Antibiotic Guidelines

BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY Dhaka, Bangladesh October 2005 Antibiotic Guidelines BANGABANDHU SHEIKH M...

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BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY Dhaka, Bangladesh October 2005

Antibiotic Guidelines

BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY Dhaka, Bangladesh October 2005

ISBN

:

984-32-2715-8

Published by : Bangabandhu Sheikh Mujib Medical University Shahbag, Dhaka, Bangladesh

© All rights reserved by the BSMMU

First Edition: October, 2005 ,

Price: T k. 50.00

Printed by: Asian Colour Printing 130, DIT Extension Road Fakirerpool, Dhaka-1000 Tel: 9357726, 8362258

Acknowledgement All teachers of BSMMU who actively participate in preparing this guidelines.

Committee to prepare the manual I.

Prof. M . A. Mannan

Chairman

Pro-Vice Chancellor (Hospital)

2.

Prof. Md. Salehuddin

Member

Department of Ophthalmology

3.

Prof. Md. Ruhul Amin Miah

Member

Department of Microbiology

4.

Prof. M. J alilur Rahman

Member

Department of Hematology

5.

Prof. M. Anwar Hussain

Member

Department of Obstetrics & Gynecology

6.

Prof. Motiur Rahman Molla

PREFACE Member

Department of Maxillofacial Surgery

7.

Prof. Zahidul Haq

Member

Department of Surgery

8.

Prof. Nasim Akhter Chowdhury

Antibiotics are an expensive sector of modem medicine.

In

Bangladesh, we spend about forty percent of our pharmacy budget of more than Taka four thousand crores on antibiotics alone. No doubt antibiotics are essential medicines. They selectively kill organisms that are sensitive to them. As a result, if used for Member

prolonged periods, not only such use is uneconomic, but they also produce unwanted side effects and may encourage the overgrowth of

Department of Medicine

resistant organisms. As antibiotic resistance is increasing, antibiotic

9.

Dr. Hossain Imam Al Hadi

Member

Department of Otolaryngology

10.

Prof. Mir Misbahuddin Department of Pharmacology

abuse carries collective penalties for the individual patient and for the community. Therefore, antibiotics should be used carefully.

Member Secretary

Owing to geographical differences in bacterial sensitivity, each hospital has its own antibiotic guideline. Therefore, this booklet is published on treatment

guideline

that may help our doctors

overcome the above mentioned problems and thereby improve the quality of treatment. Our antibiotic guideline is mainly based on empirical treatment that we are using in BSMMU Hospital. This guideline will be reviewed and updated periodically because of continuing changes in the pattern

of bacterial resistance to antibiotic. In this booklet common diseases

Contents

are highlighted and their appropriate therapeutic recommendations are mentioned. Microbiological statistics of our hospital is presented, though inadequate, may be helpful for our doctors for proper selection of the antibiotic. Constructive criticism and useful suggestions for improving the quality and contents of this booklet are welcomed from its users.

I thank the chairman and members of the committee and contributing faculty members for their active support and help without which this publication on the safe use of antibiotics would not have been seen the light of the day.

� (Prof. M.A. Hadi) Vice Chancellor

Principles of antimicrobial therapy in infectious disease Collection of sample for culture

4

Microbiological statistics

10

Desirable serum antibiotic levels

24

Treatment of specific diseases

25

Acne vulgaris

26

Alveolar abscess

27

Alveolar osteitis (dry socket)

27

Amoebiasis

28

Bite wounds

29

Breast abscess/mastitis

30

Bronchiectasis

31

Bronchitis

32

Chancroid

33

Cellulitis

34

Cerebral abscess

35

Cholecystitis (acute)

36

Cholera

36

Conjunctivitis

37

Corneal ulcer

38

Cystitis (acute uncomplicated)

39

Dysentery (bacillary)

39

Eczema (infected)

40

Enteric fever

40

Febrile neutropenia

41

Genital herpes

42

Giardiasis

43

Gingivitis

44

Pyogenic liver abscess

44

Mastoiditis

44

ANTIBIOTIC GUIDELINE Meningitis

45

Neonatal sepsis

47

Otitis externa

47

Otitis media (acute suppurative)

48

Selection of antimicrobial agent depends on the following factors:

Oral thrush (candidiasis)

49

Agent:

PRINCIPLES OF ANTIMICROBIAL THERAPY IN INFECTIOUS DISEASE

Peptic ulcer (due to helicobacter pylori)

49

Pericoronitis

50

knowledge on possible organism in particular situation

Periodontal abscess

50

aware about situation possible load and virulence

Spontaneous bacterial peritonitis

51

Pharyngitis

51

Pneumonia

52

Prostatitis

55

Pyelonephritis (acute)

55

Sepsis in neuropathic foot in diabetes mellitus

56

Sinusitis

56

Syphilis

57

Tonsillitis

58

Tuberculosis

58

Urethritis (acute, for males)

62

identification of possible agent- identify/suspect

sampling to identify agent

Host and environment: identification of host and environmental factors site of infection immunological status nutritional status precondition affecting susceptibility- congenital heart disease, presence of foreign body, steroid, susceptible disease, liver/renal impairment, heart/respiratory failure

Choice of antibiotic:

Urinary tract infections

62

Vaginal candidiasis

63

Vaginal trichomoniasis

64

which drug to choose- pharmacokinetic properties

Vaginosis (bacterial)

64

choosing combination preparation

Wounds (infected)

65

Guideline for use of antibiotics in renal failure

66

Use of antibiotics in liver disease

67

Antibiotics in pregnancy

78

Drug present in breast milk

70

Management of anaphylactic shock

71

Antibiotic prophylaxis in surgery

72

Antibiotic prophylaxis for nonsurgical conditions

80

Antimicrobial agents associated with photosensitivity

84

Hospital infection control team

85

Index

89

empiric and specific

Monitoring response: clinical estimation of drug level development of resistance/ superinfection

Representative specimen collection before starting therapy It is important to obtain adequate and representative specimens from all potentially infected sites prior to the initiation of antimicrobial therapy. Appropriate antimicrobial therapy is based on definitive identification of pathogenic organisms,

which usually requires

culture. Once antimicrobial therapy has been started, cultures often are rendered sterile, even though viable organisms may remain in the host. It is also important to avoid or minimize contamination by surface contaminants and commensals when collecting specimens.

ANTIBIOTIC GUIDELINE


Initial empirical choice based on the most likely pathogens and susceptibilities In most cases, it may be impossible to determine the exact nature of the infecting organisms before institution of antimicrobial therapy. Initial therapy must therefore be empirical - to make a rational choice

Assays for drugs with narrow therapeutic:toxic ratio For antibiotics such as the aminoglycosides and vancomycin, the measurement of their concentrations in serum/plasma or other body fluids is often useful to avoid excessive levels which are associated

from the many currently available antimicrobial agents, the clinician

with toxicity, yet ensure that adequate (therapeutic) levels are

must be able to predict or "guess" infecting microorganism(s) and the

achieved.

antimicrobial susceptibility thereof.

In these cases, the use of

"bacteriological statistics" i.e. an awareness of those microorganisms most likely to cause infection in a given clinical

setting, in

conjunction with the local antibiotic resistance patterns, may be particularly helpful in choosing an empiric antimicrobial agent.

Pharmacokinetic properties of antibiotics Knowledge of the pharmacodynamic and kinetic properties of antibiotics is imperative in choosing the correct antibiotic and correct dose.

Subsequent need to adjust antimicrobial therapy in light of the sensitivity results

Time dependant killing: (penicillins, cephalosporins, macrolides).

Since different organisms vary in their susceptibility to antimicrobial

concentration (MIC) is crucial in predicting clinical outcome and

agents, it is imperative that we have some means for determining the

cure. Concentrations of members of this group of antibiotics are

antimicrobial susceptibility of the infecting organism(s). Once the

required to be above the MIC for at least 50% of the dosing interval.

pathogen has been isolated, susceptibility testing to be done.

Monitoring therapeutic response In many patients, it is possible to monitor the therapeutic response on clinical grounds alone. Thus the subsidence of fever, the return of well-being, and the disappearance of both local and systemic signs of infection in the patient, all signify an appropriate response. No further formal monitoring is necessary in most cases. An apparent failure to respond clinically may be due to either ineffectiveness of antimicrobial agent(s) (due to resistance or inappropriate route of administration) or to other reasons e.g. a localised infection that requires surgical drainage, or a superinfection

The time that the antibiotic exceeds the mimi mal inhibitory

If the bacterium is more resistant, the MIC is higher with subsequent reduction in time that the antibiotic concentration exceeds the MIC and therefore higher dosages of the drug may be required.

Concentration dependant antibiotics: (quinolones, aminoglyco sides). The more the antibiotic concentration exceeds the MIC, the more killing will take place (irrespective and independent of the time the concentration exceeds the MIC). For this group of antibiotics a ratio of concentration: MIC 10 is required. This implies that a dose regimen should be chosen which results in a serum or tissue concentration of at least 10 times the MIC. Failure to achieve this

etc. Careful reassessment is recommended when considering changes

concentration at the site of infection will lead to clinical and

of antimicrobial therapy.

bacteriological failure, and is likely to induce resistance to the entire

In certain situations, measurement of antimicrobial activity may be

class of antibiotic.

useful in predicting clinical response, e.g. determination of serum bactericidal activity (Schlichter test) in cases of infective endocarditis.

2

3



COLLECTION OF SAMPLE FOR CULTURE

Transport: All specimens should be processed in the laboratory within

URINE SAMPLE

following. a)

Collection:

b)

1. Male: Cleaning the urethral meatus with plain tap water (free skin retracted), allow to dry and at least 30 ml of mid stream urine

2 hours of

collection; if delay is unavoidable more than 2 hours use one of the Refrigerate the urine at

° 4 C in the same container.

Collect and transport in a container with boric acid (O.lg/

10 ml of urine). Any way delay should not be longer than 18 hours after collection.

(MSU) should be collected in sterile container. It is better to collect the first MSU passed at the beginning of the day.

2.

�

Labia is separated and morning mid stream urine (MSU)

should be collected in a wide mouth sterile container.

3.

Children:

Administration of drugs or antidiarrheal substances (mineral oil, barium, bismith, magnesium, antibiotics) should be terminated at least one week before stool collection. - Stool container should be a)

(a) Sterile adhesive bag: · (b) Suprapubic tap: Tap by fingers on the suprapubic region 1 hour after feed (one tap per second) for 10 seconds; 1 minute interval repeat the proced�re.

4.

STOOL SAMPLE

Female: The vulva is cleaned by cotton plug soaked with water

Clean, dry, leak proof, disinfectant free and wide necked container.

b)

A light plastic box or a especially designed glass jar attached spoon with the stopper.

- Amount of stool that is to be collected

Suprapubic aspiration: Occasionally necessary in acute

a)

About a spoonful specimen is sufficient

retention of urine or unconscious patient.

b)

Transfer a portion of stool that contain mucous, pus, blood, if present.

5. Urethral catheterization: Rarely used in children or unconscious patients. Fresh sterile catheter should be used. Urine sample should be collected directly from the catheter, never from collecting bag.

- Send the specimen to the lab as early as possible. - If transport delay is unavoidable Transport medium

a)

surgery/ examination, when necessary.

7. Genito-urinary tuberculosis : 3 consecutive early· morning 1 % boric acid. 4

place specimen in

Cary - Blair media.

Procedure of transport:

6. Ureteric cathelerization: In operation theatre during urological

urine specimen (EMU) or

�

�

24 hours urine in a container containing

With the help of cotton swab, a portion of stool is taken.

b)

Insert the swab in the container of sterile Cary-Blair transpoi\ medium.

c)

Breaking off the swab stick to allow the bottle top to be replaced lightly.

5



- For infants or other patients if necessary 'Rectal Swab' may be collected. a)

W OUND SWAB

Moisten the swab with normal saline & introduce the swab

Sample should be collected from the base of the ulcer or nodule

into rectum (one inch into the anal canal) and kept for 10

following removal of overlying debris or by surgical biopsy of deep

seconds, tum the swab several times with a circular movement. Care should be taken to avoid unnecessary contamination of the specimen with bacteria from anal skin. - Precaution a)

Avoid contaminating the faeces with urine or water

b)

Never store in the incubator

c)

Never store in the refrigerator

ENDOMETRIUM

tissues without contact with the superficial layer of the lesion. If possible two swabs should be collected. Specimens should be placed in sterile container capped properly and send to the laboratory as easily as possible.

SPUTUM COLLECTION Patient instruction -

Collect early morning specimen before breakfast or mouthwash.

-

Rinse mouth with water before collection.

-

Remember that saliva and naso pharyngeal discharge are not sputum. Collect only the exudative material brought up from lungs after a

- Curetting / scrapings / small tissue samples of endometrium should collected aseptically, avoiding lower genital tract contamination and transported in sterile saline. - Send immediately to laboratory.

deep production cough in a dry wide necked leak-proof container. -

Send the container as early as possible. Never refrigerate such sample.

If pulmonary tuberculosis is suspected -

Collect a series of three to six single early morning sputum on successive days.

THROAT SWAB

-

If not possible the 151 sample at spot and 2nd early morning sample.

Swab should be collected in the morning before any mouthwash, food

-

If a patient produces very little sputum,

or drink. Mouth of the patient should be widely opened, neck flexed.

24-48 hours pooled

specimen is needed to yield a positive culture.

Hold the head fixed. Keep the tongue down with a tongue depressor. Oral cavity should be properly illuminated with good light source. A sterile cotton swab (supplied from dept.) is rubbed vigorously over one tonsil, then uvula, other tonsil, the posterior wall of the pharynx and over any other inflamed area. Care should be taken not to touch the tongue, buccal surface or lips. Place the swab stick in the sterile

CONJUNCTIVAL SWAB The conjunctival swab should be taken with a thin sterile cotton swab moistened with sterile trypticase soy !broth sterile normal saline. Conjunctival swab is collected across the lower tarsal conjunctiva and fornix from medial to lateral canthus-taking care not to touch the lid margin.

container tube. It is preferable to take two swabs from the same

Chlamydial infections: Specimen includes scrapings from conjunctiva.

patient. Specimen should be dispatched to the laboratory as soon as

Mycotic infections: Specimen consists of scrapings from the base of

possible.

edge of corneal ulcer.

6

7



CSF Collection and transport - Approximately 5- 10 ml of CSF (in adult patient) should be collected in two sterile tubes (Screw-Capped). Collect about I ml of CSF in tube No. I (for culture) and rest of the portion in tube no. 2 (for other tests). - The specimen should be delivered to the laboratory immediately as early as possible. Do not refrigerate the sample. - If tuberculus meningitis is suspected, 3rd tube is kept in the refrigeration undisturbed to see whether a pellicle or coagulum forms.

METHODS OF COLLECTION OF BLOOD FOR CULTURE - Asepsis of blood culture bottle top Timing of sample collection: a) At spike of febrile illness b) Before antibiotic use c) If antibiotic already started blood should be collected just before next dose of antibiotic. Optimal volume of blood culture: a) For adult minimum 5-1 0 ml b) For children 1-3 ml. c) For neonate I m!.

ASPIRATED FLUIDS Exudates from pleural, peritoneal, pericardial or synovial spaces must be

After collection immediately inoculate blood into culture bottle (Bed side inoculation) and send to laboratory within one hour.

aspirated with aseptic technique. Specimen should be placed in a sterile screw cap tube and sealed properly and transferred to the laboratory within 20 minutes of collection (syringe transport not recommended).

CERVICAL SWAB/ HVS Genital specimen from women - All specimens should be collected during pelvic examination using a speculum. - The speculum should be moistened with warm water before use, but antiseptics or gynecological exploration should not be used. - After inserting the speculum, cervical mucus should be wiped off with a cotton wool ball. -

A sampling swab should be then be introduced into the cervical canal and rotated for at least 10 seconds before withdrawal.

- Specimen should be transported in Amies and Stuart transport media. For urethral discharge and genital ulcer the patient should be referred to Microbiology Department.

8

9

ANTIBIOTIC G U I D ELINE

"DESIRABLE" SERUM ANTIBIOTIC LEVELS (MG/L) Peak

Trough

Increased risk of toxicity

Gentamicin

6

-

12

2

Tobramycin

6

-

12

2

Netilmicin

6

-

12

2

Amikacin

15 - 30

5

Vancomycin

20 - 40

5 - 10

Trough> 1 0

TREATMENT OF SPECIFIC DISEASES

24



In case of inflammatory acne, comedones, papules or pustules

ACNE VU LGARIS In case of comedonal, blackheads, whiteheads, earliest form with no inflammation

There is proliferation of P

acnes and desquamation of follicular cells.

Drug of choice

There is excessive sebum production and gland obstruction. Goal is

Erythromycin plus

Apply cream (3%) locally twice daily

prevention, reduction in the number of new comedones and creates an

Benzoyl peroxide plus


Doxycycline

100 mg orally in empty stomach twice daily for 4-5 months

environment unfavorable to

Propionibacterium acnes.

Drug of choice Tretinoin

Apply cream (0.05% ) locally once daily

Tretinoin is an acid form of retinal. It is a keratolytic agent that reduces follicular hyperkeratosis by stimulating the turnover of epithelial cells. Benefit is seen after 2 months. It has initant activity and may promote UV -induced skin cancer. The drug should be avoided in sunny weather and in pregnancy. Tretinoin may initially be applied for short intervals of time and the strength and duration gradually increased. It should not be used in combination with other keratolytics. Topical corticosteroid should not be used to treat acne.

In case of mild inflammatory acne, small papules or pustules There is proliferation of P

acnes and desquamation of follicular cells.

Drug of choice Azelaic acid

Apply cream (20%) locally twice daily for up to 6 moni hs

or Erythromycin


500 mg orally after taking meal daily for 4 days a week for 6 weeks

Azelaic acid inhibits the growth of Propiollibacterium spp. And reduces keratinization. Improvement usually occurs within 4 weeks. Topical application of azelaic acid may produce a transient skin irritation that disappears on continued treatment. It should not be applied to the eys, mouth, or other mucous membranes. Erythromycin and azithromycin are macrolid antibiotics with wide spectrum of activity. Oral administration of azithromycin is preferred over erythromycin due to its less gastrointestinal adverse effects though there may be diarrhea, nausea and abdominal pain. Azithromycin should be avoided in patient of liver disease due to high hepatic excretion.

26

Administration of doxycycline in empty stomach ensures better absorption. Oral erythromycin may be used as an alternative to doxycycline. However, resistance to erythromycin is increasing so it is usually reserved for those patients in whom other antimicrobials are unsuitable.

ALVEOLAR ABSCESS Alveolar abscess is the continuation of periapical abscess. It is caused by

Streptococcus, Peptococcus, Bacteroides and Fusobacterium.

Drug of choice Amoxycillin

500 mg orally 8 hourly for 5 - 7 days

or Flucloxacillin

250-500 mg orally 6 hourly for 5 - 7 days

plus Metronidazole

plus Azithromycin

Banzoyl peroxide has mild keratolytic properties. Topical application of benzoyl peroxide may produce skin irritation, particularly on beginning treatment. Caution is required when applying it near the eyes, the mouth and other sensitive areas.

200-400 mg orally 8 hourly for 5 - 7 days

Drainage of pus is important.

ALVEOLAR OSTEITIS (Dry socket) Alveolar osteitis is the most frequent painful complication of extraction. Pathogens are mainly anaerobes. Drug of choice Cefradine

500 mg orally 8 hourly for 5-7 days

plus Metronidazole

200-400 mg orally thrice daily for 5 days

Warm saline mouth rinses. Socket dressing is required.

27

ANTIBIOTIC GU I D ELINE

ANTIBIOTIC GU I DELI NE

BITE WOU N DS

AMOEBIASIS Amoebiasis (amoebic dysentery) is a protozoan parasite infection

Bites may be by cat, dog, rat, snake, bee, hornet, insect, bat, monkey.

Entamoeba histolytica. It exists in two forms: the hardy

Pasteurella multocida (cats and dogs), Eikenella corrodens (humans), Staphylococcus aureus, Streptococcus spp., and/or oral anaerobes.

caused by

infective cyst and the more fragile potentially pathogenic tropozoite. The disease spreads between humans by its cysts. The parasite is now

E. dispar (non-pathogenic) histolytica (pathogenic). Cysts of these two species are

known to consist of two separate species: and E.

morphologically

identical,

distinguishable only

by

molecular

techniques, isoenzyme studies or monoclonal antibody typing. Only

E. histolytica can give rise to amoebic dysentery or extraintestinal amoebiasis (amoebic liver abscess).

daily for 5-1 0 days

plus Co-amoxiclav

2 g once daily orally for 3 days

plus Rabies vaccine

or Secnidazole

2 g (30 mg/kg in children) single dose orally

Drug of choice 500 m g orally 1 2 hourly for 1 0- 1 4 days

plus 80 mg intravenously 8 hourly for 1 0- 1 4 days

plus Metronidazole

28

375 / 625 mg orally after meal 8 hourly. Duration of treatment depends on the clinical condition 1 ml intramuscularly at the deltoid region, one each on days

plus Human rabies

20 I U/kg body weight given once on day O. If a natomically

immune globulin feasible, the half dose should be infiltrated around the wound(s), the rest should be administered intramuscularly in the gluteal area There are several types of rabies vaccine available in the drug store. The dosage schedule of each vaccine varies. So, please check the dose schedule of rabies vaccine from the supplied patient information leaflet and administer accordingly. Corticosteroid should not be used because in mouse model, it increases the mortality rate and shorten the incubation period. Rabies postexposure prophylaxis , which is highly effective if given prompt/yo Combination therapy may be superior to therapy with a single agent. Because immunization by the intramuscular route may take a week or more to produce detectable immune response, multiple sites (e.g., 8 or 4 sites) intradermal immunization may be considered to accelerate the response.

BI LIARY SEPSIS

Gentamicin

All post-exposure treatment should begun with immediate, thorough cleaning of all wounds with soap and water. Then treat with 70% ethanol or an iodine tincture. Where possible, wounds should be kept open or only sutured to secure apposition

0, 3, 7, 1 4 and 28

Both metronidazole and tinidazole are effective against tropozoites. Tinidazole has longer duration of action over metronidazole. In both the cases the patient may complain nausea, vomiting, diarrhea, furred tongue and an unpleasant metallic taste in the mouth. Rashes, urticaria and angioedema may occur. Peripheral neuropathy occurs if treatment is prolonged and epileptiform seizures if the dose is high. Follow-up stool examination is always necessary because no regimen is completely effective in eradicating intestinal infection. Use of chemoprophylactic agent is not advised.

Ciprofloxacin

Drug of choice

400-800 mg (35 mg/kg/day in children) orally thrice

or Tinidazole

In case of dog bites Only 5% of the dog bites become infected. Prophylaxis may be worthwhile.

Local wound cleaning

Drug of choice Metronidazole

Microorganisms involved are

200-400 mg orally thrice daily for 5 days

Rabies vaccine is the inactivated rabies virus in chick embryo ceil culture. Its potency is equal to or more than 2.5 IU. The immunization schedule must be followed exactly, even if considerable time has elapsed since exposure. The vaccine should be stored at 0 to 4° C . It should not be used after the expiry date. The vaccine should be used immediately after reconstitution. Intravas-cular administration may cause anaphy l actic shock Human rabies immune globulin neutralizes the virus before its invasion of the

29

ANTIBIOTIC GUIDELI N E


nervous system. I t should not b e administered i n the same syringe, o r into the same anatomical site as vaccine, or more than 7 days after the initiation of vaccine. Because Human rabies immune globulin may partially suppress active production of antibody, no more than the recommended dose should be given. Amoxycillin is a 4-hydroxy analogue of ampicillin and is better absorbed from the "ut especially after food. Diarrhoea is less frequent with amoxycillin than with ampicillin. Amoxycillin is preferred because of its greater bioavailability and fewer side effects. Clavulanic acid is a beta-Iactam compound which has little intrinsic antibacterial acitivity but is important because it binds competitively to beta lactarnases. Thereby competitively penicillin protects it against bacteria which owe their resistance to production of beta-Iactamase, i.e., clavulanic acid acts as a "suicide" inhibitor. Combination of amoxycillin and c1avulanic acid is known as co-amoxiclav.

In case of snake bite (treatment within the hospital) Drug of choice

Cloxacillin is narrow spectrum penicillin that resists degradation by gastric acid and is absorbed from the gut. Food markedly interferes with absorption. Cefradine is a first-generation cephalosphorin antibiotic. It is available in oral and parenteral preparation.

In case of nonlactating woman It is usually due to anaerobes and/or

Staphylococcus aureus.

Drug of choice Flucloxacillin

500 mg orally 6 hourly

or Cloxacillin

Polyvalent

5-20 vials should be diluted ( 1 0 ml each) and then added to

or

antiserum

500 ml of intravenous fluid and infused slowly over a period

Cefradine

of about 4 hours

500 mg orally 6 hourly 500 mg intravenously or deep intramuscularly 6 hourly. I ntravenous administration should be done in 5 min

plus

plus

tetanus

250-500 units deep intramuscularly or tetanus toxoid (primary

immunoglobulin

immunization) intramuscularly depending on the immunization status of the victim

Tetanus toxoid should be given at the same time but at a separate site. Any antibiotic (preferable penicillin) may be prescribed if there is any sign of infection.

Metronidazole

7.5 mg/kg intravenously 6 hourly

Flucloxacillin is better absorbed and gives higher concentration than does cloxacillin. It may cause cholestatic jaundice, particularly when used for more than 2 weeks or to patients >55 years.

BREAST ABSCESSIMASTITIS

Metronidazole is one of the azoles and is bacteriostatic. In anaerobic microorganisms metronidazole is converted into an active form by reduction of its nitro group. This binds to DNA and prevents nucleic acid formation.

In case of lactating woman

Pretreatment aerobic culture is required. Surgical drainage for abscess may be done.

Mastitis is usually due to

Staphylococcus aureus. There is no

contraindication of breast feeding, rather continuing breast feeding helps response to antibiotic therapy. Drug of choice Flucloxacillin

Drug of choice 500 mg orally 6 hourly

or Cloxacillin

500 mg orally 6 hourly

or Cefradine

30

BRONCHIECTASIS

Ampicillin or

500 mg orally 6 hourly for 1 4 days

Amoxycillin


or 500 mg orally 6 hourly

Co-trimoxazole

1 DS tablet twice daily orally for 1 4 days

31


In case ofpseudomonas aeroginossa

ANTIBIOTIC GUI DELINE

Very rarely, an infection caused by a fungus can cause acute bronchitis. If severe, secondary bacterial infection may be assumed,

Drug of choice C iprofloxacin or

500 mg orally 1 2 hourly for 1 4 days

Cefotaxime

1 9 intravenously 8 hourly for 1 4 days

usually due to

Streptococcus pneumoniae or Haemophilus injluenzae


500 mg orally 8 hourly for 7 days

or Erythromycin

In chronic case Drug of choice Amoxycillin

Tetracycline 500 mg orally 8 hourly for 4 weeks

or Polymyxin B


or

1 -2 mega units inhaled twice daily


Dose of amoxicillin should be reduced in severe renal impairment. If the patient is a smoker, then cut down on the number of cigarette smoke, or stop smoking altogether. This will help the bronchial tree heal faster. Erythromycin is an effective alternative choice for penicillin-allergic patients.

Or Amoxycillin followed by Co-trimoxazole

500 mg orally 8 hourly for 1 4 days 1 OS tablet orally twice daily for 1 4 days

followed by Tetracycline


B RONCHITIS

In case acute exacerbation of chronic form Viruses are often implicated, at least initially. Secondary infections by bacteria such as Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus injluenzae may be involved when sputum becomes purulent and increases in volume. Although most clinicians treat patients in this setting with antibiotics, most studies comparing antibiotics with placebo have shown little difference in the rate of resolution of symptoms. If antibiotics are prescribed, these should be based on the culture and sensitivity results and should be given for 7-10 days. Amoxycillin may be considered initially for empiric antibiotic therapy.

In case of acute attack (viral cause) Acute bronchitis is almost always caused by viruses (influenza viruses, adenoviruses). Drug of choice

CHANCROID Chancroid ulcer is due to the Ducrey bacillus, Antibiotic therapy eliminates

Haemophilus ducreyi. H. ducreyi and lesions heal in 1-2

weeks. No antibiotic

In case of acute attack (bacterial cause) Bacterial infection is much less common in bronchitis than we used to think. In the immunocompetent host, acute bronchitis, even when bacterial in etiology, is self-limiting condition. Antibiotic therapy is not required. 32

Drug of choice Co-trimoxazole

1 OS tablet twice daily orally for 7 days

or Cefixime

400 mg orally as a single dose

Co-trimoxazole is a sulfonamide-trimethoprim combination (5: I). Each drug is well absorbed from the gut and is mainly excreted by the kidney. The dose of co-trimoxazole should be reduced when renal function is impaired. 33

ANTIBIOT I C GUI DELINE

ANTIBIOTIC GUIDELIN E

Cefixime is a third-generation cephalosphorin antibiotic and is stable to hydrolysis by many beta-Iactamases. Cefixime is better absorbed from oral suspension than from tablet. Absorption is fairly slow. The most frequent adverse effects are gastrointestinal disturbances especially diarrhea. It should be discontinued if diarrhea is severe.

Caution should b e exercised when gatifloxacin i s used with drugs such as astemizole, terfenadine, cisapride, erythromycin, pentamidine, phenothiazines or tricyclic antidepressants. The dose of gatifloxacin should be reduced in patient with renal im airment. p . ImtIal dose of 400 mg should be followed by maintenance dose of 200 rna ., daily in those with a creatinine clearance less than 40 mllmin.

CELLU LITIS Cellulitis is usually due to

Streptococcus pyogenes, but Staphylo coccus aureus is often also involved. When cellulitis is associated with an open wound, there is usually an exudate that can be obtained for culture. In the setting of cellulitis with unbroken skin, a needle aspiration from the advancing edge can sometimes yield a positive diagnosis. Blood cultures are also of diagnostic value. Ludwig's angina is a severe form of cellulitis which usually arise from the lower second or third molar. It involves the sublingual and

CEREBRAL ABSCESS Bacteria may enter the cerebral substance through penetrating injury, by direct spread from paranasal sinuses or the middle ear or by hematogenous spread from septicemia. Antimicrobial therapy is indicated once the diagnosis is made. Surgical treatment by burrhole aspiration or excision may be necessary. Drug of choice

submandibular spaces bilaterally and it readily spreads into the lateral

Ceftriaxone

pharyngeal and pterygoid spaces and can extend up to mediastinum.

plus

Pathogens involves are mainly Fus iform (bacilli and spiral form), Staphylococcus, Streptococcus, Bacterides, E. coli and Pseudomonas.

Gentamicin

In diabetics and debilitated patients, consider

Metronidazole

Staphylococcus aureus,

followed by

Drug of choice

Cefixime 375/ 62 5 mg orally half an hour before meal 8 hourly for 7 days

or F lucloxacillin


plus phenoxymethyl 2 50 -500 mg 6 hourly half an hour before meal for 7 days penicillin or Gatifloxacin or Ceftriaxone

2 9 intravenously daily in single or divided doses

Crystalline penicilline

200 mg orally twice daily for 6 weeks

10 lac unit intravenously 6 hourly for 1 5 days

plus 80 mg intravenously 8 hourly for 1 5 days

plus Metronidazole

Ceftriaxone is a third-generation cephalosphorin antibiotic. It is highly protein-bound and is able to displace bilirubin from albumin binding sites, causing hyperbilirubinemia.

followed by

Gatifloxacin is a fluoroquinolone antibacterial with actions and uses similar to those of ciprofloxacin. Gatifloxacin may have the potential to prolong the QT interval and should be avoided in patients with existing QT prolongation.

or

34

400 mg intravenously 8 hourly for 1 5 days

or

Gentamicin 400 mg once daily orally for 7 days


plus

Enterobactericeae and anaerobes.

Co-amoxiclav

1 9 intra muscularly or intravenously

Amoxycillin

Co-amoxiclav


500 mg orally 8 hourly for 6 weeks

37 5/ 62 5 mg orally after meal 8 hourly for 6 weeks

35



CHOLECYSTITIS (ACUTE)

CONJUNCTIVITIS

The pathogenesis of acute choleystitis is unclear, but the initial

In case of viral conjunctivitis (pink eye)

inflammation is possibly chemically induced. At the time of surgcn-y approximately 50% of cultures of the gall bladder contents are sterile. Infection occurs eventually and in elderly patients or those with diabetes mellitus a severe infection with gas-forming organism can

Viral conjunctivitis is usually unilateral and highly contagious. It is usually self-limited, but there i s evidence that treatment with a topical antibiotic shortens its course and prevent bacterial superinfection. Children are generally kept out of the school for up to

2 weeks after

cause emphysematous cholecystitis.

the onset of infection. Topical antiviral drugs are not administered.

Drug of choice

The use of topical corticosteroid therapy is controversial. Onset of ocular pain and photophobia in an adult suggests associated keratitis

Gentamicin or Ceftriaxone

80 mg intravenously 8 hourly 1 9 intravenously 12 hourly depend ing on the body weight

10 days, the patient should

be referred to an ophthalmologist.

and severity of infection

In case of bacterial conjunctivitis

500 mg intravenously 8 hourly ( 1 5 mg/kg in children)

staphylococci and/or streptococci.

Acute bacterial conjunctivitis in the adult is most often due to

plus Metronidazole

(rare). If there is no improvement in 7 to

Gentamicin is an aminoglycoside antibiotic and has adverse effects like ototoxicity and nephrotoxicity. This drug should not generally be mixed with other drugs in syringes or infusion solutions nor given through the same intravenous line. When gentamicin is given with a beta-lactam administration should generally be at separate sites.

Haemophilus inJluenzae is more

common in children. Treatment

consists

of

a

broad-spectrum

topical

antibiotic

administered 4 times daily. This empirical approach is highly effective, and adverse consequences are infrequent. Drug of choice

.

CHOLERA

Chloramphenicol

Cholera is caused by

or

Vibrio cholerae serotype 01. A new classical toxigenic strain, serotype 0139, established itself in Bangladesh in 1992 and started a new pandemic.

Ciprofloxacin (0.3%)

Antibiotic treatment in adult reduces the duration of excretion of

Ofloxacin (0.3%)

Vibrio and the total volume of fluid needed for replacement.

or

Drug of choice

Tobramycin (0.3%)

Tetracycline

40 mg/kg/day orally for 3 days

or Doxycycline

300 mg (6 mg/kg in children) single dose orally

or Erythromycin or Ciprofloxacin

1

9 single dose orally

There is no risk of staining teeth with such short courses of tetracyclines in case of children. 36

1 -2 drops 4 times daily for 7-1 0 days 1 -2 drops 4 times daily for 7-1 0 days

or 1 -2 drops 4 times daily for 7-10 days 1 -2 drops 4 times daily for 7-1 0 days

Tobramycin is an aminoglycoside antibiotic with actions and uses similar to those of gentamicin. Though highly effective and topical chloramphenicol (0.5 %) has been associated with a rare but devastating aplastic anemia. The topical ciprofloxacin (0.3 %) and ofloxacin (0.3%) are also highly effective but should be reserved for severe infections. Bacitracin (500 units/g) and erythromycin (0.5%). which are effective against Gram-positive bacteria. are available only in the form of ointments that are difficult to install and cause blurred vision. Oral antibiotics alone may be insufficient to treat bacterial conjunctivitis in adults. If the disorder does not improve in one week. the patient should be referred to an ophthalmologist. 37

ANTIBIOTIC G UI D ELINE

ANTIBIOTIC G UIDELINE

In case of conjunctivitis in the newborn It is due to Chlamydia trachomatis or Neisseria gonorrhoeae. The best form of prophylaxis is 2.5% aqueous povidone-iodine solution. In case of conjunctivitis (Chlamydia trachomatis)

CYSTITIS (ACUTE UNCOMPLICATED) This includes patients with asymptomatic bacteriuria. It is usually caused by

Escherichia coli (90%), Staphylococcus saprophyticus (5%), or other Enterobactericeae (5%). Mixed infections are rare. In view of the high prevalence of resistance to ampicillin and co

Drug of choice

trimoxazole, an oral first generation cephalosporin (e.g. cephalexin),

Tetracycline or Erythromycin

O intment twice daily in the eye for 2 weeks 2 5 m g!kg orally twice daily for 2 weeks

or a quinolone (ciprofloxacin, ofloxacin etc) is recommended empiric agents of choice.

as

the

However, some advocate the use of co

trimoxazole for uncomplicated UTI since these antibiotics frequently. achieve concentrations in urine in excess of the MICs of resistant

Investigate and treat parents for genital infection.

strains. This may explain why an uncomplicated UTI may apparently respond to an antibiotic even when the pathogen is judged resistant by

In case of conjunctivitis (Neisseria gonorrhoeae)

laboratory tests.

Drug of choice Ceftriaxone

2 5-50 m g!kg intram uscularly as a single dose

or Gentam icin!


S hould be given topically

2 50 mg 8 hourly orally for 3 days ( 50 m g/ kg/day in children)

or

bacitracin

Investigations and treatment of parents needed for genital infection.

Co-trim oxazole Ciprofloxacin

CORN EAL ULCER In case of bacterial cause Bacterial infection is a common sight threatening condition of cornea (keratitis), if untreated often leads to progessive tissue destruction with perforation. Common causes are trauma, contact lens wear and infection from ocular adnexa. Common organism is Staphyllococcus

aureus. Staph epidermis, aeruginosa etc.

Strep pneumoniae,

1 DS tablet 1 2 hourly for 3 days

or 2 50 mg orally 1 2 hourly for 3 days

Single dose therapy is no longer favored. In pregnancy, consider a 7-day regimen of amoxycillin, co-trimoxazole (not in 3rd trimester) or cephalexin. Quinolones should be avoided during pregnancy. A 3-day regimen achieves the best results in patients with uncomplicated UTI. This is considered as effective, costs less, and causes fewer side effects than 7-day regimens. One day regimens are associated with higher recurrence rates.

Pseudomonous

In case of fungal cause Fungal keratitis is common among agriculture workers.

Candida albicans (yeast) and Fusarium solani (filamentous), Aspergillous spp. are common pathogens.

5% for filamentary fungal keratitis and 0.15% solution is recommended for Aspergillous Spp.

DYSENTERY (BACILLARY) Bacillary dysenter (shigellosis) is an enteric infection caused by the Shigella spp.

S. dysentery, S. flexneri, S. boydii, or S. sonnei. Disease S. sonnei infections that may escape detection to more severe S. flexneri infections, while those due to S. dysenteriae may be fulminating and cause death within 48 hours. severity varies from mild

Topical drops of natamycin

Shigella gastroenteritis is essentially self-limiting and antibiotics are

amphotericin B

probably only indicated for severely ill patients, those with dysentery,

and yeast keratitis. 38

and the very young or old. 39

ANTIBIOTIC G UI DELI N E

ANTIBIOTIC G UI DELIN E

Drug of choice 500 mg orally 1 2 hourly for 5-7 days

Ciprofloxacin pius

A single oral dose of 200,000 I U

V itamin A (in case of children)

I n case o f severe case o f enteric fever with delirium, obtundation, stupor; coma, shock Drug of choice 15 mg/kg/day by intravenous infusion (O.2% solution) over 30 min for 1 0- 1 4 days

Ofloxacin plus Dexamethasone

ECZEMA (IN FECTED) Drug of choice Apply thrice daily for u p t o 2 weeks

Combination of gentamicin and hydrocortisone or Combination of neomycin and betamethasone

Apply thrice daily for up to 2 weeks

Use of drug after removal of crusts ensure better access of drug. Topical neomycin is preferred as it is not ordinarily used for systemic infection and therefore, development of drug resistance is less likely. Absorption of neomycin may cause serious injury to eight cranial nerve. Hydrocortisone or betamethasone is used to suppress inflammation.

3 mg/kg by slow intravenous infusion followed by 1 mg/kg every 6 hourly for eight additional doses

The mortality rate was reduced from over 50 % to 10 % in Indonesian adults and children who were given dexamethasone at an initial dose of 3 mg/kg by slow intravenous infusion over a period of 30 minutes, followed by I mg of dexamethasone per kg given at the same rate every 6 hours for 8 additional doses. Hydrocortisone at a lower dose is not effective. There are fe'w data on the treatment of pregnant women with typhoid. The beta-Iactam antibiotics are considered safe. In addition, there have been several case reports of the successful use of fluoroquino lones. Although these drugs have generally been avoided because of concern about safety, the general consensus is that they are also safe

ENTERIC FEVER Enteric fever is caused by

Salmonella typhi and paratyphi.

In case of uncomplicated enteric fever Drug of choice Co-trimoxazole

DS 1 tablet orally 1 2 hourly for 1 4 days

or P-floxacillin

400 mg 1 2 hourly for 1 0- 1 4 days

FEBRILE NEUTROPENIA Patients of febrile neutropeni a are treated at the Ward. Drug of choice Ceftazidime

1 00 mg/kg/day ( 1 .5 g/m2 /dose, maximum dose of 2 g) intravenously 8 hourly for 7 days

or Aminoglycoside

8 mg/m2/dose ever y 8 hourly

or Ciprofloxacin

500-750 mg orally 1 2 hourly for 1 0-1 4 days

No intramuscular injection

60 mg/kg/day (maximal dose- 4 g) intravenously for 7

If any of the following conditions are present, add vancomycin 400 mg/m2/dose every 8 hourly infused over I hour. First dose stat

or Ceftriaxone

days

a)

or Azithromycin

500 mg orally once daily for 7 days

Carrier state should be treated for

40

4

weeks

recent history of receiving intensive chemotherapy that produces substantial mucosal damage (defined as confluent fibrinous mucositis, ulceration, pain, superficial ulceration, necrosis, hemorrhage). 41

ANTIBIOTIC GUI DEL INE

ANTIBIOTIC G UI DEL INE b)

evidence of sepsis. including shock. hypotension. rigors. septic

emboli.

unexplained

respiratory

distress

or

III case of recurrence

hypoxemia. or poor peripheral perfusion c) If

any

proven or suspected meningitis (including eNS shunt infection) of

the

following

conditions

are

present.

substitute

imipenemlmeropenem for ceftazidime/cetriaxone: a)

b)

Topical acyclovir provides no benefit in the episodic treatment of genital herpes and is not recommended.

Drug of choice Acyclovir or

severe abdominal pain or radiographic findings suggesting

Famciclovir

typhlitis

or

severe abdominal pain with evidence of sepsis. including shock.

hypotension. rigors.

septic


Valacyclovir


1 g orally 1 2 hourly for 1 0 days

emboli. unexplained

respiratory distress or hypoxemia or poor peripheral perfusion

In case of prophylaxis

After 2 days careful reassessment of the patient via physical examination and

Drug of choice

review of culture results. If culture report is positive. then antibiotic

Acyclovir

should be changed accordingly. If culture is negative. then continue

or

ceftazidime/cefriaxone for minimum 7 days and reevaluate criteria

Famciclovir

for using vancomycin andlor imipenemlmeropenem.

or

If the patient does not respond after 7 days of using antibiotics

Valacyclovir

Begin ampotericin B empirically at 1 mg/kg/day (maximum dose of

400 mg orally 1 2 hourly 250 mg orally 1 2 hourly 0 .5-1 g orally daily

50 mg) along with antibiotics.

GIARDIASIS

If afebrile. then discontinue intravenous antibiotic therapy and change

Giardiasis is caused by a flagellate protozoan

to suitable oral antibiotic.

(also known as

Giardia intestinalis

G. lamblia).

Drug of choice

GENITAL HERPES Infection is caused by herpes simplex type 1 or type

M etronidazole

2.

400 mg orally twice daily ( 1 5 mg /k g/day in 3 divided doses children) for 7 -1 0 days

III case offirst episode or

Drug of choice Acyclovir

Tinidazole 400 mg orally 8 hourly for 7 -1 0 days

or F amciclovir or

250 mg orally 8 hourly for 7 -1 0 days

Valacyclovir

1 g orally 1 2 hourly for 7 ·1 0 days

42

2 g orally as a single dose or

2 g orally as a single dose

or Secnidazole

2 g (30 mglkg in children) single dose orally

Paromomycin can be used during pregnancy. but when disease is mild. delay of treatment till after delivery is recommended. Drug resistance and relapses may occur with any drug.

43

ANTIBIOTIC G U I DELI NE

ANTIBIOTI C G U I DELI N E

GINGIVITIS

In case of chronic mastoiditis

The vast majority of cases of gingivitis are caused by the collection of

Treatment will be surgical intervention with antibiotics.

highly infected debris on the tooth surface in the ledge formed by the

Drug of choice

gingival margin. The microorganisms present in the debris are

Ceftriaxone

500 mg intravenously 1 2 hourly for 1 0 days

or Ciprofloxacin

500 mg intravenously 1 2 hourly for 1 0 days

Streptococcus, Actinomyces, Veillonella, Treponema, Fusobacterium., .. nucleatum, Prevotella intermedia. Among gingivitis, acute ulcerative type is a purely infectous type where the causative microorganisms are mainly

Treponema and Fusobacterium nucleatum.

Drug of choice Metronidazole plus Tetracycline or Doxycycline or Amoxycillin

200-400 mg orally 8 hourly for 5-7 days 250 mg orally 6 hourly for 5-7 days 200 mg orally stat and 1 00 m g daily for 5-7 days 250-500 mg orally 8 hourly for 5-7 days

MENINGITIS

In case of bacterial meningitis S. Pneumoniae is the Commonest cause of meningitis in adult (almost

50% of all cases). N. meningitides accounts for

25% of all cases. The presence of

petechial or purpuric skin lesions can provide an important clue. Enteric gram-negative bacilli are increasingly common causes of

PYOGENIC LIVER ABSCESS

meningitis in individuals with chronic and debilitating diseases such

Drug of choice

as diabetes mellitus, cirrhosis of liver, alcoholism or those with UTI or craniotomy.

Ciprofloxacin

500 mg orally 1 2 hourly for 1 0-1 4 days

plus Gentam icin

80 mg intravenously 8 hourly for 1 0- 1 4 days

plus Metronidazole

N L. monocytogenes in neonate, pregnant women & >

200-400 mg orally thrice daily for 1 0-1 4 days

age. N H. influenzae is another important cause in our country

Group B Streptococcus or S. agalactiae in patient>

50 years of age. 60 years of

although its incidence is declining in western world due to

MASTOIDITIS

vaccination.

In case of acute mastoiditis

S. aureus & coagulase negative staphylococci are important causes in

Acute mastoiditis is due to S. pneumoniae, S. pyogens, S. aureus, H. injluenzae and P. aeruginosa. An urgent specialist opinion i s advisable, a s surgery may b e necessary.

invasive neurosurgical procedures. Treatment : Bacterial meningitis is a medical emergency. Treatment

Drug of choice

should be started within

Cefotaxim e or Ceftriaxone

1 -2 9 intravenously 4-8 hourly (depends on severity) 2 9 intravenously daily in single or divided doses on adult. The dose may be m odified in case of children according to the age

44

60 minutes of patient's arrival.

Empirical treatment should be started in suspected cases o f bacterial meningitis before doing CSF study. S . Pneumoniae and N . meningitides are the commonest organisms in adult. Due to emergence

of

penicillin

and

cep�losporin

r e s i s ta n t

S. 45



pneumoniae, empirical therapy of community acquired bacterial

NEONATAL SEPSIS

meningitis

Drug of choice

in

children

and

adult

should

include

a

third

generation cephalosporin (e.g. ceftriaxone or cefotaxime) and vancomycin.

Ampici l lin

100 mglkg body weight/day

plus

Antibiotics used in empirical therapy of bacterial meningitis and focal

eNS infections

Gentamicin If the

patient's condition is not improved, then-

Drug of choice

Indication

Antibiotics

Pre-term infants to infants 3 months

Cefotaxime or ceftriaxone

+

vancomycin

100 mglkg/day intravenously every 8 h ourly for 7 days

Amikacin

and adult < 55 years Adult > 55 years and adults of any age

Ampicillin + cefotaxime or ceftriaxone +

OTITIS EXTERNA

w�h Alcoholism or other debitlitating

vancomycin

Most are due to so-called "swimmer's ear" and the pathogens

disease Hospital-acquired meningitis,

Ampicillin + Ceftazidime + vancomycin

involved are usually

Pseudomonas aeruginosa, Poteus mirabilis

or

other gram negative bacteria. Treatment of otitis extema varies

post-traumatic or postneurosurgery

according to the disease condition, In all cases meticulous cleaning of

meningitis, cases patients with impaired

the ear if necessary by micro suction is essential for effective

immunity neu1ropenic

treatment and prevention of further recurrence. Drug of choice Gentamicin or ciprofloxacin

2-4 drops topically 6-8 hourly

Antimicrobial agent

Child «1 month)

Adult

AmpiCillin

200 mglkg/d, q 4h

12 9 mid, q 4h

Cefotaxime

200 mglkg/d, q 6h

12 9 mid, q 4h

Ceftriaxone

100 mglkg/d, q12 h

4 grnld, q 12h

Ceftazidime

150 mglkg/d, q 8h

6 grnld, q 8h

Drug of choice

Gentamicin

7,5 mg/kg/d, q 8h

7,5 mg/kg/d, q 8h

Topical antifungal cream with

Apply on a cotton bud twice daily

Vancomycin

60 mg/kgld, 16h

2g,d, q 12h

Steroid e,g, Econazole nitrate 1%

for 10-14 days

with hydrocortisone ear drop

In case of otomycosis

+ Triamcinolone

46

acetonide

47

ANTIBIOTIC GU I DELINE


In case of furunculosis

Drug of choice

Drug of choice Flucloxacin

250-500 mg daily 6 hourly for 7-1 0 days

In case of otitis externa with cellulitis of the auricle or periauricular structure Systemic antibiotics are necessary along with ear drop and ear wick (eg. Pope wick)

Co-amoxiclav

375 mg or 625 mg 8 hourly for 7 days

or Ciprofloxacin

500 mg twice daily for 7-1 0 days

or Ceftriaxone

1 9 invervenously once daily ,

Dose should be reduced in patient with severe renal impairment.

Drug of choice Gentamicin or ciprofloxacin

2-4 drops 6 - 8 hourly

with hydrocortisone ear drop plus Co-amoxiclav

Oral thrush is caused by the yeast 375/625 mg orally 8 hourly for 7-1 0 day

Candida albicans.

It is a normal

mouth commensal but it may proliferate to cause thrush. Drug of choice

Or Ciprofloxacin

ORAL THRUSH (CANDIDIASIS)

500 mg twice daily for 7-1 0 days

Nystatin

Wash with 5-10 ml of suspension (1 00,000 u nits/ml) thrice daily

In case of malignant otitis externa

or

for minimum 14 days

Drug of choice

Fluconazole

1 00 mg orally daily for 7 -1 4 days

Ciprofloxacin

500-750 mg twice daily for prolonged

or

period (up to 6-8 weeks) if there is

Itraconazole

200 mg (oral solution) orally once daily.

radiological evidence of osteomyelitis Surgical debridement may necessary if medical therapy is unsuccessful.

PEPTIC ULCER (DUE TO HELICOBACTER PYLORI)

Certain general skin conditions may cause otitis extema e.g. psoriasis,

All patients with peptic ulceration who are also infected with H.

seborrhoeic dermatitis and eczema. Treatment of any underlying

pylori should receive antibiotic therapy. Effective treatment regimens

eczema in the canal, e.g. with 1 % hydrocortisone cream introduced on

include a proton pump inhibitor plus at least two antibiotics.

a cotton bud is important when the inflammation has settled.

Drug of choice

OTITIS MEDIA (ACUTE SUPPURATIVE) Otitis media is usually caused by Streptococcus pneul11oniae, Haemophilus injluenZQe and Moraxella catarrhalis. Occa sional pathogens include Streptococcus pyogenes and Staphylococcus au reus. 48

Omeprazole

20 mg orally twice daily for 7-14 days

plus Amoxycillin

1 9 orally 12 hourly for 7-1 4 days

plus Metronidazole

400 mg orally twice daily for 7-14 days

49


ANTIBIOTIC GUIDELIN E

or

SPONTANEOUS BACTERIAL PERITONITIS

Drug o f choice

Drug of choice 30 mg orally 12 hourly for 14 days

Lansoprazole plus Amoxycillin plus Clarithromycin

1 g orally 12 hourly for 14 days 500 mg orally 12 hourly for 14 days

Lansoprazole is a proton pump inhibitor with actions and uses similar to those of omeprazole. Glossitis associated with black t?ngue or. .stomatltls may de velop. Antacids and sucralfate may reduce the blOavailabthty of lansopra zole. Treatment with lansoprazole may cause false-negatIve results III the urea breath test for H. pylori. Clarithromycin is a macrolide derived from erythromycin. It should not be used during pregnancy if po ssible. Dose should be reduced III patIents With renallhepatic impairment.

Ceftriaxone

1 g intravenously 12 hourly

or Cefotaxime

1 g intravenously 8-12 hourly (depends on severity)

or Ceftipime

1 g i ntravenously 12 hourly

Till the patient improves then switch over to 500 mg orally 12 hourly for 14 days

Ciprofloxacin

For prophylaxis of spontaneous bacterial peritonitis, tablet n orfl oxacin 400

mg 1-2 times daily for indefinite perio d PHARYNGITIS

PERICORONITIS Incomplete eruption of a wisdom tooth produces a large stagnation area under the gum flap. It can easily become infected, causing acute pericoronitis. It is caused by various microorganisms (both .aerobic and anaerobic) like

Staphylococcus, Streptococcus, Fusobacterium and Bacteroids. Drug of choice

The commonest causes are viral. Drug of choice No antibiotic.

The most important bacterial cause is

Streptococcus pyogenes. Other Corynebacterium haemoly-ticum, Corynebacterium diphtheriae, Neisseria

Amoxicillin or Cefradine plus

250-500 mg orally 8 hourly for 7 days

bacterial causes of pharyngitis inClude

250-500 mg orally 6-8 hourly for 7 days

chlamydia pneumoniae, gonorrhoeae, group C beta-haemolytica Streptococci and anaerobic bacteria.

Metronidazole

200-400 mg orally thrice daily for 5-7 days

Penicillin is the only agent conclusively shown to prevent rheumatic fever. The expense of the new macrolides and the cephalosporins do not warrant their use as first line agents.

PERIODONTAL ABSCESS Periodrullal abscess may occur as

a

sequele of chronic periodontitis.

It is caused by Fusobacterium nucleatum, Prevotella intermedia and Eikpnl"Ua corrodens. Drug of choice A!tJ oxyciliin


or Cefradine


plus Metronidazole

50

200-400 mg orally thrice daily for 5-7 days

Drug of choice Benzathine benzylpenic illin or Phenoxyme thylpenicillin or Erythromycin or Clarithromycin

600,000 unit as Single intramuscu lar dose «30 kg body weight) 1200,000 unit as single intramuscular dose (>30 kg body weight) 250-500 mg (50 mg/kg/day in children) orally 6 hourly for 10 days

250-500 mg orally 8 hourly for 10 days (in case of penicillin

allergic patient) 500 mg by mouth 12 hourly for 10 days (in case of hypersensitivity)

51

ANTIBIOT I C GUI DELINE

ANT IBIOTIC GUIDELINE

Benzathine benzylpenicillin is given by deep intramuscular injection, it forms a depot from which it is slowly released and hydrolyzed to penicillin. Depending on the dose, benzylpenicillin is usually detectable in plasma for up to 4 weeks.

In case of community acquired severe pneumonia (age above 60 years or pre-existing lung disease)

PNEUMONIA

Cefotaxime

Drug of choice 1 9 intravenously 8 hourly for 1 4 days

plus 500 mg intravenously 1 2 hourly for 14 days

In case of community acquired less-severe pneumonia (below the age of 60 years)

Clarithromycin

Drug of choice

In case of hospital acquired less-severe pneumonia

Benzylpenicillin or

1 . 2 9 intravenously 6 hourly for 14 days

Ampicillin

500 mg intravenously 6 hourly for 14 days

or Clarithromycin


or Co-amoxiclav

375 / 625 mg orally after meal 8 hourly. Duration of treatment

depends on the clinical condition

Drug of choice Cefuroxime Cefotaxime


or Co-amoxiclav

1.2 9 intravenously 8 hourly for 14 days

or Ciprofloxacin

In case ofcommunity acquired severe pneumonia (below the age of 60 years and presence of co-existing lung disease) Drug of choice Co-amoxiclav

1.2 9 intravenously 8 hourly for 14 days

plus Clarithromycin


Cefuroxime

1 .5 9 intravenously 8 hourly for 1 4 days

Clindamycin


Drug of choice Cefuroxime

Ciprofloxacin


plus Vancomycin



or

Cefotaxime


plus 80 mg intravenously 8 hourly for 14 days

or

Imipenem

1 9 intravenously 8 hourly for 14 days

plus Gentamicin

52

1.5 9 intravenously 8 hourly for 1 4 days

plus

Gentamicin

or


In case of hospital acquired severe pneumonia

plus Clarithromycin


or

Gentamicin

or

1 .5 9 intravenously 8 hourly for 1 4 days

or


53

ANTIBIOT I C GU I DELI NE

ANT IBIOTIC GUIDELINE

In case of lung abscess/suppurative pneumonia/aspiration pneumonia Drug of choice Benzylpenicillin

Drug of choice 1.2 9 intravenously

6 hourly for 4-6 weeks

plus Metronidazole

200 mg intravenously 8 hourly for 4-6 weeks

plus Gentamicin

PROSTATITIS In acute case


Ciprofloxacin

500 mg 1 2 hourly for 2-4 weeks

or Co-trimoxazole

1 double strength tablet 1 2 hourly for 2-4 weeks

Urine culture is necessary in the initial work up. and 1 0- 1 4 days after completion of treatment.

In case of mycoplasma pneumonae In chronic case

Drug of choice Ery1hromycin

Drug of choice 500 mg orally


or Tetracycline

500 mg orally


or Doxycycline

1 00 mg orally 12 hourly for 2-3 weeks

or Ciprofloxacin

500 mg orally 12 hourly for 2-3 weeks

Ciprofloxacin

500 mg 12 hourly for

4 weeks

or Co-trimoxazole If there

1 DS tablet 12 hourly for 4 weeks

is no response after 4 weeks. the same antibiotic should be given for

12 weeks.

PYELONEPHRITIS (ACUTE) In case of empyma thoracis

This is caused by the same range of pathogens as uncomplicated cystitis.

Drug of choice

except that Staphylococcus saprophyticus is a rare cause of pyelonephritis.

Benzylpenicillin plus

1.2 9 intravenously

Metronidazole

200 mg intravenously 8 hourly for

6 hourly for 4-6 weeks 4-6 weeks

or Clindamycin


In case of mild-to-moderate illness Drug of choice. Ciprofloxacin

250 mg orally 1 2 hourly for 1 4 days

Change the antibiotic that depends on culture and sensitivity

In case of acute severe illness and possible urosepsis Drug of choice

54

9 intravenously 12 hourly for 7 days

Ceftriaxone or

1

Imepenum

1 9 intravenously 12 hourly for 7 days

55


ANTIBIOTIC GUI DELI N E

SEPSIS IN NEUROPATHIC FOOT IN DIABETES MELLITUS

SYPHI LIS

Antibiotic should be used for general cover or specific if organism is

Syphilis is a sexually transmitted disease caused by the spirochaete

known .

Treponema pallidum. In case of early congenital syphilis

For general cover regimen

Drug of choice Benzylpenicillin

Drug of choice Cefuroxime

1 .5 g intravenously for 1 0- 1 4 days

plus Flucloxacillin

500 mg intravenously 6 hourly for 1 0- 1 4 days

plus Metronidazole

500 mg intravenously 6 hourly for 1 0- 1 4 days or

50,000 U/kg intravenously 1 2 hourly for 1 0- 1 4 days

or Procaine benzylpenicillin or Benzathine

50,000 U/kg intramuscularly once daily for 1 0 days for symptomatic infant or those with neurosyphilis 50,000 U/kg intramuscularly as a single injection for asymptomatic infant without neurosyphilis

benzylpenicillin

Benzylpenicillin or procaine benzylpenicillin is preferred to benzathine benzylpnicillin for infants with congenital syphylis. The pharmacokinetics of benzathine penicillin appear to be altered in late pregnancy (only

400-800 mg orally for 1 0- 1 4 days

40% achieved adequate

serum concentration

for 7 days).

In case of primary or secondary syphilis Drug of choice

SINUSITIS Sinusitis

is

caused

by

Haemophilus injl.uenzae, Streptococcus

pneumoniae and Moraxella catarrhalis. Anaerobes play a significant role in adult sinusitis especially if persistent - so-called "chronic sinusitis".

Benzathine

2.4 million U intramuscularly once per week for 1 4 days

benzylpenicillin or Doxycycline

If the patient responds poorly to first choice of therapy, consider

or

treatment which includes anaerobes in its spectrum of activity.

Tetracycline

1 00 mg orally 12 hourly for 1 4 days 500 mg orally 6 hourly for 1 4 days

If a patient is allergic to penicillin, then doxycycline/tetracycline is administered.

Drug of choice

In case of latent or tertiary syphilis Co-amoxiclav

375/625 mg orally after meal 8 hourly for 1 0- 1 4 days

Drug of choice

500 mg 1 2 hourly ( 1 25 mg 1 2 hourly in children

Tetracycline

or Ciprofloxacin

70

or Cefalaxin

4 tablets (4Fixed-dose combination) daily for first 2 months

1 -2 g daily orally in 2-3 divided doses

4 tablets (4Fixed-dose combination) daily for first 2 months followed by

For the penicillin-allergic patient, erythromycin may be used.

4 tablets

Cefalexin is a first-generation cephalosporin antibiotic. If it is taken with food, absorption may be delayed, but the total amount absorbed is not appreciably altered. Doses may need to be reduced in severe renal impairment.

4Fixed-dose combination contains 150 mg of rifampicin + 75 mg of isoniazid + 400 mg of pyrazinamide + 275 mg of ethambutol

TUBERCULOSIS In case of category-I tuberculosis [new smear-positive, new smear-negative pulmonary tuberculosis with extensive parenchymal involvement or severe forms of 58

(2Fixed-dose combination) thrice-weekly for another 4 months

2Fixed-dose combination contains 150 mg of rifampicin + 75 mg of isoniazid

In case of category-II tuberculosis (previously treated for more than I month with sputum smear-positive pulmonary tuberculosis with relapse/treatment after interruption! treatment failure). 59

ANTIBIOTIC G U I DELINE


Drug of choice

Drug of choice Patient

Patient

Dosage

weight (kg) 30-37

Dosage

weight (kg) 2 tablets (4Fixed-dose combination) daily for first 3 months plus

30-37

2 tablets (3Fixed-dose combination) daily for first 2 months followed by

Streptomycin injection 500 mg daily for first 2 months followed by

2 tablets (2Fixed-dose combination) thrice-weekly for another

2 tablets (2Fixed-dose combination)

4 months

+

2 tablets of ethumbutol

(400 mg) thrice-weekly for another 5 months

38-54

3 tablets (3Fixed-dose combination) daily for 2 first months followed by

38-54

2 tablets (4Fixed-dose combination) daily for first 3 months plus


Streptomycin injection 750 mg daily for first 2 months followed by

4 months

3 tablets (2Fixed-dose combination)

+


55-70

4 tablets (3Fixed-dose combination) daily for first 2 months

(400 mg) thrice-weekly for another 5 months

followed by

2 tablets (4Fixed-dose combination) daily for first 3 months plus

4 months

4 tablets (2Fixed-dose combination) thrice-weekly for another 55-70

Streptomycin injection 1 000 mg daily for first 2 months followed by 4 tablets (2Fixed-dose combination)

+

>70



(400 mg) thrice-weekly for another 5 months >70

2 tablets (4Fixed-dose combination) daily for first 3 months plus Streptomycin injection 1 000 mg daily for first 2 months followed by 4 tablets (2Fixed-dose combination)

+


(400 mg) thrice-weekly for another 5 months The dose of streptomycin should not exceed years

750 mg daily after the age of 50

In case of category-Ill tuberculosis [new smear-negative pulmonary tuberculosis (other than category l), less severe form of extrapulmonary tuberculosis (e.g., lymph node, pleural effusion {unilateral}, bone {excluding spine}, peripheral joint, skin tuberculosis)) 60

4 tablets (3Fixed-dose combination) daily for first 2 months followed by 4 months

3Fixed-dose combination contains 400 mg of pyrazinamide

1 5 0 mg of rifampicin

2Fixed-dose combination contains

ISO mg of rifampicin + 75 mg of isoniazid

+

75 mg of isoniazid

+

In case of tuberculosis with pregnancy Most antitubercular drugs are safe in pregnancy with the exception of streptomycin, which is ototoxic to the fetus.

In case of tuberculosis with lactation A women with tuberculosis which is breast-feeding should receive a full course of antitubercular drugs.

Regular and full course

chemotherapy is the best way to prevent transmission of tuberculi bacilli to her baby. The mother and baby should stay together and breast-feeding should be continued. 61

ANTIBIOTIC GUIDELI N E


In case of tubercuLosis woman taking oraL contraceptive

Drug of choice

A women taking oral contraceptive and antitubercular drugs has

Nitrofurantoin or

1 00 mg orally after dinner for 2-3 months

Ciprofloxacin

250 mg orally at bed time for 2-3 months

increased risk of pregnancy. Rifampicin reduces the efficacy of estrogen. So, a higher dose of estrogen with rifampicin or another form of contraception can be used.

or Ofloxacin

200 mg at bed time for 2-3 months

or

U R ETHRITIS (ACUTE, FOR MALES)

Co-trimoxazole

In case of gonococcaL or chLamydiaL infection

Duration of treatment varies according to age and clinical condition of patient.

Drug of choice

Prevention of catheter-associated UTI

Azithromycin

Administration of antimicrobials is

1 g orally as a single dose

480 mg orally at bed time for 2-3 months

not of value in preventing

colonisation/i nfection in patients with indwelling catheters. Furthermore, Gastrointestinal adverse effects are usually mild and less frequent than with erythromycin. Absorption frm the capsule formulation, but not the tablet

this has been shown to promote the selection of resistance.

formulation, is reduced by food. Capsule formulation should be given at least an hour before, or

2 hour after, meal. Concurrent administration of antacids

VAGINAL CANDIDIASIS

containing aluminium or magnesium salts can reduce the rate, but not the extent of absorption of azithromycin.

In case of non-pregnant woman Drug of choice

U RINARY TRACT IN FECTIONS

Clotrimazole

500 mg vaginal tab once

Initial management will be the use of an antibiotic that depends on

or

culture and sensitivity and general condition of patient.

two 1 00 mg vaginal tab nocte for 3 nights

Drug of choice

vaginal ( 1 %) cream nocte for 6 nights

Co-trimoxazole

1 DS tablet twice daily orally for 1 0- 1 4 days

or Fluconazole


Clotrimazole is an imidazole antifungal agent. Intravaginal preparation may

or

Ciprofloxacin

1 50 mg orally as a Single dose

damage latex contraceptives and additional contraceptive measures are

or Nitrofurantoin

or

1 00 mg 6 hourly for 7-1 4 days

therefore necessary during local administration. Fluconazole is a triazole antifungal agent. Concentration of fluconazole in

In case of recurrent infection Continuous prophylactic antibiotic therapy should be considered in

breast milk, joint fluid, saliva, sputum, vaginal fluids and peritoneal fluids are .

simi lar to those achieved in plasma.

women with more than 3 UTI' s/year.

62

63

ANTIBIOTIC G U I DELI N E


In case ofpregnant woman

WOUNDS (INFECTED)

Drug of choice

Treat according to the clinical condition and the results of culture and sensitivity tests from representative specimens. It is important to

Clotrimazole

500 mg vaginal tab for 7 days

or two 1 00 mg vaginal tab nocte for 7 nights or vaginal ( 1 %) cream nocte for 7 nights

The need for tetanus prophylaxis should be evaluated in the case of

5 g of intravaginal cream (2%) to be inserted into the vagina once

Drug of choice

or Miconazole

distinguish between superficial wound colonization and true infection. as antimicrobial therapy is generally not indicated for

daily for 1 0- 1 4 days or twice daily for 7 days Clotrimazole is not contraindicated in pregnancy but one should be cautious

colonization. traumatic wounds.

Gentamicin

about its use as there may be systemic absorption.

Fusidic acid

Miconazole is an imidazole antifungal agent. Intravaginal preparation may

or

damage latex contraceptives and additional contraceptive measures are

Mupirocin

therefore necessary during local administration.

or

VAG INAL TRICHOMONIASIS Drug of choice Metronidazole or Tinidazole or Secnidazole

Apply the cream locally 2-3 times daily

or Apply the cream/ointment locally 2-3 times daily Apply the cream/ointment locally 2-3 times daily

Combination

Apply the cream locally 2-3 times daily Fusidic acid is

of Bacitracin

a steroid antimicrobial agent which is used almost

and Neomycin

exclusively against �-lactamase-producing staphylococci.

2 g as a single oral dose or 400 mg 1 2 hourly for 7 days 2 g orally as a single dose

Fusidic acid is a steroid antimicrobial agent which is used almost exclusively against �-lactarnase-producing staphylococci.

2 g single dose for both partners

Metronidazole has been used extensively in pregnancy for the treatment of trichomoniasis. The teratogenic effect appears to be minimal and if present. greatest during the first trimester. when the drug should not be used. If therapy cannot be avoided. then it can probably be used safely in the last two trimesters of pregnancy. The sexual partner(s) should also be treated to prevent reinfection.

VAGINOSIS (BACTERIAL) Drug of choice Clindamycin

One applicatorful intravaginally at night for 7 days

or Metronidazole

64

One applicator/ul intravaginally once daily for 5 days

65

ANTIBIOTIC GUIDELINE ANTIBIOTIC GUIDELIN E

GUIDELINE FOR USE OF ANTIBIOTICS IN RENAL FAI LURE Drugs

Acyclovir

Creatinine level

Dosage recommendation

Drugs

Comment

Increase dosing interval (IV) I ncrease dosing interval (oral)

Azithromycin

Avoid; jaundice reported

Ceftriaxone

Reduce dose and monitor plasma concentration if associated renal impairment

Chloramphenicol

Avoid- increased risk of bone marrow depression

Ciprofloxacin

Hepatitis with necrosis may occur

Clarithromycin

H'i!patic dysfunction including jaundice reported

Co-amoxiclav

Cholestatic jaundice reported, mon�or liver function in liver disease

(mmolll)

1 50-350 >500

USE OF ANTIBIOTICS IN LIVER DISEASE

Aminoglycosides

1 50-300

I ncrease dosing interval; avoid if possible

Amoxicillin

>500

I ncrease dosing interval

Azathioprine

>500

Decrease dose/ increase dosing interval

Benzylpenicillin

>500

Halve the dose

Ceftazidine

>1 50-300

Increase dosing interval

Cefuroxime

>500


Cefalexin

>500


Ceftriaxone

>500

No adjustment if hepatic function is normal

Chloramphenicol

>700

Avoid

Co-trimoxazole

Avoid in severe liver disease

Chloroquine

1 50-300 300-500

Maximum 75 mg/day Maximum 50 mg/day

Doxycycline

Use with caution

Ciprofloxacin

150-300

Halve the dose

Erythromycin

May cause idiosyncratic hepatotoxicity

Cisplatin

150-300


Co-trimoxazole

>500

Maximum 960 mg/day

Flucloxacillin

Cholestatic jaundice

Cyclophosphamide

300-500

Fluconazole

Monitor liver function, discontinue if liver function impaired

Fusidic acid

Impair biliary excretion; increased risk of hepatotoxicity; avoid or reduce dose

Griseofulvin

Avoid in sevEll'e liver disease

Isoniazid

Avoid if possible; idiosyncratic hepatotoxicity more common; monitor liver function regularly

Itraconazole

Half-life prolonged; dose reduction may be necessary

Ketoconaiole

Avoid

Mefloquine

Avoid for prophylaxis in severe liver disease

Metronidazole

Reduce the dose in severe liver disease

Norfloxacin

Hepatitis with necrosis; use in spontaneous bacterial peritonitis

Ofloxacin

Reduce dose

Rifampicin

Avoid in liver disease

Decrease dose Decrease dose if GFR falls

Cyclosporine Doxycycline

1 50-300


Ethumbutol

150-300


Fluconazole

1 50-300


Isoniazid

>500

Maximum 200 mg/day

Ketoconazole

1 50-300

Unchanged

Methotrexate

300-500


Nalidixic acid

300-500

Avoid

Neomycin

150-300

Avoid

Nitrofurantoin

1 50-300

Avoid

Sulfadiazine

>500

Avoid

Sulfasalazine

>500

Ensure increase fluid intake

Tetracycline

150-300

Avoid

Vancomycin

1 50-300

Avoid

Vincristine

1 50-300

Unchanged

66 67


ANTIBIOTIC G U IDELI N E Drugs

ANTIBIOTICS IN PREGNANCY Drugs

Amikacin

Use only when potential benefit outweighs risk

2, 3

alternatives are not available

least 1 month after administration Use only i n life-threatening situations (toxicity at

Ceftriaxone

Not known to be harmful

Chloramphenicol

Neonatal 'Grey syndrome'

1 , 2, 3

Avoid- arthropathy in alternatives available

animal

studies;

safer

Not known to be harmful but use only if adequate alternatives are not available

Clindamycin


Co-amoxiclav

3

menstrual period

3

Mefloquine

1 1

Fansidar

3

Metronidazole

Nitrofurantoin

3

Theoretical teratogenic risk (trimethoprim a folate antagonist)

Norfloxacin

1 , 2, 3

Neonatal hemolysis and methemoglobinemia; fear of increased risk of kernicterus in neonates

Ofloxacin

1 , 2, 3

Effects on skeletal development in animal studies

Pentamidine

Dental discoloration; maternal hepatotoxicity with

Primaquine

3

Pyrimethamine

1

large parenteral doses

Gentamicin

68

arthropathy

in

animal

studies;

safer

alternatives available May produce neonatal hemolysis if use at term Avoid-

arthropathy

in

animal

studies;

safer

in

animal

studies;

safer

alternatives available Avoid-

arthropathy

alternatives available Avoid unless essential Neonatal hemolysis and methemoglobinemia

antagonist); adequate folate supplements should be given to mother

Possible teratogenic risk (trimethoprim a folate antagonist)

Neonatal hemolysis and methemoglobinemi a; fear of increased risk of kernicterus in neonates appears to be unfounded

Quinine Streptomycin

Tetracyclines

Teratogenic in animal studies; use only when potential benefit outweighs risk

2, 3

Avoid-

Theoretical teratogenic risk (trimethoprim a folate

May be teratogenic

with long-term high doses

Flucytosine

Teratogenic in animal studies Avoid high-dose regimen

essential

Avoid- multiple congenital abnormalities reported Fluconazole

Toxicity in animal studies

1

1 , 2, 3


Erythromycin

warning to avoid in pregnancy

Mebendazole

appears to be unfounded

1

Teratogenic in animal studies; packs carry a

Nalidixic acid

No evidence of teratogenicity but avoid unless

1

Ethionamide

contraception during treatment and until the next

Ketoconazole

Clarithromycin

Doxycycline

high doses in animal studies); ensure effective

Itraconazole

Not known to be harmful but use only if adequate alternatives are not available

Co-trimoxazole

effective contraception required during and for at

Auditory or vestibular nerve damage

Azithromycin

Ciprofloxacin

Griseofulvin

Not known to be harmful but use only if adequate

Amphotericin B

Co mment

Avoid (fetotoxicity and teratogenicity in animals);

Comment

Trimester

Acyclovir

Trimester

Auditory or vestibular nerve damage

Zidovudine

1 2, 3 1 3

Teratogenic at high doses; but in malaria benefit of treatment outweighs risk Auditory or vestibular nerve damage Effects on skeletal development in animal studies Dental discoloration; maternal hepatotoxicity with large parenteral doses Limited information available; use only if clearly indicated

69



DRUGS PRESENT IN BREAST MILK Comment

Drugs

MANAGEMENT OF ANAPHYLACTIC SHOCK Management consists of stopping the offending drug, treating the acute reaction, and making a determination concerning futures use of

Aciclovir

Significant amount is found in milk after systemic administration

the drug. A detailed medical history, knowledge of the signs and

Azithromycin

Prescribe with caution; no harmful effect is known; use only if there is no alternative

syndrome, anaphylaxis and asthma are helpful.

Chloramphenicol

Use alternative, if possible; may cause bone marrow depression; concentration in milk is insufficient to cause Grey baby syndrome

Chloroquine

Amount too small to be harmful; inadequate for reliable protection against malaria

2.

remove the cause; raising the foot end may help restore the

Ciprofloxacin

High concentration in milk; avoid

3.

give adrenaline intramuscularly (0.5 mI of 1: 1 000); repeat every

Clarithromycin

Avoid; excreted in milk

Co-trimoxazole

Small risk of kernicterus in jaundiced infant and of hemolysis in G6PD-deficient infant

Doxycycline

Avoid; if necessary discontinue breast feeding

Fluconazole

Avoid; present in milk

Gentamicin

Avoid

Interferon

Avoid; no information available

Isotretinoin

Avoid

Itraconazole

Small amount found in milk; not harmful

Metronidazole

Significant amount in milk; do not take single large dose

Ofloxacin

Avoid

Penicillamine

Trace amount in milk; use with caution

Rifampicin

Amount to small to be harmful

Tetracycline

Avoid; deformity and dental decolorization in infant

Tretinoin

Avoid

70

symptoms which often include rashes, angio-edema, serum sickness Management of acute reaction includes :

I.

secure the airway- give 1 00% oxygen. Intubate i f respiratory obstruction imminent

circulation

5 mins, if needed as guided by blood pressure, pulse, respiratory function 4.

5.

secure intravenous access chlorpheniramine 1 0 mg intravenously and hydrocortisone 200 mg intravenously

6.

intravenous infusion (0.9% saline, eg., 500 mI over 1 5 minutes; up to 2 I may be needed). Titrate against blood pressure

7.

if wheeze, nebulize salmeterol, 20 min interval. Intubate if necessary for ventilatory support

8.

if still hypotensive admission to ICU and an intravenous infusion of adrenaline may be needed

±

aminophylline and nebulized

salbutamol; get expert help

Further management: •

Admit to ward; monitor ECG

•

Continue chiorpheniramine 4 mg orally 8 hourly if itching

•

Skin-prick tests showing specific IgE help identify which allergens to avoid

71

ANTIBIOTIC G UI DELI N E

ANTIBIOTIC GUI DELIN E

ANTIBIOTIC PROPHYLAXIS IN SURGERY Fundamental principles of Surgical Prophylaxis •

The antibiotic must be in the tissue before the bacteria are introduced i . e . antibiotic must be given intravenously shortly

Operations for acute cholecystitis , empyema of the gallbladder, ascending cholangitis or liver abscess require antibiotic treatment

given too early. The half-life of the particular antibiotic is therefore important. There is no data to support more than a single dose. Further doses generally constitute treatment.

Note the waste of

resources, the increased risk of complications and the fact that mUltiple doses are not associated with increased efficiency (not to be continued after •

72 hours if not otherwise indicated).

The chosen antibiotics must be active against the most common expected pathogens.

•

High risk patients, e.g. patients with j aundice or diabetes, or

identified at the time of the operation. Timing of antibiotic prophylaxis Current recommendations are that the parenteral antibiotics used in prophylaxis should be given in sufficient dosage (according to weight of the patient) within 30 minutes preceding incision. This results in near maximum drug levels in the wound and the surrounding tissues during the operation. This can be facilitated by administer the

bile, ets for culture and sensitivity).

For which type of operations? Antibiotic prophylaxis is generally indicated for patients undergoing the following types of operations: All clean-contaminated procedures; these include penetration of the gastrointestinal tract (especially colo-rectal), whether by penetrating trauma or related to a pathological organ event (e.g. ruptured appendix, perforated colonic diverticulum) prior to the development of clinical peritoniti s. Clean operations with foreign body implant (e.g. vascular, cardiac and orthopaedic operations), and those without foreign body implants especially hernia repair, breast surgery, median

72

and/or intra-abdominal abscess, and penetrating abdominal trauma where significant gastrointestinal leakage with peritoneal soiling is

devices, generally warrant antibiotic prophylaxis. For all practical purpose suitable antibiotic to be prescribed on the basis of

•

rather than prophylaxis. The same applies to operations for a perforated appendix with evidence of local or generalized peritonitis

patients who undergo any procedures to insert prosthetic

bacteriological culture and sensitivity whenever possible (e.g., blood, pus,

•

dirtylinfected should be considered as therapeutic and is clearly not prophylactic i.e. treatment should be given for a longer duration.

before surgery to ensure high blood / tissue levels. Prophylaxis failure may be due to antibiotics given too late or more often,

•

The u s e o f antibiotics i n operations classified a s contaminated or

antibiotic in the operating room when the intravenous lines are inserted shortly before operative incision. A single preoperative dose of antibiotic has the same efficacy as multiple doses and the current recommendation is to administer a second dose only if the operation lasts for longer than

2 - 3 hours. With the oral preoperative antibiotic

preparation commonly used before elective colonic resection, the chosen agents should be given during the

24 hours before the

operation in order to attain significant intraluminal (local) and serum (systemic) levels. Route of administration of prophylactic antibiotics Intravenous administration of the prophylactic antibiotic is preferred for most patients undergoing an operative procedure. Oral antibiotics currently play a major role only in the preparation of patients before

sternotomy, vascular surgery involving the aorta and the lower

elective colon surgery.

extremities, and craniotomy.

Antibiotic prophylaxis for common surgical operations 73


ANTIBIOTIC G U I DELINE

1 . Cardiovascular surgery

2. Orthopaedic surgery

Antibiotic prophylaxis in cardiovascular surgery has proven

In case of arthroplasty ofjoints. and/or joint replacement

beneficial only in the following procedures: •

Reconstruction of the abdominal aorta

•

Procedures on the leg which involve a groin incision

•

Any vascular procedure with insertion of a prosthesis I foreign body

•

Lower extremity amputation for ischaemia

•

Cardiac surgery

In case of prosthetic valve insertion. coronary a rtery bypass graft. other open heart surgery and pacemaker implant Drug of choice Ceftriaxone

1 9 intravenously daily for 5-7 days

plus Gentamicin

80 mg intravenously 8 hourly for 5-7 days

Ceftriaxone should be started 24 hours before operation. Gentamicin should be gi ven after operation

In case of superficial infection following cardiovascular surgery Drug of choice Flucloxacillin

500 mg orally 6 hourly for 1 0-1 5 days

In case of aortic resection Drug of choice Ceftriaxone

1 9 intravenously daily for 5-7 days

plus Gentamicin

In case of open reduction of fracture. laminectomy. spinal fusion, lower limb amputation Any 3rd generation cephalosporin I

-

2 g IV pre-operatively.

Compound (open) fractures are considered contaminated. so antibiotics are essentially therapeutic in such situations. 3. Gastroduodenal surgery

Antibiotics are indicated in high risk patients only, i.e. patients with bleeding ulcer, obstructive duodenal ulcer, gastric ulcer, low gastric acidity, decreased or motility, malignancy or morbid obesity. a.

1 st generation cephalosporins e.g. cefazolin I g IV pre-operatively.

b.

For beta-Iactam allergy, gentamicin 1 20 mg plus clindamicin 600 mg IV preoperatively.

4. Biliary tract surgery

Most studies show that achieving adequate drainage will prevent post-procedural cholangitis or sepsis and there is no further benefit from prophylactic antibiotics. With inadequate drainage, antibiotics may be of value. The American Society for GI Endoscopy recommends prophylaxis for known or suspected biliary obstruction. The value of prophylaxis for ERCP is controversial. Note that cephalosporins are not active against the enterococci, yet' are clinically effective as prophylaxis in biliary surgery. With cholangitis, treat as infection, not prophylaxis. High risk patients include those >70 years of age, acute cholecystitis, non-functioning gall-bladder, obstructive jaundice or common duct stones. a.

500 mg intravenously 8 hourly for 3 days. After 3 days oral

OR

preparation of the drug should be administered

74

-


plus Metronidazole

Any 3rd generation cephalosporins I 2 g pre-operatively. If the operation is longer than 3 hours, give a second dose or for up to 48 hours after the procedure.

b.

1 st generation cephalosporins e.g. cefazolin 2 g pre-operatively as a single dose cefoxitin 2 g pre-operatively as a single dose. 75



5.

Inguinal hernia repair

recommended. For a mesh Available data is limited , routine use is not cephalosporin as a single tion genera implant, give prophy laxis e.g. I st

Prostatectomy Drug of choice 1 9 intravenously stat and daily for 3 days or till the catheter

Ceftriaxone

is removed

dose. or

6.

Appendicectomy

Ciprofloxacin

500 mg intravenously stat and then 500 mg of tablet given orally for 3-5 days

Drug of choice 2 9 intravenously preoperatively and 2 more doses.

Ceftriaxone

If perforated, continued for 3-5 days

Transrectal prostate biopsy Drug of choice

or 500 mg intravenously pre-operatively or use

Metronidazole

metronidazole in the form of suppository with beta-lactam allergy Metronidazole should be given for patients

Ceftriaxone

1 9 intravenously pre-operatively (1 5 minutes prior to operation)

followed by Cefalexine


plus

7.

Penetrating abdominal trauma

as treatment and not as Any antibiotic cover can be considered

prophylaxis.

pius Ceftriaxone

400 mg orally thrice daily for 5 days.

Kidney transplantation

Drug of choice Gentamicin

Metronidazole

In case of donar 80 mg intravenously 8 hourly for 1 0 days 2 9 intravenously on admission and then 1 9 twice daily for

Drug of choice 1 9 intravenously pre-operatively (1 5 minutes prior to

Ceftriaxone

3-5 days or

supplemented by

Cefuroxime

8.

operation) stat and then for 3 days


Urological surgery

Amoxycillin

250 mg of amoxycillin plus 1 25 mg of

plus Clavulanic

Clavulanic acid orally after meal 8 hourly.

acid

Cystoscopy

In case of recipient

Drug of choice Gentamicin

80 mg intravenously prior to anesthesia

Ceftriaxone

or Ceftriaxone

76

Drug of choice

1

9 intravenously prior to anesthesia

1 9 intravenously pre-operatively ( 1 5 minutes prior to operation) stat and then for 3 days

77


9.

Head and neck surgery

Major head, neck and oral surgery

10.

Maxillofacial surgery

Cleft lip/palate surgery, condylectomy, segmental resection of

Drug of choice 1 9 intravenously pre-operatively ( 1 5 minutes prior to operation)

Ceftriaxone


maxilla/mandible, post·excisional bone grafting, malignancy, jaw fracture.

or Gentamicin plus 80 mg of gentamicin and 600 mg of clindamycin Clindamycin

intramuscularly as single dose

Drug of choice Ceitriaxone

or 1 9 intravenously as single dose

Cefradine

1 9 intravenously pre-operatively ( 1 5 minutes prior to operation) and next 2-4 days

or

10.

Obstetrics & Gynecology

Cefradine


Cesarean section Drug of choice Ceftriaxone

1 9 intravenously pre-operatively (1 5 minutes prior to operation)

plus Metronidazole

500 mg intravenously pre-ope�atively (within 60 minutes prior to operation)

Maintenance dose: Ceftriaxone 1 9 intravenously till the patient is nothing by mouth followed by oral dose of cephalosporin 500 mg 6 hourly up to 5-7 days of operation Hysterectomy (abdominal and vaginal) Drug of choice Ceftriaxone

1 9 intravenously pre-operatively ( 1 5 minutes prior to operation)

plus Metronidazole

500 mg intravenously pre-operatively (within 60 minutes prior to operation)

Maintenance dose: Ceftriaxone 1 9 intravenously till the patient is noth ing by mouth followed by oral dose of cephalosporin 500 mg 6 hourly up to 5-7 days of operation. 78 79


ANTIBIOTIC PROPHYLAXIS FOR NONSURGICAL CONDITIONS Bacterial endocarditis

Prevention of infective endocarditis in persons with certain underlying cardiac conditions is important since this infection continues to cause serious morbidity and mortality despite advances in diagnosis and treatment.

Procedures for which Endocarditis Prophylaxis is necessary, include:


Genitourinary and gastrointestinal procedures

The relevant organisms are usually enterococci, and rarely Gram negative bacilli. Ampicillin 2 g intravenously (50 mg/kg in children) PLUS gentamicin 1 .5 mg/kg intravenously ( 1 .5 mg/kg in children) 30 minutes before the procedure followed by one dose of amoxycillin 1 g orally (25 mg/kg in children) 6 hours after the

Dental procedures known to cause mucosal or gingival bleeding e.g.extractions, dental implant placement and reimplantation of avulsed teeth, root canal instrumentation or surgery, professional cleaning

or

•

Tonsillectomy and/or adenoidectomy Surgical conditions that involve penetration of intestinal or respiratory mucosa

8 hours after the initial dose.

•

•

Bronchoscopy with a rigid bronchoscope

Vancomycin I g intravenously (20 mg/kg in children) PLUS

•

Sclerotherapy for oesophageal varices

gentamicin 1 . 5 mg/kg intravenously (2 mg/kg in children) 30

•

Biliary tract surgery

minutes before the procedure, as single dose only.

•

Cystoscopy

Contacts

•

Urethral dilatation

meningococcal infections

•

Urethral catheterisation, if infection is present

•

Prostatic surgery

•

Incision and drainage of infected tissue

•

Prophylactic regimens

In case of tooth extraction or minor oral surgery Streptococcus viridans is the most common cause of endocarditis following dental, oral, respiratory tract, or oesophageal procedures. Drug of choice Amoxicillin

80

If allergic to ampicillin/penicillin or unable to take oral medication:

of

invasive

Haemophilus influenza

type

b

and

The purpose of chemoprophylaxis in contacts is to eradicate nasopharyngeal

colonization by Neisseria meningitidis or Haemophilus influenzae type b and thus reduce both the risk of disease in contacts and the transmission to nonimmune susceptible people. Meningococcus contacts

Household contacts, day-care contacts, and only health-care workers with direct exposure to oral secretions (e.g. mouth-to infection, require prophylaxis. The index case also requires an agent to eradicate nasopharyngeal carriage, prior to discharge

For 5-7 days

plus Metronidazole

one dose of ampicillin 1 g intravenously (25 mg/kg in children)

mouth resuscitation) of patients with invasive meningococcal 500 mg orally 8 hourly for 5-7 days

or Any cephalosporin

initial dose

400 mg three times daily for 5-7 days

from hospital (unless treated with ceftriaxone or cefotaxime) since therapy with penicillin may not eliminate nasopharyngeal carriage of the organism. 81



The recommended chemoprophylactic agents include: Rifampicin for 4 doses or Ceftriaxone

20 mglkg (to a maximum of 600 mg) given 1 2 hourly orally

250 mg (in adults) or 1 25 mg (in children) intramuscularly as a single dose

or Ciprofloxacin

500 mg orally as a single dose in adults and older children

In case of rhehmatic fever with carditis but no residual valvular lesion Chemoprophylaxis is usually started after the first episode of rheumatic fever and continued for 1 0 years, or up to the age of 30 years, which ever is the longer. Drug of choice Benzathine

1 .2 million U intramuscularly every 3-weekly (600,000 U for children less than 30 kg body weight)

or

Contact with chicken pox

Acyclovir orally 20 mg/kg/day for 5 days

Phenoxymethylpenicillin or Erythromycin

Contact with measles

250 mg orally 1 2 hourly ( 1 25 mg orally 1 2 hourly in children less than 5 years) 250 mg orally 1 2 hourly ( 1 0 mg/kglday if less than 40 kg) In case of sensitivity to penicillin

Hyperimmune gamma globulin 1 .5 g/m2 single dose (if not available, then polyvalent globulin)

In case of rhehmatic fever with carditis and residual valvular lesion

Pertussis

Erythromycin may be given to household contacts in doses of 50 mg/kg/day in 4 divided doses for 14 days. Rheumatic fever

Chemoprophylaxis is usually started after the first episode of rheumatic fever and continued for lifelong. Drug of choice Benzathine

In case of rhehmatic fever without carditis

1 .2 million U intramuscularly every 3-weekly (600,000 U

benzylpenicillin

for children less than 30 kg body weight)

Chemoprophylaxis is usually started after the first episode of rheumatic

or

fever and continued for 5 years, or up to the age of 22 years, which ever

Phenoxymethylpenicillin

is the longer. The aim is to maintain antibiotic levels sufficient to prevent pharyngeal infection with Streptococcus pyogenes.

Benzathine benzylpenicillin or Phenoxymethylpenicillin or Erythromycin

or Erythromycin

Drug of choice 1 .2 million IU deep intramuscularly every 3-weekly

250 mg orally 1 2 hourly ( 1 25 mg orally 1 2 hourly in children less than 5 years) 250 mg orally 12 hourly (10 mglkg/day if less than 40 kg) In case of sensitivity to penicillin

(600,000 IU for children less than 30 kg body weight) 250 mg orally 1 2 hourly (1 25 mg orally 1 2 hourly in children less than 5 years) 250 mg orally 12 hourly ( 1 0 mg/kglday if less than 40 kg) I n case of sensitivity to penicillin

82

83

ANTIBIOTIC G U I D EL I N E


ANTIMICROBIAL AGENTS ASSOCIATED WITH PHOTOSENSITIVITY

HOSPITAL INFECTION CONTROL

The fol lowing drugs are known to cause photosensitivity in

An infection within the hospital, you can take the help of infection control team. To whom you have to contact:

some individuals:

Azithromycin, ciprofloxacin, dapsone, doxycycline, erythromycin. flucytosine, gancic\ovir, griseofulvin, interferons, levofloxacin, lomeflozacin, norfloxacin, ofloxacin, pefloxacin, pyrazinamide, saquinavir, sparfloxacin, sulfonamides, tetracyclines, tretinions, trovafloxacin, trimethoprim

Dr. Sharmin Ahmed

Associate Professor Department of Microbiology and Immunology Telephone 4424 44 1 8

84

85

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Susceptibil ity of some bacteria to certain antibiotics

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R

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0

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1

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R

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R

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0

0

0

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H influenzae

R

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1

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Ecoli

R

R

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2

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Klebsiella species

R

R

R

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2

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Serratia/Enterobacter species

R

R

R

2R

2

1R

Posteus species

R

R

1R

2R

2

1 R 2R

Pseudomonas aeruginosa

R

R

R

1R

R

Bacteroides frogilis

R

R

R

R

R

R

R

R

2

R

2

0

2R

R

R

R

1

R

2

Other Bacteroides species

2

R

R

R

R

R

R

R

2

R

2

0

2R

R

R

R

1

R

2

0

0

0

0

0

0

0

0

0

0

0

0

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2

1

0

0

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=

2nd choice, R

=

Resistance likely. 0

=

2

0

2

R

R

2R

0

R

R

2

R

2

R

R

R

R

1 R 1 R*

R

R

2

2

2R

2R

2

R

R

R

R

1 R 1 R*

R

R

2

2

2R

2R

2

R

R

R

R

1 R 1 R*

R

R

2

2R

R

2

R

R

R

R

1 R 1 R*

R

R

2

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resistance is rare in most areas.

NB : This table is a guide only, and different populations will exhibit their own (changing) patterns of resistance. .. In practice, the best thing is often to talk to a microbiologist

Classification of medically important bacteria Characteristics

I.

A.

Representative Diseases

Free-living (extracellular bacteria) 1. Gram-positive a. b.

c.

Cocci

(2) Anaerobic Non-spore-forming rods

(2) 2.

Streptococcus

Spore-forming rods ( 1 ) Aerobic Bacillus

(1 )

Nonfilamentous Filamentous

G ram-negative a. Cocci b.

Rods ( 1 ) Facultative (a) Straight (i)

(ii) co -.,J

Genus

Rigid, thick-walled cells

Staphylococcus

Pneumonia, pharyngitis, cellulites Abscess of skin and other organs

Anthrax Clostridium

Tetanus, gas gangrene, botulism

Corynebacterium

Diphtheria

Listeria

Meningitis

Actinomyces Nocardia

ActinomYCOSis

Neisseria

Gonorrhea, meningitis

Nocardiosis

» z

Respiratory organisms

Haemophilus

Zoonotic organisms

Bordetella Legionella Brucella

Whooping cough Pneumonia

Francisella

Tularemioa

Yersinia

Plagus

Meningitis

Brucellosis

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a m

r

Z m

ANTIBIOTIC G U I D ELINE

I N DEX A

B

Abdominal trauma 76

Bacitracin 38, 65

Abscess alveolar 27

Bacterial endocarditis 80 Benzylpen icillin 35,52,54, 57,58 Benzathine 5 1 , 57

breast 30 cerebral 35

Benzoyl peroxide 27

liver (pyogenic) 44

Betamethasone 40

periodontal 50

Biopsy

Acne vulgaris 26 Acyclovir 42, 43 Alveolar osteitis 27 Amikacin 47 Amoebiasis 28

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