Bronchitis - Chronic in Acute Exacerbation (1 of 11)

1 Patient w/ chronic bronchitis presents w/ increasing symptoms

2 DIAGNOSIS Is acute exacerbation of No ALTERNATIVE chronic bronchitis DIAGNOSIS (AECB) con rmed?

Yes

3 EVALUATION Mild Does patient have mild, Severe moderate or severe exacerbation?

Moderate

A Non-pharmacological A Non-pharmacological A Non-pharmacological therapy therapy therapy • Lifestyle modi cation • Lifestyle modi cation • Lifestyle modi cation • Patient education MIMS• Patient education • Patient education B Pharmacological therapy • Supportive therapy • Supportive therapy • Bronchodilators (Inhaled) - O, if required - O, if required - Noninvasive - Noninvasive positive-pressure positive-pressure ventilation, if required ventilation, if required B Pharmacological therapy B Pharmacological therapy • Bronchodilators (Inhaled) • Bronchodilators (Inhaled) • Corticosteroids (Systemic) • Corticosteroids (Systemic) © • Empiric antibiotics • Empiric antibiotics

Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

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1 ACUTE EXACERBATION OF CHRONIC BRONCHITIS (AECB)

• Chronic bronchitis: Clinical diagnosis of sputum expectoration on most days during at least 3 consecutive months for ≥2 consecutive years • Symptoms of exacerbation are increase in dyspnea, sputum volume & sputum purulence over baseline

2 DIAGNOSIS BRONCHITIS - CHRONIC • Diagnosis is typically based on clinical presentation Clinical Presentation History • History of chronic bronchitis w/ acute onset of symptoms which include the following: - Major criteria: Increase in sputum volume, increase in sputum purulence & increased dyspnea - Minor criteria: Wheezing, sore throat, cough & symptoms of a common cold (eg nasal congestion/discharge, fever, 20% increase in respiratory rate or heart rate above baseline) • Exacerbation is usually considered if at least 2 major criteria are present or depending on the de nition used, the presence of at least 1 major & 1 minor symptom for at least 2 consecutive days Physical Exam • ere are no characteristic physical ndings in acute exacerbation of chronic bronchitis (AECB) but the following physical ndings may be found: - Increased respiratory rate - Increased wheezing - Di use crackles without localization, may be present • Consider the possibility of pneumonia if there is evidence of consolidation (eg localized crackles, bronchial breath sounds, dullness on percussion) • Elevated body temperature usually suggests viral infection or underlying pneumonia as a cause of an AECB Risk Factors for Exacerbations • Tracheobronchial infections (eg in uenza, streptococcal infection) • Environmental exposures (eg air pollution) • Noncompliance w/ inhaled bronchodilator therapy or pulmonary rehabilitation program Further Investigations Chest X-Ray • Chest X-ray is not helpful in making the diagnosis of AECB - May consider if needed to exclude other diseases that may complicate the condition eg pneumonia or congestive heart failure (CHF) Gram Stain/Culture • Sputum Gram stain & culture should be limited to patients w/ severe chronic obstructive pulmonary disease (COPD), frequent exacerbations or bronchiectasis in whom the presence of more virulent &/or resistant bacteria is more likely - Gram stain/culture has a limited role in the investigation of AECB since 30-50% of chronic bronchitis su erers are colonized w/ non-encapsulated Haemophilus inﬂ uenzae, Streptococcus pneumoniae & Moraxella catarrhalis Pulmonary Function • Pre-morbid forced expiratory volume in 1 second (FEV) values are a predictor of adverse outcomes during an AECB but it is not necessary to performMIMS FEV during the actual exacerbation • ere is no clear correlation between transient falls in lung function & the severity of exacerbation - Objective measurements of pulmonary function should be done after the recovery of patients w/ AECB

O2 Saturation, Arterial Blood Gas • Measurement© of O saturation (+/- blood gases) is recommended in moderate to severe cases to guide therapy

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3 EVALUATION

Severe Exacerbation • Severe exacerbation is considered when all 3 major criteria are present: - Increase in sputum volume, increase in sputum purulence & increased dyspnea • Patients w/ severe exacerbations are more likely to bene t from antibiotic treatment Moderate Exacerbation • Moderate exacerbation is considered when 2 of the 3 major criteria are present BRONCHITIS - CHRONIC • ese patients may bene t from antibiotic treatment Mild Exacerbation • Mild exacerbation is considered when 1 of the major criteria is present along w/ at least 1 minor criteria • Studies have shown that antibiotics are generally no more e ective than placebo in these patients

GOALS OF THERAPY

• Rapid resolution of symptoms • Prevent transient loss of pulmonary function • Reduce the bacterial burden in the lower respiratory tract • Prevent relapse or lengthen the time between exacerbations • Re-evaluation of the disease to reduce the risk of future exacerbations

A NON-PHARMACOLOGICAL THERAPY

Lifestyle Modi cation Smoking Cessation • A discussion of smoking behavior & the setting of a speci c cessation date should be part of every physician-patient encounter • Patients presenting w/ AECB should be encouraged to stop smoking since it is the most e ective way to reduce the risk of future morbidity from chronic bronchitis • It can lead to dramatic symptomatic bene ts for patients w/ chronic bronchitis eg stopping cough in 94-100%; when coughing stops, it can occur in as quickly as 4 weeks in 54% of patients Reduction/Elimination of Irritants • Reduction or elimination of any source of irritants that may worsen lower airway in ammation - Includes environmental pollutants (eg dust, pollutants & second-hand smoke) & occupational irritants Patient Education • Educate patient about the nature of the chronic bronchitis (the progressive nature & its potential impact on future lifestyle & function) • Review w/ the patient the signs of onset of infection (eg increased purulence, viscosity or volume of secretions) that should be treated early • Discuss measures that may limit the spread of viral infections (eg hand washing) • Encourage patients to exercise regularly - Although not accompanied by measurable improvement in lung function, it will increase exercise tolerance & improve the patient’s sense of well-being Supportive erapy MIMS Hydration • Maintain adequate hydration to prevent excessive mucus viscosity Nutritional Programs • ere are no direct or measurable e ects on lung function in treating malnutrition but subjective relief & objective improvement in strength & exercise performance do occur - Dietary supplementation should be considered if patient is malnourished (body weight <85% of ideal) or experiencing early satiety • Advise patient© to obtain nutritional counseling to reduce weight if obese

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A NON-PHARMACOLOGICAL THERAPY (CONT'D)

Supportive erapy (Cont'd) Oxygen erapy • Cornerstone of COPD exacerbation treatment • Low- ow O should be administered if hypoxemia is present • Excess use of O should be avoided as this may lead to progressive hypercapnia, either by decreasing hypoxic ventilatory drive or by worsening ventilation-perfusion mismatching within the lungs BRONCHITIS - CHRONIC • Once O therapy is initiated, arterial blood gas should be monitored 30-60 minutes later to ensure satisfactory oxygenation without acidosis or CO retention • Goal of supplemental O therapy should be arterial oxygen partial pressure at or just above 60 mmHg Noninvasive Positive Pressure Ventilation • Frequently used for inpatient management of AECB patients who are signi cantly hypoxemic or w/ a serum pH <7.3 • Improves ventilation & lower pCO levels & may be a means of avoiding intubation • Decreases hospital or intensive care unit length of stay & morbidity

B PHARMACOLOGICAL THERAPY

Bronchodilators • Bronchodilators should be used for the treatment of dyspnea accompanying an exacerbation Short-Acting Anticholinergics (Inhaled) • Eg Ipratropium bromide • E ects: An e ective bronchodilator w/ a slower onset of action & a slightly longer duration of action compared to short-acting beta-agonists, but no appreciable di erence between the two in terms of e ects on pulmonary function - Decreased cough frequency & sputum volume have been noted in patients using Ipratropium - Side e ects may be fewer compared to Salbutamol • Available in metered-dose inhalers (MDIs) & nebulizer solution - ere is no signi cant di erence in pulmonary function outcomes between delivery system, but in most situations, MDIs w/ an appropriate spacer would be preferred Short-Acting Beta -Agonists (Inhaled) • Short-acting inhaled beta-agonists are usually the preferred bronchodilators - Addition of anticholinergics is recommended should there be no prompt response w/ inhaled beta2-agonists • Produce e ective bronchodilatation w/ a faster onset of action than anticholinergics, but no appreciable di erence between the two in terms of e ects on pulmonary function • Available in MDI & nebulizer solution • e role of long-acting beta-agonists has not been studied in AECB therefore are not recommended for treatment of the condition at the present time Methylxanthines • e use of methylxanthines in AECB is not indicated

- e addition of Aminophylline to inhaled bronchodilators does not appear to improve FEV1 • Patients already on methylxanthines should continue the medications but monitor for drug interactions w/ antibiotics MIMS Corticosteroids • e use of oral or parenteral steroids is supported for most patients w/ moderate to severe AECB • Action: Reduce airway edema & mucus hypersecretion • E ects: Rapid improvement in pre- & post-bronchodilator FEV1, rapid recovery of partial pressure of O2, decreased treatment failures, shorter hospitalization rates, speed up recovery in AECB & may reduce the frequency of exacerbations & likelihood of relapse Inhaled Corticosteroids • Recommended in stable patients when air ow obstruction is severe or very severe (eg FEV1 <50%) & when there is a ©history of frequent exacerbations

Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

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B PHARMACOLOGICAL THERAPY (CONT’D)

Corticosteroids (Cont'd) Systemic Corticosteroids • Bene cial in cases of signi cant pulmonary compromise, particularly if the patient requires hospitalization • Treatment is recommended for 5-14 days • e exact dose & duration of therapy should be individualized - Eg e use of high-dose & prolonged steroids must be carefully weighed in the elderly patients BRONCHITIS - CHRONIC - Prednisone PO is usually used initially at a dosage of 0.5-1.0 mg/kg/day & then tapered at a rate & duration based on response • IV corticosteroids may be used initially in severely ill patients or in patients who are unable to take oral medications • In studies, the major side e ect in the steroid-treated group was hyperglycemia Empiric Antibiotic erapy Based on the current available evidence, antibiotic therapy should be given in patients w/ exacerbations of chronic obstructive pulmonary disease (COPD) if: • W/ presence of the 3 cardinal symptoms (increased dyspnea, increased sputum purulence & increased sputum volume) • Two of the cardinal symptoms are present w/ increased sputum purulence as one of the 2 symptoms • e exacerbation is severe requiring mechanical ventilation (invasive or noninvasive) • e recommended duration of therapy is 5-7 days - Short-duration antimicrobial treatment is as e ective & safer than long-duration therapy & is associated w/ fewer adverse events, better compliance, reduce risk of development of bacterial resistance & lower costs erapy should be based on local resistance patterns along w/ patient risk strati cation to prevent therapeutic failure • Some studies have shown that severity of bronchitis is an important determinant of the type of pathogen - S pneumoniae predominates in patients w/ mild exacerbation - H infl uenzae & M catarrhalis are the frequent pathogens as FEV declines & patients have more frequent exacerbations &/or comorbid diseases - P aeruginosa may be present in those w/ severe airway restriction • Antibiotics used should have signi cant in vitro & in vivo activity against the pathogens most commonly associated w/ AECB, including H infl uenzae, S pneumoniae & M catarrhalis, w/ minimal adverse e ects, & good penetration into sputum & bronchial mucosa • In patients w/ more severe airway obstruction, coverage may need to be extended to include other potential pathogens (eg Gram-negative bacilli) • Aminopenicillins, Co-trimoxazole & Doxycycline are considered 1st-line antibiotics for AECB - Emergence of antimicrobial resistance in bacteria frequently associated w/ acute exacerbations of chronic bronchitis have limited its use • Amoxicillin/clavulanic acid, macrolides, 2nd- or 3rd-generation cephalosporins & quinolones are good alternatives in areas w/ increasing antibiotic resistance to older agents - Associated w/ fewer clinical failures compared w/ use of 1st-line agents Aminopenicillins • Recommendation for treatment of simple AECB w/ aminopenicillins is justi ed since there are no clinical or pharmacoeconomic studies showing the advantage of more potent agents • No activity against atypical & beta-lactamase-producing pathogens, limited activity against Enterobacteriaceae • High dose is e ective against Penicillin-resistantMIMS S pneumoniae Aminopenicillin/Beta-lactamase Inhibitors • Covers major bacterial pathogens including beta-lactamase-producing pathogens, moderate activity against Enterobacteriaceae, but no activity against atypical pathogens • High dose of Aminopenicillin component is e ective against Penicillin-resistant S pneumoniae • Short-term e ectiveness of Amoxicillin/clavulanic acid is equivalent to that of macrolides & quinolones Cephalosporins (2nd & 3rd Generation) • If resistant S pneumonia & H infl uenzae is a concern, selected 2nd & 3rd generation cephalosporins may be preferred over older agents • O er enhanced stability against beta-lactamases of H infl uenzae, H parainfl uenzae & M catarrhalis & improved e cacy against© Penicillin-susceptible S pneumoniae & Methicillin-susceptible S aureus

Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

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B PHARMACOLOGICAL THERAPY (CONT’D)

Empiric Antibiotic erapy (Cont’d) Co-trimoxazole [Sulfamethoxazole (SMZ) & Trimethoprim (TM)] • Recommendation for treatment of simple AECB w/ Co-trimoxazole is justi ed since there are no clinical or pharmacoeconomic studies showing the advantage of more potent agents • Covers major bacterial pathogens, no activity against atypical pathogens & resistance in S pneumoniae is common; resistance limits its usefulness

BRONCHITIS - CHRONIC • May be an acceptable alternative for patients who are allergic to Penicillin Doxycycline • Recommendation for treatment of simple AECB w/ Doxycycline is justi ed since there are no clinical or pharmacoeconomic studies showing the advantage of more potent agents • Covers major bacterial & atypical pathogens, but S pneumoniae resistance is common • Alternative to quinolones & macrolides when atypical coverage is required • Acceptable as an alternative for patients who are allergic to Penicillin, cephalosporins & newer macrolides Advanced Macrolides & Ketolide • If resistant S pneumoniae & H inﬂ uenzae are a concern, advanced macrolides may be preferred over older agents • Active against atypical pathogens, not active against Enterobacteriaceae, & macrolide-resistant S pneumoniae is common but this does not appear to reduce clinical e ectiveness - Ketolide is e ective against macrolide-resistant strains of S pneumoniae • Reasonable option in beta-lactam allergic patients Quinolones • Has good tracheobronchial penetration • Cover all major bacterial & atypical pathogens as well as Enterobacteriaceae & some agents cover P aeruginosa • Quinolones w/ enhanced activity to drug-resistant S pneumoniae are preferred - Eg Levo oxacin, Moxi oxacin • Cipro oxacin - Considered 1st-line agents in ambulatory AECB patients only if P aeruginosa coverage is required - Least active against S pneumoniae & should not be used routinely in the management of AECB; most active against P aeruginosa Other Pharmacotherapy Agents • Expectorants/cough suppressants have not been shown to improve lung function or hasten the clinical recovery but may produce a subjective improvement • Chronic use of mucolytics helps reduce the frequency of exacerbations & days of illness but does not improve ventilatory function • Chest physiotherapy has not been shown to improve lung function or hasten clinical recovery in AECB • ere is still no evidence supporting the use of leukotriene receptor antagonists in AECB

PREVENTION - IMMUNIZATIONS

In uenza Vaccine • e use of an annual in uenza vaccine for all patients w/ chronic bronchitis is strongly recommended - Patients w/ chronic lung disease have MIMSa higher risk of complications from in uenza infection - Annual in uenza vaccination decreases the morbidity & mortality of in uenza in the elderly by 50% • Please see In uenza disease management chart for further information Pneumococcal Vaccine • It is recommended that pneumococcal vaccine be administered at least once to patients w/ chronic bronchitis - Consider repeating vaccine every 5-10 years in high-risk patients • Pneumococcal© vaccine is safe & may reduce invasive pneumococcal infection in patients w/ COPD

Not all products are available or approved for above use in all countries. Speciﬁ c prescribing information may be found in the latest MIMS.

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Dosage Guidelines

ANTIBACTERIAL COMBINATIONS

Drug Dosage Remarks

Co-trimoxazole 800 mg SMZ & 160 mg BRONCHITIS - CHRONIC Adverse Reactions [Sulfamethoxazole TM PO 12 hrly • GI e ects (N/V, anorexia, diarrhea); Dermatological (SMZ) & e ects (rash, pruritus, photosensitivity); Trimethoprim Hypersensitivity reactions (rash, Stevens-Johnson (TM)] syndrome); Genitourinary e ect (crystallization in the urine) Special Instructions • Maintain adequate uid intake • Contraindicated in patients allergic to sulfonamides • Use w/ extreme caution or not at all in patients w/ hematological disorders especially megaloblastic anemia due to folic acid de ciency • Use w/ caution in patients w/ renal impairment & severe hepatic dysfunction

CEPHALOSPORINS

Drug Dosage1 Remarks

Second Generation Cefaclor 250-500 mg PO 8 hrly or Adverse Reactions 375-500 mg PO 12 hrly • Hypersensitivity reactions (urticaria, pruritus, rash, Max dose: 4 g/day anaphylaxis); GI e ects (diarrhea, N/V); Other e ect (candidal infections) Cefprozil 500 mg PO 12 hrly • High doses may be associated w/ CNS e ects Cefuroxime 250-500 mg PO 12 hrly (encephalopathy, convulsions) ird Generation • Prolonged prothrombin time (PT), prolonged activated partial thromboplastin time (aPTT), &/or Cefdinir 100 mg PO 8 hrly hypoprothrombinemia (w/ or without bleeding) have up to 300 mg PO 12 hrly been reported & occur most frequently w/ Cefditoren 400 mg PO 12 hrly N-methylthiotetrazole (NMTT) side chain-containing cephalosporins Cefetamet 500 mg PO 12 hrly Special Instructions Ce xime 100-200 mg PO 12 hrly • May be taken w/ food to decrease gastric distress Cefpodoxime 100-200 mg PO 12 hrly • Use w/ caution in patients allergic to Penicillin as there Ceftibuten 400 mg PO 24 hrly or may be 10% chance of cross sensitivity & w/ renal divided 12 hrly impairment ¹Unless otherwise indicated, length of therapy shouldMIMS be for 7-10 days © All dosage recommendations are for non-pregnant & non-breastfeeding women, & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. Not all products are available or approved for above use in all countries. Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information. Speciﬁ c prescribing information may be found in the latest MIMS.

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Dosage Guidelines

COUGH & COLD PREPARATIONS

Drug Dosage Remarks

Acetylcysteine 200 mg PO 8 hrly BRONCHITIS - CHRONIC Adverse Reactions (N-acetylcysteine) • GI e ects (GI disturbances, N/V); hypersensitivity Ambroxol 60-120 mg PO divided reactions (bronchospasm, rashes); Other e ect 8-12 hrly (hypotension) Extended-release: 75 mg Special Instruction PO 24 hrly • Use w/ caution in patients w/ gastric or duodenal ulcer Bromhexine 8-16 mg PO 6-8 hrly Carbocisteine Initial dose: 750 mg PO (Carbocysteine) 6-8 hrly, then 1.5 g/day PO in divided doses Cyclidrol 200 mg PO 12 hrly or up Adverse Reactions (Sobrerol) to 800 mg daily in divided • GI e ect (stomach pain); hypersensitivity reaction doses (rash) Special Instruction • Use w/ caution in patients w/ renal failure Erdosteine 300 mg PO 8-12 hrly Adverse Reactions • GI e ect (GI discomfort) Special Instruction • Contraindicated in patients w/ hepatic cirrhosis, hepatic impairment, cystathionine-synthetase enzyme de ciency & severe renal failure Guaifenesin 600 mg PO 12 hrly or Adverse Reactions 200 mg PO 4 hrly • GI e ects (GI discomfort, N/V) Max dose: 1200 mg in Special Instructions 24 hr • Use w/ caution in patients w/ persistent or chronic cough, asthma, chronic bronchitis or emphysema • Discontinue use if cough persists for >7 days w/ fever, rash or persistent headache Levodropropizine 60 mg PO 8 hrly Adverse Reactions • CNS e ect (somnolence, faintness, clouding of consciousness, dizziness, headache); Other e ects (palpitation, GI disturbances) Special Instructions • Use w/ caution in patients w/ excessive mucus discharge, limited mucociliary function, hepatic MIMSdysfunction, renal insu ciency & diabetes © All dosage recommendations are for non-pregnant & non-breastfeeding women, & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. Not all products are available or approved for above use in all countries. Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information. Speciﬁ c prescribing information may be found in the latest MIMS.

Dosage Guidelines

MACROLIDES

Drug Dosage1 Remarks

Erythromycin 1,000-2,000 mg/day PO BRONCHITIS - CHRONIC Adverse Reactions divided 6-8 hrly • GI e ects (N/V, abdominal discomfort, diarrhea & Roxithromycin 150 mg PO 12 hrly or other GI disturbances, antibiotic-associated diarrhea/ 300 mg PO 24 hrly colitis); Other e ect (candidal infections) • Azithromycin & Clarithromycin tend to cause less GI Advanced Macrolides disturbances than Erythromycin Azithromycin 500 mg PO 24 hrly x 3 days Special Instructions or • May take w/ food to decrease gastric distress 500 mg PO 24 hrly x 1 day • Use w/ caution in patients w/ hepatic dysfunction followed by 250 mg PO 24 hrly x 4 days Clarithromycin 250-500 mg PO 12 hrly Extended-release: 500-1000 mg PO 24 hrly Ketolide Telithromycin 800 mg PO 24 hrly x 5 days Adverse Reactions • GI e ects (N/V, diarrhea, atulence, abdominal pain, taste disturbances); CNS e ects (dizziness, headache, insomnia, drowsiness) Special Instructions • Avoid in patients w/ hypersensitivity to macrolide antibiotics, family history or congenital QT prolongation & myasthenia gravis • Use w/ caution in patients w/ coronary heart disease (CHD), arrhythmias, hypokalemia or hypomagnesemia, renal impairment, patients w/ history of hepatitis/jaundice

¹Unless otherwise indicated, length of therapy should be for 7-10 days MIMS © All dosage recommendations are for non-pregnant & non-breastfeeding women, & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. Not all products are available or approved for above use in all countries. Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information. Speciﬁ c prescribing information may be found in the latest MIMS.

Dosage Guidelines

PENICILLINS

Drug Dosage1 Remarks

BRONCHITIS - CHRONIC Aminopenicillins w/ or without Beta-Lactamase Inhibitors Adverse Reactions • Amoxicillin (Amoxycillin) 500 mg PO 8 hrly Hypersensitivity reactions (rash, urticaria, pruritus, Amoxicillin/clavulanic acid 625 mg PO 8-12 hrly or anaphylaxis); GI e ects (Co-amoxiclav, Amoxicillin/clavulanate) 750 mg PO 8 hrly or (diarrhea, N/V); Other 1 g PO 12 hrly e ect (candidal infections) Amoxicillin/sulbactam FC Tab 500 mg PO 8 hrly Special Instructions • Inj 1.5-3 g deep IM/IV/IV Avoid in patients w/ infusion 8 hrly Penicillin allergy • May be increased up to 150 Use w/ caution in patients mg/kg/day in severe infections w/ renal impairment Max dose: 4 g Sulbactam/ 8 g Amoxicillin 24 hrly Ampicillin 250-500 mg PO 6 hrly Routine: 250 mg PO 6 hrly High-Dose: 1 g PO 6 hrly Ampicillin/sulbactam (Sultamicillin: 375-750 mg PO 12 hrly Pro-drug of Ampicillin/sulbactam, the 2 drugs are linked chemically w/ a double ester) Antipseudomonal Penicillins w/ or without Beta-Lactamase Inhibitors Piperacillin 2-4 g IM/IV 6-8 hrly Max dose: 24 g/day Piperacillin/tazobactam 2.25-4.5 g IM/IV 6-8 hrly Ticarcillin 200-300 mg/kg/day IV divided 4-6 hrly Ticarcillin/clavulanic acid (Ticarcillin/ 1.6-3.2 g IV 6-8 hrly clavulanate) Unless otherwise indicated, length of therapy shouldMIMS be for 7-10 days © All dosage recommendations are for non-pregnant & non-breastfeeding women, & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. Not all products are available or approved for above use in all countries. Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information. Speciﬁ c prescribing information may be found in the latest MIMS.

Dosage Guidelines

QUINOLONES

Drug Dosage1 Remarks

Cipro oxacin 500-750 mg PO 12 hrly BRONCHITIS - CHRONIC Adverse Reactions • Gemi oxacin 320 mg PO 24 hrly x 5-7 days GI e ects (N/V, diarrhea, abdominal pain, dyspepsia, mesylate diarrhea, atulence, gastritis, anorexia); Hepatic e ects (increased ALT/AST, bilirubinemia, GGT, & Levo oxacin 500 mg PO/IV 24 hrly x γ-GGT); CNS e ects (headache, dizziness, sleep 7 days disorders, restlessness, drowsiness, tremor, anxiety, Lome oxacin 400 mg PO 24 hrly depression, nightmares, insomnia or suicidal thoughts); Dermatological e ects (rash, pruritus, Moxi oxacin 400 mg PO/IV 24 hrly x photosensitivity); Hypersensitivity reactions (rash, 5 days Stevens- Johnson syndrome, anaphylactic shock); O oxacin 400 mg PO 12 hrly Genitourinary e ects (vaginitis, genital pruritus, Pruli oxacin 600 mg PO 24 hrly fungal infection on reproductive organs) • Some quinolones have the potential to prolong the Sita oxacin 50 mg PO 12 hrly x 3-7 days QT interval hydrate Max dose: 100 mg PO 12 hrly Special Instructions Spar oxacin 400 mg PO 24 hrly x 1 day • Administer at least 2 hr before or 3 hr after Al- or followed by 200 mg PO Mg-containing antacids, dietary supplements 24 hrly x 5-10 days containing Zn or Fe or bu ered ddI preparations • Avoid exposure to strong sunlight or tanning beds • Use w/ caution in patients w/ epilepsy or history of CNS disorders, impaired renal or hepatic function, G6PD de ciency, history of QTc prolongation, uncorrected electrolyte disorders (eg hypokalemia or hypomagnesemia), & those receiving class IA or class III antiarrhythmic agents • Discontinue if Stevens-Johnson syndrome, epidermal necrolysis or erythema multiforme occurs

Unless otherwise indicated, length of therapy should be for 7-10 days

TETRACYCLINES

Drug Dosage1 Remarks

Doxycycline 200 mg/day PO 24 hrly or Adverse Reactions divided 12 hrly • GI e ects (N/V, diarrhea, antibiotic-associated Minocycline 100 mg PO 12 hrly diarrhea/colitis, dysphagia, esophageal ulceration); Dermatological e ect (photosensitivity); Other e ects Tetracycline 250-500 mg PO 6 hrly (candidal infections, discoloration of teeth, interference w/ bone growth in young infants/ MIMSpregnant women) Special Instructions • Avoid long exposure to sunlight or tanning beds - Take w/ plenty of uid while sitting or standing & well before retiring to bed • Patients w/ systemic lupus erythematosus are advised not to use Tetracyclines • Use w/ caution in renal or hepatic impairment

Unless otherwise indicated, length of therapy should be for 7-10 days

All dosage recommendations are for non-pregnant & non-breastfeeding women, ©& non-elderly adults w/ normal renal & hepatic function unless otherwise stated. Not all products are available or approved for above use in all countries. Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information. Speciﬁ c prescribing information may be found in the latest MIMS. Please see the end of this section for the reference list.