 g. on 8- require May handwashing. chickenpox: host, Immunocompetent Mildto Permethrin Shingles (single dermatomal or multiple dermatomes) multiple or dermatomal (single Shingles

varicella antibodies, the ti the antibodies, varicella - of rash) with with rash) of ours

Chickenpox

(mite)

exposure prophylaxis Varicella prophylaxis exposure - Etiology is based on history and distribution of skin lesions. Sometimes, Sometimes, lesions. skin of and distribution history based on is

zoster virus infections virus zoster zoster virus zoster - -

bodies. The recommended IGIV dose for post dosefor IGIV recommended The bodies. - Diagnosis Diagnosis mites or eggs from scrapings of burrows are visible. are burrows of scrapings eggsfrom or mites Mite infestation of the skin that causes intense itching that is worse at night. worse at is that itching causes intense that of the skin infestation Mite

Varicella vaccination. • anti (<24 quickly treatment ). If VZIG is not available, IGIV can be used. Although licensed licensed Although IGIV canused. be available, is VZIG not If ). (<96 hours exposure after possible as as soon therapy) steroid and pregnancy, malignancies, anti contain preparations IGIV Prevention, post Prevention, post for is recommended units) 125 is Clinical syndromes: Clinical Varicella Sarcoptesscabiei • Scabies

National Antibiotic Guidelines

171

Comments

PEDIATRIC

- Valaciclovir

Regimen ) (start within 24h of rash) rash) 24h of within (start ) SKIN SOFT TISSUE AND INFECTIONS ay

ays PO in 3 doses (Max: 1g/dose in 3 doses) in 1g/dose 3 doses (Max: in PO d

: 5 : uration doses (Max: 3200mg/d doses(Max: ay 60mg/kg/d D

Etiology National Antibiotic Guidelines

172

ed.

583. th Resistant Resistant

- Therapy 2014, 44th 44th 2014, Therapy

ons: 2014 Update by Infectious Infectious by Update 2014 ons: entof Methicillin ine. 7th Edition.USA: McGrawhill Hill.

PEDIATRIC

820. - - r2015;808

23. TISSUE INFECTIONS

43.

SKIN SOFT AND Lim, Pagcatipunan, delos Reyes. Handbook of Pediatric Infectious Disease an Easy Guide 5 Guide Disease Easy an Infectious Pediatric of Handbook Reyes. delos Pagcatipunan, Lim,

- Ong Lazarte,

mic syste A infections: skin fungal superficial of treatment for antifungals topical versus extract (Akapulko) Senna alata Gnilo. Infections in Adults and Children CID 2011: 52 (1 February) 2011: 52 (1 CID and Children Adults in Infections analysis (Unpublished) analysis 2016, 147th edition. 147th 2016,

in G., Colbourne M. Puncture wounds. In Pediatrics in Review. 1999; 20 (1): 21- (1): 20 1999; in Review. Pediatrics In wounds. Puncture M. Colbourne G., in edition. aureus Staphylococcus Diseases Society of America, IDAS Practice Guidelines for SSTIs CID: 1- CID: SSTIs for Guidelines Practice IDAS of America, Society Diseases - and meta review - Maramba Gonzales, Gatchalian, Bravo, Liu C, Bayer A, Cosgrove SE, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for Treatm the for America of Society Diseases Infectious bythe Guidelines Practice Clinical al. et SE, A, Cosgrove Bayer C, Liu MIMS Philippines 1/ Philippines MIMS AcadPediat Am Diseases. on Infectious of theCommittee Report edition. 30th 2015, Book Red - 87:581 1994; d Me Society JRoyal avoided? be complications can infective the foot: of wounds Puncture AM. O’Donnell R, Makover A, Pennycook Stevens DL, Bisno AL, Cambers HF, et al. Practice Guidelines for the diagnosis and management of skin and soft tissue infecti tissue soft and skin of and management diagnosis the for Guidelines Practice et al. HF, Cambers AL, Bisno DL, Stevens - Salud RF, Genuino , Tababa EJL

REFERENCES Baldw Gilbert DN, Chambers HF, Eliopoulos GM, Saag MS, Black, Freedman DO, Pavia AT, Schwartz B. The Sanford Guide to Antimicrobial Guide The B. Sanford Schwartz AT, Pavia Freedman DO, Black, MS, Saag GM, Eliopoulos HF, DN, Chambers Gilbert 2009 ed, 6th Diseases, Infectious Pediatric of J, Textbook et al. Cherry R, Feigin

Topical antibiotics: very few indications for use: BPJ; Issue 64, p27. 64, Issue BPJ; use: for indications very few antibiotics: Topical Wolff, K., Goldsmith L.,Katz, S., Gilchrest,B., Paller, A. and Lefell,D. (2008) Fitzpatrick’s Dermatology in GeneralMedic National Antibiotic Guidelines

173 - - Co Co

strength strength 300 mg 300 mg plus plus

- (150

I&D (ABSSSI). bid as effective as aseffective bid

instead of 2 of instead blind randomized randomized blind found to be associated be associated to found

alone showed a higher rate rate a higher showed alone

Comments I&D 00mg 160/8 trimoxazole - vs (1

with treatment failure in obese patients (BMI (BMI patients obese in failure treatment with >40). - double large Another and Clindamycin ) 160/800mg 450 mg) of instead trimoxazole two DS tabs bid. Lower dosage range of of dosage range Lower bid. tabs DS two (DS) tab of Co of clinical cure among the former group (80.5% (80.5% group former amongcure the clinical of - double One respectively). vs73.6%, controlled trial was conducted for single single conducted was for trial controlled Note: needle aspiration is inadequate. is aspiration needle Note: fluoroquinolones. Avoid a large diameter, in cm >2 abscesses For of trial controlled randomized trimoxazole ADULT

- - Co

100 mg 100 mg acquired acquired OR - 450mg 450mg tabs in in tabs

ays 300- d s infection structure and skin skin bacterial cute A 10

- Doxycycline

OR 160/800mg Clindamycin

ays tab; d 1 of skin and soft tissue infections (SSTI) infections tissue soft and skin of

10 PLUS Regimen Incision and drainage only are usually usually are only and drainage Incision

is the mainstay of therapy. therapy. of mainstay the is 160/800mg SKIN SOFT TISSUE AND INFECTIONS

(I&D) (may also be effective for community for be effective also (may

ays d 10 ADULT 160/800mg ( 160/800mg

larger (>2cm in diameter within anarea of erythema of ≥5 and drainage Incision

line:

st PO q12h x 5- q12h x PO MRSA infections) infections) MRSA obese patient, BMI>40) PO bid x 5- bid PO BMI>40) obese patient, trimoxazole Outpatient, no diabetes or immunosuppression, boil or smaller smaller or boil immunosuppression, or no diabetes Outpatient, Incision and drainage and drainage Incision 1 diameter): in cm (<2 abscess therapy. antimicrobial No need for helpful. Hot packs are effective. Outpatient, response inflammatory systemic or abscesses, multiple or cm) syndrome: x 5 PO tid BMI>40) patient, obese in dose (higher

(decolonization)

INFECTIONS -

sensitive sensitive - resistant (MRSA) resistant - Etiology in the management the in concern increasing of is MRSA associated ; Methicillin; Furunculosis Recurrent

S. aureus S. (MSSA); Methicillin - Community also See . and abscesses carbuncles furuncles, such boils, as lesions, skin purulent These include Abscess furuncles boils, abscess, Skin National Antibiotic Guidelines

SKIN SOFT AND TISSUE

174 . - . Co Report ,

Clindamycin 5 cm, and prescribed prescribed and 5 cm,

Comments ,refer to theAntimicrobial or placebo was added to I&D placeboto added was or

for 10 days regardless of abscess of 10 days regardless for trimoxazole -

Co Resistance Surveillance Program 2017 Program Surveillance Resistance There was a higher rate of clinical cure in in the cure clinical of rate higher a was There not study did the but antibiotics with groups two those with for outcomes treatment down break 2– vs cm ≤2 abscesses antibiotics ≤2 abscess single a for antibiotics of Use size. high fairly the against weighed be should cm events. adverse of proportion in the MRSA of on prevalence data For MRSA of resistance increasing and Philippines to abscesses ≤5 cm where where cm ≤5 abscesses trimoxazole

ADULT

- qid - 10 μg/mL μg/mL 10 sensitivity sensitivity

600mg IV IV 600mg

vity data vity 500mg PO tidPO 500mg 1g IV1g q8h

line antibiotic. line Clindamycin only culture missed 48% of colonized individuals. colonized 48% of missed only culture -

12h targeting troughs of of troughs 12h targeting

lactam is the preferred agent: preferred the is lactam -

Cephalexin Cefazolin

600 mg IV/PO q12h 600 mg IV/PO guided antibiotic therapy, or if C/S C/S or if therapy, antibiotic guided 20 mg/kg q8- mg/kg 20 Regimen

, follow up exudate culture and exudate up culture follow , patient should have no active skin infections and is otherwise healthy. otherwise is and infections skin active have no should patient . ays d

SKIN SOFT TISSUE AND INFECTIONS 3 Linezolid 1g IV q4h OR IV 1g -

15mg/kg q12h (trough concentrations of 5- of concentrations (trough q12h 15mg/kg 500mg PO qid OR qid PO 500mg

: culture abscess and blood. abscess and blood. culture : Oxacillin

I&D

Cloxacillin

Vancomycin line:

20 μg/mL recommended) μg/mL 20

nd For MRSA infections: MRSA For Parenteral: Inpatients: , a, betainfection MSSA documented For Oral: If no response after 2 no after response If - culture to shift and results (C/S) first another to shift available, yet not results sensiti and culture absence specific (in of therapy Empiric select an agent with activity against MRSA): against activity with an agent select infections severe for severity; moderate of infections for adequate are 15- present, is bacteremia if or 2 q8h for patients without signs and symptoms of sepsis/ bacteremia bacteremia sepsis/ of symptoms and signs without patients q8h for OR 15- oes not apply to people who inject drugs (PWID) drugs who people inject to apply oes not d

Etiology If the patient and physician wish to attempt decolonization, the the decolonization, attempt to wish and physician patient the If - Nares skin. area and inguinal nose, throat, e.g., sites, multiple culture to Need

• • Clinical setting for decolonization for setting Clinical Furunculosis, recurrent Furunculosis,

National Antibiotic Guidelines

175 ,

0012

. Dicloxacillin

Comments . In vitroClindamycin exposure prophylaxis and and prophylaxis exposure - but no clinical data. nobut clinical 0012.pdf - is resistant to to is resistant and vs. 32% of patients not treated. not patients of 32% vs.

Observe for osteomyelitis for Observe

For rabies post rabies For to2014- AO DOH refer vaccination, - http://www.doh.gov.ph/sites/default/files/basic page/ao2014 There is no "gold standard" for decolonization. decolonization. for standard" "gold no is There are treatment of duration and regimen Optimal of trial randomized a prospective In uncertain. 3 at therapy, systemic and topical combined 74% in MRSA for negative were cultures months, treated for multocida P. Cephalexin hasbeen fluoroquinolones to sensitivity to susceptible appear strains Many observed. Azithromycin

ADULT 7

- OR morbidity, e.g., diabetes.

100mg PO PO 100mg

ays. d

7 - 5

Doxycycline

presents bad co- presents OR

. POqid Regimen 4% shower daily x daily shower 4% 500mg PO q12h PO 500mg

875/125mg PO bid or 500/125 mg PO tid PO mg tid 500/125 or bid PO 875/125mg 3g IV q6h IV 3g

300mg SKIN SOFT TISSUE AND INFECTIONS

875/125mg PO bid or 500/125mg PO PO tid or 500/125mg PO bid 875/125mg

PO.

Avoid systemic antibiotics. systemic Avoid

ulbactam amoxiclav Chlorhexidine s - ointment in anterior nares and under fingernails bid x 5- fingernails under and nares anterior in ointment amoxiclav - -

Clindamycin Co Cefuroxime axetil Cefuroxime Co Penicillin VK

PLUS line: line: line:

line: OR

ays st nd st nd 2 d 1 2 IV 1 Ampicillin Treat as for furuncles and boils and furuncles as for Treat : decolonization For Mupirocin bid Penicillin to , switch can multocida G P. only for positive is culture If

sp.,

urunculosis urunculosis sp.

Fusobacterium Etiology

sp., (MSSA and (MSSA MRSA)

Capnocytophaga

4 - EF Pasteurella canis, S. aureus, S. aureus, canis, Pasteurella Bacteroides Only 5% of dog bite wounds get infected. Treat only if the bite is severe or patient patient or severe bite is the if only Treat infected. bite dog get wounds of 5% Only Dog bite Dog Pasteurella multocida; S. aureus S. multocida; Pasteurella Cat bite 24h. within develops infection multocida Pasteurella empirically. and treat Culture infected. get bites of cat 80% Bites S. aureus aureus S. f asrecurrent presenting in otherwise an boils) (abscesses, host. healthy National Antibiotic Guidelines

176

. and

- and beta borne borne ulbactam s negative bacilli. bacilli. negative - -

trimoxazole - Gram Co

, Metronidazole Ampicillin , ontaminated with another's another's with ontaminated Comments Fluoroquinolones

lactamase inhibitor inhibitor lactamase

ray would evaluate for fracture or foreign fracture for evaluate would ray , Cephalexin/Cefazolin . Erythromycin , , Clindamycin to: Resistant Nafcillin/Oxacillin Susceptible to: to: Susceptible - beta / lactam e.g., combinations:

- • • Clenched fist (and other hand) bite wounds wounds bite hand) other (and fist Clenched bone, joint, (e.g., deep infections for risk pose evaluation. careful and require sheath) tendon X body. blood - transmitting of risk Potential c injury if pathogens blood. Review tetanus status. tetanus Review sp. Eikenella Cleaning, irrigation and debridement are most are most and debridement irrigation Cleaning, by hospitalized inflicted bites For important. aerobic consider patients, ADULT 1g

1.5 to to 1.5 , OR hr infusion of of hr infusion ulbactam ulbactam ulbactam Vancomycin s s - - ADD 875/125mg PO bid x5 bid PO 875/125mg Ciprofloxacin

if parenteral therapy is therapy parenteral if

- 4 or q8h (4.5g Ampicillin

PLUS

amoxiclav 24h): - Co

Regimen azobactam azobactam t t - - Clindamycin

SKIN SOFT TISSUE AND INFECTIONS can be used in place of Ampicillinof place in used can be

penicillin: Piperacillin

Piperacillin

: (signs of infection, usually 3- usually of infection, (signs (wound not yet infected): not (wound

Carbapenem nd line: ays required. Withallergy Cefoxitin 3.375g q8h). 3.375g excluded : is MRSA until infections, serious For A Later q6h IV 3g kg) >100 wt. 1.5gif q12h q12h (or IV 2 Levofloxacin 1stline Early d

(100%); (100%);

(29%); Bacteroides sp. Bacteroides

Corynebacterium Corynebacterium Etiology (15%);

(53%); S. aureus S. Peptostreptococcus sp. Peptostreptococcus

(41%);

Eikenella sp. Eikenella (82%); (26%) sp. Viridans streptococcus Viridans epidermidis Human bite Human

National Antibiotic Guidelines

177

with an expert for for expert an with Comments exposure prophylaxis and prophylaxis exposure -

If baby If can latch onand the mother is comfortable, continuebreastfeeding during the Rabies post Rabies rat for indicated routinely not are vaccination consultation Consider bites. rodents. wild to secondary bites ADULT

300mg 300mg

100mg PO PO 100mg possible: /

If MRSA is is MRSA If ays d Clindamycin

present ays d Doxycycline Risk factors (same for MRSA and MSSA) include: mother employed mother include: and MSSA) MRSA for (same factors Risk May present with or without abscess. or without with present May breastfeeding age, maternal advance d primiparity, home, the outside difficulties

• • OR

Regimen 500mg PO OR PO 500mg qid 2MU q4h 2MU IV 875/125mg PO x bid PO 3 875/125mg

100mg PO bid bid x 3 PO 100mg SKIN SOFT TISSUE AND INFECTIONS

ays

amoxiclav d - Penicillin G If MRSA is not present: not MRSA is If

Erythromycin

ays Doxycycline 14 Co

d : : therapy

14 :

: line line

Prophylaxis:

Rat bite fever: bite Rat x 10- qid PO 1 Prophylaxis fever: bite Rat x 10- bid 2nd

; S. USA)

(Asia);

Etiology is most common etiology but other pathogens are possible. If If possible. are pathogens other but common etiology most is (Group A or B); E. coli (MRSA or (MRSA MSSA);

Poor breastfeeding technique and incomplete emptying are contributing factors. contributing are emptying incomplete and technique breastfeeding Poor aureus S. possible, obtain culture before starting empiric starting before culture obtain possible, Postpartum mastitis occurs in approximately 10% of nursing mothers. of nursing 10% approximately in occurs mastitis Postpartum

• • • pyogenes S. aureus aureus S. Postpartum Mastitis Postpartum Mastitis Streptobacillus moniliformis ( moniliformis Streptobacillus Rat bite Spirillumminus National Antibiotic Guidelines

178

specific to risks -

Comments . Need pretreatment aerobic and aerobic pretreatment Need . guided needle aspiration or surgical, surgical, or aspiration needle guided rgical rgical ofI&D an abscess. Breastfeeding

infant of infant drug exposure throughbreast milk. indicated for abscess. for indicated ither by either Drainage, cultures. anaerobic - ultrasound antibiotic therapy.Discontinue breastfeeding only if thebreast is toopainful forbreastfeeding. On occasion, feeding canbe temporarily interrupted, e.g.,su should once resume painis tolerable.Continued breastfeedingdoes not pose a risk to the infant; discusswith pediatrician age older in carcinoma inflammatory Consider if especially abscess, clear without women detected is mass or a breast microcalcification, probably not subareolar, If radiographically. Staphylococcus

ADULT

sp: sp: 12h q8-

2 tabs PO bid PO 2 tabs 300mg PO PO 300mg

300mg PO PO 300mg 15- bid PO 2 tabs 1g IV q12h; q12h; IV 1g - possible: IV

/ trimoxazole trimoxazole - - ADD If MRSA is is MRSA If Co Co

present OR OR Vancomycin ay 20mg/kg/d 160/800mg 1- 160/800mg Clindamycin qid Clindamycin qid 1 mg 160/800 Vancomycin patient q12h if IV 1.5g kg >100 weight

500 4weeks

500mg 500mg Regimen 500mg PO qid PO 500mg qid 500 mg 500 mg PO

2g q4h IV 2g q4h IV

SKIN SOFT TISSUE AND INFECTIONS Cephalexin

Cephalexin OR

500mgIV/PO tid If MRSA is not present: not MRSA is If POqid Oxacillin Oxacillin Cloxacillin OR Cloxacillin qid mg POqid 100mg PO bid x3- bid PO 100mg

Corynebacterium due Corynebacterium to mastitis granulomatous For

line: line:

st nd 2 Outpatient Doxycycline Outpatient Inpatient anaerobes: likely most & odoriferous, subareolar If Metronidazole Inpatient 1

S. ; Selected Selected ; . (less.

phylococci; phylococci;

- Coagulase rare; can rare; - sta sp.; Etiology

species; species; negative negative Peptostreptococcus puerperal mastitis puerperal -

inflammation. cause distinctive granulomatous granulomatous distinctive cause Corynebacterium sp . Corynebacterium - coagulase S. aureus; Bacteroides sp Bacteroides aureus; S. often); Non Bacteroides Bacteroides Corynebacterium negative staphylococci (e.g., staphylococci negative ) lugdunensis

National Antibiotic Guidelines

179

toxic shock toxic

cal medications. cal Comments

uld undergo quantitative wound quantitative undergo uld

Patients sho Patients Empiricand then cultures, blood cultures, results. awaiting while therapy antimicrobial ill critically in concern of complications Other aureus S. include patients burn and phlebitis, suppurative (TSS), syndrome pneumonia.

ADULT

12h - -

Gram 2g IV2g q6h

Meropenem /day6mg/kg PLUS

q6h

2g IV q8h PLUS IV 2g IV drug resistant resistant drug Aztreonam

- : 30mg/kg IV, then 15mg/kg then IV, 30mg/kg 4.5g 4.5g -

Colistin

Cefepime Fluconazole

lactams OR 30mg/kg IV, then 15mg/kg IV q8- 15mg/kg then IV, 30mg/kg ADD Regimen azobactam

t producing multi producing - 1g IV q8h IV 1g SKIN SOFT TISSUE AND INFECTIONS

loading dose of 25 dose of loading dose of 25- dose of The only alternative is is alternative The only

Piperacillin loading loading infection suspected: suspected: infection - beta to allergy mediated PLUS

- Meropenem

Vancomycin Vancomycin - carbapenemase or

- 12h - Candida

negative bacillus: negative If ESBL If Vancomycin withIf IgE 1st line: 1st IV q8 2nd line: If If

Etiology

area to cause suppurative separation of eschar or graft graft or eschar of separation to suppurative cause area and surface depth, concentration, a sufficient at pathogens by is characterized infection Invasive topi and /or substitutes, and/or skin grafts skin of application tissue, necrotic infected of debridement surgical require may Treatment unit. burn a in dedicated is care ideal The sepsis. wound burn have suspected may patients ill Critically loss, invasion of adjacent unburned tissue, or sepsis syndrome. sepsis or tissue, unburned adjacent of invasion loss, An Infected burn wound is characterized by bacteria in the wound and wound eschar at high concentration (>105/g tissue). (>105/g concentration high at wound eschar the and wound in by bacteria wound characterized burn is Infected An

• • • • S. pyogenes; Enterobacter sp.; S. sp.; Enterobacter pyogenes; S. E. faecalis; epidermidis; S. aureus; Fungi; aeruginosa P. (rare) coli; E. (rare) virus and Herpes Infected burn wound, sepsis wound, burn Infected Burns National Antibiotic Guidelines

180 le. It may may It le. Levofloxacin, Levofloxacin, :

Comments The patient may have may The patient

diabetic patient. diabetic azobactam. - t -

Assess the adequacy of arterial blood supply. supply. blood arterial of adequacy the Assess be may cultures for debridement Surgical contiguous assess for or determine to required necrotizing of presence and the osteomyelitis contiguous of The likelihood fasciitis. to one can probe if increased is osteomyelitis contiguous of The likelihood bone. the Other is negative. if MRI low is osteomyelitis a Carbapenem to alternatives Piperacillin

ADULT

- : PLUS

like area of skin usually on the lower leg, often febri often leg, lower the on skin usually of area like trimoxazole - and Co 450mg (higher dose (higher 450mg 500mg PO qid OR PO 500mg

4.5g IV q8h 4.5g OR

Carbapenem 300

aureus aureus

ays

1g IV q8h IV 1g with d

. bid IV/PO 600mg

10 - Penicillin VK azobactam t - Clindamycin

Regimen Linezolid

azobactam Meropenem t

SKIN SOFT TISSUE AND INFECTIONS Piperacillin

Piperacillin 2 tabs PO bid PLUS bid PO 2 tabs 1g IV q12h OR IV 1g 500mg PO PO 500mg qid 1g IV q24h IV OR 1g

For hospitalized patient with severe disease, forced to use forced severe disease, with patient hospitalized For Earlyor mild infection:

: : spectrum therapy that targets both S. targets that therapy spectrum rysipelas. E line line

nd st Ertapenem Cephalexin 2 Vancomycin substitute Can 160/800 mg 1- mg 160/800 : Enterobacteriaceae - broad in obese patient, BMI >40) PO tid x 5 x PO tid >40) BMI obese patient, in 1 Facial Facial

treatment of uncomplicated cellulitis, erysipelas in extremities and other ABSSSI in the non the in ABSSSI other and extremities in erysipelas cellulitis, uncomplicated of treatment

Group A, B,C, (

sp.

Etiology

- plaque tender rededematous, spreading rapidly of onset byan acute characterized is This pedis). (Tinea toes the between infection a fungal is frequently entry of The portal be associated with lymphangitis or lymphadenitis. or lymphangitis with associated be see is involved, skin facial the If This section focuses on the the on focuses section This Enterobacteriaceae Enterobacteriaceae S. aureus;

• • • • Acute bacterial skin and skin structure infections (ABSSSI) infections structure skin skin and bacterial Acute Anaerobes (poor prognosis if if prognosis (poor Anaerobes present). Streptococcus G); peripheral vascular disease. vascular peripheral atherosclerotic and/or ulceration skin contiguous Diabetes mellitus and erysipelas mellitus Diabetes tissue. subcutaneous and skin of the inflammation from suffer commonly neuropathy peripheral mellitus diabetes with Patients Cellulitis

National Antibiotic Guidelines

or 181 5d. 5d. - 10d. . Dual trimoxazole - Co

S. aureus S. associated MRSA can MRSA associated patientis afebrile for 3 is present, need incision and need incision is present, Comments for reasons of resistance and/or and/or resistance reasonsof for

S. aureus aureus S. Tinea pedis if present. pedis Tinea

Tetracycline a clinicalfailures. Treatment also includes leg elevation to reduce to elevation leg includes also Treatment and Staph.) (Strep. infection Mixed edema. local is rare.If 7- is of therapy duration Usual drainage. until the treat Some Treat Treat venous insufficiency to due dermatitis Stasis asbacterial can masquerade bilateral, often is condition cellulitis/erysipelas; antibiotics Systemic afebrile. and patient chronic benefit. al addition no offer , use a fluoroquinolone not Do ADULT

- of total

S. daily - OR ays or

mediated mediated d -

15mg/kg IV IV 15mg/kg

2g IV IV 2g

500mg PO qid PO 500mg qid

ays ), and is distinguishable from abscesses due to due to abscesses from distinguishable and is ), d Amoxicillin

- Community both. for treat doubt, in If abscess.

2MU IV q6h IV 2MU - Vancomycin 1

Cephalexin edema): neurotic therapy: Give IV until afebrile. Stepdown afebrile. until Give IV S. pyogenes S.

S. aureus S. medicated allergic reaction - to beta reaction allergic medicated 500mg PO x 1 dose then 250mg PO PO 250mg 500mg x 1 dose then PO - mediated allergic reaction reaction allergic mediated Regimen - Penicillin G 600 mg PO x 10 PO 600 mg bid

ORq8h Ceftriaxone IV 1g illpatients: PenicillinVK

inflamed skin ( skin inflamed SKIN SOFT TISSUE AND INFECTIONS

ays d . bid 600mgIV/PO Linezolid

Cefazolin 500mg PO qidac andhs (outpatient)x 10 500mg q8h PO

ays d Linezolid lly unclear whether infection is due S. pyogenes is to infection whether unclear lly

, get cultures and start empiric start and cultures get , x 4

Amoxicillin line:

line:

Penicillin VK nd st aureus If clinicaIf q12h 2 If history of penicillin skin rash and nothing to suggest IgE suggest to and nothing rash skin penicillin of history If reaction: allergic IgE past of history/evidence If (anaphylaxis), then may be forced to use: use: to forced be may then (anaphylaxis), If documented past history of of IgE history past documented If Azithromycin antibiotics: lactam daily - less for therapy Outpatient OR an IgE suggest to and nothing rash skin Penicillin of history If - angio , (anaphylaxis reaction mediated x10 bid PO 500mg therapy. to 1 therapy: parenteral Inpatient

Etiology (Groups A, B, C, G);

(rare)

infection is rare. Bedside ultrasound may be helpful in detecting deep deep detecting in helpful be may Bedsideultrasound rare. is infection purulence. loculated look for ; erysipelas mimic Erysipelas is characterized by red indurated demarcated indurated by red characterized is Erysipelas

• S. pyogenes S. aureus National Antibiotic Guidelines

182

hemolytic hemolytic

nant organism (59%). (59%). organism nant Comments morbidities. - beta due to infection for therapy of blood, exudate, and/ or bullae isbullae or and/ exudate, blood, of

hemolytic streptococci may not be necessary necessary be not may streptococci hemolytic domi the is MRSA since - beta and MSSA (17%) Others: of the culture with I&D (2.6%). streptococci beneficial. is blood and exudate Culture systemic of signs are there needed when or involvement, skin extensive toxicity, co- underlying Empiric ADULT

for -

ays d stain):

. Clindamycin

1tab PO bid bid PO 1tab Clindamycin

160/800mg (1 DS DS (1 160/800mg

OR and

bid x 5- bid

may also be effective for for be effective also may

trimoxazole. mg 160/800

- 15 mg/kg q12h (trough q12h (trough mg/kg 15 ays d

Co trimoxazole - 10 S. pyogenes 100mg PO bid bid PO 100mg Co

1g IV q12h IV 1g

PO 500mg qid 450mg (higher dose in obese patient, patient, obese dose in (higher 450mg for

Regimen OR 2g q4h IV

trimoxazole 300- - omment re re omment Vancomycin (fluctuance or positive Gram positive or (fluctuance ays c d Co

SKIN SOFT TISSUE AND INFECTIONS 10 Doxycycline 10 μg/mL are adequate for infections of moderate moderate of infections for adequate are μg/mL 10 - Cloxacillin OR See Vancomycin Oxacillin Cephalexin therapy (in absence of specific culture and culture specific of absence (in therapy

S. aureus aureus S. OR 600mg IV q8h for patients without signs and symptoms and symptoms signs without patients q8h for IV 600mg 100mg PO q12h x 5- x q12h PO 100mg

Clindamycin

(MRSA). (MRSA). Empiric

severe: 450mg PO bid bid PO 450mg - line:

st 300- MRSA (outpatient): MSSA (inpatient): MSSA (outpatient): Doxycycline community acquired MRSA infections MRSA acquired community Inpatient: tab; 2 DS tabs in obese patient, BMI >40) >40) BMI PO patient, obese in 2 DS tabs tab; For suspected suspected For MRSA (inpatient): 1 Non BMI >40)PO tid x 5 MRSA): against activity with an agent select data, sensitivity Clindamycin OR sepsis/bacteremia of 5- of concentrations Penicillin VK aureus S.

streptococci

Etiology

hemolytic hemolytic predominantly MRSA; MRSA; predominantly

aureus

also MSSA MSSA also - beta Rare: This is associated with purulent drainage or exudate, in the absence of a drainable abscess absence drainable a the of in exudate, or drainage purulent with associated is This S. Purulent cellulitis Purulent

National Antibiotic Guidelines

183 mpiric mpiric when

V.vulnificus Comments

risk risk are factors present (e.g. sepsis andseptic shock in immunocompromisedpatients including hematologicaldisease, malignancy, andliver disease. Due Due to thepotential severity of disease, therapyfor wound andseptic patientsshould includedrugs activeagainst

ADULT

- qid 20 mg/kg -

threatening threatening OR - - Piperacillin

- tid PO 500 mg OR 1g IV1g q8h

lactam agent: lactam 12h

Cephalexin

Cefazolin

Regimen or if bacteremia is present, 15 present, is bacteremia if or

daily 20 mg/kg IV q IV 8- mg/kg 20 15- 750mg PO bid or 400mg IV bid bid IV or 400mg bid PO 750mg

SKIN SOFT TISSUE AND INFECTIONS 1g IV q4h OR IV 1g

Roughly75% of patients bulloushave skin lesions.

600 mg PO q12h (MRSA) or 600mg IV q12h 600mg or 600q12h (MRSA) PO mg qid PO 500 mg

750mg IV/PO IV/PO 750mg 4.5 g IV q8h 4.5

severe infections severe Oxacillin

Vancomycin based on clinical response. on based clinical

Ciprofloxacin Linezolid Severe infections/sepsis or those at risk for life for risk at those or infections/sepsis Severe

infection: cirrhosis due to alcohol or chronic viral hepatitis, alcoholism, hemochromatosis, diabetes mellitus, mellitus, diabetes hemochromatosis, alcoholism, hepatitis, viral chronic or alcohol due to cirrhosis infection: Cloxacillin

2h) line: line: 1 line:

st nd nd azobactam Parenteral: 2 Levofloxacin : Duration t (severe) a betause - , infection MSSA documented For 2 1 infections: severity; for for severity; q8- Oral:

cus; cus; threatening threatening - associated, contaminated skin wounds skin contaminated associated, -

Etiology

Vibrio vulnificus; Vibrio alginolyti Vibrio vulnificus; Vibrio damsel Vibrio Individuals at highest risk of of life risk highest at Individuals . lymphoma and disease, renal chronic major, thalassemia Seawater, brackish water brackish Seawater, National Antibiotic Guidelines

184 - - V d for d for 1 in patients in patients

3x/ (in patients patients (in

herpetic neuralgia neuralgia herpetic - 10 mg/kg q8h x 14d IV mg/kg 10

Aciclovir Comments clovir Valaciclovir resistant VZV occurs in HIin occurs VZV resistant - reduced post reduced added to added to

Aciclovir Valaciclovir than Aciclovir rapidly more (PHN) >50 y. Toxicity of both drugs are similar. similar. are both drugs of Toxicity y. >50 Prednisone measurements. life of quality improved >50y) of treatment the drugsin antiviral of The role 15 patients of 8 out However, unproven. is PHN Aci with improved followed by oral by oral followed month. of manifestation common a is zoster Herpes HIVin ART following reconstitution immune within begin must Treatment children. infected Aciclovir h. 72 with treated previously patients positive

ADULT

- ays d Prednisone

7.5mg PO bid 7.5mg PO

21: PLUS -

ays 10d 10d d ays D15 1g PO tid x 7 x tid 1g PO There should be increasing recognition of increased risk of stroke in the the in stroke of risk increased of recognition be increasing should There Oral zoster. antivirals H. episodean of after clinical 6 months during effect. protective a have may infection

ays d d

14 • -

x 7

herpetic neuralgia. herpetic - Valaciclovir 1g PO1g x 7 tid

; PO15mg bid

Regimen

14: 800mg PO 5x/d x 7- 5x/d PO 800mg

- D8

SKIN SOFT TISSUE AND INFECTIONS

ay 5x/d PO 800mg

(notsevere): Valaciclovir

Aciclovir

patients >50y. patients

Aciclovir

30mg PO ; PO 30mg bid

(>1 dermatome, trigeminal nerve or disseminated): Aciclovir disseminated): nerve or trigeminal dermatome, (>1 7: not decrease incidence post of incidence decrease not line: 12mg/kg IV (infusion over 1hr) q8h x 7 1hr) over (infusion IV 12mg/kg line:

nd st Immunocompromised: 2 Severe 10- Immunocompetent: Days 1- Days 1 Immunocompetent: infection. of phase acute during discomfort decrease to >50y patients in Does severe: Not Immunocompromised

fold decrease in infection rate. infection in decrease fold

Etiology Infection

Effective treatment of shingles is most evident in in evident most is of shingles treatment Effective Must begin treatment within 3d of onset of rash. of rash. onset 3d of within treatment begin Must 25- in results Immunization

Diabetic Foot Infections (DFI) Infections Foot Diabetic virus) Herpes zoster virus (Varicella zoster zoster (Varicella virus zoster Herpes • • Herpes zoster, shingles zoster, Herpes • Herpes Herpes

National Antibiotic Guidelines

185

specialty specialty -

essary to determine determine to essary ray of the affected foot foot affected the of ray Comments r pain), purulent secretions, or or secretions, purulent rpain),

Management requires multi requires Management infectious control, diabetes (for collaboration surgical and other debridement diseases, by orthopedic/vascular/general interventions and consultation Orthopedic surgeons). myelitis osteo when needed is is management considered. being send infections, severe to moderate For by obtained tissue, deep from specimens has been wound the after curettage or biopsy swab Avoid debrided. and cleansed x- Plain specimens. nec be may MRI and/or Surgical infection. of depth and extent the for necessary usually is debridement DFI. severe to moderate

ADULT

- 12h x 2- 20mg/kg 20mg/kg 15-

) Cefepime

15-

OR is suspected) suspected) is daily 8hr (for Gram 6 weeks (or (or 6 weeks even - 2 weeks g debridement of g debridement 20mg/kg IV q8- IV 20mg/kg Vancomycin Vancomycin 2g IV q8h ( IV 2g - 1

4.5g IV q6- IV 4.5g

P. aeruginosa P. aeruginosa 750mg PO/IV PO/IV 750mg 300mg PO/IV qid OR PO/IV 300mg Regimen 2 tabs PO x 1- PO bid 2 tabs Ceftazidime

1g IV q8h PLUS IV 1g Tazobactam

- 3 weeks SKIN SOFT TISSUE AND INFECTIONS 500mg IV q8h PLUS IV 500mg Levofloxacin Clindamycin

(for MRSA coverage) 15- MRSA coverage) (for 160/800mg 1- 160/800mg

12h x 2- -

3 weeks OR Piperacillin Meropenem

may be as short as one week for osteomyelitis if all all if osteomyelitis for week as one be as may short

DFI:

Vancomycin Metronidazole

12h x 2- - line: line:

nd st necrotic bone. necrotic Severe DFI: Severe if especially coverage, bacilli negative PLUS 3 weeks 2 DFI: to moderate Mild Severe IV q8 PLUS q8 IV 20mg/kg Duration: is and there resected are tissue soft and bone and necrotic infected 4 for extended be may This improvement. clinical followin bone infected residual is there if longer) 1 DFI: to moderate Mild Cotrimoxazole purulent secretions, friable or discolored granulation tissue, undermining of wound edges, foul odor). edges, wound foul of undermining tissue, granulation discolored or friable secretions, purulent

negative bacilli and bacilli negative positive cocci positive Etiology - -

secondary signs (e.g., non- (e.g., signs secondary

Aerobic gram Aerobic common. are most MRSA, including The use of a validated classification system for DFI, e.g., IDSA classification, is is recommended. classification, IDSA e.g., DFI, for system classification validated a The use of This manifests in diabetic patients with any foot wound with: signs of inflammation (redness, warmth, tenderness, swelling, o swelling, tenderness, warmth, (redness, inflammation signs of with: wound any foot with patients diabetic in manifests This additional gram Aerobic organisms. anaerobes are common secondary secondary common are anaerobes National Antibiotic Guidelines

186

Refer to

decreases

schedule

. iant Cell arteritis). Comments ] and disseminated VZV VZV and disseminated ] exposure prophylaxis: exposure - immunization - - susceptible mother is exposed and exposed is mother susceptible PFV Adult Immunization Schedule 2015 Schedule Immunization Adult PFV - www.philvaccine.org/vaccination

ray, CT scan or MRI may show gas in gasin show may MRI or scan CT ray, - X debridement surgical Urgent tissue. involved therapy. of the mainstay are and antibiotics Prevention, post Prevention, - PSMID at available http:// schedules/adult a 41% with associated is pneumonia Varicella Aciclovir but pregnancy, in mortality incidence and severity of varicella pneumonia. If If pneumonia. varicella of and severity incidence - a varicella after 10d within symptoms respiratory develops Aciclovir start exposure,

ADULT x 5-

- Herpes zoster (shingles) zoster Herpes ays d ay 5x/d PO 800mg 1g PO1g x tid 5

800mg PO 5x/d ay PO 800mg

filled bullae. Typically, gas is present in tissue. in the involved present gas is Typically, bullae. filled

Aciclovir Aciclovir ays

12mg/kg IV (infused over 1 hour) hour) 1 over (infused IV 12mg/kg Valaciclovir d

10-

Regimen ays d Aciclovir SKIN SOFT TISSUE AND INFECTIONS

1g PO tid x 5 PO 1g tid

usually involving an extremity, perianal area, genitals (“Fournier’s gangrene”) (“Fournier’s genitals area, perianal an extremity, involving usually

ays Valaciclovir

d (start within 24h of rash) OR 24hrash) of within (start line: ays line: line:

10 mg/kg IV q8h x 5 mg/kg 10

nd st st

: pneumonia trimester), (3rd Pregnancy Immunocompromised: 2 7 or q8h x 7 1 1 chickenpox: host, Immunocompetent

rma. erythrode maybe and failure, respiratory failure, renal diarrhea, vomiting, nausea, by hypotension, as defined shocksyndrome

anaerobic bacteria bacteria anaerobic Etiology - zoster virus (VZV) virus zoster -

Group A Streptococcus (GAS, (GAS, Streptococcus A Group Mixed aerobic Mixed moving; fast common, most I]: [Type - blood with often skin, cyanotic and dusky, pain in by a decrease manifests Necrosis toxic have associated May Infection causing necrosis extending to fascial plane(s): plane(s): fascial to extending necrosis causing Infection Necrotizing fasciitis Necrotizing Emerging data suggests VZV may cause vasculopathy of cerebral, temporal, and other arteries (suggested as possible cause of G of cause as possible (suggested arteries and other temporal, cerebral, of vasculopathy cause may VZV suggests data Emerging Varicella Clinical syndromes include chickenpox, shingles (single dermatomal or multiple dermatomes) [see also also [see dermatomes) multiple or dermatomal (single shingles chickenpox, include syndromes Clinical involvement. disease/organ Varicella zoster virus zoster Varicella

National Antibiotic Guidelines

187 le ) have ) viab IG

IV ( recommend recommend

Comments

is supported by a small controlled study controlled small bya supported is

IG immunoglobulin intravenous

antibodies against streptococcal toxins. Use of of Use toxins. streptococcal against antibodies IV and a retrospective review. More data is is data More review. and a retrospective needed. Early exploratory surgery is recommended to to recommended is surgery exploratory Early and aerobic (include diagnosis establish non- all resect and cultures) anaerobic do not Guidelines IDSA tissue. oxygen. hyperbaric with and presents fasciitis: necrotizing II Type lots Some rhabdomyolysis. and/or TSS without of

ADULT

- 20μg/ 20μg/ 900mg 900mg - 500mg 500mg

600-

azobactam t OR

- 500mg IV q6h IV 500mg 12h (target 12h (target PLUS 12h daily C. tertium toC. tertium f with penicillin allergy: allergy: penicillin with f i

Metronidazole Clindamycin Piperacillin 1g IV q8h 1g q8h IV

20mg/kg q8- 20mg/kg

750mg IV IV 750mg PLUS Metronidazole 15- 20mg/kg IV q8- IV 20mg/kg generation cephalosporinsis

- allergy manifested as anaphylaxis as anaphylaxis manifested allergy 12h

Susceptibility of 15-

Regimen isvariable inpublished studies; Meropenem

12h (target trough concentrations 15 concentrations trough (target 12h

- q8 2g - and third

1 μg/mL) 20μg/mL) Levofloxacin n 4MU IV q4h PLUS 4MU

Penicillin

Vancomycin SKIN SOFT TISSUE AND INFECTIONS

Vancomycin manifested as skin rash only and unable to tolerate tolerate to and unable only rash as skin manifested

- q8 20mg/kg 400mg IV q12h PLUS IV 400mg Cefepime Metronidazole

1g IV q12h IV 1g Vancomycin : 15- Clindamyci

suspected, Penicillin G Penicillin allergy

and

Vancomycin streptococcal (Type II) necrotizing fasciitis, necrotizing II) (Type streptococcal

line:

S. aureus S. aureus nd IV q6h PLUS IV If PLUS For If Type II necrotizing fasciitis or clostridial necrotizing fasciitis is fasciitis necrotizing or clostridial fasciitis necrotizing Type II If Ciprofloxacin For Type 1 necrotizing fasciitis: 1 necrotizing Type For Penicillin toresistance trough concentrations 15- concentrations trough Vancomycin Carbapenem edema: angioneurotic or Vancomycin Forclostridial necrotizing fasciitis: If Type I necrotizing fasciitis is suspected: suspected: is fasciitis Type Inecrotizing If PLUSq8h IV 4.5g suspected: production) toxin block q8h (to IV suspected: MRSA is If 2 mL) Penicillin

Klebsiella Klebsiella ,

acute or or acute — Etiology [Type II] [Type

, perfringens Clostridium ) Vibrio vulnificus

MRSA, MRSA, pyogenes subacute; spp. National Antibiotic Guidelines

188 <5 In the the In

. In. Minocycline

Comments

with wounds response, systemic of absence If the infection is on the skin incision, remove incision, on the skin is infection the If and culture wound,obtain drain to sutures SeeIDSA wound. pack and the sensitivity, assessment and the for Guidelines wounds. surgical infected of management may or necrosis and no induration erythema cm

determined by the severity of infection be (may infection of bythe severity determined 2 ADULT

resistance. Based on a 2011 global survey of of survey on a 2011 global Based resistance. -

1g IV q12h IV 1g 160/800mg 1- 160/800mg 600mg IV q12h. 600mg . For. MRSA, Minocycline to weresusceptible and >98%

Vancomycin trimoxazole expected to haveactivity in

: Co

l flora).vagina or bybowel contamination potential (e.g., surgery tract genitourinary Regimen

was 9.1 % in 2014 and 7.1 % in 2015. in 2014 % in 9.1 was and 7.1 % Meropenem and SKIN SOFT TISSUE AND INFECTIONS

Tetracycline to esusceptible Clindamycin inducible out for watch resistant, 450mg PO tid OR tid PO 450mg - (sepsis; febrile patient) febrile (sepsis; Tetracycline

300- (without sepsis; afebrile), if antimicrobial needed: antimicrobial if afebrile), sepsis; (without

Vancomycin

Erythromycin line: line:

S. aureus aureus S. st nd

bid PO tabs infection Severe 2 1 Mildinfection Clindamycin weight kg) >100 if q12h (1.5g common. vitro. Linezolid caused MRSA: by fasciitis necrotizing For

genitourinary tract surgery (e.g., "clean" surgery). Treatment regimen is is regimen Treatment surgery). "clean" (e.g., surgery tract genitourinary

sp. sp. - sensitive but but sensitive skin skin

ate of resistance of of resistance of ate

- Clindamycin Etiology is operative wound infections wound operative Streptococcus Streptococcus S. aureus, gastrointestinal tract and non- tract gastrointestinal gastrointestinal tract, non tract, gastrointestinal - - -

S. aureus S. aureus

flora, Non surgery: tract genitourinary (Group A, B, C, G) , and 88.3% (by Eucast breakpoint) or 97.2% (by CLSI breakpoint) were susceptible to to were susceptible breakpoint) (by 97.2% CLSI or breakpoint) Eucast (by and 88.3% , Tetracycline to susceptible 85% were approximately. the r Philippines, the If If wer of MSSA 94% isolates, aureus S. 5,000 approximately The patient is febrile, with neutrophilia. neutrophilia. with febrile, is The patient mild in afebrile patients, or severe in febrile patients). in febrile severe or patients, afebrile in mild and non- and esophageal) oropharyngeal (including tract Gastrointestinal Post Non Wound Infection Wound

National Antibiotic Guidelines

189 in the the in

Vancomycin for

Comments

Linezolid

be treated with opening and dressing changes changes and dressing opening with treated be only. aureus S. the if wound and drain Open Surgery. or GUT GIT on suspected substitute Can regimen. primary

ADULT

- - - Co

300

160/800mg (Parenteral

750mg IV IV 750mg 100mg PO bid bid PO 100mg OR 500mg IVq6h)

600mg IV IV q12h 600mg 1g IV q12h IV 1g 450mg PO OR PO 450mg 1g IVq12h ) Clindamycin trimoxazole - 300- 4.5gIVq8h Levofloxacin

Linezolid

Doxycycline

Metronidazole

OR OR Vancomycin Vancomycin

patient): PLUS

Regimen 875/125mg PO bid or 500/125mg PO tid PO or 500/125mg bid PO 875/125mg PLUS Clindamycin tazobactam - 500mg IV q6h IV 500mg PLUS 2 tabs PO bid PO 2 tabs ADD 450mgPO tid

SKIN SOFT TISSUE AND INFECTIONS sepsis; afebrile patient): patient): afebrile sepsis; 1g q8h q8h 1g 400mg IV q12h IV 400mg

100mg PO q12h OR PO 100mg 300-

amoxiclav - 1g IV1g q12h hout Piperacillin (sepsis;febrile 1g IV q24h

Cephalosporin

Co 600mg PO/IV q12h PO/IV 600mg

(wit

160/800mg 1- 160/800mg Metronidazole

suspected:

Meropenem

reus Ciprofloxacin PLUS Minocycline Clindamycin generation

Ertapenem - : Linezolid ( line: line:

Vancomycin

line: line:

: 2tabs PObid S.au nd st nd st - Severe infection: trimoxazole 2 OR q24h IV Oral : Mild infection: Mild If third 1 Oral 1 2 OR Mildinfection tid PO 450mg infection Severe PLUS 1

stain

B. (MSSA, (MSSA,

Gram sp (e.g., sp (e.g., Etiology S. aureus positive cocci): positive

Gram ), and other anaerobic anaerobic and other ), Bacteroides Bacteroides ), ),

shows shows bacteria fragilis coli MRSA),coliform species(e.g., E. ( infection postwound For suspected MSSA or MRSA MRSA or MSSA suspected For vaginal flora, flora, vaginal skin flora, gastrointestinal and gastrointestinal flora, skin Gastrointestinal tract (GIT)or surgery: (GUT) tract genitourinary National Antibiotic Guidelines

190 is also is Streptococcus Streptococcus

idement may be idement

resistant in vitro, is being considered. being is S. aureus S. Comments - Erythromycin Clindamycin is negative bacilli are suspected: add a add suspected: are bacilli negative -

S. aureus S. aureus Clindamycin to resistance inducible laboratory microbial the that Ensure possible. if this checks Maintain dry skin surface (e.g., for intertrigo, intertrigo, for (e.g., surface skin dry Maintain if hyperglycemia and control dermatitis) diaper by caused usually paronychia Acute present. Regimen focuses on on focuses Regimen sp. IfGram debr Surgical . Fluoroquinolone indicated. If

ADULT

1g IV 160/800mg

1g IV q12h OR IV 1g 400mg IV IV q12h 400mg bid PO 600mg 1% cream; cream; 1%

Vancomycin

trimoxazole - Co

Linezolid

PLUS

2% cream applied bid applied cream 2% Vancomycin Clotrimazole OR Ciprofloxacin :

genitourinary tract surgery (e.g., potential contamination by bowel or vaginal flora). flora). vaginal or bybowel contamination potential (e.g., surgery tract genitourinary ays PLUS 4.5g q8h q8h 4.5g d

Regimen 5 - 450mg PO tid OR tid PO 450mg - Ketoconazole SKIN SOFT TISSUE AND INFECTIONS 100mg PO bid bid PO 100mg 1g IV q8h IV 1g

300 azobactam t - 750mg IV q24h IV 750mg

2% cream; cream; 2% 600mg IV/PO q12h PLUS IV/PO 600mg

Minocycline Meropenem Topical therapy for 3 for therapy Topical

Clindamycin Piperacillin

Levofloxacin line: line:

line:

line: line:

2 tabs PO bid bid PO 2 tabs nd nd st - st st

Linezolid OR 1 2 Complicated, severe, febrile patient: febrile severe, Complicated, 1 1 1 Miconazole Uncomplicated, mild or moderate, afebrile patient: afebrile moderate, or mild Uncomplicated, q12h q12h 2

genitourinary tract surgery (e.g., "clean" surgery). Treatment regimen is determined by the severity of infection (may be be (may infection of by the severity determined is regimen Treatment surgery). "clean" (e.g., surgery tract genitourinary

sp., C.

, , and non-

trauma

- Pseudomonas Aeromonas , Common types of of Common types , Other Candida spp. Candida Other , : and and (aerobic sp. Etiology sp.;especially in candidiasis C. tetani Enterobacteriaceae , , (MSSA,MRSA), gastrointestinal tract gastrointestinal -

Acinetobacter soldiers infectedin Afghanistan, Iraq sp. (water exposure), candida skin infections include: include: infections skin candida Clinical settings Cutaneous Cutaneous albicans Candida Fungal Skin Infections Skin Fungal Streptococcus S.aureus anaerobic) perfringens, Polymicrobic(Microbial flora dependenton nature of the trauma): - and non and esophageal) oropharyngeal (including tract Gastrointestinal neutrophilia. with febrile, is The patient Non patients). in febrile severe or patients, afebrile in mild Infected wound, post wound, Infected

National Antibiotic Guidelines

191 Tinea Tinea Ketoconazole

nd may require I&D if if I&D require may nd and

Comments is suspected, obtain bacterial bacterial obtain is suspected, (mycologic cure and decrease in in and decrease cure (mycologic

Akapulco 50% that showed analysis - eded to confirm these are ne confirm eded to rates up - Thiosulfate Sodium fitting clothes/underwear. If secondary secondary If clothes/underwear. fitting

cream, but larger randomized trials with good with trials randomized larger but cream, follow lotion was superior to placebo for for to placebo superior was lotion versicolor as effective as be appears to It activity). clinical 25% findings. mixed bacterial infections a infections bacterial mixed may paronychia Chronic present. abscess is the medical handif to surgeon referral require . ineffective is treatment localized, for preferred antifungals Topical Avoid lesions. noninflammatory uncomplicated tight- infection bacterial coverage. adequate antibiotic and start cultures Ameta ADULT

1% -

50- 200mg 200mg OR - 200mg 200mg 100

Clotrimazole

Fluconazole

OR k x 3 consecutive eek x 3 consecutive Itraconazole

OR 3 weeks Fluconazole

x 3 months

ays

4 weeks weeks 4 d 4 weeks (recommended) (recommended) 4 weeks daily - 4 weeks OR 4 weeks Regimen or bid x- 2 bid or 4 weeks

x 2-

200mg PO bid x 1 w x1 bid PO 200mg daily 250 mg PO PO 250 mg SKIN SOFT TISSUE AND INFECTIONS

1% cream bid x3 bid cream 1%

or 150mg once weekly x 2- x 150mgweekly once or

2% cream cream 2% Itraconazole 4 weeks or 200mg bid x 7 bid 200mg or 4 weeks 250mg PO dailyPO 250mg Terbinafine restored anatomy nail normal eek until

x 2- Topical therapy ineffective or intolerant to topical to topical intolerant or ineffective therapy Topical If topical treatment does not work: does not treatment If topical

OR Terbinafine daily every w every line: line:

line:

nd nd st Alternatives: months medications, or with extensive and/or disabling, multifocal or or multifocal disabling, and/or with extensive or medications, involvement: follicle hair with infection deeper disease, inflammatory Terbinafine PO 100mg PO dailyPO 100mg 1 Ketoconazole 2 PO x bid 2- solution powder, cream, 2

exposure (e.g., veterinarian, lab worker, farmer, shop workers) pet farmer, worker, lab veterinarian, (e.g., exposure Etiology Current and previous topical and/or systemic treatment systemic and/or topical and previous Current Occupational members) family gyms,affected rooms, locker sports, contact pets), gardening, (e.g., exposure Environmental

• • • Epidermophyton, Epidermophyton, genera: following and Trichophyton orum Microsp Certain spp. of dermatophytes of the the of of dermatophytes spp. Certain Check for history of: history for Check Tinea corporis/cruris Tinea dermatitis, balanitis, and paronychia balanitis, dermatitis, intertrigo, diaper dermatitis, erosion erosion dermatitis, diaper intertrigo, perianal blastomycetica, interdigitalis National Antibiotic Guidelines

192

on. 2% bid, 2% compared to compared to

multiple, verypruritic, : Terbinafine after 1 week of treatment treatment of 1 week after

Comments negative toe web infecti web toe negative - od 1% and Ketoconazole seated vesicles on the fingers and fingers on the vesicles seated Clotrimazole

(84.6% vs 55.8%, respectively). Another RCT Another respectively). vs 55.8%, (84.6% between efficacy comparable showed Clotrimazole A randomized controlled trial showed faster faster showed trial controlled randomized A topical with response topical an “id” can trigger Tinea pedia 28d. for applied hands on the reaction deep- minute phase a chronic to progress May palms. hand eczema. resembling bemay corticosteroids: systemic or Topical severe or extensive of cases in considered systemic or Topical pedis. tinea inflammatory be ne may cases of eded in antibiotics: Gram secondary

x ADULT OR

- 150mg 150mg 1% bid 1%bid Fluconazole

Clotrimazole

4 weeks (recommended) (recommended) 4 weeks -

x 2

6 weeks OR 6 weeks daily Regimen

SKIN SOFT TISSUE AND INFECTIONS 250mg PO x 2 weeks 2 weeks x PO 250mg 1% cream cream 1%

2% cream bid x 3- x cream bid 2% x 4 weeks

Terbinafine Terbinafine weekly line: line:

4 weeks - nd st

PO 2 Ketoconazole 2 1

. style: powdery plaques with mildly erythematous base on heels, soles, and lateral aspects of feet of the aspects lateral and soles, heels, base on erythematous mildly with plaques powdery style: Etiology rubrum, Trichophyton Trichophyton rubrum,

digital, especially common in the 3rd and 4th web spaces web 3rdand 4th the in common especially digital, Epidermophyton floccosum, floccosum, Epidermophyton - Moccasin instep on the usually exudate, have purulent may Vesicobullous: Inter-

• • • Rare: Fusarium Acremonium, Candida, mentagrophytes Trichophyton Trichophyton Trichophyton interdigitale, May manifest as: manifest May Tinea pedis Tinea

National Antibiotic Guidelines

193

015. 55.

ions: 2014 Update by the Update 2014 bythe ions: ent of Methicillinent resistant

Antimicrobial Therapy, Inc. Therapy, Antimicrobial

ADULT

38. a Clinical Practice Guidelines for the Diagnosis and Treatment of Diabetic Diabetic of DiagnosisTreatment and the for Guidelines Practice a Clinical

59.

2016).

SKIN SOFT TISSUE AND INFECTIONS The Sanford Guide to Antimicrobial Therapy, 2016. Therapy, to Antimicrobial Guide The Sanford iseases 2014; 59: 147- 59: 2014; iseases

- 376:2545 2017; J Med Engl New abscesses. skin smaller for ofantibiotics trial controlled

73.

- 52:1 2011; Diseases Inf Clin and children. adults in infections

Infectious Diseases Society of America. Clin Inf D Inf Clin America. of Society Diseases Infectious aureus Staphylococcus - 4:132 2012; Diseases Clin Inf Infections. Foot Antimicrobial Resistance Surveillance Program. Manila: Department of Health; 2 of Health; Department Manila: Program. Surveillance Resistance Antimicrobial Health. of Department Medicine, Tropical for Institute Research Infect Tissue Soft and Skin of Management and Diagnosis the for Guidelines Practice et al. HF, Chambers AL, Bisno DL, Stevens Liu C, Bayer A, Cosgrove SE, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for treatm the for America of Society Diseases Infectious bythe Guidelines Practice Clinical al. et SE, A, Cosgrove Bayer C, Liu Lipsky BA, Berendt AR, Comia PB, et al. 2012 Infectious Diseases Society of Americ of Society Diseases al. 2012 Infectious et PB, Comia AR, Berendt BA, Lipsky Daum RS, Miller LG, Immergluck L, et al. etal. placebo L, A LG, Immergluck Miller RS, Daum National Antibiotic Guidelines

REFERENCES – (@2000 Guide ABX Johns Hopkins in Editor Chief. JG, Bartlett

Chambers HF, Eliopoulos GM, Gilbert DN, Saag MS (eds.). (eds.). MS Saag DN, Gilbert GM, Eliopoulos HF, Chambers 194 and negative negative osthetic osthetic for the resistant resistant

adding cefazolin cefazolin adding Vancomycin

For clean surgeries, no surgeries, clean For

lactam dose) or exfoliative dermatitis dermatitis exfoliative or dose) lactam negative bacteria are a concern (as shown shown (as a concern are bacteria negative - lactams (anaphylaxis, laryngeal edema, edema, laryngeal (anaphylaxis, lactams

- methicillin with infection operative - lactams, use vancomycin with another Gram- another with vancomycin use lactams, there is excessive blood loss (>1,500 mL), intraoperative intraoperative mL), (>1,500 loss blood excessive is there

exceed the risks and the anticipated costs. anticipated the and risks exceed the SURGICAL PROPHYLAXIS

negative organisms. When Gram When organisms. negative - - beta to reaction allergic of type life to achieve activity throughout the operation is sufficient for prophylaxis under under prophylaxis for is sufficient operation the throughout activity to achieve life -

dosing interval is measured from time of the preoperative dose. preoperative the time of from is measured interval dosing when or agent, prophylactic of the lives -

hour infusion times; hence, dose is started 2 hours before surgical incision. Rapid infusion of infusion Rapid incision. surgical before hours 2 started hence, dose is times; infusion hour - h long a enough half

to 2

procedure doses are generally not not needed. generally dosesare procedure - - to beta allergic or of intolerant patients In patient. allergic

is discouraged but may be justifiable in centers where rates of post of rates where centers in justifiable be may but discouraged is (MRSA) are high, or in patients with known MRSA colonization or at high risk for this (e.g., hemodialysis patients). It is It patients). hemodialysis (e.g., for this risk at high or known colonization with MRSA patients in high, or are (MRSA) require 1- require associated with the specific procedure at the time of incision and throughout the duration of the procedure. of the duration the throughout and of incision the time at procedure specific the with associated

may result in hypotension and other signs and symptoms of histamine release (red man syndrome). man (red release histamine of and symptoms signs other and hypotension in result may aureus lactams, vancomycin has no activity against Gram against activity hasno vancomycin lactams, Johnson syndrome). Johnson

Vancomycin Vancomycin A single dose of antimicrobial wit antimicrobial of dose single A half two than more lasting procedures For most circumstances. Post circumstances. most supplementary dose(s) may be required. - Re required. be may dose(s) supplementary es Fluoroquinolon : Exceptions incision. surgical before minutes 60 within be started must antimicrobial Intravenous crucial. is Timing - beta Unlike by local surveillance data), adding a second agent with appropriate in vitro activity may be necessary. This candone by be This be necessary. may activity in vitro appropriate with secondagent a adding data), surveillance bylocal non- the in vancomycin to aztreonam). or fluoroquinolone, aminoglycoside, (e.g., antibiotic

Staphylococcus Staphylococcus immediate an of history a have when patients alternative an also - a beta after immediately occurring rash pruritic or urticaria swelling, local hypotension, bronchospasm, - Stevens (e.g., Surgical prophylaxis is recommended only when the potential benefits benefits potential the when only recommended is prophylaxis Surgical patterns. resistance local account andinto take site operative the for pathogens expected the cover st chosen mu The antibiotic prophylaxis is recommended as a general rule. Exception: procedures where there are severe consequences of infection (e.g. pr (e.g. infection of consequences severe are there where procedures Exception: rule. general asa recommended is prophylaxis procedures) cardiac implants, The use of Effective prophylaxis requires antimicrobial serum and tissue concentrations above the minimum inhibitory concentration (MIC) concentration inhibitory minimum the above concentrations and tissue serum antimicrobial requires prophylaxis Effective probable organisms probable A. B. C. A.

I. II. III. IV. Adults: General Comments General

SURGICAL PROPHYLAXIS National Antibiotic Guidelines

195 ndations have ndations ty, and increased and increased ty,

SURGICAL PROPHYLAXIS

dosing.

rapeutic antibiotic(s) for infection remote to surgery site and when the antibiotic regimen is appropriate also for for also appropriate is regimen antibiotic the when and site surgery to remote infection for antibiotic(s) rapeutic

should not be used because of the potential for toxicity. for potential the of because used be not should

fection and allergic reactions. Improper antimicrobial prophylaxis leads to to leads prophylaxis antimicrobial Improper reactions. allergic and fection in difficile Clostridium include prophylaxis surgical inciples mirror those for antibiotic prophylaxis in adults. However, data in the pediatric population are limited and recomme and limited are population the pediatric in data However, adults. in prophylaxis antibiotic for those mirror inciples

- pre of The risks and mortali morbidity increased stay, hospital prolonged most studies), in 52% (upto rate infection wound surgical excessive health care cost. care health The pr largely been extrapolated from studies in adults. in studies adults. from been extrapolated largely For patients currently given the given currently patients For incision. to prior an hour within given be a dose should prophylaxis, Recommendations are generally the same as for adults except for for except adults same the asfor generally are Recommendations Fluoroquinolones

II. V. III. I. VI. Pediatrics: National Antibiotic Guidelines

196 risk

risk - is

Ceftriaxone

Comments preferred in hospitals in hospitals preferred be may patients, and those colonized with MRSA. with colonized and those patients, Gastroduodenal (PEGplacement) high conditions include:marked obesity,obstruction, decreasedgastric acid or decreasedmotility, bleeding,gastric cancer. Single infusion just before surgery is as is surgery before just infusion Single Prophylaxis doses. as multiple effective No recommended. not is hours beyond 24 cardiac for needed is prophylaxis and brachiocephalic carotid catheterization, prosthetic of insertion without procedures insertion line central intravascular and grafts, (tunneled/untunneled). is recommended it valves, heart prosthetic For ofthe removal after either prophylaxis stop to givejust a or catheters drainage retrosternal bypass. off coming 2nd dose after Vancomycin with increased frequency of MRSA, in high - in MRSA, of frequency increased with recommendedcenters where forthere is

Ceftriaxone OR

OR 2g IV 2g IV

120kg

≥

with positive patients in surgery Cefoxitin - 3g IV

SURGICAL PROPHYLAXIS the on surgery, evening before the OR or post on Regimen Vancomycin

120kg) 120kg)

≥

or <120kg <120kg or upirocin lactams: M - to beta to

1.5g IV 1.5g 1 dosex y

2g IV (3g if wt. 2g x 1 dose f x1 2g

intranasal intranasal 1.5g IV x 1 dosex1 IV 1.5g

allerg with Consider 5 days for and bid surgery, day of . S.aureus for culture nasal : 1g IV x 1 dose 1g IV ≤90kg: >90kg: Cefazolin dose x1 IV 2g Cefazolin Cefuroxime If

Procedure

Implanted cardiac defibrillators cardiac Implanted Heart transplant Heart pacemakers Permanent surgery Cardiac Any vascular procedure with with procedure vascular Any prosthesis/foreign of insertion body for amputation extremity Lower ischemia procedures that that procedures Leg vascular incision groin a involve aorta Reconstruction of abdominal abdominal of Reconstruction

• • • • pancreaticoduodenectomy (Whipple (Whipple pancreaticoduodenectomy procedure) Gastroduodenal, includes includes Gastroduodenal, endoscopic percutaneous only), risk (high gastrostomy Gastroduodenal/Biliary Surgery Gastroduodenal/Biliary • Cardiovascular Surgery Cardiovascular • • •

Procedure Surgical by Regimen Prophylaxis Antibiotic Recommended National Antibiotic Guidelines

197

eae to Cefazolin op dose.op can be given can be given

. functioning functioning

. epeat epeat R e infection includes a includes e infection ours Cephalosporins. Avoid h

in neonates. IV antibiotic

suppression, acute acute suppression, Comments , , preparation bowel echanical m Metronidazole

and

risk factors include: age >70 years, years, >70 age include: factors risk - and Ceftriaxone ralantibiotic Prevention of surgical sit surgical of Prevention of combination o Cefazolin increasing resistanceEnterobacteriac of 1st and2nd generation using Biliaryhigh o immun diabetes, non- pregnancy, cholecystitis, common or jaundice obstructive gallbladder, or spillage bile anticipated stones, duct >2 duration procedure together in same IV same in bag. together - pre the initial after dose 4 hours

)

) Gentamicin Gentamicin ( 0.5g IV 0.5g

400mg IV 2h prior IV 400mg 2h prior 400mg IV 400mg

PLUS OR

2g IV ) 4.5g IV 1h prior to IV 1h prior 4.5g

0.5 g IV 0.5 Metronidazole 900mg IV IV 900mg

Cefoxitin

750mg PO or PO 750mg

R Ciprofloxacin Ciprofloxacin

SURGICAL PROPHYLAXIS O PLUS

500- ] OR Regimen tazobactam -

120kg 120 kg) 120 kg) 2g IV IV 2g Clindamycin Clindamycin

≥ ≥ Metronidazole Metronidazole

3g IV 3g

No Prophylaxis No

Ciprofloxacin

3g wt.if Piperacillin [

Aztreonam

OR 2g IV2g PLUS : allergy lactam Sulbactam 2g IV2g

- 2g IV (3g if wt. if IV 2g (3g 2g IV 2g IV

Cefazolin procedure 5mg/kg IV OR IV 5mg/kg If without obstruction: without If obstruction: with If procedure to ( Cefoxitin Ceftriaxone No prophylaxis No Cefazolin If withIf beta Ampicillin

surgery

Procedure Colorectal surgery Colorectal Colorectal/intestinal Endoscopic retrograde retrograde Endoscopic cholangiopancreatography Biliary, includes high risk risk high includes Biliary, cholecystectomy, laparoscopic cholecystectomy open cholecystectomy Low risk, laparoscopic laparoscopic risk, Low National Antibiotic Guidelines

198

Comments

. ours operative day: operative h - Do bowel preparation using 4L using preparation bowel Do PO solution electrolyte glycol polyethylene 2 over only. diet liquid Clear midnight. after NPO

1. 2. 3. Clean, uncontaminated head and neck and neck head uncontaminated Clean, does not suchas thyroidectomy, surgery, is there when except prophylaxis require Prophylaxis material. prosthetic of placement and functional tonsillectomy for indicated not is procedures. sinus endoscopic On the pre the On

0.5g IV 0.5g Neomycin Neomycin

OR :

) 5mg/kg x 1 5mg/kg IV 0.5 g IV 0.5 Metronidazole

Gentamicin

SURGICAL PROPHYLAXIS

Metronidazole Metronidazole

Regimen 120 kg) PLUS≥120 kg) 120 kg) PLUS ≥ base 1g PO

900mg IV x 1 dose x1 900mgIV

600- 2gIV (3g wt.if 2g IV2g 1 x dose

2g IV (3g wt.if 2g IV 2g IV

Erythromycin

colorectal parenteral regimen parenteral colorectal

given x 3 doses over approximately 10h the afternoon and afternoon the 10h x 3 doses approximately given over (

Cefazolin Cefazolin

PLUS Clindamycin Cefazolin Cefazolin As for Cefoxitin OR ( ( Oral preparation) bowel and after operation the before evening Cefazolin dose) 1g

Procedure

surgery. Wound infection infection Wound surgery. rates can still be high though even though high be can still rates prophylaxis. with The efficacy of prophylaxis is best best is prophylaxis of The efficacy neckhead and for established cancer Head and Neck Surgery and Neck Head appendicitis obstruction uncomplicated for Appendectomy Small bowel surgery with with surgery bowel Small Small bowel surgery without without surgery bowel Small obstruction

National Antibiotic Guidelines

199 risk risk

MRSA.

Comments may be preferred in hospitals in hospitals preferred be may in hospitals preferred be may

Administer before skin incision. before Administer Vancomycin high - in MRSA, of frequency increased with with colonized and those patients, Vancomycin high - in MRSA, of frequency increased with MRSA. with colonized and those patients,

3g IV 3g 3g IV

OR OR 5mg/kg IV x 1 5mg/kg IV x 1 5mg/kg IV sulbactam sulbactam -

sulbactam sulbactam - 0.5g IV 0.5g Gentamicin Gentamicin Ampicillin

Ampicillin

OR PLUS PLUS SURGICAL PROPHYLAXIS

OR Regimen 2g IV 2g IV

20kg)

1 Metronidazole

900mg IV IV 900mg IV 900mg ≤90 kg: 1g IV; >90 kg: 1.5g IV IV 1.5g kg: >90 IV; 1g kg: ≤90 ≤ 90 kg: 1g IV; >90 kg: 1.5g IV IV 1.5g kg: >90 1g IV; kg: 90 ≤ ≥ daily daily

PLUS Cefoxitin

daily OR

900mg IV IV 900mg 900mg IV IV 900mg 900mg IV x 1 dose IV 900mg

1.5g IV 1.5g 2g IV IV 2g - Vancomycin Clindamycin Clindamycin Vancomycin

: 1 IV 2g IV 2g 2g IV (3g wt.if

Cefazolin Alternative: Clindamycin Cefazolin Alternative dose Cefazolin Alternative: dose vaginal uncomplicated for recommended NOT is prophylaxis Antibiotic . an episiotomy without or with birth Cefazolin Alternative: Clindamycin Clindamycin Cefuroxime

hysterectomy Procedure implant; e.g. elective elective e.g. implant; -

Episiotomy for vaginal birth vaginal for Episiotomy Caesareansection premature for rupture ofmembranes or active labor Obstetric/Gynecologic Surgery Obstetric/Gynecologic abdominal or Vaginal CSF shunt surgery, intrathecal surgery, shunt CSF pumps sinuses, or naso/oropharynx) or sinuses, Clean, contaminated (cross (cross contaminated Clean, craniotomy Neurosurgical Procedures Neurosurgical non Clean, National Antibiotic Guidelines

200 Vancomycin s.

risk patients, and patients, risk

. Comments

impregnated bone cement in in cement bone impregnated - those colonized with MRSA with colonized those Most available data involve cataract cataract involve data available Most procedures. For surgery. of 24h within prophylaxis Stop antibiotic the initial finish hip), than (other TJR inflated. is the tourniquet before infusion Antibiotic commonly is antibiotic intravenous to addition replacement joint for practiced may be preferred in hospitals with increased increased with in hospitals be preferred may - high in MRSA, of frequency

1mg 1mg

. OR roxime roxime Fluoroquinolone

Cefu

OR 100mg by subconjunctival by subconjunctival 100mg

SURGICAL PROPHYLAXIS

Gramicidin Cefazolin

– x 5 doses within the hour before start start hour before the x 5 doseswithin

if colonized with S. aureus with colonized if Regimen ≤90 kg: 1g IV; >90 kg: 1.5g IV IV 1.5g kg: >90 IV; 1g kg: ≤90

2.5mg intracameral OR intracameral 2.5mg . - s min 15

1 -

5 upirocin op - Polymyxin B Polymyxin - pre 900mg IV 900mg

Cefazolin

Vancomycin

2g IV IV 2g

Neomycin intracameral injection of procedure. of procedure: of end at the Optional M intranasal Consider Cefazolin Alternative: Clindamycin indicated not Prophylaxis Topical Topical every as 1 drop given

implantation of of implantation

o ith

Procedure Clean operations of hands, feet and feet of hands, operations Clean w arthroscopy foreignmaterials Total joint replacement (TJR), (TJR), replacement joint Total fracture hip procedures, spinal repair, implantation of internal nails, (screws, devices fixation wires) plates, Orthopedic Surgery Orthopedic Ophthalmic Surgery Ophthalmic

National Antibiotic Guidelines

201

resistant resistant

procedure for for procedure and/or and/or

- - luoroquinolone resistance among enteric enteric among resistance Comments F trimoxazole -

. Co negative bacteria has been a concern. concern. a been has bacteria negative - Treat patients with UTI based on urine c/s prior c/s UTIbased on urine with patients Treat Fluoroquinolone Gram organisms is increasingly used to guide the the guide usedto increasingly is organisms to procedure to biopsy, ureteroscopy, include Procedures targeted UTIwith Treat etc. TURP, fulguration, possible. if procedure before therapy pre culture stool Screening with colonization be ideally should which prophylaxis, of choice urinary target to antimicrobial Modify patterns. resistance local on based pathogens Increasing

3g IV x1 dose IV 3g

500mg PO 500mg

sulbactam

- for those with potentially adverse potentially those with for

SURGICAL PROPHYLAXIS

Regimen Levofloxacin

Ampicillin

OR trimoxazole -

or 500mg PO 500mg after 12h biopsy repeated and to prior 12h PO 500mg etc.) generally not necessary if urine is sterile. May May a give sterile. is urine if necessary not generally

900mg IV x 1 dose IV 900mg is

2g IV x1 IV dose 2g

oxacin luoroquinolone host factors (e.g., advanced age, immunocompromised state, anatomic anatomic state, immunocompromised advanced age, (e.g., factors host abnormalities, Prophylaxis Prophylaxis F Ciprofloxacin Ciprofl dose 1st Cefazolin Clindamycin

Procedure

Surgery/ Procedure Surgery/ assisted thoracoscopic thoracoscopic assisted Transrectal prostate biopsy prostate Transrectal Cystoscopy with manipulation with Cystoscopy Urologic Urologic Cystoscopy - Video surgery and thoracotomy resection, Noncardiac procedures, including including procedures, Noncardiac lung pneumonectomy, lobectomy, Thoracic Surgery Surgery Thoracic National Antibiotic Guidelines

202

Comments sceptibility of prevailing prevailing of sceptibility

based on su based organisms.

3g IV x IV dose 3g 1

sulbactam -

SURGICAL PROPHYLAXIS Ampicillin Regimen OR

900mg IV x 1 dose x1 900mgIV 2g IV x IV dose 2g 1 -

Clindamycin Clindamycin

Cefazolin OR

Procedure

Breast surgery, herniorrhaphy surgery, Breast Others

National Antibiotic Guidelines

203

6 2 2 2 4 4 4 2 NA NA NA NA NA (hours) ** (hours) Redosing Interval (From (From Interval Redosing Initiation of Preoperative Dose) Dose) of Preoperative Initiation

7 4 3 8 1.2 1.3 2.4 2.2 2 1.1 10.9 ------1.9 - 30 - 3 2 2 6 1 1 0.7 0.8 1.3 1.2 0.7 Redosing Intervals for Commonly Used Antimicrobials for for Antimicrobials Used Commonly for Intervals Redosing 5.4 Function (hours)* Function Life in Adults with Normal Renal Renal Normal Adults with in Life SURGICAL PROPHYLAXIS - Half

Prophylaxis Surgical

80mg/kg

75mg/kg weight 9 mos: - 6mg/kg - 30mg/kg 30mg/kg 50mg/kg 40mg/kg 10mg/kg 10mg/kg 15mg/kg 50mg/kg 50 Dose for Pediatrics for Dose Infants 2 Infants

2.5mg/kg based on dosing on dosing based 2.5mg/kg Children >9 mos and <40kg: mos >9 Children

50mg/kg (ampicillin component) (ampicillin 50mg/kg

azobactam

Sulbactam

Antibiotic (piperacillin component) (piperacillin Piperacillin Metronidazole Fluconazole Gentamicin*** Clindamycin Ciprofloxacin Cefoxitin Ceftriaxone Cefuroxime Aztreonam Cefazolin Ampicillin Ampicillin Recommended Doses for Pediatric Patients (beyond the Newborn Period) and Period) Newborn the (beyond Patients Pediatric for Doses Recommended National Antibiotic Guidelines

204 A)are / s actual body s actual based doses unless based doses unless -

NA NA NA NA

ned as follows: DW = IBW + 0.4 (actual =0.4 DW + (actual IBW ned asfollows:

3 - 8 3 10 - - - 4 2 6 0.8

SURGICAL PROPHYLAXIS r long procedures, redosing during surgery is recommended at an interval of an interval at is recommended surgery during redosing long procedures, r )used fo

Cefoxitin or

Cefazolin 15mg/kg 20mg/kg 15mg/kg 15mg/kg 100mg/kg life (e.g.,

life of the agent in patients with normal renal function. Recommended redosing intervals marked as “not applicable” (N applicable” “not as marked intervals redosing Recommended function. renal normal with patients in of the agent life - for surgical antibiotic prophylaxis should be limited to a single dose given preoperatively. Dosing is based on the patient’ the based on is Dosing preoperatively. dose given a to single limited be should prophylaxis antibiotic surgical for

Oral Antibiotics for Colorectal Surgery in Conjunction with Mechanical Bowel Preparation Bowel Mechanical with Conjunction Surgery in for Colorectal Antibiotics Oral

e length; for unusually long procedures, redosing may be needed. be may redosing procedures, long unusually for e length;

IBW)

– Metronidazole Neomycin Erythromycin base Erythromycin Vancomycin

*** In general, GentamicinIn general, *** based on typical cas on typical based candetermi be (DW) weight dosing the (IBW), bodyweight above ideal 20% than more is bodyweight actual If weight. wt. approximately two times the half the times two approximately

exceed the usual adult dose. Pediatric patients weighing more than 40 kg should receive weight receive kg 40 should more than weighing patients Pediatric dose. adult usual exceed the not dose should pediatric maximum The * National Antibiotic Guidelines

the dose or daily dose exceeds the recommended adult dose. adult recommended the dose exceeds daily or dose the half short a with For antimicrobials ** 205

guidelines/en/. guidelines/en/.

627. o Antimicrobial Therapy Therapy o Antimicrobial - prevention - ssi

c/ 3. 90. 2014; 35(6): 605- 35(6): 2014;

2015:883 Hill Graw Mc edition 13th ,

SURGICAL PROPHYLAXIS

ommendations for Adult Inpatients. Available at: at: Available Inpatients. Adult for ommendations Rec Treatment 2016.

ntrol and Prevention and Prevention ntrol Co Disease for Centers Committee. Advisory Practices Control Infection Healthcare al; et DW, Bratzler UmscheidCA, SI, Torres - - 2008 Apr;179(4):1379 J Urol. prophylaxis. antimicrobial surgery on urologic statement policy Best practice al. et Jr1, JS lf 0.1001/jamasurg.2017.0904. 2017. doi:1 3, May online Published JAMA Surg. 2017. infection, site surgical of prevention the for guideline 2016. 2016. 14 November Accessed http://www.hopkinsmedicine.org/amp/guidelines/antibiotic_guidelines.pdf Katzung BG, Masters SB, Trever AJ editors. Basic and Clinical Pharmacology and Clinical Basic editors. AJ Trever SB, Masters BG, Katzung Gilbert DN, Chambers HF, Eliopoulis GM, Saag MS, Pavia AT, Black DB, Freedman DO, Kim K, Schwartz BS editors. Sanford Guide t Guide Sanford editors. BS Schwartz Kim K, DO, Freedman DB, AT, Black Pavia GM, MS, Saag Eliopoulis HF, DN, Chambers Gilbert Report 2015 Annual Program Surveillance Resistance Antimicrobial Medicine. Tropical for Institute Research 2008. SIGN; Edinburgh: surgery. in prophylaxis Antibiotic (SIGN). Network Guidelines Intercollegiate Scottish Wo www.who.int/gps at: Available Infections. Site Surgical of Prevention on the Guidelines 2016 Global Organization Health World 2015 Organization; Health World Geneva: infections. peripartum of maternal treatment and prevention for recommendations WHO Berrios National Antibiotic Guidelines

REFERENCES Epidemiol Hospital Control Infect Surgery. in Prophylaxis Antimicrobial for Guidelines Practice Clinical al. et DJ, Anderson 2015- Guidelines Antibiotic 201 70:195, Pharm Syst Health J Am Surgery. in Prophylaxis Antimicrobial for Guidelines Practice Clinical et al. DW, Bratzler

206

38°C 38°C e following e following is not is

Cefotaxime neonate is not jaundiced. not is neonate Comments if

specific conditions are based are conditions specific inical findings in the history, history, in the findings inical who have bacteriuria and fever > and fever bacteriuria have who

Ceftriaxone If there are signs of sepsis, treat as neonatal neonatal as treat sepsis, of signs are there If Early culture. basedon therapy Adjust sepsis. transmission. maternal to due usually is onset Use the and available

q24h the sensitivity pattern of a of pattern sensitivity the Once years. two the past

q24h q24h

Dose 10mg/kg Daily dose Daily - 200 mg/kg/day q6h 200 mg/kg/day 7.5mg/kg 7.5mg/kg - 50mg/kg/dose 8h 50mg/kg/dose 7.5 50mg/kg/dose q12h 50mg/kg/dose q12h 50mg/kg/dose 100

2000g - Weight Weight >2000g <1200g >1200g <1200g Regimen 1200

URINARY TRACT INFECTIONS URINARY

<7d >7d >7d ≤7d ≤7d Age Age 4 weeks - >4 weeks >4 0 and local patterns of drug resistance reported for reported resistance of drug patterns and local

Cefotaxime <2 mos mos <2 old: PLUS Amikacin effectiveness

IONS cost

- pathogen selected for treatments antimicrobial recommended The following evaluation. diagnostic n may present with any or all of the following symptoms of of symptoms of the following any or all with present n may and childre infants where involvement bladder urinary indicates that ondition that indicates renal parenchymal involvement where infants and children may present with fever with any or all of all th any or with fever with present may and children infants where involvement parenchymal renal indicates that ondition

and

c ,

Infection in Children in Infection condition

Etiology ary Tract Tract ary , Group B B Group , Enterococcus Streptococcus E. coli,Klebsiella, Enterobacter, Acute cystitis: Acute symptoms. or signs havesystemic no usually Patients urine. and malodorous incontinence, pain, suprapubic frequency, urgency, dysuria, symptoms: abdominal, back, or flank pain; malaise; nausea; vomiting; and, occasionally, diarrhea. Infants and children children and Infants diarrhea. occasionally, and, nausea; vomiting; malaise; pain; or flank back, abdominal, symptoms: pyelonephritis. acute up for be worked should bacteriuria and pain/tenderness loin with <38°C fever with presenting those OR Acute Uncomplicated UTI Uncomplicated Acute pyelonephritis: Acute specific pathogen has been obtained from the urine culture requested, antibiotic therapy may be adjusted accordingly. adjusted be may therapy antibiotic requested, culture urine the from been obtained has pathogen specific physical examination physical , efficacy clinical of evidence on Urin cl accompaniedby culture urine in pathogen single a of presence by the is defined (UTI) Infection Tract Urinary children, In

URINARY TRACTINFECT National Antibiotic Guidelines

207

up. - of antibiotic antibiotic of IV therapy. therapy. IV

to due to poor poor due to

NOT be used for for used be NOT

UTI in children <6 <6 children in UTI d

st are not useful if if useful not are Comments shoul

is suspected. is ultrasoundand abnormal, if referto has been afebrile for 24h and able to to 24h and able for has been afebrile al medications. Obtain renal ultrasound ultrasound renal Obtain medications. al

old months apediatric nephrologist for further work Cephalosporins Enterococcus Nitrofurantoin pyelonephritis and renal sepsis and renal pyelonephritis concentrations. serum on antibiotics review Cochrane a to According children in infection tract urinary lower for datato insufficient are “there 2012), (August type on which question the answer treat to effective most is duration and which that found review This UTI. lower symptomatic Oral therapy is equally effective effective equally is therapy Oral children ill seriously for preferred is therapy IV therapy. oral take cannot who those and for prevent to necessary is therapy antibiotic Early once the therapy oral to Switch damage. renal patient take or take 1 for 6 weeks within

- 75- q24h

q12h

)

div div PO Nitrofurantoin

7.5mg/kg Cefuroxime

ay OR q6h (ampicillin q6h (ampicillin

div

). ).

/d mg/kg 30 s min 15

(amoxicillin component) or 25 or component) (amoxicillin 2000g ay mg/d 400 q6h (Max: - 48 hours. Antibiotic coverage should

- 48h. - div div Regimen 500mg PO q12h OR PO 500mg q8h

1200 : amoxiclav

ay - /day 200mg/kg div

250- 12years: 20- 12years:

400mg/5mL or 20mg/5mL the using Co ays - ay d URINARY TRACT INFECTIONS URINARY 100- ay 6 g/d dose: (Max

14 - q12h

7mg/kg/d q8h use adult dose. use adult -

s expecteds in 24

>7d >3mos div

ay) 2g/d q8h (Max: 875mg div

14 days14 /d 40mg/kg Cefuroxime - ay ulbactam s

- 10 500- 20-

(IV/PO): 7 : assessed still if unwellin 24

- Cefuroxime

>40 kg: >40 /d 45mg/kg <40 kg: <40 Parenteral: Adolescent: Adolescent: (only for cystitis) 5 For those >40 kg, >40 those For OR /day 150mg/kg component) IM or IV infusion over 10- over or IV infusion IM component) Ampicillin Duration Duration Oral: : 18 years to months >2 Clinicalresponse i be re

Etiology

E. coli,Klebsiella, Enterobacter, Citrobacter National Antibiotic Guidelines

208 are are in

- e single than

instead of of instead

Ceftriaxone Cephalosporins Comments

instead of of instead . culture

Ceftazidime

the the of

Cefotaxime results day antibiotic treatment is more likely to more likely is treatment day antibiotic - suspected, use suspected, 10 eliminate bacteria fromthe urin dose treatments.” Use Pseudomonas If patients. jaundiced on depending antibiotics Adjust . Cefotaxime the . Enterococcus against active not

pediatric urologist. pediatric

ayq24h ay q24h ay d ose ose ayq24h ayq24h ayq24h ayq24h / d ayq24h ayq24h d d d d d / / / /

ailyd ailyd D D 10mg/kg 75mg/kg/ - - 50mg/kg/d 50mg/kg/ nephrologist and nephrologist 7.5mg/kg 7.5mg/kg 7.5mg/kg mg/kg 10

50 7.5

)

100 mg/kg/dose q24h 100 mg/kg/dose ay -

50 g/d pediatric

: 22.5mg/kg/day or q8h (Max: 24 (Max: q8h or 22.5mg/kg/day a - 2000g 2000g

15 - - : Weight Weight <2000g >2000g <1200g >2000g >2000g Regimen 1200 1200

URINARY TRACT INFECTIONS URINARY

Infants & children & Infants depending on response. depending

7d 7d <7d >7d >7d < < >7d >7d Age Age 4 weeks ays - Infants & children & Infants

d 0

14 -

morbids - Duration AND/OR Amikacin Ceftriaxone PLUS

orwith co

related -

catheter

Etiology Enterobacteriaceae, P. aeruginosa, aeruginosa, P. Enterobacteriaceae, Enterococcus These patients require a referral to a pediatric infectious disease specialist, specialist, disease infectious a pediatric to a referral require These patients UTI, recurrent recurrent UTI,

National Antibiotic Guidelines

209

- for

effective effective - treatment

trimoxazole - specialist or or specialist

and

are considered as considered are if MRSA is suspected. Refer Refer suspected. is MRSA if

Comments

ampicillin for drainage. for

treatment is the most cost is most the treatment

should bebased oncurrent antimicrobial

Vancomycin specialist are not recommended for empiric for recommended not are to resistance of prevalence high the given agents. these Fluoroquinolones propensity of because drugs reserved Empiric - notpre culture urine and urinalysis approach; requisites. Amoxicillin drug for selection (e.g., damage collateral Use Use to Choice patternsusceptibility in theinstitution. disease an to infectious Refer nephrologist

) ay Note: [

not locally notlocally

100 mg/d 200mg bid x 7 bid 200mg

) OR ays ) d

ay ay Max: (

120ml) water 120ml) Cefixime

(100mg bid) is bid) (100mg

pregnant, otherwise healthy premenopausal female premenopausal healthy otherwise pregnant, ) OR ays

ay d 100mg qid x 5 x qid 100mg 2 div doses

ays - PLUS 4 oz (or 90- 4 oz(or d

q8h (Max: 24 g/d q8h (Max: q6h IV q8h (Max: 6 g/d q8h (Max: IV

div div Regimen macrocrystals POin 1 div

/day ay ay ay d 625mg bid x 7 bid 625mg /d macrocrystals URINARY TRACT INFECTIONS URINARY

250mg bid x 7 x bid 250mg mg/kg 150 2mg/kg/d - - monohydrate/ monohydrate/ 1

200mg/kg 22.5mg/kg/ - 3g x 1 dose sachet in 3- in dose sachet x1 3g 100 amoxiclav -

15 24g/d IV (Max: q24h 15mg/kg

100 ] Co

Cefuroxime

Nitrofurantoin

OR line: line:

ays st nd 2 available. d Nitrofurantoin Nitrofurantoin 1 Fosfomycin Oxacillin Amikacin Ceftazidime Amikacin Acute dysuria, frequency, urgency in a non- a in urgency frequency, Acutedysuria,

n Adults n i

saprophyticus UTI

S. Etiology 90%), 90%), - acquired -

(75

15%) - (5 Acute uncomplicated cystitis (AUC): cystitis uncomplicated Acute E. coli Uncomplicated UTI Uncomplicated Urinary Tract Infection Infection Tract Urinary

Prophylaxis for Recurrent UTI Recurrent for Prophylaxis Hospital Perinephric abscess Perinephric aureus S. Enterobacteriaceae, National Antibiotic Guidelines

210 f

day - - ost , p ,

not recommended. not

en in patients not not patients in en stain, culture and culture stain,

Comments Gram presenceof possible complicatingconditions signs of sepsis of signs medications/hydration oral totake inability compliance re concern

4. 1. 2. 3. treatment urine culture is culture urine treatment d imaging not not and imaging evaluation urologic Routine I 72 hr. after febrile still unless recommended treatment to responding clinically resistant bacteria); but are efficacious in in 3 efficacious but are bacteria); resistant for same the is atment tre The regimens. AUC. with women elderly healthy otherwise analysis, Urine Blood be done. should tests susceptibility septic. done unless routinely not are cultures antibiotic dose of IV/IM initial giving Consider regim by oral followed hospitalization. requiring regimen: hospitalization/parenteral for Indications

x OR

750mg 750mg OR

400 mg daily400 mg 400mg q12h 400mg

(when GS shows shows GS (when Levofloxacin

15mg/kg q24h 15mg/kg ays Cefixime

OR d

48 hr. and able to take oral takeoral and able to hr. 48

ays Ciprofloxacin 8h

d ays Amikacin OR

10 d 1.5g q6h (when GS shows gram shows GS (when q6h 1.5g

OR Ampicillin

Regimen 4.5g q6- 4.5g - 625 mg tid x 14 tid 625 mg q24h 2g q24h - - 2.25

1 URINARY TRACT INFECTIONS URINARY resistant organisms: resistant sulbactam - 500mg bid x 7- bid 500mg 750mg 500 x 14 bid mg amoxiclav - 5mg/kg+/ q24h

250- -

3 tazobactam Co 1g q24h (if ESBL rate >10%) >10%) ESBL rate q24h (if 1g -

Ampicillin Ceftriaxone

ays d OR cocci) cocci)

flank pain, costovertebral angle tenderness, nausea/vomiting, with or without signs or symptoms of cystitis in an in cystitis of symptoms signs or or without with nausea/vomiting, angle tenderness, costovertebral pain, flank Cefuroxime Ciprofloxacin , x 5

ays

line: d line:

nd st 2 Gram+ cocci) Gram+ Parenteral: Gentamicin Parenteral: Oral: Oral: daily Levofloxacin 14 positive 1 - multidrug for Reserved Piperacillin Switch to oral regimen once afebrile for 24- for once afebrile regimen oral to Switch available. result once culture regimen antibiotic Tailor medicines. Ertapenem Fever

is predominant, is predominant,

Etiology E. coli As for AUC, As for Enterobacteriaceae asother aswell Acute uncomplicated pyelonephritis uncomplicated Acute female premenopausal healthy otherwise

National Antibiotic Guidelines

211 ay regimen is is ayregimen d

ic abnormalities in: abnormalities ic guided. A 7- A guided. Comments

stain of unspun urine (>2 (>2 unspun urine of stain

Gram

period

recommended. microorganisms/oif) in two consecutive consecutive in two microorganisms/oif) be used to samples may urine midstream treatment When indicated, ASB. for screen - culture be should Radiologic or imaging studies not routinely routinely not studies imaging or Radiologic urolog for Screen indicated. Antibiotics do not decrease asymptomatic decrease asymptomatic do not Antibiotics subsequent prevent or bacteriuria screening The optimal UTI. of development not culture urine If culture. a urine is test a or wbc/hpf) (>10 pyuria significant possible, positive

nth mo

in:

except

persons with urologic urologic with persons abnormalities persons with indwelling indwelling with persons catheter urinary HIV with persons

• • •

Regimen

URINARY TRACT INFECTIONS URINARY

pregnant women women pregnant persons with spinal cord injury cord spinal with persons patients elderly patients with diabetes mellitus diabetes with patients persons undergoing invasive genitourinary tract procedures (likely to to (likely procedures tract genitourinary invasive undergoing persons bleeding) cause mucosal non- pregnant women pregnant adults healthy

• • • • • UTI uncomplicated for episode as acute Treat No screening and treatment recommended recommended treatment and screening No • TREATNOT ASB in: DO •

catch voided urine with one bacterial species in a quantitative count ≥100,000 cfu/mL cfu/mL ≥100,000 count quantitative a in species bacterial one with urine voided catch

Etiology

single catheterized urine specimen with one bacterial species in a quantitative count ≥100 cfu/mL; pyuria, odor and color of of andcolor odor pyuria, cfu/mL; ≥100 count quantitative a in species bacterial one with specimen urine catheterized a single women: and men both In In women: 2 consecutive voided urine specimens with the same organism in quantitative counts ≥100,000 cfu/mL cfu/mL ≥100,000 counts quantitative in organism same the with specimens urine voided consecutive 2 women: In - clean single, men: In urine not relevant to decision to treat. to to decision relevant not urine

≥3 episodes of acute uncomplicated cystitis documented by urine culture in 1 year or ≥ 2 episodes in a 6- a in 2episodes ≥ or year 1 in culture urine by documented cystitis uncomplicated acute of episodes ≥3 Similar to cystitis Recurrent UTI Women UTI in Recurrent Similar to acute uncomplicated uncomplicated acute to Similar cystitis • • • Diagnosis: Diagnosis: Asymptomatic bacteriuria (ASB) bacteriuria Asymptomatic UTI. of and symptoms signs without urine the in bacteria of Presence National Antibiotic Guidelines

212 - , , Co -

Proteus term labor trimester to 32 to trimester

treatment. -

)

splitting bacteria ( bacteria splitting from the 2

Comments 2 weeks post 2 weeks Providencia especially during the first and first the during especially

- of pre risk those at in

- urea with on Nitrofurantoin History of acute pyelonephritis acute of History History of or symptoms suggestive of of urolithiasis suggestive symptoms of or History Obstructive symptoms Obstructive Gross hematuria/persistent microscopic microscopic hematuria/persistent Gross hematuria UTI of childhood History Elevated serum creatinine serum Elevated Infecti , Morganella No response to treatment to response No

• • • of becauserisk of trimesters third Co Avoid and kernicterus. teratogenicity amoxiclav necrotizing neonatal for potential of because Use Use only, weeks if possible,because of potential for defects birth and hemolytic anemia. Avoid trimoxazole • • • • • 100 mg 100 mg - 50

100 x 1 mg

50-

OR vaginal estriol nightly nightly estriol vaginal ays d Nitrofurantoin treatment urine must be submitted for culture and susceptibility; adjust adjust and susceptibility; culture for be submitted must urine treatment

Nitrofurantoin

OR ays Regimen

d 40/200mg ays

d 400mg 400mg ays d

days URINARY TRACT INFECTIONS URINARY dose sachet - intra women, menopausal

- weekly for at least 8 months. at least for weekly

80/200- OR trimoxazole 12 mos (continuous prophylaxis) prophylaxis) 12 (continuous mos 320/1600mg x 1 dose at symptom onset symptom 320/1600mg dose x 1 at 40- -

- macrocrystals 100mg qid x 7 qid 100mg macrocrystals 625mg bid x 7 bid 625mg

- single 3g antibiotic immediately, but pre immediately, antibiotic 500mg 500mg x7 bid Co

coital) 500mg qid x 7 qid 500mg -

200mg bid x7 200mg

Lactobacilli is not recommended. Cranberry juice and products and products juice Cranberry recommended. isnot Lactobacilli

empiric amoxiclav trimoxazole trimoxazole - - - - twice then 2 weeks

Others: Co dose (post Fosfomycin Co x Co Cefixime Nitrofurantoin can be used. For post For can be used. Start 1- culture urine with a repeat bacteriuria of clearance Document accordingly. treatment Cefalexin Cefuroxime Prophylaxis: at bedtimefor 6

Etiology mplicated Cystitis Pregnancy in Cystitis mplicated (70%), Other Enterobacteriaceae, Group B B Group Enterobacteriaceae, Streptococcus Acute Unco Acute E. coli UTI in Pregnancy in UTI

National Antibiotic Guidelines

213

and

are are

term labor and and labor term - pre week, preferably preferably week,

Nitrofurantoin th Comments treatment essential. Follow is stainand culture/susceptibility -

and 17

th Fluoroquinolones

Gram . amoxiclav with monthly urineculture until delivery. - Screen all pregnant women for ASB once ASB for women pregnant all Screen otherindications aslisted above for acute uncomplicatedpyelonephritis. Switch tooral regimenwhen afebrile x48 hrs. and based on culture/susceptibilityresult. Test of cure with a culture urine post up of use for caveats Note Co 9 the between enterocolitis. contraindicated. Urinalysis, shouldtests be done. Blood cultures are not routinelydone unless septic. Ultrasound of KUB respondfor treatment. reserved failure to to Indications for admission: ays d - 500mg 500mg ram g on

shows shows

q8h 2g

Cefuroxime

ays d OR

ays d 200mg bid to complete 14 complete to 200mg bid

Ceftazidime

1.5g q6h (when GS (when q6h 1.5g OR

Regimen Cefixime

OR URINARY TRACT INFECTIONS URINARY q24h 2g - 1 Sulbactam ays - 14 complete to 625mg bid d 500mg to complete 14 complete to 500mg

ays

Ampicillin Ceftriaxone cocci) cocci) amoxiclav - Cefalexin

Co line:

line:

st nd

2 positive Oral: Duration: OR Parenteral: 1 14 complete to bid weight birth and low UTI symptomatic of risks the to reduce ASB Treat based is of Choice regimen infants. and preterm neonates result. test culture/susceptibility n Pregnancy n

n Pregnancy n i

Etiology

Similar to acute cystitis in in cystitis acute to Similar pregnancy Asymptomatic Bacteriuria (ASB) (ASB) Bacteriuria Asymptomatic Similar to acute cystitis in in cystitis acute to Similar pregnancy Acute Pyelonephritis Pyelonephritis Acute National Antibiotic Guidelines

214 -

asimaging treatment treatment

- 2 weeks post underlying underlying -

stain,culture and

week post week

Gram ester until delivery. until ester Comments presence of an of presence ; week. The standard urine urine The standard week.

p urine culture 1- culture p urine u - and monitor every trim every and monitor treatment. Referral toa specialist often warranted. during the 16 the during of choice. test the is culture/susceptibility Do ASBscreening. for inadequate is Urinalysis follow Alwaysobtain urine for priorsusceptibility to of start treatment, and adjustregimen as neededbased on culture result. Ancillarydiagnostic testssuch of theurinary tract (CTor ultrasound)are often warranted. Repeaturine culture 1

OR 3g

daily daily ays d q24h 1g

750mg 750mg -

5mg/kg q24h uations, such as in catheterized patients. catheterized suchas in uations, - ays 500 Fosfomycin 3

d OR Ertapenem Ertapenem

500mg bid x 7 bid 500mg

OR ays d 8h

Gentamicin Gentamicin

Levofloxacin Levofloxacin

625mg bid x 625mg7 bid OR OR

- q6 4.5g Cefuroxime

functional or anatomic abnormalities of the urinary tract urinary ofthe abnormalities anatomic or functional

1g bid Regimen OR

or - 2.25 amoxiclav ays - spectrumantibiotic forseverely ill patients,and - d 750mg bid 750mg

- URINARY TRACT INFECTIONS URINARY Co

15mg/kg q24h 15mg/kg

500 any condition that increases the risk of persistent infection and/or treatment failure. failure. treatment and/or infection persistent of risk the increases that any condition OR 625mg tid 625mgtid

1g q8h q8h 1g ays tazobactam tazobactam

- d macrocrystals 100mg qid x 7 qid 100mg macrocrystals

14 - Amikacin

500mg qid x 7 qid 500mg

amoxiclav - dose sachet dose Ciprofloxacin Ciprofloxacin

Co Piperacillin Meropenem

Start withparenteral broad Parenteral: - single : 7 : Duration Oral: OR OR then switch to anoral regimen/ deescalate when there clinical is improvement. Cefalexin Nitrofurantoin OR

–

P. aeruginosa

Etiology E. coli), off for significant bacteriuria in cUTI is 100,000 cfu/mL; may be lower in certain clinical sit clinical certain in may lower be cfu/mL; is100,000 cUTI in bacteriuria significant for off - ore varied and may include drug drug include may and varied ore M - ESBL (e.g., organisms resistant producing ; or mechanisms defense host with interferes that disease Cut Complicated UTI Complicated of the setting in occurring symptoms clinical plus bacteriuria Significant and enterococci

National Antibiotic Guidelines

215

; if; still antibiotics is is antibiotics

empiric stain and culture/ stain

s and severity of illness. of s and severity factors (ex. indwelling indwelling (ex. factors Comments Choice of Choice of

specific depending on the local local dependingon the specific remove indwelling catheter indwelling remove - Elimination of risk clear to adequate usually catheter) urinary candiduria. candiduria if CT kidneys or of ultrasound Do patients. immunocompromised in persists Pyuria, odorous or cloudy urine alone is not an not is alone cloudy urine or odorous Pyuria, Whenever antibiotics. initiating for indication possible, institution pattern susceptibility ew catheter and catheter new a with replace needed, Gramfor urine obtain susceptibility test priorto initiatingtreatment. if culture for urine obtain NOT DO asymptomatic.

Ceftazidime

2g q6h IV - 1

12h

procedure. Treat also Treat procedure. 1g IV q24h IV 1g - Cephalosporin

4.g IV q8h IV 4.g

- q8 IV 2g - gen. gen. Ampicillin

1 750mg IV/PO q24h IV/PO 750mg rd and post x 2 weeks

Ertapenem

Regimen daily tazobactam OR -

Cefepime

URINARY TRACT INFECTIONS URINARY OR Levofloxacin

: h 8 with no previous 3 previous no with use

400mg PO PO 400mg - Piperacillin

- pre mg/kg) (6 400mg 200 1g IV q IV 1g

When undergoing urologic procedure, treat with oral oral with treat procedure, urologic undergoing When OR

15mg/kg IVq24h 15mg/kg igns and symptoms; 10 - of and symptoms; signs resolution 7 days w/ prompt

q8h IV 2g - For susceptible enterococcal infection: enterococcal susceptible For 1 Duration: Duration: Fluconazole Fluoroquinolone indicated treatment No Exceptions: Fluconazole patients). neutropenic (e.g., dissemination for risk at those Amikacin Meropenem infections mild For days of antibiotic treatment for patients with delayed response delayed with patients for treatment antibiotic days of

–

P. aeruginosa

Etiology

E. coli), Associated UTI (CAUTI) UTI Associated - , w/ prior surgical surgical prior w/ , device urinary indwelling w/ diabetic, female, elderly, in the often more colonization; represents always almost urine in sp.

ore varied and may include drug drug include may and varied ore albicans Symptomatic Cystitis Symptomatic agent: etiologic common Most

tioncoloniza from infection.in differentiating helpful not pyuria of and presence colony count antibiotics; and taking procedure, Asymptomatic Candiduria Asymptomatic Candida Candiduria - ESBL (e.g., organisms resistant producing Catheter M and enterococci National Antibiotic Guidelines

216 - cannot

trimoxazole - resistance to Co to resistance

Co treatment despite its high its despite treatment Comments

E.coli

is high sohigh is

empiric

) Caveat: line

st oodstream infection is present. is infection oodstream be 1 be prostatic concentration. prostatic culture. trimoxazole relieve to intervention surgical Consider If ball). fungus (e.g., any if obstruction if as treat suspected, disease disseminated bl and urine urinalysis cultures, blood CBC, Do

AmB ): tazobactam AmB

2g IV2g q4h; - Levofloxacin ):

OR glabrata

C. glabrata Piperacillin or or

Ampicillin

OR ays

ays d

7 bid bid 7 C.krusei C.krusei ( ( x 1-

x 1- (if ampicillin resistant) Regimen x 2 wks.

q12h daily Candida

160/800mg

URINARY TRACT INFECTIONS URINARY 500mg PO or 400mg IV bid bid 400mg IV or PO 500mg

/day 0.6mg/kg /day 0.6 mg/kg daily - - resistant resistant Candida resistant - 0.3 0.3 15mg/kg 200 mg PO PO 200 mg

trimoxazole -

8h 2 weeks; extend to 4 weeks if patient still symptomatic. still patient if weeks 4 to 2 weeks; extend

Co Ciprofloxacin

750mg IV/PO IV/PO 750mg line: line:

st nd If enterococcus is suspected/documented: is enterococcus If 1 500- Vancomycin q6- IV 4.5g : Duration For fluconazole For deoxycholate Fluconazole - fluconazole For deoxycholate 2

without risk of STD of risk without

C. titis (ABP)

Etiology

Prostatitis

Enterobacteriaceae, enterococci, enterococci, Enterobacteriaceae, aeruginosa Acute Bacterial Prosta Bacterial Acute Most cases of bacterial prostatitis are preceded by a urinary tract infection. infection. tract are precededurinary bya prostatitis bacterial casesof Most pathogens transmitted sexually due to (usually or urethritis stricture, urethral instrumentation, tract urinary factors: Risk Bacterial Bacterial Most common etiologic agent: agent: etiologic common Most albicans Pyelonephritis

National Antibiotic Guidelines

217

Consider genitourinary genitourinary Consider

not recommended for for recommended not

Comments week regimen. week - imaging. Drain abscess. Switch to oral oral to Switch abscess. Drain imaging. and has cleared once bacteremia regimen drained. is abscess Fluoroquinolones infection. gonococcal a 4 Consider cultures. blood Obtain

4.5g IVq8h

750mgIV q24h

750mg IV IV q24h 750mg

100mg bid bid 100mg

1g IV q8h (for (for q8h IV 1g

azobactam t - Levofloxacin

Levofloxacin

Doxycycline

OR Meropenem

PLUS PLUS OR

Regimen Piperacillin

OR daily daily URINARY TRACT INFECTIONS URINARY 2gIVq24h - 400mg IV q12h q12h IV 400mg 1

1g IV IV 1g 2g IV q12h IV 2g

1g IV q24h

500 PO mg

250mg IM x 1 dose 250mg IM

4 weeks 2 weeks

s) Cefepime Ceftriaxone Ertapenem

Ciprofloxacin

nth Ertapenem line: line: line:

line:

st nd nd st

: Duration OR 1 ) Pseudomonas 2 1 2 Ceftriaxone Azithromycin : Duration

., >3 mo

P. . i

Resistant Pathogens Resistant -

.g., bacteremia or suspected prostatic abscess) or prostatic suspected bacteremia .g., C. trachomatis C. e and

(

resistant resistant - and ESBL or AmpC beta beta AmpC or ESBL Etiology

producing producing ic BacterialProstatitis (CBP) Hallmark: relapsing UTI relapsing Hallmark: Chron ( symptoms urogenital Prolonged Enterobacteriaceae, enterococci, enterococci, Enterobacteriaceae, aeruginosa Enterobacteriaceae ABP Complicated - lactamase Enterobacteriaceae Pseudomonas, ABP with risk of Antibiotic Fluoroquinolone ABP with risk of STD risk with ABP gonorrhoeae N. National Antibiotic Guidelines

218

Comments ifall other options have failed.

rostatectomy treatintermittently for symptomaticepisodes; suppressive ortreatment; p

If refractory, options are: options refractory, If • • • 750 mg IV IV 750 mg

Levofloxacin

OR bid Regimen 160/800mg

URINARY TRACT INFECTIONS URINARY 400mg IV q12h IV 400mg

trimoxazole 6weeks - -

: 4 : Co Ciprofloxacin

line: line:

st nd 1 q24h 2 Duration

enterococci, enterococci,

Etiology

Enterobacteriaceae, aeruginosa

National Antibiotic Guidelines

219 52: e103 52:

tal. PIDSP Journal Journal PIDSP tal. Philippines. PIDSP J PIDSP Philippines. o Antimicrobial Therapy Therapy o Antimicrobial - Asia in infections tract urinary Tertiary Hospi Tertiary term Management. NICE guideline 54 guideline NICE Management. term 663 summary_1.pdf on September 7, 2016 7, September on summary_1.pdf -

Associated Urinary Tract Infection in Adults: 2009 International International 2009 Adults: in Infection Tract Urinary Associated

report - Infect Dis 2010;50 (5): 625- (5): 2010;50 Dis Infect annual

ARSP- Lim AT, Pagcatipunan MR, delos Reyes CA. Hand book of Pediatric Infectious Diseases Diseases Infectious Pediatric of book Hand CA. Reyes delos MR, AT, Pagcatipunan Lim URINARY TRACT INFECTIONS URINARY 123 clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a women: in and pyelonephritis cystitis acute uncomplicated of treatment the for guidelines practice clinical - Ong CC, Lazarte

- content/uploads/2016/06/2015

85. 16.

Lazarte CC, Bunyi MAC, Gallardo EE, Lim JG, Lobo JJ, Aguilar CY. Etiology of neonatal sepsis in five urban hospitals in the the in hospitals urban five in sepsis neonatal of Etiology CY. LoboAguilar LimJJ, JG, EE, Gallardo MAC, Bunyi CC, Lazarte

- http://arsp.com.ph/wp at Accessed BA, Byren I, Hoey CT. Treatment of Bacterial Prostatitis. Clin Infect Dis 2010; 50:1641. Dis Infect Clin Prostatitis. Bacterial of Treatment CT. Hoey I, Byren BA, e120. 2016. 2016. 2016. Inc.; Therapy, Antimicrobial VA: 2016. 2011; Dis Infect Clin Diseases. Infectious and Microbiology for Society and European the America of Society Diseases Infectious by the update 2010 2012, 5th edition. Manila: Section of Infectious and Tropical Diseases; 2012. Diseases; Tropical and ofInfectious Section Manila: edition. 5th 2012, - 2010;11(1):10 - Clin America. of Society Diseases the Infectious from Guidelines Practice Clinical 75- 12(2): 2011; nice.org.uk/cg54 at on 7/13/15 accessed Pacific region. Journal of Infection (2011) 63, 114 - 63, (2011) of Infection Journal region. Pacific National Antibiotic Guidelines

REFERENCES Philippines Manila, Report, nual An 2015 Program Surveillance Resistance Antimicrobial Health. of Department Laboratory, Surveillance Resistance Antimicrobial al. International et KG, TM, Naber Hooton K, Gupta

Gilbert DN, Chambers HF, Eliopoulis GM, Saag MS, Pavia AT, Black DB, Freedman DO, Kim K, Schwartz BS editors. Sanford Guide t Guide Sanford editors. BS Schwartz Kim K, DO, Freedman DB, AT, Black Pavia GM, MS, Saag Eliopoulis HF, DN, Chambers Gilbert - Maramba ML, Gonzales SR, Gatchalian LC, Bravo Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, Prevention, and Treatment of Catheter of and Treatment Prevention, Diagnosis, et al. DD, Cardenas SF, Bradley TM, Hooton Bay AG, Anacleto F. Clinical and Laboratory Profile of Urinary Tract Infection Among Children at The Outpatient Clinic of A A of Clinic The Outpatient at Children Among Infection Tract Urinary of Profile and Laboratory F. Clinical Anacleto AG, Bay - Maramba National Institute for Health and Care Excellence. Urinary Tract infection in Children: Diagnosis, Treatment and Long- and Treatment Diagnosis, Children: in infection Tract Urinary Excellence. and Care for Health Institute National Lipsky Lipsky complicated of therapy antimicrobial appropriate and the epidemiology of review Consensus al. Y, et Carmeli D, Hoban P, Hsueh 220 ate last last ate Tropical Tropical

for

946. Term Management, 2007. Available at: at: Available 2007. Management, Term

URINARY TRACT INFECTIONS URINARY Children: Diagnosis, Treatment and Long- and Treatment Diagnosis, Children:

Tropical Medicine. Antimicrobial Resistance Surveillance Program 2014 Annual Report. Muntinlupa: Research Institute Research Institute Muntinlupa: Report. 2014 Annual Program Surveillance Resistance Antimicrobial Medicine. Tropical

for - 2012;86(10):940 Phys Family Am Children. and Young Infants Febrile on UTI in Guideline AAP Revised KB. erts http://guidance.nice.org.uk/cg54. Accessed on July 13, 2015. 13, on July Accessed http://guidance.nice.org.uk/cg54. 2013. Diseases; and Infectious Microbiology 2016 25, August updated Medicine; 2015. Medicine;

NICE Clinical Guidelines 54, Urinary Tract Infection in Infection Tract Urinary 54, Guidelines Clinical NICE ate. Quezon City: Philippine Society of of Society Philippine City: Quezon ate. Upd 2013 in Adults Infections Tract Urinary of Management and Diagnosis on the Guidelines Practice Clinical Philippine Institute Research UpToD and prognosis. imaging management, acute and young children: than one month older infants in infections tract Urinary Hoberman. N, Shaikh Rob National Antibiotic Guidelines

221

limited. -

4 days after the 4 daysafter

and are usually self usually and are

Comments DEC. Pain, inflammation, and inflammation, Pain, ually begins 2- begins ually DEC Fever, headache, malaise, myalgia myalgia malaise, headache, Fever,

first dose of doseof first Treatment of pregnant women should be should women pregnant of Treatment delivery. after until deferred individuals in contraindicated is Treatment diseases. kidney and cardiac severe with If patient is <2 years old, refer to specialist. refer years <2 old, is patient If : Localized adenitis, nodules, of tenderness filarial adult of due to death lymphangitis worms. Us : Systemic of death due to occur and hematuria 48 hours to few begin from Usually microfilariae. taking after Individual with asthma, seizure disorders or disorders seizure asthma, with Individual with should be treated malnutrition severe when treatment initiate not Do caution. asthma Treat attack. has asthma patient drugs. antifilarial taking before first

• • • • • • Precautions: Adverse Reactions Adverse

400 day FILARIASIS

3 doses

in Albendazole 6mg/kg body with

Regimen once annually for at least 5 years at least for annually once 3 doses (after meals) PLUS meals) 3 doses(after (DEC) in 6mg/kg div div 6mg/kg DOHPUBLIC HEALTH PROGRAMS DEC

g/kg div g/kgdiv 6m 400mg

DEC

should be given within 2 hours after a meal. a after 2 hours within be given should is free and only available at DOH Central office and government government and office Central DOH at and onlyavailable free is Day 1: Day 12: Day to 2 Day On Albendazole On Tablets treatment: DEC endemicareas. in facilities health in microfilariae for positive patients for Treatment Selective ais 12- test, diagnostic or rapid examination blood nocturnal mg tablet as single dose given as single tablet mg Mass Drug Administration for individuals 2 years old and old above years 2 individuals for Administration Drug Mass areas endemic established in all living Citrate Diethycarbamazine

E TREATMENT) Brugia Brugia , . These .

Etiology cases, these worms lead lead worms these cases, Wuchereria bancrofti Wuchereria Brugia timori and Brugia , malayi Lymphatic filariasis is caused by the iscausedby the filariasis Lymphatic worms Roundworms of the Filarioidea type. type. Filarioidea the of Roundworms worms occupy the lymphatic lymphatic occupy the worms nodes; lymph the including system, chronic in elephantiasis. of syndrome the to National Antibiotic Guidelines For more information regarding the mass drug administration of the program of the refer DOH, please the to website,www.doh.gov.ph. For patients (+) for microfilariae in nocturnal blood examination (NBE) or Immunochromatographic test(ICT) or Immunochromatographic (NBE) examination blood nocturnal in for microfilariae (+) patients For FILARIASIS (SELECTIV

222 Filariasis Elimination Program National

FILARIASIS

DOHPUBLIC HEALTH PROGRAMS

Department of Health.Guidelines forthe Implementation of the National Filariasis Elimination Program, 2009. Manila: National

Center for Disease Prevention and Control; 2009. REFERENCE National Antibiotic Guidelines

223

that

and

. Leprosy

omplication omplication checkups

s. treatment, provide the following steps: following the infectious. - monthly monthly is necessary e.g., is necessary take

Comments

en determined that a leprosy leprosy a that determined en possibly can have c can possibly Before the start of start the Before need other treatment other need egular treatment egular eprosy

R Take medication Take medication infection. curable a is and have regularly L will to ready always is or clinic center The health have any problems. they if see them

• • • Step 2: Determine Step dose level: therequired pediatric. or adult 3: Step other or members family the patient, the counseling: with orientation partner treatment non patient the renders When it has be it When needsMDT, patient required: MDT of the type Determine 1: Step paucibacillary (PB) or multibacillary (MB). : Give the first dose of treatment and treatment of dose first Give the 4: Step athome. treatment take to how explain bacilli leprosy kills the rapidly Treatment

LEPROSY every every 28

- -

1mg/kg BW mg 50 mg 50

100 mg 50 mg 50 2mg/kg BW 2mg/kg mg 50 mg 50

Daily: Days 2 Days Daily: Lapses in taking MDT MDT taking Lapses in

. Dapsone Clofazimine Dapsone Clofazimine day other Dapsone Clofazimine Dapsone Dapsone

Regimen 300 mg 150 mg 6 mg/kg BW 6 mg/kg BW y specialists at referral units. Lepra reactions may occur before, during, and after and after during, before, occur may Lepra reactions units. referral at y specialists

600 mg 450 mg 450 mg 10mg/kg BW BW 10mg/kg 450 mg

12 blister packs to be taken monthly within a within monthly be taken packs to blister 12 a within monthly packs be taken to 6 blister 50 mg 50 100 mg mg 50 mg 50

DOHPUBLIC HEALTH PROGRAMS Monthly: Day 1 Day Monthly: Dapsone Rifampicin Clofazimine Dapsone Duration: MDT taking Lapses in 18 of months. period maximum months <3 be should Rifampicin Dapsone Rifampicin Dapsone Duration: 9 of months period maximum month <1 be should Rifampicin Clofazimine Rifampicin Clofazimine

14 14 - -

≥15 ≥15 10 ≥15 <10 10

poor response to treatment is defined as a less than +1 reduction in average BI after 12 months of MBMDT. This This MBMDT. of 12 months after BI average in reduction +1 as than a less defined is treatment to response poor b taken be only may decision MB Adult PB Pedia PB Adult A of treatment. 12 months than need more +4+6) may of to (BI index bacillary average high a baseline with patient A Pedia MB Pedia

that affects affects that

Etiology

A chronic disease caused by caused disease chronic A leprae Mycobacterium the skin, peripheral nerves, upper upper nerves, peripheral skin, the mucosa and eyes, tract respiratory therapy bymultidrug curable is can it untreated When (MDT). and progressive permanent cause organs. affected the to damage National Antibiotic Guidelines

LEPROSY

224

Comments

LEPROSY

- free world. Operational Manual. Geneva: World Health Health World Geneva: Manual. Operational world. free

Regimen DOHPUBLIC HEALTH PROGRAMS

- leprosy a towards Accelerating 2020:

treatment. These complications should be detected and treated early. The treatment of leprosy should still be continued continued be still should leprosy of The treatment early. and treated be detected should These complications treatment. reactions. lepra during

2016.

Etiology anization; anization; Org

REFERENCES 2016. of Health; Department Manila: 2016. Procedures, of Manual Programme Control Leprosy National Health. of Department World Health Organization. Global Leprosy Strategy 2016– Leprosy Strategy Global Organization. Health World National Antibiotic Guidelines

225 or to -

is highly highly is Primaquine

withmilk or fat

AL nts less than 6 months months 6 than less nts or coconut milk, buko milk, coconut or Comments Lumefantrine gata gata to infa

, and cookies), particularly on particularly and , cookies), trationof the firstline drugs, then te are detected in blood films during during bloodfilms in detected te are upt transmission via anopheline anopheline via upttransmission

Advise patients to take to patients Advise ( food containing suman sa latik suman treatment. days of second and third the that Considering - enhanced byco is absorption its lipophilic, with levels blood ofLow fat. administration potentially could failure treatment resultant Repeat intake. fat inadequate from result event the dosage in ofthe first administration administration. one of hour within vomiting of AL give not Do or less than 5 kg. Do not give give Do kg. 5 not than less or medical past Obtain 1 year old. below infants before deficiency G6PD of histories and family

3 - 2 MALARIA

- dose 1 ays

give give

–

s PLUS Clindamycin ays tabbid for d d also be immediately reported to the Department of Health. of Department to the reported be immediately also (20mg/120mg) (20mg/120mg)

dose 6 q12h. PLUS ays

until d 6 doses 56 hour in

Regimen days div umefantrine (AL) umefantrine l 10mg salt/kg q8h x 7 salt/kg 10mg

PO –

eliminate the disease by 2030; thus, compliance to guidelines and treatment with highly effective effective highly with and treatment guidelines to compliance thus, by 2030; disease the eliminate DOHPUBLIC HEALTH PROGRAMS mg/tab) 0.25mg base/kgon dose 1 0.25mg mg/tab) dose 2 and dose 3 dose 2

(15 sulfate ays 10mg salt/kg q8h X 7 q8h X 10mg salt/kg d then Adult: 10mg/kg bid x 7 bid 10mg/kg Artemether

x 7 (Coartem) 20mg/120mg

Quinine :

: Quinine P.malariae AL

1, 1 tab followed by 1 tab after 8h; then 1 then 8h; after by 1 tab 1 tab followed 1, Primaquine or ay line: line:

11 months: 11 - st nd : 3 kg: >60 tabs adults For 2 and dose 2 q8h PLUS Children and Children 1 On d Pediatric Clindamycin Pediatric mos: <6 bid 10mg/kg 6 combination

Plasmodium falciparum falciparum Plasmodium

Etiology

malariae Plasmodium falciparum falciparum Plasmodium Uncomplicated National Antibiotic Guidelines

MALARIA to interr areas, endemic in residing patients for and, severe malaria prevent areto treatment antimalarial of The objectives aims to Program Malaria National The others. among vectors, adminis of end the until microscopy film blood daily with be monitored must treatment Response malaria to critical. are drugs parasi ofthe forms asexual when administered is drug line The second of treatment. start the 28th after day the until weekly must drugs line first with the parasitemia asexual of Recurrence period. specified this

226 or referral

. The normal The normal .

2 years of age of 2 years malaria shouldmalaria be done, precaution below. below. precaution - used as a pre strictly Comments Primaquine s administration. Do not give give not Do administration. deficiency. G6PD with patients to If referral is impossible, continue the the continue is impossible, referral If

ng facility lasts longer than 1 hour to to hour 1 than longer lasts facility ng . P.falciparum Doxycycline suppository i suppository

severe hyperpyrexia, e.g., convulsions, hypoglycemia, severe anemia, pulmonaryedema and respiratory failure, acuterenal failure,bleeding. AS initial the from time travel when drug diagnosi AS use The of point. referral next the 1 to limited is suppository younger administration of administration of units/gram 20.5 to is5.5 adults for level G6P be cannot G6PD status the If globin. hemo withhold required when documented Primaquine Primaquine See such as effects side for infants monitor Closely anemia, hemolytic , methemoglobinemia G6PDdeficiency in hemoglobinuria dysfunction. and renal neutropenia, Concomitant managementof complications of

(15 (15 MALARIA

- OR Clindamycin Artesunate Artesunate

ays

(15mg/tab) (15mg/tab) d . Shiftq12h. to Primaquine Primaquine PLUS

ays d

Primaquine

Diluted in 5mL D5W IV drip or D5W 5mL drip in IV Diluted 250mg qid x 250mg7 qid . if patient can tolerate oral oral tolerate can patient if PLUS

Regimen ays

d NaHCO3 (pediatric and adult). and (pediatric x 7 Tetracycline

20 kg: 3mg/kg per dose IV or IM or IM IV dose per 3mg/kg kg: 20 DOHPUBLIC HEALTH PROGRAMS 10mg salt/kg q8h x 7 salt/kg 10mg

OR dose 1 Infusion Dihydrochloride Quinine

2.4mg/kg/dose. Give 3 IV/IM doses IV/IM 3 Give 2.4mg/kg/dose. 3 tabs

ays

base/kg on dose 1 base/kg d - sulfate

/day /day 3mg/kg

IV or IM For children < Forchildren

Parenteral base/kg on base/kg

once patient can tolerate oral medicines AND medicines oral can tolerate patient once

: AS Quinine

powder dissolved in 5% 5% in dissolved powder : AL line line

nd st - 0.25mg For adults >60kg: adults For Doxycycline WHO2015) thigh; (anterior IM Adult: mg/tab) 0.25 mg 0.25 mg/tab) adult). and (pediatric medicines 3 s kg: >60 tab adults For 2 1 Pediatric: (AS) oral Adult x 7 bid 10mg/kg

Etiology

Plasmodium falciparum or P. or P. malariae falciparum Plasmodium

Plasmodium falciparum falciparum Plasmodium malariae Severe

National Antibiotic Guidelines

227

Primaquine and

Comments the of thirds two using one to

in adults. in

It may reduce the efficacy of oral contraceptive contraceptive oral of efficacy the reduce may It options. contraceptive other Consider pills. May cause photosensitivity. Avoid sun Avoid cause photosensitivity. May exposure. pressure. intracranial sed cause increa May or vision, blurred headache, for out Watch May cause autoimmune vision. in changes joint rash, fever, out for Watch reactions. or tiredness. pain, Diarrhea may occur. may Diarrhea Avoid during pregnancy unless benefit benefit unless pregnancy during Avoid alternatives. consider risks; outweighs Skin, nail, eye, tooth or gum discoloration discoloration gum or eye,tooth nail, Skin, occur. may

• • • • according to schedule for uncomplicated uncomplicated for schedule to according falciparum Doxycycline: using when Precautions • •

application of of application until the dose maintenance dose as initial at which medication oral can tolerate patient with treatment point,

MALARIA

- NaCl

ays d day 3 Tetracycline

once patient can tolerate once patient

OR AL

250 mg qid x 7 qid 250 mg ays d

, and 5 mg/kg on mg/kg and 5 ,

2 - Regimen

Shiftto oral days 1 Doxycycline

DOHPUBLIC HEALTH PROGRAMS OR

10mg/kg bid x 7 days bid 10mg/kg 10 mg/kg bid x 7 bid mg/kg 10 P.malariae

ays referral to hospital to referral or d - 10mg/kg on 10mg/kg in 500 mL D5W or 0.9 NaCl for 4h IV drip (total dose not (total 4h drip IV for 0.9 NaCl 500 or D5W in mL

15mg salt/kg IV drip for 4h in 10mL/kg D5W or 0.9 or 4h D5W in 10mL/kg for IV drip salt/kg 15mg x 7

10 mg salt/kg in IV drip for 4h as loading dose, then 10mg 10mg then dose, as 4h loading for IV drip in salt/kg mg 10

for pre : Clindamycin Clindamycin Clindamycin : ears

y : : ears suppository (pediatric) 10mg/kg (pediatric) suppository line: y /day /day g/kg

16 - nd 2 3m (infusion rate must not exceed 5mg/kg/h) as loading dose, then 10mg 10mg then dose, loading as not exceed 5mg/kg/h) must rate (infusion dose 4h for drip as maintenance q8h IV salt/kg PLUS Adult dose as maintenance q12h drip IV salt/kg 8 PLUS AS Chloroquine salt/kg 20mg Pediatric ≤7 for D5W IV drip or in kg 0.9NaCl salt/ 10mg then mg), exceed2,000 to dose. as maintenance q8h 4h

Plasmodium falciparum falciparum Plasmodium P. malariae P.

Etiology nd Neonatal nd Neonatal a Plasmodium falciparum Congenital Congenital National Antibiotic Guidelines

228 or

to the the

vivax relapse may may relapse

ivax

transmitted or or transmitted - deficiency. deficiency. - Comments 120mg because of the the of because 120mg 20- (see regimen for dosage). for regimen (see

should be taken with meals meals with taken be should

AL transmission, then v then transmission, transmission in the area where he/she where area the in transmission

ovale

ovale any of recent is no history re the if OR resides vivax with areas currently anyother to travels or vivax previous of has a history patient the If current the 30 months of within infection of history no is there and consultation documented resistance of chloroquine chloroquine of resistance documented areas. these in resistance If thepatient isa locally given is e patient th case, indigenous Chloroquine be entertained. There is currently no laboratory no laboratory currently There is entertained. be could which locally available procedure of phenotyping if except relapse diagnose Primaquine an on taken discomfort abdominal (causes Primaquine Do give not stomach). empty patients with G6PD with patients to travel recent of has a history patient the If is patient the New Papua Guinea, or Africa on started - 1 MALARIA

- , then, tablet tablet 2 dose 1 and - 1dose for

give give

PLUS – days1

s Primaquine q12h day 1 base/kg/dayx

PLUS with mild deficiency may deficiency mild with , 4 tabs followed by 4 followed tabs 4 day 1, 10mg/kgon

dose 6 dose

3 eek for 8 weeks. eek for 0.25mg those

56 hour 56 in 6 doses

Regimen in

once a w a once Chloroquine div 14 g on startin base/kg deficiency: DOHPUBLIC HEALTH PROGRAMS - Primaquine

days 1- dose 2 and dose 3 until 2 and dose 3 dose on PLUS

20mg/120mg

tablet 0.25mg- tablet

then

day3 (20mg/120mg) combination on combination (20mg/120mg) AL

: Pediatricand Adult: base/kg

: line: line:

st nd 2 14 days 14 Pediatric dose 2 q8h days 2- for 4 bid 8h, then tabs after tabs mg/kg 0.75 a dose of receive 1 5mg/kgon - 0.25mg G6PD with patients For Primaquine

Adult

Plasmodium vivax or ovale or P. vivax Plasmodium Etiology Uncomplicated Uncomplicated

National Antibiotic Guidelines

229

AS.

indication exists exists indication

Comments 120mg. appearance of parasitemia in in parasitemia of appearance . Lumefantrine 20- –

is given at 0.25mg/kgBW to start to start 0.25mg/kgBW given at is AL Papua New Guinea, Myanmar and Myanmar Papua Guinea, New

, - contra unless 14 species is done. These patients are also also are These patients done. is species

(children below 12 mos, pregnant or lactating lactating or mos, pregnant 12 below (children nursing the of status G6PD the where women Primaquine d1- on For Falciparum recrudescence (persistence of of (persistence recrudescence Falciparum For treatment) following parasites malaria asexual cause of alleged into investigation following and admitted is patient failure, treatment IV case with malaria asa severe treated vivax on started unknown). is infant

MALARIA

- day 3 PLUS and refers to infections resulting from activation of of activation from resulting infections to refers and ovale P. malaria) 45 mg/d) (do not (do not mg/d) 45 or (Max: 30– (Max:

based on previous treatment treatment based on previous , and 5 mg/kg BW on ,BW mg/kg 5 and 14 - or re persistence to refers Recrudescence unlikely. 2

day 1. days1- Regimen days 1 on DOHPUBLIC HEALTH PROGRAMS to start on start to 120mg oral in 6 doses within 3 days then 3 daysthen give doses6 within in oral 120mg 20-

10mg/kg BW for for BW 10mg/kg

ay 0.75mg/kg/d

is known to exist in nearby countries particularly in East Timor, Indonesia Timor, in East particularly countries nearby in exist to known is

Primaquine patient is G6PD deficient) is patient

vivax uncomplicated for regimen days(see 3 for vivax

Chloroquine with treated previously For Primaquine if give 0.25mg 0.25mg Chloroquine AL AL give records:

erant

tol -

rimaquine P o hypnozoites of of o hypnozoites and

Etiology -

, the patient is treated with Artemether with is treated patient the , of Chloroquine the start 28 days after is within parasitemia of recurrence If Plasmodium vivax or P. ovale or vivax Plasmodium with laboratory laboratory with

elapse refers to recurrence of of recurrence to refers elapse confirmation. parasitemia due t parasitemia vivax P. R is infection/diagnosis an initial daysof 28 within occurrence Its hypnozoites. case. as the same counted is It failure. treatment of an indication is it diagnosis initial days 28 the of within a patient Thailand. Thailand. vivax P. with associated is Relapse recrudescence. from be distinguished must Relapse Relapse Relapse Chloroquine National Antibiotic Guidelines

230

Comments malaria.

Management is similar to that of severe ofsevere to that similar is Management falciparum dose MALARIA

powder powder -

until AS

day 1 div 6 doses in 56 6 doses in div

Infusion

per dose IV or IM or IM IV dose per dose 2 and dose 3

once patient can tolerate oral oral can tolerate oncepatient ays 20mg/120mg BW

d then 20 mg/120 mg combination on day 1, on day 1, combination mg/120 mg 20 base/kg starting on starting base/kg ) as loading dose, then 10mg salt/kg salt/kg 10mg then dose, as loading ) Regimen 3mg/kg 3mg/kg

2.4 mg/kg/dose. Give for at least 24 hours. 24 hours. at least for Give mg/kg/dose. 2.4 . Diluted. in 5ml D5W IV drip or IM (anterior Lumefantrine - DOHPUBLIC HEALTH PROGRAMS Lumefantrine – our 5mg/kg/h 10mg/kg bid x 7 bid 10mg/kg dihydrochloride Quinine Lumefantrine - mg 0.25 tablet IVor IM –

dose 1 and dose 2 q8h 5% NaHCO3 5% Artemether r 4h q8h as maintenance dose. 4h q8h as r maintenance

15mg salt/kg IV drip for 4h in 10mL/kg D5W or 0.9 NaCl 0.9 or 10mL/kg D5W 4h in for drip IV salt/kg 15mg

Artemether

Parenteral Parenteral : : For children – <20kg Forchildren give give : rate infusion

10mg salt/kg in IV drip for 4h as loading dose, then 10mg salt/kg salt/kg 10mg then dose, 4h as loading for drip in IV salt/kg 10mg

Clindamycin Clindamycin Primaquine Artesunate Artemether –

16y: : : - s

line:

Max Max line:

<7y: 8y ( IV drip q12h as maintenance dose q12h as maintenance drip IV IV drip fo q12h st nd f patient can tolerate oral medications, shift to: shift medications, oral can tolerate patient f 6 Adult dissolved in in dissolved 2015) WHO thigh; 2 PLUS Adult Shift tooral Pediatric hour anddays2 3 for 4 bid 8h, then tabs by4 after tabs followed 4 tabs PLUS Pediatric 1 treatment days of three complete to medicines, I ovale

Etiology Plasmodium vivax or P. or vivax Plasmodium

Severe ovale P. or vivax Plasmodium

National Antibiotic Guidelines

231 P. is by PCR. by PCR. is

; and infrequently, P. and infrequently, ; during the entire period period entire the during

P. knowlesi knowlesi P. Comments

. Primaquine P. vivax even P. or

Withhold Withhold . pregnancy of Definite diagnosis for for diagnosis Definite for mistaken is usually it microscopy, By malariae malariae falciparum

5 14

- 56 dose PLUS MALARIA

- 3 , then, 14 until 2 days 1 - ion on day 1, day 1, on ion for

14 10mg/kg q8h x 7 10mg/kg days 1- days 1 /day div 6 doses in 6 doses in div

ays d dose 2 and dose 3 dose 2 and dose

bid for days 2 and 3 and days2 bid for

20mg/120mg

tarting on days 1- tarting then 0.25 base/kg 0.25 mg sulphate Quinine

20 mg/120 mg combinat mg/120 mg 20 (20mg/120mg) combination on day combination (20mg/120mg) base/kg starting on starting base/kg tablet 10 mg/kg 10 mg/kg tablet

Regimen hen 4 tabs base/kg s base/kg 10mg/kg bid x 7 bid 10mg/kg DOHPUBLIC HEALTH PROGRAMS Lumefantrine Lumefantrine Primaquine

– – Chloroquine Lumefantrine Lumefantrine Lumefantrine

- mg 0.25 tablet 0.25mg- : – – PLUS Adult dose 1 and dose 2 q8h dose 1 and dose tablet tablet Clindamycin

4 tabs after 8h, t 8h, after 4 tabs

Artemether Artemether day 3

and

: : give give

Primaquine Artemether Artemether

–

PLUS : : s q12h ays , 4 tabs followed by 4 tabs after 8h, then 4 tabs bid for days 2 - for bid 4 tabs 8h, then after by 4 tabs followed tabs 4 , 6 Adult Primaquine d Pediatric PLUS 1 Pediatric on mg/kg Pregnant: pregnancy: of trimester first the On Pediatric hour and 4 tabs Adult

and

P. malariae

and and P.malariae

Plasmodium Falciparum Plasmodium Etiology knowlesi with/ without

Plasmodium Falciparum Plasmodium Uncomplicated Uncomplicated Pregnant and Lactating Women Lactating and Pregnant Plasmodium vivax Plasmodium Plasmodium falciparum Plasmodium vivax Mixed Infections Mixed Plasmodium knowlesi Plasmodium Plasmodium National Antibiotic Guidelines

232 onlyif AL Primaquine

are secreted in in the secreted are Withhold Withhold

is contraindicated contraindicated is AL

2 weeks after delivery until until delivery 2 after weeks Comments

Primaquine

Plus is not available, give give not available, is Plus .

g and is not available. not is k Primaquine ide protection against malaria. against protection ide weeks after delivery in single dose at at dose single in delivery after weeks

Quinine ive ive 2 breast milk in amounts that are not harmful to to harmful are not that in amounts milk breast amounts to inand insufficient infant the prov / 0.75mg give give but pregnancy of period entire the during it G , Chloroquine ascertained. is status G6PD Quinine If on trimester is the 2nd and 3rd patient the uncomplicated for guidelines the to according P. falciparum. While during the first trimester, give it as the last as last give the it trimester, first the during 1st the womenduring pregnant for resort consent when informed patient’s with trimester Quinine MALARIA

- dose 1

assoon as

give give

–

PLUS s Lumefantrine – dose 6 q12h

Clindamycin

until 20mg/kg infused over 4h (in 500 4h (in over infused 20mg/kg

Artemether

56 hour 56 6 doses in Regimen 0.25mg/kg, single dose after 7 days7 of dose after single 0.25mg/kg, 0.25mg/kg, single dose on day 1 to the the day1 to dose on single 0.25mg/kg,

DOHPUBLIC HEALTH PROGRAMS dose 2 and dose 3 2 dose

4 hours as maintenance dose. dose. asmaintenance 4 hours then Primaquine Primaquine

10mg/kg IV bid; shift to oral oral to shift bid; IV 10mg/kg may be given div in div given be may

ADD Quinine Dihydrochloride Quinine ADD

ating: and dose 2 q8h Clindamycin 7 days. complete to dose same at the it tolerates patient Lact Pregnant: dose and 10mg/kg asloading saline) 0.9% or water dextrose 5% mL 2- over q8h infused Sulphate Quinine oral to shift meds, oral tolerate can already patient If dose the same 7 days at complete to q8h) (10mg/kg tothe regimen. above , Clindamycin On the second to the third trimester: third the second to the On 20mg/120mg Lactating: regimen above

Etiology Plasmodium Falciparum Plasmodium

Severe

National Antibiotic Guidelines

y 233

onlyif - 45 G6PD

mum of 30- of mum be non- be during the entire period period entire the during during the entire period period entire the during period entire the during it 2 weeks after deliver 2after weeks it

website DOH to the

Comments , refer, or a list of newborn screening screening a ofnewborn or list F Primaquine Primaquine Primaquine 0.75 mg/kg/ day mg/kg/ (maxi 0.75 - www.doh.gov.ph/newbornscreening

mg/d) for 14 days. for mg/d) Withhold Withhold give but pregnancy of Withhold Withhold delivery 2 after weeks it give but pregnancy of For 14 days. for mg/kg/day 0.25 at Primaquine give women, breastfeeding Withhold delivery 2 after weeks it give but pregnancy of at 0.5 their infant is confirmed to to confirmed is infant their coordinators deficient. http:// at 0.5 mg/kg/day for for 14 days. mg/kg/day 0.5 at

MALARIA

- to the the to day 1

, and 0.5 mg/kg on d3 mg/kg and 0.5 , , and 0.5 mg/kg on mg/kg and 0.5 , 2 2 - - days 1 days 1 day beginning day 1 to 14 to 14 to day 1 to day beginning to the above the regimen to Regimen 14 0.25mg/kg, single dose on single 0.25mg/kg, - day (mmax:30 per bodyweight 0.25mg/kg / 0.25mg/kg 150mg base/tab 2 tabs per week for 8 weeks for week per tabs 2 base/tab 150mg on 10mg/kg tab tab 10mg/kg on 10mg/kg tab

DOHPUBLIC HEALTH PROGRAMS

Primaquine Primaquine Primaquine

ADD ADD ADD Chloroquine Chloroquine Chloroquine : : : Pregnant : Lactating days 1- beginning day) mg/ 45 Pregnant : Lactating above regimen. the Pregnant day 3 : Lactating . regimen above

Etiology Plasmodium vivax Plasmodium

Plasmodium vivax Plasmodium

Plasmodium ovale ovale Plasmodium ovale Plasmodium Relapse Acute National Antibiotic Guidelines

234

during the entire period period entire the during

Comments Primaquine

Withhold Withhold delivery 2 after weeks it give but pregnancy of 0.75 mg/kg. dose of single a in ay the the 3 tabs 3 tabs

MALARIA

1 to the above 1 to <35 kg: <35 14 1 to the above the 1 to PLUS

ays 2, and 0.75 mg/kg on mg/kg and 0.75 2, 2, and 5 mg/kg on d on and 5 mg/kg 2, - - d

1 1 3 > 35 kg: 4 on day 1 35 kg: 3 > tabs -

2 ays

on d

3 - 2

Regimen days 0.25 mg/kg/day on days1- mg/kg/day 0.25

10mg/kg q8h x 7 10mg/kg combination (20mg/120mg) 0.25mg/kg, x 1 doseday on 0.25mg/kg,

is not available, and if the patient is on patient the if and available, not is 0.25mg/kg X 1 X doseday on 0.25mg/kg AL

tab 10mg/kg on days 10mg/kg tab tab 10mg/kg 10mg/kg tab

DOHPUBLIC HEALTH PROGRAMS Primaquine x 7 bid 10mg/kg Clindamycin Primaquine

+ withhold untildelivery ADD Chloroquine Chloroquine Quinine Sulphate Quinine

: : :

1 and 8 h after, 3 tabs bid on days 3 bid tabs 1 and 8 h after, Primaquine partum/lactating women: partum/lactating - Quinine

f second or third trimester: third second or PLUS Pregnant and 8 h after, 4 tabs on days 4 tabs bid and 8 h after, Pregnant Clindamycin : Lactating regimen I ayd on Post Pregnant 3 : Lactating day 3 PLUS regimen

Etiology

Mixed Infections Mixed

Plasmodium malariae Plasmodium malariae Plasmodium

National Antibiotic Guidelines

235

el, (b) relative length of Comments

(a) reasons for trav for reasons (a)

MALARIA .

Geneva: WHO Geneva:

Regimen DOHPUBLIC HEALTH PROGRAMS

. matter and not prescriptive. Patients are given the entire spectrum of preventive measures they may undertyake including including undertyake may they measures preventive of spectrum entire the are given Patients notand prescriptive. matter

The patient is further assisted by assessing the relative risk of disease acquisition given thegiven of acquisition disease risk relative the by assessing assisted further is The patient

Etiology stay in the endemic endemic area the in stay DOH is advisory on the advisory is DOH chemoprophylaxis. Chemoprophylaxis National Antibiotic Guidelines

Department of Health. (2014). National Malaria Control Program: Manual of Operations, 5th edition. 5th of Operations, Manual Program: Control Malaria National (2014). Health. of Department REFERENCES , 3rdMalaria of edition. Treatment the for Guidelines (2015). Organization. Health World

236

onth later because later onth

intestinal schistosomiasis and schistosomiasis intestinal

should be given on a full full on a given be should

Comments

Praziquantel

does not kill developing worms. worms. developing kill does not

information regarding the mass drug administration of the of the mass administration the drug regarding information hypersplenism, development of portosystemic collateral blood blood collateral portosystemic of development hypersplenism, SCHISTOSOMIASIS Presence of complications, such as periportal fibrosis, splenomegaly splenomegaly fibrosis, such asperiportal complications, of Presence with glomerulonephritis or pulmonale, cor vessels, deficit, neurologic focal seizures, with (patients schistosomiasis CNS encephalitis). diffuse or pressure intracranial increased of signs or

Observe patients for 1 to 3 hours for possible adverse reactions, such as reactions, adverse possible for hours 3 1 to for patients Observe stomach. Follow up treatment of confirmed cases 1 m cases1 ofconfirmed up treatment Follow stomach. Praziquantel program of the DOH, please refer to the website, www.doh.gov.ph. website, the to refer please the DOH, of program • • more For This regimen may also be given for hepato for be given also may regimen This schistosomiasis. pulmonary nausea, commonly, and less discomfort, abdominal dizziness, headache, watch to afterwards them ct Instru and urticaria. fever diarrhea, vomiting, may given be treatment Supportive 24 hours. for reactions these for out as appropriate. reactions adverse relieve to referral: hospital of Indications

is and is free

3 dosesx1

- 2

IS in

div

Central office and office Central ay Praziquantel Regimen 40 mg/kg/d 40

DOHPUBLIC HEALTH PROGRAMS ova by stool exam and or rectal imprint rectal and or exam ovaby stool japonicum Schistosoma Passive or Active Surveillance)] Active or Passive (

ay only available at the the DOH at available only areas. endemic in facilities health government Dose is increased to 60 mg/kg in in mg/kg 60 to increased is Dose neuroschistosomiasis. Praziquantel d GRAMS: SCHISTOSOMIAS

Selective Treatment Selective [

Etiology S. japonicum. S. being Philippines the Schistomes, the most common in in common most the Schistomes,

OH PUBLICDOH HEALTH PRO SCHISTOSOMIASIS

Supported by a positive result on kato katz for katz for kato on result positive bya Supported National Antibiotic Guidelines

237 Infections in the the in Infections

SCHISTOSOMIASIS

- DOHPUBLIC HEALTH PROGRAMS

Schistosoma japonicum Schistosoma of and Prevention Treatment Diagnosis, the for Guidelines Practice Clinical of Health. Department

Philippines: 2013 Update. 2013 Philippines: National Antibiotic Guidelines

REFERENCE:

238

generation generation

should be should rd

evaluated to confirm confirm to evaluated generation generation - are limited in their coverage in their limited are Comments ness or adnexal tenderness adnexal ness or hird

regimens, continue treatment treatment continue regimens, itching to outpatient regimen. regimen. outpatient to itching Cephalosporins Metronidazole anaerobes. of t with considered cephalosporins. For inpatient inpatient For 24h least at for response satisfactory until sw before therapy IM/oral respond to do not who Women - be re should 72h within intravenous given be and should diagnosis the 3 recommended The y. therap

s if: ays

d 100mg 100mg 48h of ovarian ovarian -

2mg/kg IV/IM IV/IM 2mg/kg Doxycycline

x 14 q12h PO 100mg ays d PLUS

Gentamicin Gentamicin disorders of the upper female genital tract, including any combination of of any combination including tract, genital upper female the of disorders Doxycycline PLUS

3g IV q6h IV 3g 250mg IM/IV x 1 dose x1 IM/IV 250mg

Regimen PLUS

h SEXUALLY TRANSMITTED INFECTIONS

100mg PO q12h x 14 PO 100mg sulbactam sulbactam -

Ceftriaxone

900mg IV q8h 900mgIV 2g IV q6 2g IV

f with uncertain diagnosis, presence of tubo presence of diagnosis, uncertain with f IM/PO

5mg/kg) can be used. 5mg/kg) : i : Ampicillin Cefoxitin Cefoxitin Doxycycline Doxycycline Clindamycin Clindamycin line:

line:

nd st PO q12h x 14 days q12h x PO Outpatient: THEN 2 Parenteral vomiting and nausea >38.5˚C, fever infection, HIV pregnancy, abscess, after of improvement lack medications, oral use of precluding oralantibiotic 1 OR daily Single dose. q8h maintenance by 1.5mg/kg followed dose, loading – (3 dosing

INFECTIONS

ovarian abscess, and pelvic peritonitis. and pelvic abscess, ovarian - (PID) comprises a spectrum of inflammatory inflammatory of spectrum a comprises (PID)

Etiology ; Enterobacteriaceae

S. agalactiae; agalactiae; S. rods; negative - no cause for the illness other than PID canidentified be PID than other illness the causeno for tender uterine tenderness, motion cervical exam: on pelvic present are criteria clinical minimum following of the more one or pain abdominal or lower pelvic with

• • • Cytomegalovirus (CMV); Cytomegalovirus hominis; U. urealyticum; M. urealyticum; U. hominis; genitalium ; Bacteroides Enteric H. influenzae; vaginalis; G. Gram r trichomoniasis, bacterial vaginosis, and syphilis. vaginosis, bacterial trichomoniasis, r fo Screen C. trachomatis; gonorrhoeae; N. endometritis, salpingitis, tubo STfor I at risk women and other women young active sexually in be initiated should treatment Presumptive Pelvic Infections Pelvic Disease Inflammatory Pelvic

SEXUALLY TRANSMITTED SEXUALLY National Antibiotic Guidelines

239

Comments ovarian abscess should have abscess should ovarian -

Patient with tubo that treatment of inpatient 24 hours least at Clinical coverage. anaerobic includes and 72 hours in noted be should response to note repeated be should ultrasound pelvic the abscess. of size in the increase any further

OR cm abscess has a 20% chance of requiring surgical surgical requiring chance of hasa 20% abscess cm 100mg 100mg ays - d to 6

100mg PO PO 100mg

2mg/kg IV/IM IV/IM 2mg/kg 100mg PO PO 100mg bid 500mg PO bid x14 bid PO 500mg Doxycycline Doxycycline

100mg PO q12h x 14 PO 100mg

Gentamicin PLUS Doxycycline

of ays d PLUS Regimen 14 Doxycycline the presence of a pelvic abscess are pain, persistent fever, adnexal tenderness (for days) >7 (for tenderness adnexal fever, persistent pain, are abscess a pelvic of presence the Ultrasonography of the pelvis is valuable in confirming the presence of an abscess. An An abscess. an presenceof the confirming in valuable is the pelvis of Ultrasonography

SEXUALLY TRANSMITTED INFECTIONS 1.0g IM xIM 1 dose 1.0g - PLUS cm abscess has a 35% chance,4- a and hasa 35% abscess cm at least 21 days at least - 900mg IV q8h 900mgIV 0.5

5 mg/kg) can be substituted PLUS substituted can be 5 mg/kg) abdominal pain (lasts about 48 h) that often radiates to the shoulder. the to radiates often 48 that about h) (lasts pain abdominal Metronidazole WITHOUT or WITH to 9 450mg PO qid x qid PO 450mg ays

d therapy oral Continuing

2g q6h IV (IV/PO): ays) ays)

d quadrant quadrant

Cefotaxime Clindamycin (

Outpatient: OR Parenteral: Cefoxitin Single dose. q8h maintenance mg/kg by 1.5 followed dose, loading – (3 dosing daily x 14 bid PO Clindamycin Duration OR x 14 bid days

- Curtis syndrome Curtis -

Hugh -

E. coli; Etiology

ovarian Abscess ovarian - sexually active: E. coli,active: α sexually - erobic streptococci erobic ate manifestation of PID; Useful clinical features that suggest suggest that features clinical Useful of PID; manifestation ate Non hemolytic streptococci; anaerobes streptococci; hemolytic Classic manifestation is severe right upper right severe is manifestation Classic Perihepatitis or Fitz a Peptostreptococcus; Peptococcus; Peptococcus; Peptostreptococcus; Bacteroides spp.; spp.; Bacteroides ; Other fragilis Bacteroides intervention. intervention. active: Sexually and an erythrocyte sedimentation rate greater than 30 mm/hr. than greater rate sedimentation erythrocyte and an chance,7- a 60% hasa than 10 cm r large abscess Tubo L National Antibiotic Guidelines

240

Comments hepatitis, pleuritis, subphrenic subphrenic pleuritis, hepatitis,

of the exanthems suggests oophoritis. suggests exanthems the of The presence of an enlarged, tender, boggy, tender, an enlarged, of The presence mumps with or a child ovary in mobile smooth, one The diagnosis is made by having a high index index high a having by made is The diagnosis mimics frequently Perihepatitis suspicion. of cholelithiasis, ulcer, peptic perforated abscess, ectopic appendicitis, nephrolithiasis, and trauma, abdominal pregnancy, pancreatitis. ays

d 100mg 100mg

ays ays ays d d d

2mg/kg IV/IM IV/IM 2mg/kg Clindamycin

Doxycycline 500 mg PO PO 500 mg q4h

OR x 14 q12h PO 100mg ays PLUS

Gentamicin

100mg PO bid x 14 bid PO 100mg 500mg PO bid x14 bid PO 500mg 500mg PO bid x14 bid PO 500mg

6h(Pediatric) ; Doxycycline PLUS 3g IV q6h IV 3g daily IM 250mg

Regimen

SEXUALLY TRANSMITTED INFECTIONS Doxycycline

100mg PO bid x 14 x bid PO 100mg . ays Metronidazole Metronidazole sulbactam d

Ceftriaxone

900mg IV q8h 900mgIV 2g IV q6h PLUS q6h 2g IV 15 mg/kg PO q4- PO 15 mg/kg PLUS 5 mg/kg) can be used. can be 5 mg/kg) ays

d 10-

IM/PO

: Ampicillin Doxycycline Cefoxitin

Clindamycin Cefotaxime line:

line:

st nd st Outpatient 450mg PO qid x14 qid PO 450mg 2 PO q12h x14 q12h PO OR mg/kg q8h maintenance dose. Single Single dose. q8h maintenance mg/kg 1.5 by followed dose, loading – (3 dosing daily Paracetamol (Adult) 1 OR or WITHOUT WITH palliative is Treatment Treatment similar as with PID as with similar Treatment Parenteral: 1 or WITH WITHOUT Oral:

C. trachomatis C. , Etiology

nflammation of the ovaries, the oocytes in particular in oocytes the ovaries, of the nflammation I Cytomegalovirus virus, Mumps Oophoritis Oophoritis N. gonorrhoeae N.

National Antibiotic Guidelines

241 s, I C.

by NAAT. by NAAT. gonorrhoeae N. Comments should be advised to abstain abstain to advised be should

and for and for : care tests - of - including HIV. Tests should be done for be done for Tests should HIV. including trachomatis NAAT for specimen preferred the is Urine men. in testing or confirmed epididymitis have acute who Men or gonorrhoeae by N. be caused to suspected trachomatis C. and their they until intercourse sexual from and treated have been adequately partners acute with men All have resolved. symptoms ST other for be tested should epididymitis

;

100mg 100mg

q8h - 2g IV IV 2g

ays d 300mg PO bid x10 bid PO 300mg

Doxycycline Doxycycline 14 Ceftriaxone 800mg PO q6PO 800mg

- - ays d OR 400

give as single agent if no risk risk no if agent single as give Ofloxacin

PO x10 PO IV/POx 10 OR

h or 4h infusion of 2.25g 2.25g of 4h infusion IVor q6h 4.5g

3g IV IV 3g q6h

y caused by chlamydia and gonorrhea) by chlamydia y caused Regimen 8h (Pediatric); 8h - /day 500mg /day 750mg 250mg IM x 1 dose PLUS1 x IM 250mg ulbactam SEXUALLY TRANSMITTED INFECTIONS azobactam S t - 500mg PO dailyPO 500mg

(for caseslikel (for ays 10mg/kg PO q6 PO 10mg/kg d - Bed rest, scrotal elevation, and analgesics. elevation, scrotal Bed rest,

Levofloxacin Ceftriaxone

Levofloxacin Ampicillin 5

- Piperacillin

All:

; or; urine void

OR Levofloxacin if patient is a man who practices insertive anal sex since he will will he sex since anal insertive is a man practices who patient if - .

line: line:

ays st nd 2 q8h also be at risk for enteric organisms, OR organisms, enteric for risk at be also and gonorrhea chlamydia for years: >35 d q24h ADD >35 years: >35 ≤35 years: ≤35 1 years: ≤35 x 10 bid PO Ibuprofen (Adult) C.

N. gonorrhoeae N.

Etiology

, Enterobacteriaceae Enterobacteriaceae , of the following point the following byone of inflammation of evidence objective for epididymitis acute cases of suspected ll a Positive leukocyte esterase test on first on test esterase leukocyte Positive Gram or methylene blue or gentian violet (MB/GV) stain of urethral secretions demonstrating ≥2 WBC/oif ≥2 demonstrating secretions urethral of stain (MB/GV) violet gentian or blue methylene or Gram ≥10WBC/hpf ona spunfirst void urine

valuate valuate • • • Enterobacteriaceae (occasional) years: >35 Age Age ≤35 years: ≤35 Age trachomatis E . weeks <6 lasts that epididymis the of and inflammation swelling, pain, of consisting syndrome Clinical Epididymitis National Antibiotic Guidelines

242

x 6 resistant). Coumadin consider consider

is preferred to preferred is

f there is ensures adequate adequate ensures

Clindamycin aparotomy is indicated. indicated. is aparotomy Comments Ceftriaxone and l + sus ESBL producing aerobic GNB. aerobic producing sus ESBL Carbapenem

ensure activity versus Group B Strep - (one Strep B Group versus activity ensure are of isolates third therapy ver therapy hysterectomy Clindamycin Curettage, supportive therapy, and intensive intensive and therapy, supportive Curettage, I monitoring. cardiovascular orresponse no , deterioration Treatment is a combination of effective effective of a combination is Treatment ( anticoagulation and antibiotics infected on surgery for role clear No weeks). and WBC when antibiotic(s) Discontinue veins. afebrile is patient and normal are differentials 48 hrs. for

3g q6h IV

2.25g IV q6h IV 2.25g

1g IV q8h IV 1g

1g IV q24h OR IV 1g

Sulbactam 500mg IV q8h IV 500mg OR -

azobactam t - hr infusion of 2.25g q8h) of infusion hr section delivery); can complicate postpartum endometritis or pelvic orpelvic endometritis postpartum can complicate delivery); section - ays ays -

Meropenem 4 d d

or Ertapenem

Ampicillin

OR Piperacillin OR

Regimen Metronidazole 8h – 5 MU q6h 5 MU IV 4.5g IV ( q6h 4.5g

PLUS SEXUALLY TRANSMITTED INFECTIONS

1g IV q8h IV 1g

100mg PO q12h x 7 PO 100mg 100mg PO q12h x 7 PO 100mg 2g q6 IV

enicillin

azobactam

2g IV2g daily t . -

Meropenem Cefoxitin

: : prevalence (≥ 20%) of MDR GNB: MDR of 20%) (≥ prevalence Doxycycline Doxycycline High Dose P Dose High line

line

st nd PLUS Piperacillin 2 PLUS If low prevalence of MDR GNB: MDR of lowprevalence If q8h OR gm IV 4.5 or highIf 1 OR Ceftriaxone

CT scan or MRI scan or CT

, bivia

Diagnosis:

Prevotella Etiology Bacteroides sp., especially especially sp., Bacteroides sp. Streptococcus bivia; Prevotella Enterobacteriaceae; B); A, (Groups trachomatis; Chlamydia (less urealyticum Ureaplasma perfringens; C. common); Septic Abortion Septic Bacteroides sp., sp., Bacteroides sp. Streptococcus anaerobes, other B), Enterobacteriaceae A, (Group inflammatory disease. inflammatory Pelvic Vein Suppurative (Septic) Thrombophlebitis (Septic) Suppurative Vein Pelvic C or vaginal (either postpartum usually veins; orpelvic deep ovarian of Infection

National Antibiotic Guidelines

243 or -

Clindamycin third of isolates are are of isolates third

should include include should

ant). Comments to decrease the risk of postof risk decrease the to resist is preferred to ensure activity activity ensure to preferred is

For Cesarean section: Cesarean For as such coverage anaerobic Metronidazole Clindamycin endometritis. partum Clindamycin Ceftriaxone - (one Strep B Group versus

- 3

3g q6h IV

2g IV q24h IV 2g 2g IV q24h or IV2g or q24h

Miconazole

150mg PO x 1 x PO 150mg

. OR

1g IV q24h OR IV 1g

Sulbactam

- Ceftriaxone hr infusion of 2.25g q8h) 2.25g q8h) of infusion hr - ose 4 d

Ceftriaxone

(

or Fluconazole Gentamicin

Ertapenem

Ampicillin Clotrimazole

PLUS OR PLUS

OR Regimen

– 4.5g IV ( q6h 4.5g

SEXUALLY TRANSMITTED INFECTIONS 200mg PO bid x1 bid PO 200mg 900mg IV q8h PLUS IV 900mg

1g IV q8h IV 1g

Ampicillin 100mg PO q12h] PO 100mg

900mg IV q8h IV 900mg 2g q6 IV 450–

– 5mg/kg/day 2g x2g dose1

azobactam 450 t

g/day) 5mg/k - Topical azoles suchas azoles Topical

Itraconazole

Meropenem Cefoxitin : : Doxycycline OR

Gentamicin Clindamycin line

line

ays st nd Piperacillin PLUS [ 2 OR severe cases: severe and more Unresponsive 1 OR delivery: vaginal For cases: Mild d dose Metronidazole Clindamycin Gentamicin

bivia

Escherichia

ther bacteria bacteria ther

Prevotella o , Etiology . (40%).

; Mycoplasma; Pathogenic Pathogenic Mycoplasma; ; Gardnerella sp. Gardnerella anaerobes) (e.g., Balanitis sp Candida coli (e.g., anaerobes Amnionitis/ chorioamnionitis Amnionitis/ Streptococci; B Group National Antibiotic Guidelines

244 C. , rhoeae include dysuria, dysuria, include

N.gonor has not yet been yet has not may

. Comments

infections . ee recommendations for for recommendations ee Group A streptococcal balanitis has been balanitis streptococcal A Group sex. oral after reported S trachomatis sexually to other similar factors Risk transmitted work diagnostic When are fi , known symptoms not is and cause done urethral of and no evidence present and Chlamydia for NAAT testing inflammation, Use the infection. identify might gonorrhea negative is NAAT even if therapy combination Chlamydia. for

100mg PO PO 100mg PO in 4 div in 4 div PO and anaerobes and anaerobes infectious causes. Symptoms, when present, when Symptoms, causes. infectious Doxycycline

ay 50mg/kg/d

OR C. trachomatis trachomatis C. 250mg IM x 1 dose x PLUSIM 250mg nate) 125mg IM x 1 dose x PLUSIM 125mg 250mg IM x 1 dose PLUS x IM 250mg

Regimen due to infectious non- or infectious due to ays d Ethylsucci Ceftriaxone

1g PO x 1 dose PO 1g SEXUALLY TRANSMITTED INFECTIONS Ceftriaxone Ceftriaxone

) x14 ) Base

1g PO1g x 1 dose . weeks

Azithromycin ays d

Erythromycin

Adult: EITHER x 7 bid >45kgs and <8yrs old: <8yrs and >45kgs Azithromycin old: >8years and >45kgs ay 2g/d doses(Max: ( Pediatric: old: <8yrs and <45kgs cause to likely is it because Do aspirate not and drain. Incise or fistulization. marsupialization infection: Recurrent recurrences. , gonorrhoeae N. for coverage Antibiotic 2 at least for

. (GBS). C. trachomatis C. , Etiology haracterized by urethral inflammation which may which inflammation by urethral haracterized

is c

is holinitis and Bartholin abscess Bartholin and holinitis naerobes and facultative and facultative naerobes N. gonorrhoeae; C. trachomatis; M. M. C. trachomatis; gonorrhoeae; N. T. vaginalis; genitalium; Urethrit . discharge purulent or mucopurulent mucoid, pruritus, urethral Urethritis and Cervicitis and Urethritis Ureaplasma N. gonorrhoeae N. a organisms Bart Streptococcus sp Streptococcus

National Antibiotic Guidelines

245

minimize

en and symptoms symptoms and en dose therapy or until until or dose therapy . To . Doxycycline day regim Comments should be administered to to men administered be should

Azithromycin initially treated with for treated men and reinfection, transmission from abstain to be instructed should NGU and their they until intercourse sexual (e.g., treated adequately have been partner(s) - single daysafter 7 for a 7- of completion resolved). Men who receive a diagnosis of of diagnosis a receive who Men resolved). and syphilis. HIV for be tested should NGU

1g PO x PO 1g

base

Ofloxacin PO 800mg

/day 500mg

ays)

100mg PO bid bid PO 100mg Erythromycin d

OR OR ays

1g PO x 1 PO 1g dose d

400mg PO xPO 400mg 1 dose

ays Azithromycin ( ays d

ays) Erythromycin d

d negative diplococci negative Levofloxacin -

Doxycycline Ethylsuccinate POx 7

2g PO x 1 dose. PO 2g PLUS OR

Cefixime OR 500mg PO bid x7 bid PO 500mg ays Azithromycin

d : : Doxycycline /day 500mg Regimen or 500mg PO qid x7 qid PO 500mg Erythromycin 300mg PO bid x7 bid PO 300mg

Metronidazole 100mg PO q12h x 7 PO 100mg OR is not available, available, not is SEXUALLY TRANSMITTED INFECTIONS

1g PO x 1 dose PO 1g base

Doxycycline 1g PO x 1 dose x 1 PO 1g 250mg IM x 1 dose x IM 250mg

ays ays d d Ofloxacin 500mgIM Levofloxacin 800mg PO qid x 7 x qid PO 800mg

OR OR Doxycycline

Ceftriaxone f I ays ays

Azithromycin Ceftriaxone Erythromycin

d :

Azithromycin ays Cefotaxime d line line:

line line:

st nd st nd f initiallyf treatedwith

400mg PO bid x7 bid PO 400mg qid x 7 qid POx 7 500mg PO qid x7 qid PO 500mg PLUS OR Azithromycin to Alternatives (AlternativeRegimen: Metronidazole 2 with vaginalis T. for Treat 1 x 7 2 Ethylsuccinate I 1 1 dose OR

ecurrent N ecurrent r Etiology nd occal Urethritis occal a ; Ureaplasma; ; Persistent Persistent vaginalis Confirmed in symptomatic men when staining of urethral secretions without Gram without secretions urethral of staining when men symptomatic in Confirmed C.trachomatis; M.genitalium; T. Nongonoc National Antibiotic Guidelines

246 not not

swab urethral or nasopharyngeal swab (if (if swab nasopharyngeal

those who are those are who Women treated for cervicitis cervicitis for treated Women Comments

swab specimen, and 2) 2) and specimen, swab

catch urine or swab specimens specimens swab or urine catch

catch urine catch first- first-

Infants and Children: and Children: Infants (if eyelid inner from swabs pneumonia); conjunctivitis) NAAT, Tissue culture, and Direct Fluorescent Fluorescent Direct and culture, Tissue NAAT, Test. Antibody Specimen: Women: vagina or endocervix the from Men: Treatment of cervicitis in pregnant women women pregnant in cervicitis of Treatment from differ does not women. pregnant recommended): routinely (not test Diagnostic should be instructed to abstain from sexual sexual from abstain to instructed be should ) have partner(s their and they until intercourse treated. adequately been Women with a new episode of cervicitis should should cervicitis newa of with episode Women

100mg PO PO 100mg

100mg PO x bid PO 7 100mg

100mg PO bid x7 bid PO 100mg

ays Doxycycline d

gonorrhoeae. Doxycycline

1g x 1 dose PO q6h x N. Doxycycline

1g PO PO 1g x 1 dose and Regimen OR 1g PO x 1 dose OR PO 1g SEXUALLY TRANSMITTED INFECTIONS ay 50mg/kg/d Azithromycin : 1g PO x 1 dose OR 1 dose x 1g PO old Azithromycin

1g PO1g x 1 dose

Azithromycin

ays

Erythromycin

d old :

Azithromycin :

line

ays st ays Adult bid x 7 bid ≥8 yrs yrs <8 and kg ≥45 Consider concurrent treatment for gonococcal infection if patient is at is patient if infection gonococcal for treatment concurrent Consider of prevalence the where a community orin lives gonorrhea for risk high. is gonorrhea 1 Pediatric kg: <45 d Women: Pregnant Azithromycin d

Etiology

C. trachomatis C. Chlamydial Infections Chlamydial genitalium C. trachomatis C. trachomatis for should and tested be PID of signs for assessed be M. gonorrhoeae; N. trachomatis; C. Diagnostic signs: 1) a purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical endocervical on an or canal endocervical the in visible exudate endocervical mucopurulent or 1) a purulent signs: Diagnostic os. cervical the through swab a cotton of passage bygentle induced easily bleeding endocervical sustained Cervicitis

National Antibiotic Guidelines

247 to

quinolones

should be should and limited on the limited

is Comments stained smears of exudate, exudate, of smears stained - for the treatment of chlamydial chlamydial of the treatment for Doxycycline ram

zation for hepatitis B and HPV. B hepatitis for zation available for persons whose adherence is a is adherence whose persons for available concern. Do not give not Do Data women. pregnant <45 weigh who and children infants in infection dose observed single directly Onsite, kg. Azithromycin with therapy effectiveness and optimal dose of dose of and optimal effectiveness Azithromycin

base lete immuni lete 800mg 800mg /day 500mg

Comp endocervical swabs, vaginal swabs, urethral swabs (men), and (men), swabs urethral swabs, vaginal swabs, endocervical Erythromycin ays

OR d

ays d Erythromycin

ays ays POx 3 d d

OR Levofloxacin

/day ays OR

d N. gonorrhoeae. N. ays ays d d 20mg/kg 500mg PO tid x 7 tid PO 500mg Regimen

Ethylsuccinate Erythromycin

300mg PO bid x7 bid PO 300mg 500mg PO qid x 7 x qid PO 500mg OR SEXUALLY TRANSMITTED INFECTIONS

Base ays 500mg PO qid x7 qid PO 500mg

d Amoxicillin

Azithromycin

Ofloxacin 800mg PO qid x 7 x qid PO 800mg 400mg PO qid x 14 400mg qid PO

Base OR OR

<45 kg: <45 ays

d :

Erythromycin line

nd Erythromycin 250mg PO qid x14 qid PO 250mg x 7d qid PO Pregnant Women: Pregnant POx 7 2 Pediatric: Adult: Ethylsuccinate

endocervical (women) or urethral (men) swab specimens NAAT - NAAT specimens swab (men) urethral or (women) endocervical

gonorrhoeae Etiology N. d reduced effectiveness of some medicines, good practice dictates that the choice of treatment treatment choice of the that dictates good practice medicines, some of effectiveness reduced and infections gonococcal for data resistance emerging CSF, or joint aspirate provide a presumptive basis for initiating treatment for for treatment initiating for basis presumptive a provide aspirate joint or CSF, depends on reliable local data on antimicrobial susceptibility. on antimicrobial data local dependson reliable G Positive infection. gonococcal neonatal of complication a rare is and or meningitis arthritis, as sepsis, present might DGI urine (from both men and women). menwomen). and both (from urine to Due by Caused – and Culture stain Gram’s Gonococcal Infections Gonococcal National Antibiotic Guidelines

248

is not rs.hou 24 but with test withtest but

he use of dual dual of use he negative diplococci diplococci negative Cefixime - are no longer no longer are

a diagnosis of of a diagnosis

are not recommended for for recommended not are 2 g IV every 12– every 2 IV g Comments – to 1

Cephalosporins

of cure one week later. Medication for for Medication later. one week cure of on provided be should infection gonococcal observed. directly and site t regarding exists data No gonococcal with children treating for therapy gonorrhea for treated Persons infection. sexual from abstain to instructed be should all and until treatment days 7 after for activity All treated. adequately are sex partners receive who persons STIs, other for tested be should gonorrhoea and HIV. syphilis, chlamydia, including Fluoroquinolones Gonococcal For urethritis. gonococcal increase endocarditis, and meningitis Ceftriaxone Gonococcal ophthalmia is strongly suspected suspected strongly is ophthalmia Gonococcal Gram intracellular when are identified on Gram stain of conjunctival conjunctival of on stain Gram identified are exudate. Oral Ceftriaxone if except recommended consider then available;

Cefotaxime

ay 12mg/kg/d 12mg/kg/d 1g PO x 1 dose - 1g PO PO 1g x1 dose 1g PO x 1 dose 1g PO OR ax: 1g) ax: 10- 10 OR 1g PO x 1 dose 1g PO

1g PO x PO 1g 1 dose

ays

ays (M ays d

d Azithromycin 14

Azithromycin Azithromycin

Azithromycin Azithromycin Azithromycin 10-

Azithromycin

V/IM x 1 dose (Max: 125mg IM) x 1 dose (Max: V/IM IV/IM x7

PLUS PLUS PLUS PLUS PLUS PLUS /day PLUS Regimen IV/IM x 1 7 dose x IV/IM ay

ay 50 mg/kg I mg/kg 50 days SEXUALLY TRANSMITTED INFECTIONS 50 mg/kg 50 25–

1g IV q8h IV 1g

1g IV/IM q24h q24h 1g IV/IM ay 8 mg/kg/d 8 mg/kg/d

1g IM x 1 dose 1 dose x 1g IM 250mg IM x 1 dose PLUS IM 250mg

50mg/kg/d 25mg/kg IM x 1 dose (Max: 75 mg) (Max: dose x1 IM 25mg/kg 50mg/kg IV/IM x 1 dose (Max: 125mg) 125mg) dose (Max: 1 x IV/IM 50mg/kg 400mg PO x 1 dose x PO 400mg dose 1 - –

25 25

if meningitis is documented, is meningitis if Cefixime

Ceftriaxone Cefixime Ceftriaxone

Cefotaxime Ceftriaxone

Cefixime Ceftriaxone Ceftriaxone

: : : : line: line line

line:

nd st nd st Pediatric: Pediatric: Adult Pediatric: Adult 1 Ceftriaxone Spectinomycin Ceftriaxone q12h 7 x IV/IM 25mg/kg : Duration 1 Pediatric: Adult 2 Adult 2

Etiology ) and Gonococcal Scalp Scalp )Gonococcal and GI Abscesses in Neonates in Abscesses (D Infection Gonococcal Disseminated Ophthalmia Neonatorum Ophthalmia

Disseminated Infection Disseminated than urogenital or anorectal sites) anorectal or urogenital than Conjunctivitis Gonococcal pharynx (more difficult to eradicate to eradicate difficult (more pharynx uncomplicated infections of the the of infections uncomplicated Uncomplicated infections of the the of infections Uncomplicated and rectum; urethra, cervix,

National Antibiotic Guidelines

249

addition of 10% KOH addition variable rods rods and cocci variable - Comments in the vagina with high with vagina the in negative and Gram negative

Lactobacillus sp. sp. Lactobacillus 2g ays d

PLUS ) characteristic of BV. of ) characteristic Mobiluncus rods (e.g., negative

positive rods), Gram rods), positive - - Metronidazole

ays d PO div q12h x 7 q12h div PO OR

a fishy odor of vaginal discharge before or after after or before discharge vaginal of odor a fishy (Whifftest)

• ays ays /day d d

250mg IM x 1 dose PLUS x IM 250mg 125mg IM x 1 dose x IM 125mg

15mg/kg

li (e.g., long Gram Regimen 500mg PO bid x7 bid PO 500mg div q6h x 14 q6h x div SEXUALLY TRANSMITTED INFECTIONS 300mg PO bid x7 bid PO 300mg Ceftriaxone Ceftriaxone

Metronidazole ay 50mg/kg/d 1g PO1g x 1 dose Metronidazole

<45 kg: kg: <45 line: Clindamycin

st 1

: line:

PO single dose single PO >45kgs and <8yrs old: <8yrs and >45kgs Azithromycin Pediatric: Adult 2 old: <8yrs and <45kgs Erythromycin

sp.; , and peptostreptococci), and curved Gramcurved and and peptostreptococci), , Porphyromonas t least 3 of the following symptoms or signs must be present: must signs or symptoms of 3 the following tleast a

Mobiluncus Mobiluncus , Prevotella ,

astidious anaerobes astidious Porphyromonas; Porphyromonas; F Etiology sp.; Enteric bacteria including including bacteria Enteric

vaginalis

G. clue cells on microscopic examination examination on microscopic cells clue pH of vaginal fluid >4.5 fluid vaginal of pH homogeneous, thin, white discharge that smoothly coats the vaginal walls; vaginal the coats smoothly that discharge white thin, homogeneous,

Shigella species Shigella Group A Streptococci; E. coli; E. coli; Streptococci; A Group N. virus; simplex Herpes T. trachomatis; C. gonorrhoeae; vaginalis; Vaginitis, Prepubertal Vaginitis, Peptostreptococci; Peptostreptococci; • Prevotella Mycoplasma; • • Ureaplasm; vaginalis; G. (e.g., criteria: Diagnostic Amsel’s concentrations of anaerobic bacteria. anaerobic of concentrations lactobacil of concentration the relative determine is used to stain Gram Bacterial Vaginosis Bacterial producing peroxide hydrogen normal the of replacement from resulting syndrome clinical polymicrobial A Vaginal Discharge Vaginal National Antibiotic Guidelines

250

some infected women women infected some

Comments s, and

arge. n, swelling, and redness. n, swelling,

Treatment of partner is recommended. If single If single recommended. is partner of Treatment 2g give fails, regimen dose metronidazole 5 days. for orally

ays d ays EITHER

14 ay d x 7– PLUS

daily 100mg PO bid x7 bid PO 100mg

500mg PO bid x7 bid PO 500mg

250mg IM x 1 dose x IM 250mg bid x bid 7 days

Doxycycline

2g PO PO 2g x 1 dose Regimen green with or without vulvar irritation. vulvar or without with green - Metronidazole

2g PO x 1 dose PO 2g 500mg PO 500mg SEXUALLY TRANSMITTED INFECTIONS

1% cream 5g intravaginally 5g intravaginally cream 1% Ceftriaxone

150mg PO x 1 dose 1 x PO 150mg :

ld Metronidazole

1,200mg vaginal suppository, 1 supp1 1 x suppository, vaginal 1,200mg 1g PO1g OR x 1 dose 8yrs o 8yrs

Metronidazole Clotrimazole Metronidazole Fluconazole

: : :

Miconazole line: line

line line

st nd st nd

Women with HIV Infection: HIV with Women OR women: Pregnant 1 2 1 2 >45kgs and > and >45kgs Azithromycin days

mount microscopy NAAT, Trichomonas Rapid Test (dipstick). Test Rapid Trichomonas NAAT, microscopy mount

- Wet

ae. ae. pseudohyph or hyphae, yeasts, budding demonstrates which discharge vaginal of or Gram stain KOH) 10% (saline, preparation Wet

Etiology

ests:

t Candida spp. Candida Diagnostic Diagnostic pai s, pruritu and vulvar dysuria external of presence by the clinically is suggested vaginitis Candida of Adiagnosis Culture. Typical symptoms include pruritus, vaginal soreness, dyspareunia, external dysuria, and abnormal (thick, curdy) vaginal disch vaginal curdy) (thick, and abnormal dysuria, external dyspareunia, soreness, vaginal pruritus, include symptoms Typical Candidiasis T. vaginalis T. have vaginal discharge that might be diffuse, malodorous, or yellow or malodorous, be diffuse, might that discharge have vaginal Tests: Diagnostic Most infected persons have minimal or no symptoms. Some infected men have symptoms of urethritis, epididymitis, or prostatiti epididymitis, urethritis, of have symptoms men infected Some no or symptoms. have minimal persons infected Most Trichomoniasis

National Antibiotic Guidelines

251

80% 80%

–

Comments : Viral: culture, PCR, HSV to patient’s onset of symptoms. onset of to patient’s infection by darkfield examination of ulcer of ulcer examination by darkfield infection Diagnostic tests Diagnostic is healing if treatment Extend serology. days. 10 after incomplete reduces: therapy Suppressive by 70% recurrences of frequency 1. transmission. of disease risk 2. Sex partners of patients who have chancroid have chancroid who patients of partners Sex hadthey if treated and examined be should 10 days within the patient with contact sexual prior

. OR

500mg 500mg 200mg 200mg

OR 250mg 250mg

T. pallidum pallidum T. or

ays Valaciclovir

Base d ays 10 days10 d

10 10 - 8h (Max: 1.2g/day) 1.2g/day) (Max: 8h Famciclovir

250mg IM x 1 dose x IM 250mg

no evidence of of evidence no 7 days at least performed syphilis for test a serologic by or exudate of ulcers onset after OR

• Erythromycin

daily PO div q6- div PO 1g PO bid x 7- x bid PO 1g

400mg PO bid OR 400mg bid PO

ays Ceftriaxone ays d

suggests the diagnosis of chancroid of diagnosis the suggests 1g PO1g 400mg PO bid x 7 400mg bid PO d

10 OR Regimen - Aciclovir 40mg/kg/day div q12h x 7- div 40mg/kg/day

): Valaciclovir /day 80mg/kg

SEXUALLY TRANSMITTED INFECTIONS Aciclovir ulcer exudate ulcer OR

Adult Valaciclovir

ays d Aciclovir OR

Valaciclovir

lymphadenopathy 500mg PO bid x3 bid PO 500mg 10 1g PO1g x 1 dose

250mg PO tid x 7 250mg tid PO

OR ays

x 7-

d 45 kg:45

ays d

10 x 7- Children < Children PObid Famciclovir 500mg PO dailyPO 500mg Azithromycin Ciprofloxacin POtid x 7 episode: clinical First ay 5x/d PO Herpes Genital Recurrent ( Therapy Suppressive

Etiology

HSV2

and egative HSV PCR test or HSV culture performed on the the on performed culture HSV or test PCR HSV egative regional lymphadenopathy regional n one or more painful genital ulcers genital painful more one or

• • •

HSV1 Genital HSV HSV Infections Genital H. ducreyi H. Criteria for probable diagnosis: probable for Criteria Chancroid inguinal suppurative ulcer tender plus genital Painful Genital, Anal, or Perianal Ulcers orPerianal Anal, Genital, National Antibiotic Guidelines

252 tion tion

for1 year.

is less effective than than effective less is

daily Comments

Famciclovir

500mg 500mg or 1 mg/kg IV q8h can be added if can be added if q8h 1 mg/kg IV

for as long as 6 years and with and with as long years as6 for

the prodrome. the other regimen in those with ≥10 recurrences recurrences ≥10 with those in regimen other starting is recommended Treatment year. per episodic Effective gestation. of 36 weeks at Valaciclovir Gentamicin few the first within evident not is improvement therapy. days of Safety and efficacy have been documented been documented have efficacy and Safety with therapy daily receiving patients among Aciclovir Valaciclovir initiation requires herpes of recurrent treatment or onset day1 lesion of within therapy of during days of 21 requires encephalitis HSV func renal Impaired therapy. intravenous warrants dose adjustment. warrants

ays 800mg 800mg d

500mg PO or

Valaciclovir

OR or until clinical 500mg bid PO 500mg

ays

OR d 125 mg PO bid x 125 mgbid PO

ays 500mg PO bid x 500mg bid PO ays

d d tid

7 daily

- 10 - if disease is limited to to limited is disease if Valaciclovir

Valaciclovir

ays OR

500 mg 500 mg d

, then 250mg bid x 2 bid 250mg ,then Famciclovir OR

Famciclovir

ays OR d

OR daily OR 400mg PO tid x 5 tid PO 400mg - bid PO 800mg ly

PO 500mg bid ays

Regimen d 400mg PO tid x 5 PO 400mg tid 400–

10mg/kg IVq8h x 2 10mg/kg 500mg 500mg –

10 5 400mg PO tid tid PO 400mg

or Aciclovir

): SEXUALLY TRANSMITTED INFECTIONS 1g PO week PO 1g

Aciclovir Aciclovir 20mg/kg IV q8h x 14 IV 20mg/kg

800mg PO tid x 2 800mg tid PO Famciclovir Adult

Aciclovir Aciclovir

daily x 5 daysx5 PO1g daily OR

O bid bid O daily 1g PO1g x 5- bid or

ays

d Aciclovir 1g P 1g

ays Azithromycin

or d : infected Adults: infected infected Adults: infected - - ays line

10 days10 d -

st 5 Valaciclovir HIV 5 bid x 3 bid Severe Disease: Severe to complete therapy antiviral oral by followed observed, is improvement 10 days. least at Neonatal: disseminated 21for daysfor or membranes, and mucous skin the system. nervous central the and involving disease 1 Pregnant Women: Pregnant HIV ( Therapy Episodic x 5 bid PO 500mg PO bid bid PO 500mg

(formerly

Etiology Calymmatobacterium Calymmatobacterium nuloma Inguinale (Donovanosis) (Donovanosis) Inguinale nuloma Klebsiella granulomatis Klebsiella as known Characterized by painless, slowly progressive ulcerative lesions on the genitals or perineum without regional lymphadenopathy regional without perineum or genitals on the lesions ulcerative progressive slowly bypainless, Characterized ) granulomatis Gra

National Antibiotic Guidelines

253

Comments 12 months after therapy for primary or or primary for therapy after months 12 – For primary and secondary syphilis, clinical clinical syphilis, and secondary primary For performed be should evaluation and serologic of Failure treatment. after 6 and 12 months at fourfold decline to titers test nontreponemal within 6 Persons with a clinical syndrome consistent consistent syndrome a clinical with Persons genital or proctocolitis including LGV, with should lymphadenopathy, with disease ulcer LGV. for treated presumptively be

ABS or TPHA, EIAs, immunoblots). EIAs, TPHA, or ABS - 750mg PO bid bid PO 750mg

ays d trimoxazole

- Co ays

d Ciprofloxacin

OR 2.4MU dose 1 IM x 2.4MU

50,000 U/kg IM (Max: 2.4 MU x 1 dose) MU 2.4 (Max: IM U/kg 50,000

G Regimen

500mg PO qid x 21 x qid PO 500mg Base SEXUALLY TRANSMITTED INFECTIONS 100mg PO bid bid PO 100mg 100mg PO bid x21 bid PO 100mg

Penicillin Penicillin

base 500mg PO qid OR qid PO 500mg base

PO bid bid PO

for at least 3 weeks and until all lesions have completely have completely lesions all and until 3 weeks least at for

scent test, NAAT (if available) NAAT (if test, scent Benzathine Doxycycline Erythromycin

Benzathine Doxycycline

: :

: Erythromycin ine line line

line: l

st nd st nd healed. 160/800mg) Duration:

1 2 Pediatric: Adult 1 2 OR

culture, immunofluore culture,

syphilis for HIV

examinations Darkfield diagnosis: Definitive serovars L1, L2, L3 L2, L1, serovars Etiology Presumptive diagnosis: Nontreponemal tests (VDRL or RPR) Treponemal tests (FTA tests or Treponemal (VDRL RPR) tests Nontreponemal diagnosis: Presumptive

chance Primary Syphilis of presence Presentation: Clinical Test all patients with with patients all Test Diagnostic tests: Diagnostic Treponema pallidum Treponema by Caused Syphilis C. trachomatis trachomatis C. Lymphogranuloma Venereum Lymphogranuloma tests: diagnostic Special National Antibiotic Guidelines

254

cannot be cannot

24 months of of months 24

be indicative of indicative be Tetracycline Comments and

signs or symptoms attributable to syphilis syphilis to attributable symptoms or signs an initially hightiter (≥1:32)fails todecline 12– within fourfold least at therapy develop a sustained (>2 weeks) fourfold increase or or increase fourfold weeks) (>2 a sustained observed, is in titer greater

1. 3. 2. A CSF examination should be performed if performed be should examination CSF A secondary syphilis might might syphilis secondary ≥1 aged children and Infants failure. treatment syphilis andsecondary primary with month abuse. sexual for evaluated be should Doxycycline women. pregnant to given tests serologic nontreponemal Quantitative 12,months. and 24 6, at repeated be should

OR OR OR

ays ays ays d d d 14 14 14 10- 10-

(Max: 2.4 MU MU x2.4 1 (Max: Tetracycline Tetracycline Tetracycline

OR OR OR

week intervals (total (total intervals week ays ays ays d d d

IV/IM q24h x q24h IV/IM

1g IV/IM q24h x 1g IV/IM 1g 1g IV/IM q24h x 10- 1g IV/IM 0,000 U/kg IM, up to the adult up to the adult IM, 0,000 U/kg 50,000 U/kg IM 50,000U/kg 5

2.4MU dose 1 IM x 2.4MU 2.4MU dose 1 IM x 2.4MU G

50,000 U/kg IM (Max: 2.4 MU x 1 dose) MU 2.4 (Max: IM U/kg 50,000

G Regimen

Ceftriaxone Ceftriaxone Ceftriaxone

SEXUALLY TRANSMITTED INFECTIONS penicillin

100mg PO bid x 14 x bid PO 100mg 14 x bid PO 100mg 100mg PO bid x14 bid PO 100mg

OR OR OR Penicillin penicillinG Penicillin

ays ays ays d d d 2g PO2g x 1 dose 2g PO2g x 1 dose 2g PO2g x 1 dose

Benzathine Benzathine Penicillin G Penicillin Benzathine

Benzathine Doxycycline Doxycycline Doxycycline

Benzathine Benzathine

: : : line: line: line: line: line:

nd st nd nd st Azithromycin 2 2 500mg qid x 14 qid 500mg x 14 qid 500mg Adult 7.2 MU) dose of total adult the to up units/kg 150,000 Azithromycin Pediatric: dose) 1 Pediatric: 1- as 3 dosesat administered MU, 2.4 dose of Adult 2 x 14 qid 500mg Azithromycin Pediatric: Adult 1

year year

Fever,

: Etiology or tertiary disease. tertiary or

atent syphilis of less than one- less than of syphilis atent Latent syphilis of less than unknown unknown less than of syphilis Latent duration Late Latent Syphilis Syphilis Latent Late Characterized by serore activity activity byserore Characterized primary, evidence of other without secondary, duration Early Latent Syphilis Syphilis Latent Early L puplosquamous rash often involving involving often rash puplosquamous feet of soles handsand of palms Clinical Presentation Clinical Secondary Syphilis Secondary

National Antibiotic Guidelines

255

VDRL is VDRL is

titer;OR

Comments

VDRL in the presence of reactive reactive of presence the in VDRL mother’s the than

nontreponemal serologic titer fourfold fourfold titer serologic nontreponemal higher PE consistent with congenital syphilis; OR syphilis; congenital with consistent PE

2. 1. Any neonate with: neonate Any Pregnant women and those who are allergic to to allergic are who those and women Pregnant ated and tre desensitized be should penicillin withpenicillin. dependson a neurosyphilis of Diagnosis a and protein or count CSF cell of combination - CSF reactive and signs and neurologic results test serologic signs ic neurolog person a with In symptoms. - CSF reactive a symptoms, or neurosyphilis. of diagnostic considered

, asdoses3 ay

, administered administered ,

ay Tetracycline

ays d Procaine Penicillin G Penicillin Procaine

OR 14

OR 24 MU/d 24 ays 150,000 U/kg/d 150,000 – d – ays ays

d 18 d

intervals week 15

7.2 MU total, administered as 3 administered 7.2 MU total, 100,000

7.2 MU total, administered total, 7.2MU Regimen

Penicillin G

SEXUALLY TRANSMITTED INFECTIONS week interval week 100mg PO bid x 30 x bid PO 100mg ays Penicillin G

Doxycycline Benzathine Penicillin G Penicillin Benzathine : Aqueous Crystalline Aqueous Benzathine Penicillin G Penicillin Benzathine

q4h or continuous infusion x 10- infusion or q4h continuous IV 4 MU

: : line line:

st nd 500mg PO qid x 30 x qid PO 500mg 50,000 U/kg/dose IM x 1 dose for 10- for dose x1 IM U/kg/dose 50,000 Adult as3– Crystalline Aqueous 7 life daysof first the q12h during IV U/kg/dose as 50,000 administered of 10 – total a for and q8h thereafter 1 1- ck at butto each IM MU 2.4 dosesof 2 Adult each at1- MU IM 2.4 of

Etiology efers to gummas and gummas to efers Congenital Syphilis Congenital Proven or Highly Probable Highly or Proven Congenital Syphilis Congenital

Neurosyphilis cardiovascular syphilis but not not to but syphilis cardiovascular neurosyphilis. R Tertiary Syphilis Tertiary

National Antibiotic Guidelines

256 or an

Erythromycin

Comments

ent was appropriate for the stage of stage the for appropriate was ent

opriate regimen nonpenicillin (e.g. G) mother was treated during pregnancy, pregnancy, during treated was mother treatm administered was and treatment infection, and delivery, before weeks >4 or reinfection of evidence has no mother relapse relapse positive darkfield test or PCR of lesions or of lesions PCR or test darkfield positive body fluid(s). delivery. before weeks <4 mother was not treated, inadequately inadequately treated, not was mother having of or hasno documentation treated, treatment; received motherwas treatedwith inappr treatment recommended received mother

1. 2. 3. examination and a serum quantitative quantitative and a serum examination or less to equal titer serologic nontreponemal of the and both titer maternal the fourfold than are true: following Any neonate who has a normal physical physical normal a has who neonate Any quantitative serum and a examination or less to equal titer serologic nontreponemal and one of the titer maternal the fourfold than following: 1. physical normal a has who neonate Any 3. 2. -

of life ays , d

ay Do not treat notDo treat

Benzathine Penicillin Penicillin Benzathine

Procaine Penicillin G Penicillin Procaine

OR 150,000 U/kg/d 150,000

– 3 months for 6 months for monthsfor 6 for 3 months

OR ays d ays d 100,000

Regimen up every 2– every up -

DRL RPR <1:2; <1:4). 50,000 units/kg IM x 1 dose units/kg 50,000

SEXUALLY TRANSMITTED INFECTIONS Penicillin G

50,000 U/kg IM x dose 1 IM U/kg 50,000

and q8h thereafter for a total of 10 total a for and q8h thereafter 10 x 1 dose for IM kg/dose U/ 50,000 Benzathine penicillin G penicillin Benzathine follow serologic do close but fourfold least at decreased titers nontreponemal mother’s whose infants low for stable remained or syphilis early for therapy appropriate after titer,latent syphilis (e.g., V Crystalline Aqueous 7 first the q12h during IV U/kg/dose as 50,000 administered

Etiology

Congenital Syphilis less likely less Syphilis Congenital

Possible Congenital Syphilis Congenital Possible

National Antibiotic Guidelines

257

ptoms. Treatment of of Treatment ptoms.

Comments

s treatment was adequate before was before adequate s treatment to penicillin should be desensitized and shoulddesensitized be penicillin to RPR <1:4). mother’ and pregnancy titer serologic nontreponemal mother’s during and before and stable low remained <1:2; (VDRL delivery at and pregnancy

The aim of treatment is removal of the wart wart of the removal is treatment of The aim sym of and amelioration bywart be guided should warts anogenital patient site; and anatomic number, size, convenience; treatment; of cost preference; experience. and provider effects; adverse in to 22 effective are methods Therapeutic Any neonate who has a normal physical physical normal a has who neonate Any serologic nontreponemal and a examination maternal the thanfourfold or less to equal titer true: are following of the both and titer 1. 2. for be screened women should pregnant All women Pregnant pregnancy. in early syphilis allergic treated with penicillin

pregnant women women pregnant

up is uncertain and the neonate has a neonate the and uncertain is up - Regimen 5% (or 3.75%) cream 3.75%) (or 5%

50,000 U/kg as a single IM injection might be might injection IM as U/kg single a 50,000

ffollow Cryotherapy with liquid nitrogen or cryoprobe cryoprobe or nitrogen liquid with Cryotherapy Trichloroacetic (TCA) acid Trichloroacetic SEXUALLY TRANSMITTED INFECTIONS

Imiquimod

is the only drug recommended for treatment of pregnant of pregnant treatment for recommended only drug the is

Administered: – Applied: - Surgical removal either by tangential scissor excision, tangential tangential excision, scissor by tangential either removal Surgical

. syphilis stageof the for appropriate Penicillin non- doseas in same the Give syphilis. with women Patient Provider OR or (electrocautery or electrosurgery laser, curettage, excision, shave electrocoagulation) No treatment is required, but infants with reactive nontreponemal tests tests nontreponemal reactive with but infants required, is treatment No test nontreponemal the ensure to serologically followed be should negative. to returns G penicillin Benzathine i particularly considered, test. nontreponemal reactive

Etiology n Pregnancy n i HPV and genital warts and genital HPV papillomavirus Human Anogenital Warts Anogenital

Syphylis Syphylis

Congenital Syphilis unlikely Syphilis Congenital National Antibiotic Guidelines

258 washed, washed,

c genital warts, warts, c genital molluscum molluscum limited and may not not and may limited - Comments . Infants and young children young children and .Infants

enital lesions to prevent prevent to lesions genital Treat . dried using the hot cycle, or dry or cycle, hot the using dried - Permethrin

be treated should children and young Infants with machine 94% in clearing exophyti in clearing 94% 25% least at , high is rate recurrence however 3 months. within and effective most the is destruction Physical curing of means rapid contagiosum healthy in Lesions contacts. sexual to spread self are individuals a have lesions Genital treatment. necessitate and neutropenia carcinogenicity, potential as nephrotoxicity. as well permanent potential aged <10 years should not be treated with with be treated not should years <10 aged be should and clothing Bedding lindane. - machine either (e.g., decontaminated

00ug/kg PO, PO, 00ug/kg Electrodessication Electrodessication

Ivermectin

OR Regimen 14h

rinse applied to affected areas and washed off off washed and areas toaffected applied rinse the neck bodyfrom the areas of all to applied SEXUALLY TRANSMITTED INFECTIONS

Imiquimod

Cryotherapy with liquid nitrogen nitrogen liquid with Cryotherapy

OR OR minutes Chemical agents (podophyllin, tretinoin, cantharidin, 25% to 50% 25% to 50% cantharidin, tretinoin, (podophyllin, agents Chemical

2 weeks in repeated

Permethrin 1% cream 1% Permethrin 10 after cream 5% Permethrin 8– after off washed and down Curettage OR potassium or iodine of tincture nitrate, silver acid, trichloroacetic hydroxide)

Etiology

Scabies scabiei Sarcoptes Pubic Lice Pubic Persons with pubic lice usually seek medical attention because of pruritus or because of lice or nits on hair. nits pubic or lice of because or pruritus because of attention seek medical usually lice pubic with Persons Ectoparasitic Infections Ectoparasitic Pubis Pediculosis

Molluscum contagiosum Molluscum

National Antibiotic Guidelines

259

Comments cleaned) or removed from body contact for at at for body contact from removed or cleaned) be should scabies with Persons . 72hours least to trimmed closely keep fingernails to advised excessive scratching. from jury in reduce

Regimen SEXUALLY TRANSMITTED INFECTIONS

Etiology National Antibiotic Guidelines

260

12).

. Edition 8th Set, Volume

2016.

. SEXUALLY TRANSMITTED INFECTIONS 29 August 2016. August 29 28 August 2016. August 28

. Diseases of Infectious the on Committee Report . Medicine JohnHopkins Inpatients. Adult for Recommendations Treatment 2014.

Chlamydia trachomatis trachomatis of Chlamydia the treatment for guidelines WHO Feigin RD, et.al, Textbook of Pediatric Infectious Diseases. 7th edition, Philadelphia: Saunders Elsevier; 2014. Elsevier; Saunders Philadelphia: edition, 7th Diseases. Infectious Pediatric Textbook of et.al, RD, Feigin 2- Diseases: Infectious of and Practice Principles and Bennett’s Douglas, Mandell, 2015 Edition. 30th Book, Red e.com) (http://webedition.sanfordguid Edition. Web 2015. Guide Sanford Edition 44th Therapy2014, to Antimicrobial Guide The Sanford REFERENCES - 2013 Guidelines Antibiotic Antimicrobial Resistance Surveillance Program 2014 Report 2014 Program Surveillance Resistance Carlos C. Antimicrobial 3. 64. No. Vol. 2015: 5, June Rep Recomm 2015. MMWR Guidelines, Treatment Diseases Transmitted Sexually CDC RR- 2010;59(No. Rep MMWR Recomm guidelines. treatment diseases transmitted Sexually CDC. August 29 (syphilis) of Treponema pallidum the treatment for guidelines WHO Neisseria gonorrhoeae gonorrhoeae of Neisseria the treatment for guidelines WHO National Antibiotic Guidelines

261

is poor. is ents should be should ents - Directly centered, morbid conditions conditions morbid -

TB treatment shall be done shall treatment TB of SDFs availability ocal ALL children being treated for TB TB for treated being children ALL once least at weighed be should adjustment for allow to month every pati All dosage(s). of dose possible for monthly weighed adjustments. Anti- a patient through

1 2 3 4 HR Prothionamide (Pto), Cycloserine (Cs), Linezolid Linezolid (Cs), Cycloserine (Pto), Prothionamide (4 mos. HR) mos. (4 ethambutol 275 mg per per tablet. 275 mg ethambutol - Continuation phase Continuation pyrazinamide 150 mg per tablet. Give the entire dailydose entire the Give tablet. per 150 mg pyrazinamide

TUBERCULOSIS

400 mg, +/ 400 mg, 1 2 3 4

E (100 mg) (100 E pyrazinamide

(No. of tablets) (No.

) 3 4 1 2 HRZ Intensive phase (2 mos. HRZE) mos. (2 phase Intensive

aminosalicylic Acid (PAS) and Imipenem (Imp). These drugs will only be used in certified PMDT be certified only used in will drugs These and (Imp). Imipenem (PAS) Acid aminosalicylic -

DOHPUBLIC HEALTH PROGRAMS

15 24 7 11

- - – – 4 8 16 12 (Bdq), Para BODY WEIGHT (kg) WEIGHT BODY

Pediatrics (<15Y): Pediatrics

dose combination (FDC) preparation. (FDC) dose combination drugs: Rifampicin (R), Isoniazid (H), Ethambutol (E), Pyrazinamide (Z) Pyrazinamide (E), Ethambutol (H), Isoniazid (R), Rifampicin drugs:

Amikacin (Akx) Amikacin (Mfx), Moxifloxacin (Lfx), Levofloxacin (S), Streptomycin TB drugs: - TB drugs are: drugs TB - TB - (no treatment or or treatment (no

ed for the following situations: adverse reactions or at risk for adverse reactions; co- reactions; adverse for risk at or adversereactions situations: following the ed for recommend still are (SDF) formulations drug - susceptible TB susceptible

- - in fixed drugs TB once a day. once a Pediatric FDC dispersible scored tablet: Contains isoniazid 50 mg and rifampicin 75 mg, +/ 75 mg, rifampicin and mg 50 isoniazid Contains tablet: scored dispersible FDC Pediatric Adult FDC tablet: Contains isoniazid 75 mg and rifampicin 150mg, +/ 150mg, rifampicin and mg 75 isoniazid Contains tablet: FDC Adult centers. Bedaquiline (Cfz), Clofazimine (Lzd), Second line anti line Second First Line anti Line First

requiring dose adjustments (especially liver, kidney diseases); or expected to have significant drug interactions. However, l However, interactions. drug have significant to expected or diseases); kidney liver, (especially dose adjustments requiring Single • • Anti- • joints not involving meningitis, bones, bones, meningitis, involving not diagnosed) dissemination or with TB Miliary confirmed or clinically clinically or confirmed whether bacteriologically bacteriologically whether had undergone previous previous had undergone a month; than less for treatment Drug TB Pulmonary The available anti The available • TUBERCULOSIS (TB) TUBERCULOSIS National Antibiotic Guidelines

DOH PUBLICDOH HEALTH PROGRAMS (TUBERCULOSIS

262 -

TB drugs: drugs: TB - morbid morbid TB treatment treatment TB - TB regimen shall be shall regimen TB - gimens for EPTB. gimens for

ldren. Single drug formulation drug formulation Single ldren. conditions. anti patient’s A first (4) four least at of comprised dose combination Fixed drugs. line even for be used should (FDC) chi subsets specific for used be should such as those with patients of to reactions hypersensitivity and other anti rifampicin or renal hepatic reactions; drug impairment. belowon Summary Table to Refer of treatmentre Observed Treatment (DOT) to foster foster to (DOT) Treatment Observed Anti adherence. based be on shall regimen and bacteriologic site anatomical and resistance drug including status as as well treatment, prior of history co- of presence the

600 400 (mg)

2,000 1,200

Max dose/d Max

2 3 4 5

Adults 30) 20)

12) 6)

Continuation phase Continuation (4 mos. HR) mos. (4 – – – – BW)

Continuation phase Continuation 5 (4 5 (4 10 (8 (8 10 TUBERCULOSIS 25 (20 (20 25 (15 15

Dose (mg/kg (mg/kg Dose -

drug formulations) drug -

300 600

(mg) 2,000 1,200

Max dose/d dose/d Max

4 5 2 3

HRZE 15) 20) 40) 25) Pediatrics

– – – – BW) HRZE) (No. of tablets) (No. HRZE) Intensive phase (2 mos. HRZE) mos. phase (2 Intensive Intensive phase (2 mos. mos. phase (2 Intensive 10 (10 (10 10 (10 15 (20 30 (15 20 Dose (mg/kg (mg/kg Dose Adult dose and preparations dose Adult

DOHPUBLIC HEALTH PROGRAMS

70 54 37

- 25 – –

TB Drug >70 > -

30 55 38

ANTI BODY WEIGHT WEIGHT BODY

BODY WEIGHT (kg) WEIGHT BODY

Ethambutol (<15Y): Pediatrics Isoniazid Rifampicin Pyrazinamide Drug Dosage per kg body weight (if using single (if kg body weight per Dosage Drug Adults:

pulmonary TB (EPTB): TB (EPTB): pulmonary susceptible TB susceptible - - CNS, bones or joints or bones CNS, Drug Extra bones, joints bones, diagnosed) EXCEPT CNS, CNS, EXCEPT diagnosed) confirmed or clinically clinically or confirmed (whether bacteriologically bacteriologically (whether Extrapulmonary TB (EPTB) TB Extrapulmonary

National Antibiotic Guidelines

263

weeks, 30 weeks, 8, 15 for 8, mg 8 weeks

10 and 5 mg for week week for mg 5 and 10 resistance profile. Empirical Empirical profile. resistance

Prednisolone pericarditis: TB 4 first the for mg 60 5- weeks for mg 9- weeks 11. Dexamethasone meningitis: TB a reducing with 0.4mg/kg/24h 6- over course

• • Refer to Table below on Summary belowon Summary Table to Refer EPTB. for regimens treatment of All newly diagnosed PLHIV should should PLHIV diagnosed newly All All TB. active for screened be cough of any duration, with PLHIV Referral to relevant specialties is is specialties relevant to Referral of Use EPTB. for recommended as adjunctive corticosteroids for ONLY recommended is therapy and/or meningitis TB with patients pericarditis. TB

HR)

- 1 2 3 4 HR) HR

resistant TB. The standard of care is performance performance is care of The standard TB. resistant mos. mos. - drug based on the ent - HR 10 ( mos. mos. 10 ( resistant TB. resistant - Continuation phase Continuation

TUBERCULOSIS

- 5 2 3 4

1 2 3 4 fordrug

s E (100 mg) (100 E

HRZE

(No. of tablets) (No. sputum specimens and then treatm specimensthen and sputum

f 1 2 3 4 o HRZ HRZE) (No. of tablets) (No. HRZE) Intensive phase (2 mos. mos. (2 phase Intensive

2 3 4 5 Adult dose and preparations dose Adult

TB) DOHPUBLIC HEALTH PROGRAMS

37 54 70

7 15 24 11

testing susceptibility 25 – – – – – – – 4 > (kg) 8 12 16 > 70 kg > 30 38 55 related TB, the priority is to treat TB. Standard TB regimen for HIV for regimen TB TB. Standard to treat is TB, the priority related

- BODY WEIGHT (kg) WEIGHT BODY

In HIV population. general as the same the is TB associated Adults: resistant TB (MDR/RR resistant - orRifampin

Xpert MTB/RIF, mycobacterial culture and culture mycobacterial MTB/RIF, Xpert (HIV) PEOPLE LIVING WITH HUMAN LIVING PEOPLE VIRUS IMMUNODEFICIENCY INDIVIDUAL CONDITIONS/SPECIAL SITUATIONS CONDITIONS/SPECIAL INDIVIDUAL of center treatment to be must referred patients Such recommended. NOT is treatment Multidrug of drug risk at are disease of or have recurrence failed have been interrupted, treatment whose Persons National Antibiotic Guidelines

264

void void

infected infected - Pyridoxine because of of because - x chest dergo 25 mg/d. - is the preferred NNRTI NNRTI preferred the is nevirapine

drug interactions. interactions. drug individuals, it is important to note note to important is it individuals, last. be reintroduced should RIF that - drug (Vitamin B6) at 10 Glucose control should be optimal, optimal, be should control Glucose is specialist to referral control to difficult for recommended diabetes nota or whether ascertain Always she before pregnant is woman t. treatmen TB First linestarts anti - pregnant for safe are drugs TB fever, night sweats, or loss of weight weight of loss or sweats, night fever, for collection sputum undergo shall these without PLHIV testing. Xpert un should symptoms rule to assessment clinical or ray EPTB. out be cutaneous there Should HIV in observed reactions Efavirenz forPLHIV on TB treatment. A the use of use of the

ay. 25mg/d TUBERCULOSIS

week of TB treatment. For patients with TB TB with For patients TB of treatment. week

nsive Phase of TB treatment. treatment. of Phase TB nsive Inte the after given be should DOHPUBLIC HEALTH PROGRAMS ARV should be initiated after 2 the after initiated be should

Standard TB regimen for pregnant is the same as the general population. Pregnant Pregnant population. general the as the same is pregnant for regimen TB Standard 10- at B6) (Vitamin Pyridoxine given be should Isoniazid taking patients Same as general population general as Same ARV meningitis,

S MELLITUS S E

PREGNANCY DIABET

National Antibiotic Guidelines

265

TB -

equal to only a small small a only to equal

women, EXCEPT streptomycin (an (an streptomycin EXCEPT women, contraindication). ABSOLUTE with afflicted woman Breastfeeding of course full a receive should TB mothers In lactating treatment. TB most anti treatment, TB on in milk in breast be found will drugs concentrations in dose therapeutic of the fraction infants. 10

Pyridoxine Pyridoxine should be given at 5- at given be should TUBERCULOSIS

- treatment that she has the following options: hasthe she following that treatment or whose breastfeeding mother is is mother breastfeeding whose or

isoniazid

9HRE Refer to the the to Refer symptoms. of absence the even in should be interrupted treatment

or aking aking

Pyridoxine Supplemental 25mg/day.

2HSE/10HE DOHPUBLIC HEALTH PROGRAMS at 10- or to the infant t is who infant the to

. isoniazid ay Take an OC pill containing a higher dose of estrogen (50 u) following consultation with a clinician with consultation u) following (50 estrogen dose of a higher containing pill an OC Take Use another form of contraception form another Use

1. 2. For compensated liver cirrhosis): liver compensated For

(Vitamin B6) mg/d specialist. appropriate ( 2HRSE/6HR pregnancy. Advise a woman receiving OC while on Rif on Rif while OC receiving woman a Advise pregnancy. alanine with those used for regimen oralternative modified generally and interrupted be should Treatment jaundice. symptoms/or hepatitis presence of the in (ULN) ofnormal limit upper the >3x elevation (ALT) aminotransferase ULN, 5x the elevated is ALT If general population. Breastfeeding/Lactating women should be given given be should women Breastfeeding/Lactating population. general against efficacy decreased protective of a risk with medications (OC) contraceptive oral with interacts Rifampicin Standard TB regimen for breastfeeding/Lactating women is the same as the as the the same is women breastfeeding/Lactating for regimen TB Standard

taking taking

CHRONIC LIVER DISEASE LIVER CHRONIC DISEASE LIVER OF LIVER DISEASE / HISTORY / DISEASE LIVER

ORAL CONTRACEPTIVES ORAL BREASTFEEDING/LACTATING BREASTFEEDING/LACTATING WOMEN National Antibiotic Guidelines

266 R.It

TB - drug FDC FDC drug

medications should should medications

TB drug FDC (HR) for the rest of of rest the for (HR) FDC drug medications be taken after after taken be medications hemodialysis. Noting the recommendations cited, cited, recommendations the Noting togive a 4- possible is it week give 3xper and then (HRZE) a 2- Intensive the during week the may Phase Continuation Phase. Otherwise, 4HR. with proceed is 2HRZ/4H option safe another anti that recommended is drugs should be used. be should drugs

go regular ophthalmologic screening (visual acuity and acuity (visual screening ophthalmologic regular go TUBERCULOSIS

Dose Adjustments for Patients with Kidney Anti. Kidney Disease - with Patients for Adjustments Dose is recommended. is

ethambutol DOHPUBLIC HEALTH PROGRAMS and 15 mg/kg/dose 2 or 3x per week 2 or mg/kg/dose 15 25 mg/kg/dose 3x per week (NOT daily) (NOT week 3xper mg/kg/dose 25 35 mg/kg/dose 3x per week (NOT daily) (NOT week 3xper mg/kg/dose 35 - -

Please refer to the Table below on Tablebelow to the refer Please over preferred are SDFs dialysis. peritoneal during ANYTIME or hemodialysis AFTER immediately administered be drugs. line second receiving those for made are adjustments Same adjustments. dose proper facilitate to FDCs S: 12 E: 15 H: 300 mg od; or 900 mg 3x per week or 3xper 900 mg od; 300 mg H: week or 3xper 600 mg od; 600 mg R: 25- Z: It is possible to defer TB treatment until acute hepatitis has been resolved. When it is necessary to treat TB during acute acute during TB treat to necessary is it When resolved. been has acute hepatitis until treatment TB defer to ispossible It has the hepatitis Once for 3 months. and ethambutol streptomycin of combination the is safest option the hepatitis, be should SE resolved, been hasnot hepatitis the If (3SE/6HR). given is monthsHR 6 of Phase a Continuation resolved, to a specialist. patients all Refer (12SE). months 12 of a total for continued daily of instead weekly Thrice clearance. on creatinine based dosagefrequency and in modified 2HRZE/4HR pyrazinamide Patients undergoing prolonged ethambutol treatment should under should treatment ethambutol prolonged undergoing Patients is SLDs possible use of because tospecialist a Refer cirrhosis: liver Fordecompensated discrimination). color red/green hepatotoxic of number fewer the disease, liver advanced The more the warranted.

th reduced reduced th

hemodialysis) renal function or receiving or receiving function renal RENAL FAILURE (wi RENALFAILURE

SE DISEA KNOWN CHRONIC CHRONIC KIDNEY KNOWN

ACUTE VIRAL HEPATITIS ACUTEVIRAL

National Antibiotic Guidelines

267

Dialysis Peritoneal Peritoneal None

Hemodialysis

After dialysis

Dose Adjustment Dose GFR ≤30 ml/min

TUBERCULOSIS

evidence STRONG recommendation, STRONG evidence quality Low evidence quality Moderate recommendation, STRONG evidence quality Moderate recommendation, STRONG evidence quality Moderate recommendation, STRONG recommendation, STRONG evidence quality Low Recommendation/ Level of Evidence of Level Recommendation/ recommendation, STRONG quality High evidence quality Moderate recommendation, STRONG evidence quality Moderate recommendation, STRONG GFR ≥30 ml/min

DOHPUBLIC HEALTH PROGRAMS HR 4 HR None pulmonary TB pulmonary -

2 HRZE / 4HR 2 HRZE / 2 HRZE / 2 HRZE / 10 HR 2 HRZE / 10 HR 2 HRZE / 4HR 2 HRZE / 4HR 2 HRZE / 4 2 HRZE / 4HR 2 HRZE / Regimen

function) 6) mg/kg/d - (normal renal (normal

(4 Reference dose Reference 5 300 mg/d) (max

Anti TB Drug

Isoniazid Kidney and Genitourinary tract and Genitourinary Kidney Liver Peritoneum Gastrointestinal, Pleura Lymph node Lymph Pericardium Bone and Joints and Bone Site System Nervous Central National Antibiotic Guidelines

Dose Adjustments for Patients with Kidney Disease with Patients for Adjustments Dose

Summary of treatment regimens for Extra for regimens treatment of Summary

268

35 mg/kg, 35 mg/kg, 25 - - None 25 3x/week 15 3x/week

dialysis dialysis

35 mg/kg, 35 mg/kg, 25 - - After dialysis 25 after 3x/week, 15 after 3x/week,

35 mg/kg, 35 mg/kg, 25 - - pine Coalition Against Tuberculosis Tuberculosis Against pineCoalition Philip Manila: Update. 2016

– 25 3x/week 15 3x/week

TUBERCULOSIS

3x/week

25 mg/kg, 25 edition. Sta. Cruz, Manila: DOH, 2014. DOH, Manila: Cruz, Sta. edition.

None

th Geneva, Switzerland: WHO, 2010. WHO, Switzerland: Geneva,

DOHPUBLIC HEALTH PROGRAMS None None 70 ml/min: > GFR - 70 ml/min:15 < GFR

20) mg/ 20) 30) mg/ 30) - - 12) mg/kg/d 12) - 15 (15 15 g/d) 1.2 (max kg/d 10 (8 10 600 mg/d) (max (20 25 g/d) 2 (max kg/d

Pyrazinamide Ethambutol Rifampicin (PhilCAT);2016 CPG for the Diagnosis, Treatment, Prevention and Control of Tuberculosis in Adult Filipinos Filipinos Adult in of Tuberculosis Control and Prevention Treatment, Diagnosis, the for CPG

REFERENCES

WHO Treatment of Tuberculosis Guidelines, 4th edition. edition. 4th Guidelines, of Tuberculosis Treatment WHO National Tuberculosis Control Program Manual of Procedures, 5 Procedures, Manual of Program Control Tuberculosis National National Antibiotic Guidelines