Cover Design John Michael L. Roque Layout Design Adell R. Azuelo Lora Alaine D. Raymundo John Michael L. Roque All rights reserved 2017 National Antibiotic Guidelines Committee Pharmaceutical Division Department of Health Philippine Blood Center, Lung Center Compound, Quezon Avenue, Quezon City, 1100 ISBN - 978-621-95675-1-0 Any part of the book or its entirety may be reproduced or transmitted without any alteration, in any form or by any means, with permission from DOH provided it is not used for commercial purposes. . National Antibiotic Guidelines 2017 Department of Health Manila. Philippines . . ….....…………………............…………………………………………………………… 219 SURGICAL PROPHYLAXIS …………………………………….... 86 LOWER RESPIRATORY INFECTIONS …………………………...........……………... 26 CARDIOVASCULAR INFECTIONS ………….......... 47 DENTAL AND ORAL INFECTIONS ……………………..……… 196 TUBERCULOSIS …....... 33 CENTRAL NERVOUS SYSTEM INFECTIONS ……………………………........... 230 ........... ii EDITORIAL TEAM ........ 19 BONE AND JOINT INFECTIONS IN ADULTS ……………………………...............……………………….................. v INTRODUCTION TO THE NATIONAL ANTIBIOTIC GUIDELINES .. 1 BONE AND JOINT INFECTIONS IN PEDIATRICS ……………………….....……………...................... viii BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES ......... 61 OCULAR INFECTIONS ………………………………………………………..........…………….........................………………...................................................................…………..........................................……… 195 SEXUALLY TRANSMITTED INFECTIONS ……………………....... 124 SKIN AND SOFT TISSUE INFECTIONS IN ADULTS ……………………......…….......................…… 183 LEPROSY ………………………………………………………………………………................... 170 PUBLIC HEALTH PROGRAMS FILARIASIS ………………………………………………………………………….................................................................. 150 URINARY TRACT INFECTIONS ………………………………............................................. TABLE OF CONTENTS MESSAGE OF THE SECRETARY OF HEALTH .. 74 UPPER RESPIRATORY INFECTIONS ……………………….........….............. 184 MALARIA …………………………………………………………………………................................................ iv ACRONYMS AND ABBREVIATIONS .........……………......... 105 SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRICS ………………............ i ACKNOWLEDGMENTS ..... 55 GASTROINTESTINAL TRACT INFECTIONS ……………………………....... 186 SCHISTOSOMIASIS …………………............. . i . Hepatology and Nutrition (PSPGHAN) ii . former editor DOH offices: Disease Prevention and Control Bureau (DPCB) Epidemiology Bureau (EB) Food and Drug Administration (FDA) Health Facility Development Bureau (HFDB) Professional Associations: Pediatric Infectious Disease Society of the Philippines Pediatric Nephrology Society of the Philippines (PNSP) Philippine Academy of Family Physicians (PAFP) Philippine Academy of Ophthalmology (PAO) Philippine Academy of Pediatric Pulmonologist (PAPP) Philippine Coalition Against Tuberculosis (PhilCAT) Philippine College of Chest Physicians (PCCP) Philippine College of Physicians (PCP) Philippine College of Surgeons (PCS) Philippine Dental Association (PDA) Philippine Dermatological Society (PDS) Philippine Hospital Infection Control Society. Inc. (PPhA) Philippine Society for Microbiology and Infectious Disease (PSMID) Philippine Society of Nephrology (PSN) Philippine Society of Newborn Medicine (PSNBM) Philippine Society of Otolaryngology Head and Neck Surgery (PSO-HNS) Philippine Society for Pediatric Gastroenterology. former NAG Committee Chair Dr. (PHICS) Philippine Neurological Association (PNA) Philippine Obstetrical and Gynecological Society (POGS) Philippine Orthopedic Association (POA) Philippine Pediatric Society (PPS) Philippine Pharmacists Association. Estrella B. Inc. ACKNOWLEDGMENTS The participation and assistance of the following experts and reviewers of this document are gratefully acknowledged: Dr. Ivan Olegario. Paje-Villar. Philippine General Hospital (UP-PGH) Development Partners: World Health Organization iii . Philippine Society of Pediatric Surgeons (PSPS) Philippine Urological Association (PUA) Hospitals: Philippine Children’s Medical Center (PCMC) Research Institute for Tropical Medicine (RITM) San Lazaro Hospital (SLH) The Medical City (TMC) UP. MPH. RPh. MSCCT ROSALIND G. MD. LIMUACO. FLORES. RPh. LANSANG. NIÑA ISABELLE M. SANIEL. ANNE JULIENNE M. EDITORIAL TEAM National Antibiotic Guidelines Committee Chair MEDIADORA C. MD. MMEDSC CECILIA C. RPH. MD. RPH iv . PhD VITO G. GALVEZ. GUERRERO. FPPS. MD. MD. FPPS. MD. MBA-H. MPH CYNTHIA S. RAYMUNDO. LORA ALAINE D. RPH MS. ROBLES. FPAPP MARI ROSE A. MD. CESO IV ANNA MELISSA M. TOLENTINO. FPCP Members CELIA C. MARAMBA-LAZARTE. MD Antimicrobial Resistance Program Secretariat CORAZON I. MD. FPCCP MARY ANN D. MSCID. DPCOM OLIVIA M. DE LOS REYES. RPH MS. PhD YOLANDA R. VIANZON. CARLOS. GENUINO. FPCP BENILDA B. MNSA MS. FPIDSP. ROQUE. MD. FPSMID CARMINA A. Jr. FLORENTINO-FARIÑAS. FABREGAS. DELOS REYES. MD. MD. MD. MPH (HTA) IRENE V. ABBREVIATIONS AND ACRONYMS ABECB Acute bacterial exacerbation of chronic bronchitis ABP Acute bacterial prostatitis ABRS Acute bacterial rhinosinusitis ABSSSI Acute bacterial skin and skin structure infections AL Artemether-lumefantrine ALT Alanine aminotransferase AOM Acute otitis media ARSP Antimicrobial Resistance Surveillance Program ART Antiretroviral therapy ASB Asymptomatic bacteriuria AUC Acute uncomplicated cystitis BMI Body mass index BUN Blood urea nitrogen CAMRSA Community associated MRSA CAP Community acquired pneumonia CBP Chronic bacterial prostatitis CHD Congenital heart disease CMV Cytomegalovirus CNS Central nervous system CRP C-reactive protein CRS Chronic rhinosinusitis CSF Cerebrospinal fluid CSOM Chronic suppurative otitis media CT Computed tomography CVC Central venous catheter CVS Cardiovascular system DAIR Debridement and retention of prosthesis DEC Diethyl carbamazine DFI Diabetic foot infections DOT Duration of Therapy EIA Enzyme immunoassay ELISA Enzyme-linked immunosorbent assay ENT Ears. nose and throat EPTB Extra pulmonary tuberculosis ESBL Extended spectrum ß-Lactamase ESR Erythrocyte sedimentation rate ETEC Entero-toxigenic Escherichia coli FDC Fixed dose combination v . Measles. Aggregatibacter sp. HAI Hospital-associated Infections HAP Hospital acquired pneumonia HBIG Hepatitis B Immunoglobulin HBeAg Hepatitis B envelope antigen HBsAg Hepatitis B surface antigen HBV Hepatitis B virus HCV Hepatitis C virus HR Isoniazid + Rifampicin HRZE/S Isoniazid + Rifampicin + Pyrazinamide + Ethambutol/Streptomycin HSV Herpes simplex virus HIV Human immunodeficiency virus ICT Immunochromatographic test IDSA Infectious Diseases Society of America IE Infective Endocarditis I&D Incision and drainage IRIS Immune reconstitution inflammatory syndrome ISPD International Society for Peritoneal Dialysis LBW Low birth weight LP Lumbar puncture MAP Mean arterial pressure MDR-TB Multiple drug resistant tuberculosis MDT Multidrug therapy MIC Minimum inhibitory concentration MMR Mumps.. Eikinella corrodens. and Kingella sp. Cardiobacterium hominis.FQ Fluoroquinolone FTA-ABS Fluorescent treponemal antibody absorption test GIT Gastro-intestinal tract GABHS Group A Beta-hemolytic Streptococci GAS Group A streptococcus GCSF Granulocyte stimulating factor GNB Gram-negative bacteria GUT Genitourinary tract HACEK Haemophilus sp.. Rubella MRI Magnetic resonance imaging MSSA Methicillin-susceptible Staphylococcus aureus MRSA Methicillin-resistant Staphylococcus aureus MTB Mycobacterium tuberculosis NAAT Nucleic acid amplification testing NBE Nocturnal blood examinations vi . NT Neutralization test OC Oral contraceptive OGTT Oral glucose tolerance test PANDAS Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcus Infections PCAP Pediatric community acquired pneumonia PCR Polymerase chain reaction PHN Post-herpetic neuralgia PICC Peripherally inserted central catheter PID Pelvic Inflammatory Disease PLHIV People living with HIV PMDT Programmatic Management for drug-resistant Tuberculosis PT Prothrombin time PVL Panton valentin leukocidin PWID People who inject drugs RHD Rheumatic Heart Disease RPR Rapid plasma reagin RSU Respiratory syncytial virus SIRS Systemic inflammatory response syndrome SLDs Second line drugs SLE Systemic Lupus Erythematosus SOFA Sequential organ failure assessment STD Sexually Transmitted Disease STI Sexually Transmitted Infections TALF Treatment after lost to follow up TB Tuberculosis TMP-SMX Trimethoprim-sulfamethoxazole TCA Trichloroacetic acid TSS Toxic shock syndrome TEE Transesophageal echo TPHA Treponema pallidum haemagglutination TTE Transthoracic echocardiogram ULN Upper limit of normal UTI Urinary tract infection VAP Ventilator associated pneumonia VDRL Venereal Disease Research Laboratory VP Ventriculoperitoneal VSD Ventricular septal defect VZIG Varicella zoster immunoglobulin VZV Varicella zoster virus WHO World Health Organization vii . health practitioners at all levels of healthcare are then empowered to appropriately treat common infectious disease syndromes seen among children and adults (e. balance of potential benefits and harm. guidelines and clinical pathways to improve antimicrobial prescribing and dispensing. Divided into subgroups. availability of diagnostic tests. gives structure and direction to healthcare facilities to adopt a proactive multidisciplinary approach to promote rational antimicrobial use. cost-effectiveness. respiratory and urinary tract infections. INTRODUCTION The National Antimicrobial Stewardship (AMS) Program. epidemiology. pharmacology and public health program management. with priority given to guidelines that utilized the GRADE (Grading of Recommendations Assessment. quality of the evidence. diarrhea. Interim recommendations were viii . The challenging task of formulating the Guidelines was given by the Department of Health to the National Antibiotic Guidelines Committee (NAGCOM). One of the six core elements of AMS is the development and implementation of policies.g. skin and soft tissue infections. a multidisciplinary group of experts in the fields of infectious diseases. list of approved drugs in the National Formulary. feasibility and resource implications. Development and Evaluation) system. Specifically. It was decided from the outset that there would be no need to reinvent the wheel. Core Element 2 states that “all hospitals shall adopt or adapt to their local context the National Antibiotic Guidelines” to optimize antimicrobial use and help improve the quality of patient care and patient safety. the NAGCOM reviewed existing evidence-based local and international guidelines and relevant literature. tuberculosis) as well as other diseases for which much irrational antibiotic use prevails in the country. Adaptations of available guidelines and treatment recommendations were made taking into consideration the latest national Antimicrobial Resistance Surveillance Program resistance rates. Armed with enhanced knowledge provided by the Guidelines. an integral component of the Philippine Action Plan to Combat Antimicrobial Resistance (AMR). de-escalation) and prospective audit and feedback. has been added since antibiotic misuse to prevent surgical site infections also needs urgent attention. The interim guidelines were then sent to the specialty/subspecialty societies for their inputs prior to finalizing the Guidelines. frequency and duration) for pediatric and adult patients. A section on surgical prophylaxis. Consultations with external technical experts and public health program implementers were also done as needed. corresponding antibiotic regimens (dose.discussed en banc and a consensus was usually reached.gov. the AMS Committee of a health facility can adopt or adapt portions of the Guidelines. dose optimization. The Guidelines are not intended to supersede a healthcare provider’s sound clinical judgment. There are several other ways by which the Guidelines. The Guidelines in this handbook contain treatment recommendations for infectious diseases grouped by organ systems and presented in a tabular format for ease of use. Variations in a patient’s clinical presentation (such as presence of co- morbidities). and available resources. Depending on local antibiotic susceptibilities. formulary options. patient’s preferences and availability of resources may require judicious adaptation of the Guidelines by individual users. although not treatment-focused. can be used in AMS (http://icamr. How should the Guidelines be used in health facilities? The AMS program stipulates that hospitals should have facility-specific antibiotic guidelines. implementation of point-of-care interventions (e. ix . development of educational modules (print and electronic) for healthcare professionals. Brief descriptions of disease categories with their etiologic agents. route.doh. relevant comments and key references are presented. adopted or adapted. costs.g.ph) including: creation of clinical pathways. and performance evaluation. etc. chloramphenicol.. which may not be reached by significant levels of the principal antibiotic being used (e. Age – a major factor that can influence gastric acidity.g. route of administration. Pregnancy and Nursing Status (See Appendix for Pregnancy Risk Categories by the US FDA). Bacterial load (inoculum size). Genetic factors – e. sulfones. etc. nitrofurans. or aplastic anemia from chloramphenicol as an idiosyncratic reaction. nasopharyngeal carriage).GENERAL PRINCIPLES OF ANTIMICROBIAL THERAPY: The fundamental questions to ask in anti-infective therapy are: • WHAT am I treating? – The infectious disease/clinical syndrome and the likely or proven pathogen [The MICROBIOLOGIC FACTORS] • WHO am I treating? – The patient’s demographic. presence of pus. v. and behavioral characteristics [The HOST-RELATED FACTORS] • WHICH antimicrobial (or antibiotic combination) is most appropriate? [The DRUG- RELATED FACTORS] • HOW do I administer the appropriate antimicrobial(s)? – Dose. foreign body. renal function and hepatic function. Site of infection – adequate concentration of the antibiotic at the site of infection must be attained. etc. regrowth pattern and susceptibility pattern of the pathogen. impaired penetration of antibiotic into the affected area.g. endocarditis..g. interval/frequency. iii. meningitis.. vi. devitalized tissue.g. Prior antimicrobial therapy: exert selection pressure for micro-organisms resistant to the antibiotic previously given to outgrow the rest of the microflora. x . as well as propensity to develop hypersensitivity. ii. Infection at sequestered sites. ii. Local factors – e. 2. especially when high serum or tissue levels are potentially toxic. duration of treatment. Severity of infection: serious life-threatening infections (e. MICROBIOLOGIC FACTORS: the disease/clinical syndrome and the likely/proven pathogen(s) i.. clinical.. iv. FACTORS TO CONSIDER IN THE CHOICE OF ANTIMICROBIALS: 1. iv. invade and cause infection. glucose-6-phosphate dehydrogenase deficiency causes hemolytic anemia and jaundice with the administration of primaquine. Hepatic and renal function – the ability of the patient to metabolize/inactivate or excrete the antimicrobial is one of the most important host factors.) require early empiric therapy after appropriate specimens are obtained to determine the pathogen involved. virulence. pH changes. HOST-RELATED FACTORS influence the efficacy and toxicities of antimicrobials i. iii. sepsis. [The DOSING REGIMEN including duration of therapy] A. sulfonamides. excretion.. however. recipients of cytotoxic drugs. DRUG-RELATED FACTORS i. stability.). v. Others: ease and accuracy of dosing. etc. intraocular tissues and prostate. concentration- dependent vs. Host defense mechanisms. obesity. leprae. the physician is often tempted to use a combination of 2 or more for the sense of security they provide. Drug interactions – could be pharmaceutical. ANTIBIOTIC COMBINATION THERAPY: Antibiotic combinations provide a broader spectrum coverage than single agents. 3. xi . but increased with inflammation. bacteriostatic vs. when inappropriately used. pharmacodynamic or pharmacokinetic in nature. iii. iii. pre-existing organ dysfunction. vi. Treat polymicrobial infection (e. etc. ii.. immunocompetent vs. distribution.g. poor antimicrobial penetration of the blood-brain barrier. carbapenems. atopy... newer generation fluoroquinolones. M. biotransformation/metabolism. e. the relationship between the antimicrobial concentration at the site of action and the minimum inhibitory concentration for the pathogen is the major determinant of successful therapy.g. diabetic foot infection. Previous history of adverse drug reactions (e. ii. hence.). immunocompromised host (e. vii. RATIONALE FOR ANTIBIOTIC COMBINED THERAPY: i. or beta-lactam plus beta- lactamase inhibitor combinations can be employed as monotherapy). should be considered. Pharmacodynamics – “what the drugs does to the pathogen and to the body” – antimicrobial spectrum.g. and acceptability. bactericidal. However. Prevent/delay emergence of resistance (e. iv. Cost/benefit ratio – the total cost of the regimen and not the unit cost of the drug. both humoral and cellular.g. Provide broad-spectrum empiric therapy in the initial therapy of critically ill patients and neutropenic patients with severe life-threatening infections. beta-lactam antibiotic plus aminoglycoside for sepsis in neonates.g. time-dependent bacterial killing. diseases due to Mycobacterium tuberculosis. Pseudomonas aeruginosa.) vi. intolerance. Adverse effects: risk/benefit ratio. HIV infection. etc. B. use of anti-aerobes and anti-anaerobes for intraabdominal abscess. burn patients. allergy. Pharmacokinetics – “what the body does to the drug” – includes the processes of absorption. Co-morbid conditions: HIV/AIDS. impaired localized phagocytosis. diabetes mellitus and other metabolic disorders. with vascular abnormalities. antibiotic combination can lead to deleterious effects. v. etc. transplanted organs. 3. C. GENERAL ADVERSE REACTIONS TO CHEMOTHERAPEUTIC AGENTS: 1. etc. Masking effect. Adverse drug interactions with other drugs – e. e. HOST FACTORS such as poor host defense.g. nephrotoxicity. 5. bacterial load.. anatomic defects. Biologic and metabolic reactions in the host (e. Treatment failure/relapse.. 6. route. b. intervals and duration of administration. Hypersensitivity reaction – ranges from mild skin rash to severe anaphylactic reactions. Decrease dose-related toxicity (e. impaired elimination. etc. Obtain enhanced inhibition/killing (synergism) (e. deterioration during storage.g. v. drug interactions. 6. Formulate a clinical diagnosis of microbial infection. hepatotoxicity. 2. flucytosine plus amphotericin B in cryptococcal meningitis). 5. SUITABILITY and COST of the antimicrobial options in the selection process.). sulfamethoxazole plus trimethoprim. 7.g.g. GENERAL STEPS IN APPROPRIATE ANTIMICROBIAL THERAPY: 1. not dose-related. neurotoxicity. etc. superinfection. superinfections). xii . drug resistance. 3. c. Determine the need for empiric therapy.. iv. not dose-related. and following the “RULES OF RIGHT”. 4. etc. Institute adjunctive and non-pharmacologic therapy. Obtain appropriate specimen for laboratory exam when applicable. 4. Idiosyncratic reaction – may be genetic in origin. inadequate absorption. metabolic enzyme inhibition or induction. SAFETY. Sound clinical judgment/assessment remains the most important method to determine the efficacy of the treatment. protein binding displacement. 7. Toxicity reactions – augmented reactions (dose-related). penicillin plus aminoglycoside in enterococcal endocarditis and Streptococcus viridans endocarditis. alteration of normal microflora. ototoxicity. distribution. dual or mixed infection not detected. wrong dose. presence of foreign body.g. E. HOST and DRUG FACTORS and using EFFICACY. correlated with the patient’s clinical response (DIRECTED or TARGETED ANTIMICROBIAL THERAPY). Formulate a specific microbiologic diagnosis. Institute pharmacologic treatment considering MICROBIAL. DRUG FACTORS such as wrong choice of antimicrobial. D. 2. MICROBIAL FACTORS such as wrong microbiologic diagnosis. etc. Adjust antimicrobial regimen according to the isolated pathogen and its susceptibility pattern. CAUSES OF FAILURE IN ANTIMICROBIAL THERAPY: a. Inappropriate dosing – e. FACTORS THAT LEAD TO INAPPROPRIATE USE OF ANTIMICROBIALS: a. Complete reliance on chemotherapy with omission of surgical drainage and other non-pharmacologic therapy when necessary. Inadequacy of knowledge of diagnostic procedures and management of infectious diseases.g. use in agriculture and aquaculture. UNWANTED CONSEQUENCES OF MISUSE/INAPPROPRIATE USE OF ANTIMICROBIALS: a. Use of multiple/broad-spectrum antibiotics to cover the possibility of infection from numerous microorganisms as a substitute for appropriate diagnostic evaluation. Increased cost of therapy. Pressure from patients/parents to be treated with antimicrobials. Adverse drug reactions. beliefs that higher doses or more prolonged administration is better. Inappropriate choice of antibiotic dosage. Cost and availability of diagnostic test. Time constraint – more time required to explain why antibiotic is not needed than simply writing the prescription. Recycling antibiotic prescription and/or self-medication. d. e. Emergence of drug-resistant organisms. 10. 8. 5. Inappropriate chemoprophylaxis. Malpractice considerations and fear of litigation. b. Concern about increasing prevalence of antibiotic resistance. Inappropriate chemoprophylaxis – timing and duration of surgical prophylaxis and a variety of other prophylactic purposes in hospitalized patients. Easy solution provided by pharmaceutical companies and aggressive promotion. Inappropriate antibiotic combination. Use of antimicrobials as growth promoters in farm animals. 7. 2. d. e. 4. Good intention – to give the best treatment without regard to spectrum of activity of the antibiotic and its cost. Predisposition to secondary infections. MISUSE/ABUSE OF ANTIMICROBIALS: 1. h. complications and even death. Increased length of hospital stay.F. Empiric use on fever of undetermined origin. which are not evidence-based. H. Use in untreatable (viral) infection. 9. Lack of appropriate bacteriologic information when indicated. j. c. f. c. k. 3. xiii . Over-the-counter sale of antibiotics. g. intervals and duration of administration. i. G. route. b. 6. . Mean RR >2 standard deviations for age or mechanical ventilation for an acute process not related to an underlying neuromuscular disease or to general anesthesia 4. ≤7d old: 50mg/kg q12h 5mg/kg q48h 15mg/kg q48h ≤2 kg. If no pathogen has been isolated but bacterial sepsis cannot be excluded. ≤7d old: 50mg/kg q8h 4mg/kg q24h 15mg/kg q24h >2kg. SEPSIS IN CHILDREN Systemic Inflammatory Response Syndrome (SIRS) The presence of two or more of the following four criteria. NEONATAL SEPSIS Etiology: Gram-negative bacilli. Tachycardia or bradycardia 3. Age Ampicillin Gentamicin Amikacin ≤2 kg. Core temperature (rectal. Group B streptococci. fever >38°C before delivery or during labor and/or foul-smelling or purulent amniotic fluid Preferred Regimen: Ampicillin PLUS Gentamicin or Amikacin Weight. S. S. 8-28d old: 50mg/kg q6h 4-5mg/kg q24h 17. a negative CRP test at 72 hours can help support decision to discontinue antibiotics. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES I. or central catheter probe) >38. aureus National Antibiotic Guidelines 1 . membranes ruptured >18h before delivery.5°C (101. oral. one of which must be abnormal temperature or white blood cell count: 1.8°F) 2. bladder. Abnormal WBC count or >10% immature neutrophils Sepsis: SIRS in the presence of or caused by suspected or proven infection A.5mg/kg q24h Comments: For infants who remain asymptomatic and whose initial blood cultures are negative after 48-72 hours of incubation. 8-28d old: 50mg/kg q8h 5mg/kg q36h 15mg/kg q24h >2kg. antimicrobial therapy can be discontinued. pneumoniae.3°F) or <36°C (96. Neonate POTENTIALLY SEPTIC NEONATE Etiology: Asymptomatic neonates with documented maternal risk factors like history of UTI during the last trimester. ≤7d old: 50mg/kg q12h >2kg. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES Neonates with bacterial sepsis may present either with non-specific signs and symptoms or focal signs of infection. abdominal distention DERMATOLOGIC: skin pustules. 8-28d old: 5mg/kg q36h >2kg. drowsy or unconscious. decreased activity. 8-28d old: 15mg/kg q24h ≤2 kg. 8-28d old: 15mg/kg q24h >2kg. The clinical criteria for the diagnosis of bacterial sepsis by the Integrated Management of Childhood Illness (IMCI) and WHO are as follows: NEUROLOGIC: convulsions. ≤7d old: 15mg/kg q24h >2kg. or feels cold) Preferred Regimen: 1st line: 2nd line: Cefotaxime Ceftazidime ≤2 kg.5mg/kg q24h WITH OR WITHOUT Oxacillin ≤2 kg. sever chest indrawing. 8-28d old: 17. 8-28d old: 50mg/kg q8-12h ≤2 kg.5mg/kg q24h >2kg. or feels hot) or <35. 8-28d old: 50mg/kg q6h or Vancomycin (for MRSA) Meningitis: 15mg/kg/dose Bacteremia: 10mg/kg/dose 2 National Antibiotic Guidelines . ≤7d old: 25mg/kg q12h ≤2 kg. 8-28d old: 50mg/kg q8h Ceftriaxone 50mg/kg q24h PLUS PLUS Gentamicin Gentamicin ≤2 kg. 8-28d old: 4-5mg/kg q24h or Amikacin Amikacin ≤2 kg. 8-28d old: 50mg/kg q8h >2kg. ≤7d old: 50mg/kg q12h ≤2 kg. ≤7d old: 4mg/kg q24h >2kg. periumbilical erythema or purulence MUSCULOSKELETAL: edema or erythema overlying bones or joints OTHER: Temperature >37. 8-28d old: 50mg/kg q8h or >2kg. rapid and weak pulse GASTROINTESTINAL: jaundice. bulging fontanel RESPIRATORY: respiratory rate >60 breaths/min. ≤7d old: 5mg/kg q48h ≤2 kg. ≤7d old: 50mg/kg q8h >2kg. ≤7d old: 50mg/kg q12h ≤2 kg.5°C (95. 8-28d old: 50mg/kg q8-12h >2kg. poor feeding. grunting. central cyanosis CARDIAC: poor perfusion. ≤7d old: 50mg/kg q12h >2kg. 8-28d old: 17.9°F. ≤7d old: 15 mg/kg q48h ≤2 kg. 8-28d old: 5mg/kg q36h ≤2 kg. ≤7d old: 5mg/kg q48h ≤2 kg.9°F.7°C (99. 8-28d old: 4-5mg/kg q24h or >2kg. ≤7d old: 15mg/kg q48h ≤2 kg. ≤7d old: 4mg/kg q24h >2kg. ≤7d old: 15mg/kg q24h >2kg. Likewise. neonates should not receive ceftriaxone intravenously if also receiving intravenous calcium in any form. Add Oxacillin or Vancomycin (MRSA) if with skin/soft tissue infections (refer to the Skin and Soft Tissue Infections guidelines). Oxacillin 150-200mg/kg/d q4-6h (Max: 4-12 g) or Meningococci Vancomycin 40-60mg/kg/d q6h (for MRSA) (Max: 2-4g/d) DOT: 10-14d or longer depending on established foci of infection Comments: Check on immunization status against Pneumococcus and H. ceftriaxone can displace bilirubin from albumin-binding sites. B. with the potential risk of inducing kernicterus. Provide coverage for S. Immunocompetent CLINICAL SEPSIS WITHOUT FOCUS Etiology: Preferred Regimen: S. aureus if with concomitant skin/soft tissue infections or previous trauma. aureus (MSSA & Cefotaxime 200-225mg/kg/d q4-6h (Max: 8-12g/d) MRSA). influenzae B. pneumoniae. Child. National Antibiotic Guidelines 3 . including parenteral nutrition. Thus. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES Dosing Interval chart Gestational Postnatal Interval Age(weeks) (days) (hours) ≤29 0-14 18 >14 12 30 to 36 0-14 12 >14 8 37 to 44 0 to 7 12 >7 8 ≥45 ALL 6 DOT: 7-10d or approximately 5-7d after clinical signs and symptoms of infection have disappeared Comments: Precautions for ceftriaxone: Because of its extensive protein binding. because of the risk for precipitation of ceftriaxone-calcium salt. May use oxacillin only if culture-proven sensitive. Use Ceftazidime if Pseudomonas or Burkholderia is suspected. Ceftriaxone 100mg/kg/d IV q12-24h (Max: 2-4 g/d) or S. its use should be avoided in jaundiced neonates. WITH OR WITHOUT H. influenzae B. 7 g/d) DOT: 10-14d or longer depending on established foci of infection POST-SPLENECTOMY/ FUNCTIONAL ASPLENIA Etiology: Preferred Regimen: S. Ceftriaxone 100mg/kg/d IV q12-24h (Max: 2-4g/d) or P.5mg/kg/d q8h or Piperacillin-tazobactam 300mg 5-7.5g/d) or Amikacin 15-22. Bacteroides sp. Ceftriaxone 100mg/kg/d IV q12-24h (Max: 2-4 g/d) H.5 mg/kg/d qd or (piperacillin component) (Max: 9- Amikacin 15-22.5mg/kg/d qd or (Max: 1.5mg/kg/d q8-12h or 15-20mg/kg/d qd DOT: 10-14d or longer depending on established foci of infection INTRA-ABDOMINAL SOURCE Etiology: Enterobacteriaceae. COMPLICATED) Etiology: Preferred Regimen: Enterobacteriaceae.7g/d) Ceftriaxone 100mg/kg/d IV q12-24h (Max: 2-4 g/d) or Cefotaxime 200-225mg/kg/d q4-6h (Max: 8-12g/d) PLUS Metronidazole 30-50mg/kg/d q8h (Max: 1. aeruginosa. P. influenzae.5mg/kg/d qd or Amikacin 15-22.8-2.5mg/kg/d q8h or 5-7.8-2. Enterococci. OR 4 National Antibiotic Guidelines . aeruginosa Preferred Regimen: 1st line: 2nd line: Ampicillin 200-400mg/kg/d IV q8h Ampicillin-sulbactam 200 mg/kg/d (Max: 6-12 g/d) q6h (ampicillin component) (Max: 8 PLUS g/d) or Gentamicin 6-7. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES URINARY SOURCE (SEE UTI.5g/d) or Clindamycin 20-40 mg/kg/d IV q6-8h (Max: 1.5mg/kg/d q8-12h or 16g/d) 15-20 mg/kg/d qd WITH OR WITHOUT PLUS Gentamicin 6-7. pneumoniae.5mg/kg/d q8-12h or Clindamycin 20-40mg/kg/d IV q6-8h 15-20 mg/kg/d qd or (Max: 1. Cefotaxime 200-225 g/kg/d q4-6h (Max: 8-12g/d) Enterococcus PLUS Gentamicin 6-7.5mg/kg/d q8h or Metronidazole 30-50mg/kg/d q6h 5-7. If with previous surgery. meningitides Cefotaxime 200-225mg/kg/d q4-6h (Max: 8-12g/d) HEALTHCARE-ASSOCIATED SEPSIS Etiology: Gram-negative bacilli. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES N. SEVERE SEPSIS AND SEPTIC SHOCK Severe Sepsis: Sepsis plus one of the following: cardiovascular organ dysfunction. breathing. For severe infections with Pseudomonas and/or if antimicrobial resistance is suspected add aminoglycosides. aureus Preferred Regimen: Ceftazidime 150-200mg/kg/d q8h (Max: 6 g/d) or Cefepime 100-150mg/kg/d q8h (Max: 4-6g/d) or Piperacillin-tazobactam 300mg/kg/d q8h (piperacillin component) (Max: 9-16 g/d) or Meropenem 60-120mg/kg/d q8h (Max: 1. IV therapy or other instrumentation and staphylococcal infection is suspected.5mg/kg/d q8-12h or 15-20mg/kg/d qd WITH OR WITHOUT Vancomycin 40-60mg/kg/d q6h (Max: 2-4 g/d) Comments: Choice of empiric antibiotic therapy should be based on current antimicrobial susceptibility pattern within an institution. acute respiratory distress syndrome or two or more other instances of organ dysfunction as defined in the consensus statement Septic Shock: Sepsis and cardiovascular organ dysfunction Preferred Regimen: Piperacillin-tazobactam 300mg/kg/d q8h (piperacillin component) (Max: 9- 16g/d) or Meropenem 60-120mg/kg/d q8h (Max: 1. and circulation (the ABC’s) plus early National Antibiotic Guidelines 5 . S.5-6g/d) PLUS Vancomycin Neonates* Child Meningitis: 15mg/kg/dose 40-60 mg/kg/d q6h Bacteremia: 10mg/kg/dose (Max dose: 2-4 g/d) *See previous Dosing Interval Chart in Neonatal Sepsis DOT: 10-14d in the absence of a complication Comments: The initial assessment and treatment of the pediatric shock patient should include stabilization of airway.5-6g/d) WITH OR WITHOUT Amikacin 15-22. Modify antibiotic regimen based on culture and sensitivity. anticipatory management of multisystem organ failure. surgical debridement. leptospirosis. Serologic tests for Rocky Mountain spotted fever. clinical situation.7 g/d) PLUS IVIG 150-400mg/kg x 5d or 1 dose of 1-2 g/kg DOT: 10-14d in the absence of a complication Comments: Immediate aggressive fluid management.000/mm3 • CNS: disorientation or alterations in consciousness without focal neurologic signs when fever and hypotension are absent Negative results on the following tests. and the antibiotic resistance patterns in the community and/or hospital settings. if obtained: Blood. or cerebrospinal fluid cultures (blood culture may be positive for S.8-2. unless the patient dies before desquamation could occur Preferred Regimen: Oxacillin 150-200mg/kg/d IV q4-6h (Max: 4-12g/d) or Cefazolin 75-100mg/kg/d IV q8h (Max: 3-6g/d) or Vancomycin (for MRSA): 40-60 mg/kg/d IV q6h drip x 1h (Max: 2-4 g/d) PLUS Clindamycin 30-40mg/kg/d IV q6-8h (Max: 1. AST. or conjunctival hyperemia • Renal: BUN or serum creatinine > 2x upper limit of normal or ≥5 wbc/hpf in the absence of UTI • Hepatic: Total bilirubin. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES administration of broad spectrum antibiotics. fingers. aureus. or measles) Case Classification Probable: A case with 5 of the 6 clinical findings as above Confirmed: A case with all 6 of the clinical findings as above. STAPHYLOCOCCAL TOXIC SHOCK SYNDROME Clinical Findings: Fever: Temperature ≥38. or ALT > 2x upper limit of normal for the laboratory • Hematologic: platelets <100. Intravenous immunoglobulin (IVIG) can 6 National Antibiotic Guidelines . oropharyngeal. throat. The choice of antimicrobial agents depends on the predisposing risk factors. including desquamation. and toes Hypotension Involvement of ≥3 of the following organ systems: • GIT: Vomiting or diarrhea at onset of illness • Muscular: Severe myalgia or creatinine phosphokinase > 2x twice the upper limit of normal • Mucous membrane: Vaginal. on palms. soles.9°C (102°F) Rash: Diffuse macular erythroderma Desquamation: 1-2 weeks after onset of illness. hepatic involvement. or skin or soft- tissue infection. Streptococcus. STREPTOCOCCAL TOXIC SHOCK SYNDROME Clinical Criteria: Hypotension plus 2 or more of the following: renal impairment. adult respiratory distress syndrome. Anticipatory management of multisystem organ failure.25 g/d). PO: 30-50mg/kg/d q8h (Max: 2. Etiology: Staph including MRSA. P. Enterococci. difficile infection consider adding Metronidazole IV: 22.000-300. followed by 0. aeruginosa and other gram-negative bacilli.5 g/kg on d2-3 DOT: 10-14d or longer depending on established foci of infection Comments: Immediate aggressive fluid management.5-40mg/kg/d q8h (Max: 1. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES be considered in severe staphylococcal TSS unresponsive to other therapeutic measures. Fungi Preferred Regimen: Cefepime 150mg/kg/d div q8h or Piperacillin-tazobactam 300mg/kg/d div q6h or Meropenem 60-120mg/kg/d div q8h (Max: 2-4g) If antimicrobial resistant pathogens are suspected consider adding Amikacin 15- 20mg/kg/d qd. coagulopathy. Febrile Neutropenia in Children Neutropenia is defined as an ANC of < 500 cells/mm3 or an ANC that is expected to decrease to <500 cells/mm3 during the next 48h. Intravenous immunoglobulin (IVIG) may be considered if refractory to several hours of aggressive therapy or in the presence of undrainable focus or persistent oliguria with pulmonary edema.8-2.000 U/kg/d IV q4-6h (Max: 12-24 MU/d) OR Ceftriaxone 100mg/kg/d q12-24h (Max: 2-4 g/d) PLUS Clindamycin 30-40mg/kg/d IV q6-8h (Max: 1.5 g/d). pneumonia. National Antibiotic Guidelines 7 . Surgical debridement.7 g/d) PLUS IVIG 1g/kg on d1. In cases of suspected catheter-related infection. and soft-tissue necrosis Definite Case: Clinical criteria plus Group A streptococcus from a normally sterile site Probable Case: Clinical criteria plus Group A streptococcus from a nonsterile site Preferred Regimen: Penicillin G Na 200. generalized erythematous macular rash. or hemodynamic instability consider adding Vancomycin 40-60mg/kg/d q6h (Max: 2-4g/day) If with abdominal symptoms (pain or blood per rectum) or suspected C. with a set collected simultaneously from each lumen of an existing central venous catheter (CVC). Non-Neutropenic SOURCE IS UNCLEAR Preferred Regimen: 1st line: 2nd line: Piperacillin-tazobactam 4. Septic Shock is defined as sepsis plus need for vasopressor to increase MAP to > 65 mmHg and lactate >2mmol (18 mg/dL) A. and from a peripheral vein site. Sepsis. Baseline laboratory tests to request for are: • (CBC) count with differential leukocyte count and platelet count • creatinine and BUN • electrolytes • hepatic transaminase enzymes • bilirubin • blood cultures.5g IV q6-8h Meropenem 1g IV q8h PLUS PLUS Vancomycin 25-30mg/kg loading Vancomycin 25-30mg/kg loading dose then 1g IV q8h dose then 1g IV q8h 8 National Antibiotic Guidelines . Treatment is continued until patient is afebrile and ANC >500 cells/μl. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES Empirical antifungal coverage should be considered in high-risk patients who have persistent fever after 4–7 days of a broad-spectrum antibacterial regimen and no identified fever source. 2 blood culture sets from separate venipunctures should be sent if no central catheter is present. • Culture of specimens from other sites of suspected infection should be obtained as clinically indicated • CXR for patients with respiratory signs and symptoms GCSFs are not routinely recommended II. SEPSIS IN ADULTS Sepsis is defined as presence of suspected or documented infection associated with life threatening organ dysfunction represented by a quick SOFA (Sequential Organ Failure Assessment) score of 2 or more of the following: 1) respiratory rate of 22/min or more. 3) systolic BP of 100 mmHg or less. Comments: Start empiric antibiotics as soon as possible after taking blood cultures and refer to an ID specialist. at least 2 sets of which are recommended. if present. 2) altered mentation. Initial fluid resuscitation of crystalloid at 30ml/kg should be given in first 3 hours. aureus Vancomycin 25-30mg/kg loading dose then 1g IV q8h PLUS Piperacillin-tazobactam 4.5g IV q8-6h Ceftriaxone 1g IV q24h OR Ertapenem 1g IV q24h Comments: Base recommendation on local/ hospital antibiogram results. Target MAP to >65 mmHg in patients receiving vasopressors. Intravenous antibiotics should be given as soon as sepsis or septic shock is recognized and within the 1st hour. Always assess for risk factors for antibiotic resistance (e.5g IV q8-6h National Antibiotic Guidelines 9 . Enterococcus species Preferred Regimen: 1st line: 2nd line: Piperacillin-tazobactam 4. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES Comments: Do source control. Use Ertapenem if with risk for antibiotic resistance. coli). URINARY TRACT INFECTION Etiology: Aerobic Gram-negative bacilli (E.g. ESBL production because of prior fluoroquinolone use). if possible. SUSPECT COMMUNITY-ACQUIRED PNEUMONIA (See treatment of high risk pneumonia) SUSPECT ILLICIT IV DRUG USE SOURCE Etiology: Preferred Regimen: S.5 g IV q8-6h 2nd line: Ceftriaxone 2g IV q12h PLUS Metronidazole 1g loading dose then 500mg IV q6h or 1g IV q12h OR Ciprofloxacin 400mg IV q12h or Levofloxacin 750mg IV q24h PLUS Metronidazole 1g loading dose then 500mg IV q6h or 1g IV q12h SUSPECT. Appropriate routine microbiologic cultures (including blood) be obtained before starting antimicrobial therapy in patients with suspected sepsis or septic shock if doing so results in no substantial delay in the start of antimicrobials SUSPECT INTRA-ABDOMINAL SOURCE Etiology: Aerobic and anaerobic gram-negative bacilli Preferred Regimen: 1st line: Piperacillin-tazobactam 4. gram negative bacilli. Also start IVIG 1g/kg on d1 then 500mg/kg on d2-3 for patients unresponsive to vasopressor. LOW RISK Etiology: Gram positive organisms (predominantly coagulase negative staphylococci and S. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES SUSPECT MENINGOCOCCEMIA Etiology: Preferred Regimen: N. uncommon 10 National Antibiotic Guidelines . or <1000/μL and expected to fall below 500/μL over the next 48h. meningitides Ceftriaxone 2g IV q12h SEPTIC SHOCK.3°C or two consecutive readings of >38. aureus). fungal inf. POST SPLENECTOMY Preferred Regimen: Comments: Ceftriaxone 2g IV q12h Increase dose if considering meningitis STAPHYLOCOCCAL TOXIC SHOCK Preferred Regimen: Comments: Vancomycin 25-30mg/kg loading Note: Intravenous Immunoglobulin has dose then 1g IV q8h PLUS the potential to neutralize super antigen Clindamycin 900mg IV q8h PLUS and to mitigate subsequent tissue IVIG 1g/kg d1 then 500mg/kg/d for damage 2-3d STREPTOCOCCAL TOXIC SHOCK Preferred Regimen: 1st line 2nd line Penicillin G 24 MU/d IV in 4-6 div Ceftriaxone 2g IV q24h PLUS doses PLUS Clindamycin 900mg IV q8h PLUS Clindamycin 900mg IV q8h IVIG 1g/kg on d1 then 500mg/kg on d2-3 If with Penicillin allergy: Clindamycin 900mg IV q8h PLUS Vancomycin 25- 30mg/kg loading dose then 1g IV q8h. B. Febrile Neutropenia in Adults Defined as an oral temperature of >38. DOT is individualized. Assess for risk (low or high risk) of complication for severe disease at presentation of fever.0°C for >1h and an absolute neutrophil count (ANC) of <500/μL. Min of 14d if with bacteremia. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES Preferred Regimen: Ciprofloxacin 750mg PO bid or Levofloxacin 750mg PO qd PLUS Amoxicillin clavulanic acid 625mg tid Penicillin Allergy: Ciprofloxacin 750mg PO bid or Levofloxacin 750mg PO qd PLUS Clindamycin 300mg PO q6h DOT: Until patient is afebrile and absolute neutrophil count >500cells/μl Comments: Those with anticipated <7 days of neutropenia.5g IV q6h PLUS Aminoglycoside or Fluoroquinolone or Vancomycin if with suspected central line infection. Instead an IV regimen as recommended for high risk patients should be administered. fungi (esp. hemodynamic instability. HIGH RISK Etiology: Gram positive (staph. National Antibiotic Guidelines 11 . In patients with unexplained fever. initial regimen should be continued until marrow recovery Comments: Those with profound neutropenia of <100 cells/μl and anticipated fever >7days and/or significant medical comorbidities. skin and soft tissue infection. Candida and Aspergillus) Preferred Regimen: Initial therapy for fever Monotherapy with: Cefepime 2g IV q8h or Meropenem 1-2g IV q8h or Piperacillin-tazobactam 4. mucositis grade 3 or 4. able to take oral medications. Other infections may be treated for 14 days. A fluoroquinolone (FQ) should not be used in patients given a FQ-based antibacterial prophylaxis. Empiric antibiotic Rx should be started as soon as possible after taking blood cultures. uncontrolled or progressive cancer. severe mucositis. aeruginosa) causing the more serious infections. prolonged (4-6 weeks) if disseminated or deep infection. P. hepatic or renal insufficiency. no medical co-morbidities. pneumonia. enterococci) and gram-negative bacteria w/ GNB (e. hypotension PLUS Antifungal treatment if fever continues beyond 4-7d and no source is identified DOT should be dictated by particular organism and site: Staphylococcus bacteremia should be treated for at least 2 weeks after negative blood culture. strep.g. new onset neurologic/mental changes. and no significant liver or renal dysfunction. GCSFs are not routinely recommended as an adjunct to antibiotic Rx. pneumonia or other complex infections. ANTICANDIDAL PROPHYLAXIS Etiology: Preferred Regimen: Allogeneic hematopoietic stem cell Fluconazole 400mg IV/PO q24h OR transplant (HSCT) recipients. Continue treatment until patient is afebrile and absolute neutrophil count is >500 cells (some >1000 cells). inpatient status at time of development of fever. may be considered in the presence of serious infectious complications such as progressive course. and invasive fungal infection.induction or salvage DOT: until recovery of neutropenia therapy. Empiric antibiotic Rx should be started ASAP after blood cultures. and GI symptoms. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES IV catheter infection. Modifications to the initial antibiotic regimen should be guided by clinical and microbiologic data. acute Micafungin 150mg/d IV OR leukemia undergoing intensive Itraconazole 200mg PO bid remission . These patients should be admitted in the hospital. Use of CSF is controversial. For high risk patients with expected duration of neutropenia of >7d and ANC≤ 100 cells/mm3 ANTI-ASPERGILLUS PROPHYLAXIS Etiology: Preferred Regimen: Patients undergoing chemotherapy Voriconazole 200mg PO/IV bid OR for AML/MDS with neutropenia and Posaconazole 200mg PO tid for allogeneic HSCT recipients patients ≥13 years of age Comments: Prophylaxis against aspergillus infection in pre-engraftment allogeneic or autologous transplant recipients has not been shown to be efficacious 12 National Antibiotic Guidelines . ANTIBACTERIAL PROPHYLAXIS For high risk patients with expected duration of neutropenia of > 7 days and ANC ≤100 cells/mm3 Preferred Regimen: 1st line 2nd line Levofloxacin 500-750mg PO/IV qd Ciprofloxacin 500-750mg PO or 400mg IV q12h Comments: Not routinely recommended for low risk patients. pneumonia. TYPHOID FEVER UNCOMPLICATED TYPHOID FEVER Preferred Regimen: 1st line 2nd line PEDIATRICS Amoxicillin 75-100mg/kg/d q8h x 14d Cefixime 15-20mg/kg/d q12h x 7- (Max: 500mg 2 caps q6h) OR 10d (Max: 200mg 1 tab q12h) OR Ampicillin 100-200mg/kg/d IV q6h x 14d Azithromycin 20mg/kg/d q24h x 5- (Max: 12g/24h) OR 7d (Max: 500mg 1-2 tabs q24h) OR Chloramphenicol 50-75mg/kg/d q6h x Ciprofloxacin 30mg/kg/d q12h x 7- 14-21d (Max: 500mg 2 caps q6h) OR 10d (Max: 500mg 1 tab q12h) TMP-SMX 8mg/kg/d (TMP component) q12h x 14d (Max: 160/800mg 1 tab q12h) ADULTS Amoxicillin 1g q6h x 14d OR Cefixime 200mg PO q12h x 7. Salmonella typhi remained susceptible to the 1st line agents like ampicillin. chloramphenicol & TMP-SMX. ampicillin and TMP-SMX.10d TMP-SMX 800/180mg I tab q12h x 14d OR OR Chloramphenicol 1g PO q6h x 14d Azithromycin 500mg-1g PO qd x 5- OR Ciprofloxacin 500mg 1 tab q12h x 7d 7-10d Comments: Based on ARSP 2015. MDRTF is defined as typhoid fever caused by Salmonella typhi strains which are resistant to the first-line recommended drugs for treatment namely chloramphenicol. • Household contact with a documented case or during an epidemic of MDRTF. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES ANTIVIRAL PROPHYLAXIS Etiology: Preferred Regimen: HSV seropositive patients undergoing Aciclovir 800mg PO bid OR allogeneic HSCT or induction for acute Aciclovir 400mg PO tid-qid leukemia III. and/or National Antibiotic Guidelines 13 . The use of second line antibiotics should be reserved for suspected or proven Multi-drug resistant typhoid fever (MDRTF). MDRTF should be suspected in any of the following situations: • Failure to respond after 5-7 days treatment with a first line antibiotic. Ciprofloxacin 30mg/kg q12h x 7- 7d (Max: 1g q24h) 10d (Max: 500mg 1 tab q12h) ADULTS Ceftriaxone 1-2g IV x 10-14d OR Cefixime 200mg 1tab q12h x 7-10d Ciprofloxacin 400mg IV q12h x 7-10d OR Azithromycin 500mg 1-2tabs q24h x 5-7d OR Ciprofloxacin 500mg 1tab q12h x 7-10d CHRONIC CARRIER Defined as asymptomatic shedding of typhoidal S. intestinal perforation. enterica for 1 year or more 14 National Antibiotic Guidelines . typhoid encephalopathy. An irreversible type of marrow depression leading to aplastic anemia with a high rate of mortality may occur after short or long-term use of chloramphenicol. etc. Ciprofloxacin is not recommended for pregnant women. Stepping down to an oral antibiotic may be done if patient is afebrile for 48hrs and is able to tolerate oral medications. High–dose parenteral Ampicillin can be used if fluoroquinolone is not well tolerated. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES • Clinical deterioration or development of complications during conventional antibiotic treatment Serious and fatal blood dyscrasias (aplastic anemia. Cefixime 15-20mg/kg q12h x 7-10d 14d (Max: 2-3g q24h) OR (Max: 200mg 1 tab q12h) OR Ciprofloxacin 30mg/kg/d q12h x 7-10d Azithromycin 20mg/kg q24h x 5-7d (Max: 500mg/dose q12h) OR (Max: 500mg 1-2 tabs q24h) OR Azithromycin 20mg/kg/d IV q24h x 5. thrombocytopenia and granulocytopenia) are known to occur after the administration of chloramphenicol. hypoplastic anemia. It can be used among children if the benefits outweigh the potential harms. De-escalation to oral antibiotics should be based on results of culture and sensitivity if available.) Preferred Regimen: 1st line Step down antibiotics PEDIATRICS Ceftriaxone 75mg/kg/d IV q24h x 10. SEVERE/COMPLICATED TYPHOID FEVER (Gastrointestinal bleeding. malaria • Malnutrition National Antibiotic Guidelines 15 . Osteomyelitis: 4-6 weeks Comments: Antibiotics are not generally recommended for the treatment of uncomplicated Salmonella gastroenteritis because they may suppress normal intestinal flora and prolong both the excretion of Salmonella and the remote risk for creating the chronic carrier state. especially leukemia • Impaired intestinal motility and lymphoma • Schistosomiasis. Indications for antibiotic treatment include any of the following: • Neonates and young infants (≤3 • Hemolytic anemia. Meningitis: 4 weeks. meningitides Ceftriaxone 100 mg/kg/d IV q12-24h (Max: 2- 4g/d) DOT: Bacteremia: 10-14d. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES Preferred Regimen: 1st line 2nd line PEDIATRICS Ciprofloxacin 30mg/kg/d q12h x 4 Ampicillin 100-200mg/kg/d IV q6h x weeks (Max: 1-1. meningitis. and • HIV/AIDS bartonellosis • Other immunodeficiencies and • Collagen vascular disease chronic granulomatous disease • Inflammatory bowel disease • Immunosuppressive and • Achlorhydria or use of antacid corticosteroid therapies medications • Malignancies. malaria. including sickle months old) cell disease.5g/d) 4 weeks (Max: 12g/d) ADULTS Ciprofloxacin 500-750mg q12h PO x 28d NONTYPHOIDAL SALMONELLOSIS (Salmonella gastroenteritis) Preferred Regimen: 1st line 2nd line Cefotaxime 100-200 mg/kg/d IV q6h Ciprofloxacin 10-20 mg/kg/d q12h x x 5-14d (Max: 8-12 g/d) OR 7-10d (Max:1-1. osteomyelitis) Etiology: Preferred Regimen: N.5g/d) OR Ceftriaxone 75 mg/kg/d IV q24h x7d Chloramphenicol 50-75 mg/kg/d (Max: 2-4 g/d) OR q6h x 7d (Max: 2-4 g/d) Cefixime 15 mg/kg/d PO q12h x 7-10d (Max: 400mg/d) EXTRA-INTESTINAL INFECTIONS (bacteremia. LEPTOSPIROSIS Suspected leptospirosis case: • Fever of at least 2d. Take doxycycline with food or after a meal. IV. GI upset and interaction if co-administered with iron. conjunctival suffusion. abdominal pain. AND • Either residing in a flooded area or has high-risk exposure (wading in floods and contaminated water. chills. vomiting and diarrhea breathing • Oliguria/anuria • Hemoptysis 16 National Antibiotic Guidelines . interaction with birth control pills. jaundice or oliguria MILD LEPTOSPIROSIS: A suspected case of leptospirosis with: • Stable vital signs • NO evidence of meningismus/ meningeal • Anicteric sclerae irritation. contact with animal fluids. • At least two of the following: myalgia. MODERATE TO SEVERE LEPTOSPIROSIS: A suspected case of leptospirosis with: • Unstable vital signs • Meningismus/ meningeal irritation • Jaundice/ icteric sclerae • Sepsis/ septic shock • Abdominal pain • Altered mental states or difficulty of • Nausea. calf tenderness. difficulty of • Good urine output breathing. statins. sepsis/ septic shock. jaundice • Can take oral medications Preferred Regimen: 1st line 2nd line <8 yo: Amoxicillin 50mg/kg q8h x 7d Azithromycin 1g loading dose then 10 (Max: 500mg q8h) mg/kg qd x 2d (Max: 500 mg/d) ≥8 yo: Doxycycline 2-4mg/kg/d bid x 7d (Max: 200mg/d) Comments: Precautions for doxycycline: children <8 years. supplements. photosensitivity. other antibiotics and laxatives. headache. nontyphoidal Salmonella is also susceptible to chloramphenicol & ciprofloxacin. swimming in flood water or ingestion of contaminated water with or without cuts or wounds). diarrhea. pregnancy. AND. Antibiotics should be revised depending on the susceptibility pattern. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES Based on ARSP 2015. not routinely recommended except for travelers.com/contents/fever-in-children-with-chemotherapy-induced- neutropenia. those engaged in water-related recreational and occupational activities in highly endemic areas. Post-exposure doses may be repeated once weekly if with continued exposure to risk factors (e.5 MU q6-8h) (Max: 0. If children are exposed for more than 7d. the dose should be repeated after 1 week. use protective measures such as boots.000-400. Post-exposure prophylaxis depends on type of risk. soldiers. Available at: http://www. protective measures should still be used.g. goggles. Any oral antibiotic under mild leptospirosis can be selected.000 U q4-6h Ampicillin 100 mg/kg q6h x 7d x 7d (Max: 1. Comments: The most effective preventive measure is avoidance of high-risk exposure. If unavoidable. Preferred Regimen: 1st line 2nd line Doxycycline 4mg/kg x 1 dose Amoxicillin 50mg/kg/d q8h x 3-5d (Max: 200mg regardless of age) (Max: 500mg q8h) OR Azithromycin 10mg/kg x 1 dose Take 100mg bid if 200 mg qd is not (Max: 500 mg) tolerated. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES Preferred Regimen: 1st line 2nd line Penicillin 250.uptodate. Fever in children with chemotherapy –induced neutropenia. over-alls.5-1. Antibiotic prophylaxis not 100% effective. et al. National Antibiotic Guidelines 17 . ANTIBIOTIC PROPHYLAXIS Pre-exposure prophylaxis . staying in a constantly flooded area) REFERENCES: • Ahmed NM. and rubber gloves.0 g q6h) OR Cefotaxime 100-150 mg/kg q6-8h x 7d (Max: 1g q6h) OR Ceftriaxone 80-100 mg/kg q24h x 7d (Max: 2g q24h) OR Azithromycin 500mg qd x 5d Comments: Step-down therapy can be instituted once patient is clinically stable and bale to tolerate oral medication. • Pediatric Infectious Diseases Society of the Philippines. Quezon City: PIDSPI. BLOOD-BORNE INFECTIONS AND OTHER SYSTEMIC SYNDROMES • American Academy of Pediatrics. PIDSP Core Group Recommendation: Clinical Practice Guidelines on Childhood Leptospirosis 2015. Clin Infect Dis. Philadelphia. March 2014 • Kliegman RM. • Freifeld A. 2015.52(4): e56-93. 20th ed. et al.. Philadelphia: Elsevier Inc. Available at: www. • Integrated Management of Childhood Illness Chart Booklet. Harrison GJ. PA: Elsevier.. Clinical Practice Guideline for the Use of Antimicrobial Agents in Neutropenic Patients with Cancer: 2010 Update by the Infectious Diseases Society of America. Elk Grove Village.ccmjournal. Brady MT. Manila: Department of Health. et al. Geneva: World Health Organization. eds. • Cherry JD. Nelson Textbook of Pediatrics. The Lancet Infectious Dis. et al. 9 (5): May 2009. Pediatrics. • Pediatric Infectious Diseases Society of the Philippines.123 (4): e609-e613. et al. Red Book 2015 Report of the Committee on Infectious Diseases. Post-Disaster Interim Advice on the Prevention of Leptospirosis in Children 2012.30th ed. Feigin and Cherry’s Textbook of Pediatric Infectious Diseases. 2012. Steinbach WJ. Hotez PJ. 2016. • Dellinger RP. In: Kimberlin DW.2009.2015 • Antimicrobial Resistance Surveillance Program. 18 National Antibiotic Guidelines . 2014.eds. Gram positive toxic shock syndrome. Kaplan SL. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. 2015 • Bradley JS. et al. Quezon City: PIDSPI. • Emma Lappin et al. Intravenous ceftriaxone and calcium in the neonate: assessing the risk for cardiopulmonary adverse events. 2011 Feb 15.org. Group A Streptococci. aureus. interval 2.200.200 0-4 10mg/kg/d in age (weeks)* g BW weeks 2 doses 10-15mg/kg/d in 1 1. 0-7d 10mg/kg/d in <26 dose 2. Vancomycin is (Max: administered at 20 mg/kg/dose.2 g/d) 200mg/kg/d in 3-4 doses Option 4: Cotrimoxazole 8- Infants and older 100.000 0-7d 15mg/kg/d in 40-60mg/kg/d in 3-4 g BW old 3 doses > 42 doses** >7d 20mg/kg/d 100-200mg/kg/d in old in 4 doses 7 days 4 doses Infants and older 25- *Post conceptual age= gestational age + children 40mg/kg/d weeks of life in 3-4 doses **at 28 days of life. 0-7d 100mg/kg/d in 3 doses (Max: 1. 1st line: 2nd line Vancomycin Option 1: Clindamycin IV Post Vancomycin dose Neonates conceptual <1. Enterobacteriaceae 4 months to adolescents: S.2 g/d) 2.000 g old 2 doses 27-34 10-15mg/kg q18h** BW >7d 15mg/kg/d in 20-30mg/kg/d in 2 old 3 doses 35-41 doses** >2.000g 0-7d 100mg/kg/d in >12y: 1200mg/d in 2 doses BW old 2 doses PLUS Ciprofloxacin 20-30mg/kg/d in >7d old 150. aureus.000g old 2doses BW >7d 150mg/kg/d in Option 3: Linezolid IV old 3 doses <12y: 30mg/kg/d in 3 doses >2. OSTEOMYELITIS (HEMATOGENOUS) Etiology: Newborn to <4 months: S.7g/d) remains the same PLUS Cefotaxime PLUS Cefotaxime+ or Ceftriaxone+ +see regimen under 1st line treatment Neonates <1. Group B Streptococci. should be considered in developing countries or among patients with sickle cell disease.200. 12mg/kg/d (trimethoprim children 200mg/kg/d in National Antibiotic Guidelines 19 .200g 0-4 100mg/kg/d in Option 2: Vancomycin+ PLUS BW weeks 2 doses Ciprofloxacin 20-30mg/kg/d IV in 2- 1. 2 or 3 doses (Max: 1. Enterobacteriaceae are uncommon Salmonella sp. Infections caused by Kingella kingae is increasingly recognized in children under age 4 years. BONE AND JOINT INFECTIONS IN PEDIATRICS A. Start empiric therapy with antibiotics against MRSA after collection of blood and joint fluid for culture.200g 0-4 50mg/kg/d BW weeks in 1 dose 1. use cefotaxime only when Pseudomonas aeruginosa is deemed unlikely. its use should be avoided in jaundiced neonates. shift to oxacillin. aureus to oxacillin at 62. Thus.000g BW >2. When either Gram-positive or Gram-negative bacilli are possible pathogens. Revise quickly to specific therapy according to culture results. Clindamycin is an alternative if there are no signs of sepsis.6%. ceftriaxone can displace bilirubin from albumin-binding sites.200. Osteomyelitis of the long bones is more common in children. neonates should not receive ceftriaxone intravenously if also receiving 20 National Antibiotic Guidelines . An antibiotic active against MRSA is recommended for the following: • Patients who have failed initial recommended antibiotic treatment against MSSA • Those with markedly impaired host defences • Those with SIRS and hypotension Precautions for ceftriaxone: Because of its extensive protein binding. BONE AND JOINT INFECTIONS IN PEDIATRICS 3-4 doses (Max: component) in 2 doses (Max: 12 g/d) 320mg/d) PLUS OR Ceftriaxone Ciprofloxacin 20-30mg/kg/d in 2 or Neonates 3 doses (Max: 1. Other bones are less commonly involved. Likewise. with the potential risk of inducing kernicterus.000g 0-7d BW old >7d old 75mg/kg/d in 1 doses Infants and older 100-200 children mg/kg/d in 1- 2 doses (max: 4 g/d) DOT for neonates is not well-defined but 3 weeks is considered adequate. Comments: Select antibiotics appropriate for the patient age. Vertebral osteomyelitis is most common site in adults.2 g/d) <1. DOT for other age groups is 3-6 weeks. In the primary regimens. The ARSP 2015 showed increased resistance of S. review Gram stain of joint fluid. vancomycin is typically used to cover MRSA and high-dose β-lactams are given to cover Gram-negative organisms. If cultures grow MSSA.2. longer if hardware retained.7 g/d) or Linezolid (Empiric) Vancomycin 45-60mg/kg/d in 3-4 <12y: 30mg/kg/d IV in 3 doses doses (Max: 4 g/d) >12y: 1200mg/d IV in 2 doses PLUS PLUS Ceftazidime 100-150mg/kg/d div in 3 Ceftazidime 100-150mg/kg/d div in 3 doses (Max: 6 g/d) or doses (Max: 6 g/d) or Cefepime 100-150mg/kg/d in 2-3 Cefepime 100-150mg/kg/d in 2-3 doses (Max: 6 g/d) doses (Max: 6 g/d) Specific therapy based on culture Methicillin-susceptible or results: methicillin-resistant staphylococci If susceptible gram-negative bacillus: (culture-proven): Ciprofloxacin 20-30mg/kg/d in 2 or 3 Ciprofloxacin 20-30mg/kg/d IV in 2-3 doses (Max: 1. because of the risk for precipitation of ceftriaxone calcium salt.. OSTEOMYELITIS. aureus. including parenteral nutrition.2 g/d) PLUS If methicillin-sensitive staphylococci: Rifampin 10-20mg/kg/d in 1-2 doses Oxacillin (Max: 600 mg/d) Mild to moderate infections: 100- 150mg/kg/d in 4 doses (Max: 4 g/d) Severe infections: 150-200mg/kg/d in 4-6 doses (Max: 12 g/d) OR Cefazolin Mild to moderate infections: 50mg/kg/d in 3 doses (Max: 3 g/d) Severe infections: 100-150mg/kg/d in 3 doses (Max dose: 6 g/d) DOT: not well defined but 6 weeks is generally recommended. Coagulase-negative staphylococci. Comments: The ARSP 2015 showed increased resistance of S. BONE AND JOINT INFECTIONS IN PEDIATRICS intravenous calcium in any form. B. P. CONTIGUOUS FOCUS Etiology: S. aureus to oxacillin at 62. Start empiric therapy with antibiotics against MRSA after collection of blood and joint National Antibiotic Guidelines 21 . Enterobacteriaceae.6%. Streptococcus sp.2 g/d) doses (Max: 1. aeruginosa Preferred Regimen: 1st line 2nd line Clindamycin 25-40mg/kg/d in 3-4 If methicillin-resistant staphylococci: doses IV (Max: 2. treat for 6 weeks. SUPPURATIVE ARTHRITIS INFANTS <3 MONTHS OLD Etiology: S. Etiology: S. aeruginosa. Prolonged course of therapy is typically recommended but 6 weeks may be adequate if surgical debridement is performed. Comments: Important therapeutic adjuncts include: • Removal of orthopaedic hardware • Surgical debridement (critical) • Vascularized muscle flaps • Distraction osteogenesis (IIizarov) techniques D. shift to oxacillin. Streptococci Preferred Regimen: Empiric therapy is not recommended. Enterobacteriaceae. Clindamycin is an alternative if there are no signs of sepsis. N. aureus. P. Enterobacteriaceae. • It implies a long-standing infection and the presence of dead bone. gonorrhoeae 22 National Antibiotic Guidelines . C. Treatment should be guided by valid cultures and sensitivity studies Optimal DOT: unknown. It may be necessary to remove hardware and use external fixation if there is persistent bone non-union. Group B Streptococci. and treat for 6 weeks. • If hardware is retained. CHRONIC OSTEOMYELITIS • Chronic osteomyelitis usually occurs in adults following trauma or surgery. Early hardware infection (symptoms <4 weeks): • If hardware is removed. Late infection: • Remove the hardware if possible. Otherwise. await culture results. Empiric therapy is indicated in septic patients. review Gram stain of joint fluid. Consider intermittent therapy or chronic suppressive therapy for relapses if surgical debridement was unsuccessful or not feasible. • If the hardware is retained. BONE AND JOINT INFECTIONS IN PEDIATRICS fluid for culture. treat until bony fusion or hardware removal. aureus. Involves long bone or post internal fixation of fracture. treat for 3-6 months or until the hardware removed. If cultures grow MSSA. BONE AND JOINT INFECTIONS IN PEDIATRICS Preferred Regimen: 1st line: 2nd line Vancomycin Clindamycin IV Post Vancomycin Neonates conceptual dose <1.000g BW National Antibiotic Guidelines 23 .2.000g old 2 doses BW >7d 150mg/kg/d in old 3 doses >2. 0-7d 10mg/kg/d <26 dose 2.200.200g 0-4 50mg/kg/d in BW weeks 1 dose 1. >7d 20mg/kg/d > 42 4 doses** old in 4 doses 100-200mg/kg/d in Infants and older 25- 7 days 4 doses children 40mg/kg/d in *Post conceptual age= gestational age + 3-4 doses weeks of life (Max: **at 28 days of life.000 g old in 2 doses 10-15mg/kg BW >7d 15mg/kg/d 27-34 q18h** old in 3 doses 20-30mg/kg/d in 2 >2.200.200.200g 0-4 100mg/kg/d in BW weeks 2 doses 1.000 0-7d 15mg/kg/d 35-41 doses** g BW old in 3 doses 40-60mg/kg/d in 3.000g 0-7d 100mg/kg/d in BW old 2 doses >7d old 150- 200mg/kg/d in 3-4 doses Infants and older 100- children 200mg/kg/d in 3-4 doses (Max: 12 g/d) or Ceftriaxone Neonates <1. 0-7d 100mg/kg/d in 2. interval remains the same PLUS Cefotaxime+ OR Ceftriaxone+ +see regimen under 1st line treatment PLUS Cefotaxime Neonates <1. Vancomycin is 2.200 0-4 10mg/kg/d age (weeks)* g BW weeks in 2 doses 10-15mg/kg/d in 1 1.7g/d) administered at 20 mg/kg/dose. shift to oxacillin. gonorrhoeae. Clindamycin is an alternative if with no signs of sepsis. There is no need to inject antimicrobial agents into joints because of their excellent penetration. subtle symptoms such as pain with diaper change may be the only sign. See comments on Precautions for ceftriaxone. Infants with septic arthritis may present with fever and irritability. Blood cultures are frequently positive. Pseudoparalysis can occur. H. no fever.7 g/d) or cocci: Linezolid Vancomycin 40-60mg/kg/d in 3-4 <12y: 30mg/kg/d IV in 3 doses doses (Max: 4 g/d) PLUS >12y: 1200mg/d IV in 2 doses Cefotaxime 100-200mg/kg/d in 3-4 PLUS doses (Max: 12g/d) or Cefotaxime 100-200mg/kg/d in 3-4 Ceftriaxone 100mg/kg/d in 1-2 doses doses (Max: 12 g/d) or (Max: 4g/d) Ceftriaxone 100mg/kg/d in 1-2 doses If Gram stain is positive for Gram. meningitidis) (14%). pyogenes or S. Unknown (36%) Preferred Regimen: 1st line 2nd line If Gram stain is negative OR if Gram Clindamycin 25-40mg/kg/d IV in 3-4 stain is positive for Gram positive doses (Max: 2. If cultures grow MSSA.6%. ARSP 2015 showed increased resistance of S.000g 0-7d BW old >7d 75mg/kg/d in old 1 doses DOT for neonates is not well-defined but 3 weeks is considered adequate. aureus to oxacillin at 62. aureus (27%). Treatment of septic arthritis requires both adequate drainage of purulent joint fluid and appropriate antimicrobial therapy. N. Modify regimen to treat specific pathogen based on results of blood or joint fluid culture. Adjacent bone is involved in 2/3 of patients. (Max: 4 g/d) negative organisms: 24 National Antibiotic Guidelines . CHILDREN AGED 3 MONTHS TO 14 YEARS Etiology: S. toxemia or leucocytosis is present. Others (including N. Start empiric therapy with antibiotics against MRSA after collection of blood and joint fluid for culture. S. pneumoniae (14%). BONE AND JOINT INFECTIONS IN PEDIATRICS >2. review Gram stain of joint fluid. Comments: In most neonates. Gram-negative bacilli (6%). influenzae (3%). infections with Enterobacteriaceae are rare occurrences. Bayer A. Makati: MIMS.sanfordguide. Cosgrove SE. review Gram stain of joint fluid. therapy is usually completed with oral therapy for a total of 2-3 weeks. Textbook of Pediatric Infectious Diseases. Septic arthritis due to Salmonella has no association with sickle cell disease. New York: Elsevier. Clindamycin is an alternative if with no signs of sepsis. 147th edition.com/. aureus to oxacillin at 62. • MIMS Philippines 1/2016. 2016. Cherry J.6%. • Feigin R. Comments: Drainage of purulent joint fluid (needle aspiration sufficient in most cases. et al. unlike Salmonella osteomyelitis. Handbook of Pediatric Infectious Disease an Easy Guide 5th ed. shift to oxacillin. influenzae since use of conjugate vaccine. If cultures grow MSSA. et al. ARSP 2015 showed increased resistance of S. BONE AND JOINT INFECTIONS IN PEDIATRICS Cefotaxime 100-200mg/kg/d in 3-4 DOT: 3-6 weeks. DOT: After initial response. Start empiric therapy with antibiotics against MRSA after collection of blood and joint fluid for culture. e18-55. REFERENCES: • Bravo L. 6th ed. No need to inject antimicrobial agents into joints because of their excellent penetration. et al. repeated as needed for re-accumulated fluid) is a critical component of therapy. Clin Infect Dis 2011:52. Mark decrease in H. Beyond the neonatal period. National Antibiotic Guidelines 25 . Minimum duration doses (Max: 12 g/d) OR should be 3 weeks because some Ceftriaxone 100mg/kg/d in 1-2 doses cases may actually have coincident (Max: 4 g/d) bone infection. 2009 • The Sanford Guide to Antimicrobial Therapy 2014. Manila: Philippine Pediatric Society. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus aureus Infections in Adults and Children. Available at: http://webedition. • Liu C. ADD: rarely Ceftazidime 2g IV q8h or Piperacillin-tazobactam 4. Surgical intervention. Adjust treatment based on culture and sensitivity results. MRSA likely: Vancomycin 15-20mg/kg IV q8-12h Group A streptococci. BONE AND JOINT INFECTIONS IN ADULTS I.5g IV q8h or Levofloxacin 750mg IV q24h MRSA unlikely: Oxacillin 2g IV q4h PLUS Ceftriaxone 2g IV q24h or Piperacillin-tazobactam 4. usually not required. aureus.5g IV q8h or Levofloxacin 750mg IV q24h Optimal DOT is unknown. severe or progressive neurological signs and symptoms. streptococci. BONE INFECTIONS A. PLUS Ceftriaxone 2g IV q24h or Piperacillin- Gram-negative bacilli tazobactam 4. usually 6-12 weeks. Etiologic diagnosis is essential. The MRI is the optimal diagnostic imaging. other than obtaining tissue specimen. MRSA unlikely: Oxacillin 2g IV q4h Gram-negative bacilli If Gram-negative bacilli seen on Gram stain. hemodynamic instability. aureus most MRSA likely: Vancomycin 15-20mg/kg IV q8-12h common. Collect blood and bone cultures before giving empiric antibiotic therapy. Comments: Perform image-guided aspiration biopsy for histopathology or appropriate cultures when etiologic diagnosis is not established by blood cultures.5g IV q8h or Ceftriaxone 2g IV q24h DOT: 4-6 weeks Comments: Not common in adults. INCLUDING DISC SPACE INFECTIONS AND OTHER SITES Etiology: Preferred Regimen: S. Consider tuberculous etiology when course is subacute and the following characteristic radiologic findings are seen: • Destruction of 2 or more vertebrae and opposed endplates • Spread along the anterior longitudinal ligament • Disk infection with or without paraspinal mass or fluid collection • Spondylitis without disc involvement Do not start antibiotics until etiologic diagnosis is established EXCEPT in the following situations: sepsis. OSTEOMYELITIS (HEMATOGENOUS) LONG BONES Etiology: Preferred Regimen: S. VERTEBRAL. 26 National Antibiotic Guidelines . POST-SURGERY Etiology: Preferred Regimen: S. aeruginosa Piperacillin-tazobactam 4. bone or joint surgery FOOT BONE (CALCANEUS) FOLLOWING PUNCTURE WOUND Etiology: P. Gram-negative bacilli less often Vancomycin 15-20mg/kg IV q8-12h Comments: Debridement is needed. OSTEOMYELITIS (CONTIGUOUS WITHOUT VASCULAR INSUFFICIENCY) • Usually follows trauma. aureus. Ceftazidime 2g IV q8h or P.5g IV q8h Comments: Removal of internal fixation hardware is a must even without bone union because of biofilm formation on metal implant. Vancomycin 15-20mg/kg IV q8-12h PLUS Gram-negative bacilli. LONG BONE. SPINAL IMPLANT Etiology: Preferred Regimen: S. If Gram-negative bacilli is likely. Vancomycin 15-20mg/kg IV q8-12h PLUS Gram-negative bacilli Ceftazidime 2g IV q8h or Piperacillin-tazobactam 4.5g IV q8h Comments: Obtain bone biopsy culture (gold standard). Adjust antibiotic based on susceptibility results. aeruginosa Preferred Regimen: 1st line 2nd line Ciprofloxacin 750mg PO bid OR Ceftazidime 2g IV q8h OR Levofloxacin 750mg PO q24h Piperacillin-tazobactam 4. STERNUM. Need debridement and removal of foreign body.5g IV q8h National Antibiotic Guidelines 27 . aureus. add appropriate antibiotic based on local susceptibility profile. aureus. BONE AND JOINT INFECTIONS IN ADULTS B. External fixation can be done to stabilize fracture. POST-INTERNAL FIXATION OF FRACTURE Etiology: Preferred Regimen: S. OSTEOMYELITIS (CONTIGUOUS WITH VASCULAR INSUFFICIENCY) • Mostly seen in diabetics (See Diabetic Foot) Etiology: Preferred Regimen: Usually polymicrobial Empiric treatment is not indicated unless acutely ill. present for weeks to months. BONE AND JOINT INFECTIONS IN ADULTS Comments: Onset within 30d: early debridement. Antibiotics Enterobacteriaceae. associated with dead bone Etiology: Preferred Regimen: Staphylococci. Revascularize. and definitive antibiotic x 6 weeks C. and definitive antibiotic x 3 months Late-onset (>30d): implant removal. Culture of swab of overlying ulcer unreliable. is standard of care. Osteomyelitis more likely: ulcer >2cm². must be chosen based on culture/sensitivity results. D. MRI – best imaging. antibiotic treatment is usually prolonged (usually 6 weeks). retention of implant. ESR>70. debridement. positive probe to bone. in etiology (aerobic Choose antibiotic treatment based on and anaerobic) culture/sensitivity results DOT (IV to oral): Approximately 6 weeks from the last debridement Comments: Bone/tissue biopsy culture essential. OSTEOMYELITIS (CHRONIC) • Usually occurs by contiguous spread.allows higher concentration of antibiotics without systemic toxic effects • Hyperbaric oxygen • Rifampin combined w/ another active agent vs chronic staphylococcal and orthopedic implant infections 28 National Antibiotic Guidelines . P. The optimal treatment duration and route is uncertain. together with antibiotic therapy. if possible. Treatment adjuncts include: • Antibiotic-impregnated cement for local antibiotic delivery. Empiric treatment is not recommended. aeruginosa Comments: Surgical resection of necrotic or infected bone and removal of orthopaedic hardware. abnormal x-ray. BONE AND JOINT INFECTIONS IN ADULTS II. predominate. Empiric antibiotic choices should be based on joint fluid Gram stain. If occurring after articular injection. streptococci. Culture other sites: urethra. Empiric therapy is not recommended National Antibiotic Guidelines 29 . and polyarthritis. Gram-negative bacilli in 5-20% Comments: Consider as an emergency. ACUTE BACTERIAL ARTHRITIS • Joint fluid WBC count usually >50. aureus. MONOARTICULAR Etiology: Preferred Regimen: At risk for sexually Ceftriaxone 1g IV q24h transmitted infection Treat presumptively for concomitant Chlamydia (STI): N. treat based on joint fluid culture result. Not at risk for STI: Differentials for gram-stain negative arthritis include gout and pseudo gout. Adjust treatment based on culture/sensitivity results. Joint drainage is essential. Look for crystals in joint fluid. tenosynovitis. aureus and Strep. Gram-negative bacilli Gram-positive cocci Vancomycin 15-20mg/kg IV q8-12h Gram-negative cocci Ceftriaxone 1g IV q24h Gram-negative Ceftazidime 2g IV q8h OR bacilli Piperacillin-tazobactam 4. gonorrhoeae infection: Azithromycin 1g PO x 1 dose likely DOT (min): 7d Not at risk for STI: S. and throat. JOINT INFECTIONS A. sp.5g IV q6-8h Vancomycin PLUS Negative on Gram stain Ceftazidime OR Piperacillin-tazobactam DOT: 2-4 weeks Comments: At risk for STI: May manifest as disseminated gonococcal infection. cervix. Collect blood and joint fluid for culture before starting empiric antibiotic treatment.000/mm³ but lower counts do not exclude the diagnosis Etiology: S. presenting with the classic triad of dermatitis. Some cases may require bursectomy. SEPTIC BURSITIS • Usually involves olecranon. aureus (21-43%). Coagulase-negative staphylococci (17-39%). Etiology: S. Gram stain and culture/sensitivity. Streptococci (7-12%). BONE AND JOINT INFECTIONS IN ADULTS POLYARTICULAR Etiology: Preferred Regimen: N. At least 3 and optimally 5-6 periprosthetic tissue specimens or the prosthesis itself should be sent for aerobic/anaerobic cultures. PROSTHETIC JOINT INFECTIONS Definitive diagnosis: presence of a sinus tract communicating with the prosthesis or purulence (without another etiology) surrounding the prosthesis • Highly suggestive diagnosis: acute inflammation on histopathology examination of periprosthetic tissue obtained at the time of debridement or prosthesis removal. • Other diagnostic evidence: growth of the same organism in at least 2 intra- operative cultures or in a combination of pre-operative aspirate and intra- operative cultures. Ceftriaxone 1g IV q24h rheumatic fever. Gram-negative bacilli (5-12%). Viruses Comments: Work up for other causes including reactive arthritis B. Etiology: Preferred Regimen: S. aureus (or other virulent organism) in tissue biopsy or synovial fluid. aureus in > 80% MSSA Oxacillin 2g IV q4h OR Cefazolin 2g IV q8h MRSA Vancomycin 15-20mg/kg IV q8-12h DOT: 14-21d Comments: Treatment includes antibiotics and daily aspiration of bursa until sterile. or growth of S. gonorrhoeae. Propionibacterium acnes associated with shoulder arthroplasty infection 30 National Antibiotic Guidelines . prepatellar and postpatellar bursae • Diagnosis is based on aspiration of fluid from the bursa for WBC count (usually >1. Anaerobes (2-6%). Acute If sexually active.000/mm³). C. Enterococci (1-8%). Antibiotic cement spacers are used to deliver higher concentrations of local antibiotics without systemic side effects and to prevent joint contractures Etiology: Preferred Regimen: Methicillin. Penicillin G 20-24MU IV q24 continuously (or in 6 div susceptible) doses) or Ampicillin 2g IV q4h x 4-6 weeks 1-/2-stage: as above x 4-6 weeks National Antibiotic Guidelines 31 . low-virulence organism. Treat based on culture/ sensitivity results. BONE AND JOINT INFECTIONS IN ADULTS Preferred Regimen: Referral to specialist. 2-stage exchange There is insufficient evidence to make a recommendation on the safety and efficacy of antibacterial cement spacers. 1-stage/direct exchange 3. Debridement and retention of prosthesis (DAIR): within 30 days of prosthesis implantation or symptoms <3 weeks. DAIR PLUS susceptible S. DAIR PLUS acnes Penicillin G 20-24MU IV q24 continuously (or in 6 divided doses) or Ceftriaxone 2g IV q24h x 4-6 weeks 1-/2-stage: as above x 4-6 weeks Enterococci DAIR PLUS (penicillin. aureus or Vancomycin 15-20 mg/kg IV q8-12h PLUS epidermidis Rifampin 300 mg po bid x 2-6 weeks FOLLOWED BY Levofloxacin 750 mg PO q24h or Ciprofloxacin 750 mg PO bid PLUS Rifampin 300 mg PO bid for 3 months (6 months for total knee arthroplasty) 1-stage: IV PO regimen as for DAIR for 3 months 2-stage: IV PO regimen as above for 4-6 weeks Streptococci or P. Comments: Surgical strategies: 1. aureus Oxacillin 2g IV q4h or Cefazolin 2g IV q8h PLUS or epidermidis Rifampin 300mg PO bid x 2-6 weeks (coverage for BIOFILM) FOLLOWED BY Levofloxacin 750mg PO q24h or Ciprofloxacin 750mg PO bid PLUS Rifampin 300mg PO bid for 3 months (6 months for total knee arthroplasty) 1-stage: IV PO regimen as for DAIR for 3 months 2-stage: IV PO regimen as above for 4-6 weeks Methicillin-resistant DAIR PLUS S. with a well-fixed prosthesis. and absence of a sinus tract 2. Empiric therapy is not recommended. Systemic Antibiotic Therapy for Chronic Osteomyelitis in Adults. • Tande A. Berbari EF. Patel R. Published July 29. 32 National Antibiotic Guidelines . Bayer A. et al. 52: e18. • Antibiotic Guidelines 2015-2016. Douglas and Bennett’s Principles and Practice of Infectious Diseases. Clin Infect Dis 2013. et al.com/. BONE AND JOINT INFECTIONS IN ADULTS Enterococci DAIR PLUS (penicillin-resistant) Vancomycin 15mg/kg IV q12h x 4-6 weeks 1-/2-stage: as above x 4-6 weeks Enterobacteriaceae DAIR PLUS IV B-lactam or fluoroquinolone based on susceptibility results x 4-6 weeks 1-/2-stage: as above x 4-6 weeks P. 2015. • Osmon DR. Clin Microbiol Rev 2014. • The Sanford Guide to Antimicrobial Therapy 2016. • Berbari EF et al. Prosthetic Joint Infections. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children.54(3):393–407. • Trampuz A. • Mandell. aureus or epidermidis: confirm isolate susceptibility to rifampin and fluoroquinolones For Entercocci and P. Cosgrove SE. Treatment Recommendations for Adult Inpatients. Clin Infect Dis 2012. 2015 Infectious Diseases Society of America (IDSA) Clinical Practice Guidelines for the Diagnosis and Treatment of Native Vertebral Osteomyelitis in Adults. 69: 309–322. • Spellberg B.sanfordguide. Oral antibiotic treatment of staphylococcal bone and joint infections in adults. • Liu C. Clin Infect Dis 2011. Zimmerli W. 8th ed. Curr Infect Dis Rep 2008. aeruginosa: may add an aminoglycoside (optional) REFERENCES: • Antimicrobial Resistance Surveillance Program.302-345. Berendt AR. aeruginosa DAIR PLUS Ceftazidime 2g IV q8h or Cefepime 2g IV q12h 1-/2-stage: as above x 4-6 weeks Comments: For Methicillin-susceptible/resistant S. New York: Elsevier. Diagnosis and Treatment of Implant-Associated Septic Arthritis and Osteomyelitis.56: e1. 10:394–403. et al. J Antimicrob Chemother 2014. • Baek-Nam K. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. 2015. Manila: Department of Health. Clin Infect Dis Advanced Access. Lipsky B. Available at: http://webedition. 2015. or S. in the absence of a primary focus) • Microorganisms consistent with IE from persistently positive blood cultures (at least two positive cultures of blood samples drawn >12 hours apart. pulmonary infarcts. Embolism evidence: arterial emboli. Pathological criteria (any one): 1. Osler’s nodes. or on implanted material in the absence of an alternative anatomic explanation. rheumatoid factor 5. or abscess. or HACEK group. or new partial dehiscence of prosthetic valve or new valvular regurgitation (worsening or changing of pre-existing murmur not sufficient) Minor criteria 1. Fever >38°C 3. or community-acquired enterococci. bovis including nutritional variant strains. aureus. Active endocarditis B. Immunological problems: glomerulonephritis. or intracardiac abscess from the heart revealing microorganisms 2. defined as one of the following: • Typical microorganism consistent with IE from 2 separate blood cultures (viridans group streptococci. Histology or culture of a cardiac vegetation. INFECTIVE ENDOCARDITIS (IE) DIAGNOSTIC CRITERIA (MODIFIED DUKE’S CRITERIA) A. an embolized vegetation. Positive blood culture with typical IE microorganism. CARDIOVASCULAR INFECTIONS I. Roth spots. Predisposing factor: known cardiac lesion. Clinical Criteria: Major criteria 1. with first and last sample drawn > 1 hour apart) • Coxiella burnetii detected by at least one positive blood culture or IgG antibody titer for Q fever phase 1 antigen >1:800. in the path of regurgitant jets. recreational drug injection 2. Microbiologic evidence: Positive blood culture (that doesn't meet a major criterion) or serologic evidence of infection with organism consistent with IE but not satisfying major criterion Definitive (any one of these Possible (any one of these combinations): combinations): • 2 major clinical criteria • 1 major and 1 minor criteria • 1 major and 3 minor criteria • 3 minor criteria are fulfilled • 5 minor criteria • 1 pathological criterion National Antibiotic Guidelines 33 . Janeway lesions. or all of 3 or a majority of 4 separate cultures of blood. or S. Evidence of endocardial involvement with positive echocardiogram defined as oscillating intracardiac mass on valve or supporting structures. 2. conjunctival/intracranial hemorrhages 4. Haemophilus sp.000-300. • Transthoracic echocardiogram (TTE) must be done in all suspected cases. Eikenella corrodens. Culture negative 10% Preferred Regimen: Community-acquired Healthcare-associated PEDIATRICS Ampicillin-sulbactam 200-300mg/kg Vancomycin 60 mg/kg/d IV q6h IV q24h div 4 or 6 doses (Max: (Max: 2 g/d) for 6 weeks PLUS 12g/24h) x 4 weeks PLUS Gentamicin 3–6 mg/kg/d IV q8h Gentamicin 3-6 mg/kg/d IV/IM q8h PLUS Cefepime 100-150 mg/kg/d q8-12h (Max: 6 g/d) or Ceftazidime 100-150 mg/kg/d IV q8h (Max: 2-4 g/d) ADULTS Ampicillin 12g/d IV q4h PLUS Vancomycin 15-20 mg/kg IV q8-12h Gentamicin 1mg/kg IV q8h PLUS Gentamicin 1 mg/kg IV q8h OR PLUS Cefepime 2g IV q8h or Ceftazidime 2g IV q8h Vancomycin 15-20mg/kg IV q8-12h (if MRSA likely pathogen) PLUS Ceftriaxone 2g IV q24h or Gentamicin 1mg/kg IV q8h Comments: • At least 3 sets of blood cultures must be obtained. Enterococci (5-18%). viridans or S. gallolyticus) with Penicillin G MIC ≤0. and Kingella species (HACEK) (5%).. Cardiobacterium hominis.000 U/kg/d IV q4h weeks or Ceftriaxone 2g IV q24h x 2 (Max: 12-24 MU/d) x 4 weeks OR weeks 34 National Antibiotic Guidelines . CARDIOVASCULAR INFECTIONS A.12 mcg/mL Preferred Regimen: PEDIATRICS ADULTS Aqueous crystalline penicillin G Na Penicillin G 12-18MU/d IV q4h x 2 200. Other streptococci (15-25%). • Transesophageal echo (TEE) must be done when TTE is negative if there is ongoing suspicion of IE or concern about intracardiac complications. PATHOGEN-SPECIFIC TREATMENT Etiology: S. Aggregatibacter sp. bovis (S. Staphylococci (20-35%).. Native Valve Infective Endocarditis EMPIRIC THERAPY Etiology: Streptococcus viridans (30-40%). vancomycin. gallolyticus) with Penicillin G MIC >0. gallolyticus) with Penicillin G MIC >0. Obtain the trough level before the 4th dose. Treatment with vancomycin must achieve trough concentration of 10-15 mcg/mL.g. bovis (S. tumor) when the etiologic agent is S. bovis. Etiology: S. 6 weeks if symptoms >3 months National Antibiotic Guidelines 35 . Etiology: S. viridans or S.5mcg/mL Preferred Regimen: PEDIATRICS ADULTS Ampicillin 200-300mg/kg/d IV q4-6h Penicillin G 24MU/d IV q4h x 4 weeks (Max: 12 g/d) x 4 weeks or PLUS Gentamicin 3mg/kg qd x 2 weeks Ceftriaxone 100mg/kg/d IV/IM q12h OR or 80mg/kg/d qd (Max: 2g q12h) x 4 Ceftriaxone 2g IV qd x 4 weeks weeks If unable to tolerate Penicillin or PLUS Ceftriaxone: Gentamicin 3-6mg/kg/d IV q8h x 2wks Vancomycin 15 mg/kg IV q12h x 4 wks Comments: Check susceptibility to ceftriaxone. A: A 2-week combination regimen is reasonable with uncomplicated IE..12 to ≤0. gentamicin (synergy positive) Preferred Regimen: 1st line 2nd line Penicillin G 18-30 MU/d IV q4h or Ampicillin 12 g/d IV q4h Ampicillin 12 g/d IV q4h x 4-6 weeks PLUS PLUS Ceftriaxone 2 g IV q12h x 6 weeks Gentamicin 1 mg/kg IV q8h x 4-6 weeks DOT: 4 weeks if symptoms <3 months. rapid treatment response and without renal disease. CARDIOVASCULAR INFECTIONS Ceftriaxone 100mg/kg/d IV/IM q12h PLUS or 80mg/kg/d qd (Max: 2g q12h) x 4 Gentamicin 3mg/kg/d qd x 2 weeks or wks Penicillin G 12-18MU/d IV q4h x 4 weeks or Ceftriaxone 2g IV q24h x 4 weeks If unable to tolerate Penicillin or Ceftriaxone: Vancomycin 15mg/kg IV q12h x 4 wks Comments: P: Suspect occult bowel pathology (e.5 mcg/mL and Enterococci susceptible to ampicillin/ Penicillin G. viridans or S. bovis (S. aureus (MRSA) Preferred Regimen: P: Vancomycin 60mg/kg/d IV q6h (Max: 2 g/d) 36 National Antibiotic Guidelines . Dose must be adjusted to achieve vancomycin target trough concentration of 15-20 mcg/mL. creatinine clearance < 50 mL/min) Etiology: Enterococci. Etiology: Enterococci. aminoglycoside-resistant (gentamicin MIC >500 mcg/mL). aminoglycoside-sensitive Preferred Regimen: PEDIATRICS ADULTS Vancomycin 60mg/kg/d IV q6h (Max: Vancomycin 15-20mg/kg IV q8-12h 2g/d) PLUS PLUS Gentamicin 3-6mg/kg/d IV q8h x 6 wks Gentamicin 1mg/kg IV q8h x 6 wks Comments: Potential increased nephrotoxicity and ototoxicity with this combination.and aminoglycoside-resistant or vancomycin- resistant Refer to specialist. penicillin-resistant. penicillin-susceptible. Refer to specialist. penicillin. streptomycin susceptible Preferred Regimen: PEDIATRICS ADULTS Ampicillin 200–300mg/kg/d IV div q4-6h Ampicillin 12g/d IV div q4h (Max dose 12 g/d) PLUS PLUS Ceftriaxone 100mg/kg/d IV/IM q12h or Ceftriaxone 2g IV q12h x 6 weeks 80mg/kg/day od (Max: 2 g q12h) x 6 weeks Etiology: Enterococci. CARDIOVASCULAR INFECTIONS Comments: Alternative double B-lactam regimen may be used when unable to use gentamicin (ex. Etiology: Methicillin-susceptible Staphylococcus aureus (MSSA) Preferred Regimen: PEDIATRICS ADULTS Oxacillin 200mg/kg/d IV div 4–6 doses Oxacillin 2g IV q4h x 4-6 weeks OR (Max: 12 g/d) x 6 weeks Cefazolin 2g IV q8h x 6 weeks WITH or WITHOUT Gentamicin 3-6mg/kg/d IV/IM q8h x 3-5d Etiology: Methicillin-resistant S. aureus mostly Late (>2 months post-surgery): S. S. and Kingella species (HACEK) Preferred Regimen: PEDIATRICS ADULTS Ceftriaxone 100 mg/kg/d IV/IM q12h or Ceftriaxone 2g IV q24h x 4 weeks 80 mg/kg/d qd (Max: 2g q12h) x 4 weeks If beta-lactamase producing: If beta-lactamase producing: Ampicillin-sulbactam 3g IV q6h x 4 Ampicillin-sulbactam 200-300mg/kg weeks q24h IV div 4 or 6 doses x 4 weeks B. PROSTHETIC VALVE IE EMPIRIC THERAPY Etiology: Early (<2 months post-surgery): S. aureus Preferred Regimen: PEDIATRICS ADULTS Vancomycin 40-60mg/kg/d q6-8h Vancomycin 15-20mg/kg IV q8-12h PLUS PLUS Gentamicin 1mg/kg IV q8h Gentamicin 3–6mg/kg/d IV q8h PLUS PLUS Rifampin 600mg PO q24h Rifampin 20mg/kg/d IV/PO div 3 doses x 6 weeks (Max: 900 mg/d) DOT: 6 weeks Comments: Early surgical consultation is recommended. aureus (MSSA) National Antibiotic Guidelines 37 . Aggregatibacter sp. enterococci. CARDIOVASCULAR INFECTIONS A: Vancomycin 15-20mg/kg IV q8-12h x 6 weeks Etiology: Haemophilus sp. Cardiobacterium hominis. epidermidis and S. S. annular or aortic abscess • Recurrent emboli • Caused by fungal or highly resistant organisms PATHOGEN-SPECIFIC TREATMENT Etiology: Methicillin-susceptible S. viridans. epidermidis. Eikenella corrodens. Surgical indications: • Signs and symptoms of congestive heart failure due to valve dehiscence • Intracardiac fistula and prosthetic valve dysfunction • Persistent bacteremia despite 5-7 days of treatment • Heart block. 3. CARDIOVASCULAR INFECTIONS Preferred Regimen: PEDIATRICS ADULTS Oxacillin 200mg/kg/d IV div 4–6 Oxacillin 2g IV q4h doses x 6 weeks (Max: 12g/d) PLUS PLUS Rifampin 20mg/kg q24h IV/PO div 3 Rifampin 300mg PO q8h x 6 weeks doses x 6 weeks (Max: 900 mg/d) PLUS PLUS Gentamicin 1mg/kg IV q8h x 2 weeks Gentamicin 3-6 mg/kg/d IV/IM div 3 doses x 2 weeks Etiology: Methicillin-resistant S. INFECTIVE ENDOCARDITIS (IE) PROPHYLAXIS Summary Statements: 1. or perforation of the oral mucosa. Only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. 2. 38 National Antibiotic Guidelines . For patients with these underlying cardiac conditions. aureus (MRSA) Preferred Regimen: PEDIATRICS ADULTS Vancomycin 40mg/kg/d IV div 2-3 Vancomycin 15-20mg/kg IV q8-12h doses x 6 weeks PLUS PLUS Rifampin 20mg/kg/d IV/PO div 3 Rifampin 300mg PO q8h x 6 weeks doses x 6 weeks (Max: 900 mg/d) PLUS PLUS Gentamicin 1mg/kg IV q8h x 2 weeks Gentamicin 3-6mg/kg/d IV/IM div 3 doses x 2 weeks DOT: 6 weeks Etiology: Gram-negative enteric bacilli Preferred Regimen (Pediatrics): Ceftazidime 100-150mg/kg/d IV q8h x 6 weeks (Max: 2-4 g/d) or Cefotaxime 200mg/kg/d IV q6h x 6 weeks (Max: 12 g/d) or Ceftriaxone 100mg/kg/d IV q12h or 80 mg/kg/d IV q12-24h x 6 weeks (Max: 2 g/d) PLUS Gentamicin 3-6mg/kg/d IV q8h C. IE prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE. prophylaxis is reasonable for all dental procedures that involve manipulation of the gingival tissue or the periapical region of teeth. Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE. placement of orthodontic bands) • The following procedures and events do NOT need prophylaxis: o Routine anaesthetic injections through non. during the first 6 months after the procedure** o Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) • Cardiac transplantation recipients who develop cardiac valvulopathy *Except for the conditions listed above. Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. including palliative shunts and conduits o Completely repaired congenital heart defect with prosthetic material or device. suture removal. Situation Agent before procedure ADULTS PEDIATRICS Oral Amoxicillin 2g 50mg/kg Unable to take Ampicillin OR 2g IM/IV 50mg/kg IM or IV oral medication Cefazolin OR 1g IM/ IV 50mg/kg IM or IV National Antibiotic Guidelines 39 . CARDIAC CONDITIONS WITH THE HIGHEST RISK OF ADVERSE OUTCOME FROM IE WHERE PROPHYLAXIS FOR DENTAL PROCEDURES IS REASONABLE • Prosthetic cardiac valve or prosthetic material used for cardiac valve repair • Previous IE • Congenital heart disease (CHD)* o Unrepaired cyanotic CHD.infected tissue o Dental radiographs o Placement of removable prosthodontic or orthodontic appliances o Adjustment of orthodontic appliances o Placement of orthodontic brackets o Shedding of deciduous teeth o Bleeding from trauma to the lips or oral mucosa. whether placed by surgery or by catheter intervention. 5. RECOMMENDED REGIMEN FOR DENTAL PROPHYLAXIS Regimen: Single dose 30-60 min. **Prophylaxis is reasonable because endothelialization of prosthetic material occurs within 6 months after the procedure. antibiotic prophylaxis is no longer recommended for any other form of CHD. CARDIOVASCULAR INFECTIONS 4. DENTAL PROCEDURES FOR WHICH IE PROPHYLAXIS IS REASONABLE FOR PATIENTS WITH SPECIFIED CARDIAC CONDITIONS (SEE ABOVE STATEMENTS) • All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa (biopsies. especially when caused by organisms other than sensitive streptococci or in patients with prosthetic valves 40 National Antibiotic Guidelines ..or second-generation oral cephalosporin in equivalent adult or pediatric dosage. Periannular extension (Most patients with abscess formation or fistulous tract formation) 3. INDICATIONS FOR SURGERY 1.g. coma) 5. angioedema. by valve obstruction caused by vegetations • Severe acute aortic or mitral regurgitation with echocardiographic signs of elevated left ventricular end-diastolic pressure or significant pulmonary hypertension • Congestive heart failure as a result of prosthetic dehiscence or obstruction 2. assuming that vegetations or other lesions requiring surgery persist and that extracardiac sources of sepsis have been excluded • Relapsing IE. Congestive heart failure* • Congestive heart failure caused by severe aortic or mitral regurgitation or. Systemic embolism† • Recurrent emboli despite appropriate antibiotic therapy • Large vegetations (>10 mm) after 1 or more clinical or silent embolic events after initiation of antibiotic therapy • Large vegetations and other predictors of a complicated course • Very large vegetations (>15 mm) without embolic complications. Cerebrovascular complications‡ • Silent neurological complication or transient ischemic attack and other surgical indications • Ischemic stroke and other surgical indications. Persistent sepsis • Fever or positive blood cultures persisting for >5 to 7 days despite an appropriate antibiotic regimen. especially if valve-sparing surgery is likely (remains controversial) 4. or urticaria with penicillins or ampicillin. CARDIOVASCULAR INFECTIONS Ceftriaxone 1g IM/ IV 50mg/kg IM or IV Allergic to Cephalexin* OR 2g 50mg/kg penicillins or Clindamycin OR 500 mg 20mg/kg ampicillin—oral Azithromycin OR 500 mg 15mg/kg Clarithromycin 15mg/kg Allergic to Cefazolin OR 1g IM/ IV 50mg/kg IM or IV penicillins or Ceftriaxone† OR ampicillin and Clindamycin 600mg IM/IV 20mg/kg IM or IV unable to take oral medication *Or other first. †Cephalosporins should not be used in an individual with a history of anaphylaxis. more rarely. provided that cerebral hemorrhage has been excluded and neurological complications are not severe (e. aureus. S. Enterobacteriaceae PEDIATRICS ADULTS Vancomycin 60mg/kg/d q6h Vancomycin 15-20mg/kg IV q8-12h (adjusted based on TDM) PLUS PLUS Ceftriaxone 2g IV q24h or Ceftriaxone 100mg/kg/d IV q12-24h Levofloxacin 750mg IV q24h or (Max: 2 g q12h) Aminoglycoside (Gentamicin 5mg/kg/day or Amikacin 15 mg/kg/day) Comments: Initial antibiotic regimen should consist of 2 or more drugs. II. pneumoniae. Etiology: Methicillin-resistant S.g. depending upon tolerance of the valve lesion. aureus • Late prosthetic valve endocarditis with heart failure caused by prosthetic dehiscence or obstruction. in patients with persistent pulmonary edema or cardiogenic shock. pneumoniae resistant to extended-spectrum cephalosporins. surgery for the prevention of embolism must be performed very early since embolic risk is highest during the first days of therapy. Drainage usually necessary. or other indications for surgery *Surgery should be performed immediately. Prosthetic valve endocarditis • Virtually all cases of early prosthetic valve endocarditis • Virtually all cases of prosthetic valve endocarditis caused by S. ‡Surgery is contraindicated for at least one month after intracranial hemorrhage unless neurosurgical or endovascular intervention can be performed to reduce bleeding risk. intervention can be postponed to allow a period of days or weeks of antibiotic treatment under careful clinical and echocardiographic observation. In patients with well tolerated severe valvular regurgitation or prosthetic dehiscence and no other reasons for surgery. BACTERIAL PURULENT PERICARDITIS Etiology: S. irrespective of antibiotic therapy. aureus or vancomycin-resistant enterococci) and rare infections caused by Gram- negative bacteria • Pseudomonas aeruginosa IE • Fungal IE 7. conservative therapy under careful clinical and echocardiographic observation is recommended with consideration of deferred surgery after resolution of the infection. when etiologic agent cannot be detected rapidly. or nosocomial infections National Antibiotic Guidelines 41 . aureus is isolated and/or with history and clinical features for MRSA infection. Staphylococcus lugdunensis) • IE caused by multiresistant organisms (e. methicillin-resistant S. CARDIOVASCULAR INFECTIONS 6. Group A Streptococcus. †In all cases. S. If congestive heart failure disappears with medical therapy and there are no other surgical indications. Difficult organisms • Staphylococcus aureus IE involving a prosthetic valve and most cases involving a left-sided native valve • IE caused by other aggressive organisms (Brucella. influenzae type B (for children who may be inadequately immunized) Preferred Regimen: Cefotaxime 200-300 mg/kg/d IV q6-8h (Max: 12g/d) OR Ceftriaxone 100 mg/kg/d IV q12-24h (Max: 2g q12h) Comments: An aminoglycoside should be added when: 1.00 U IM Azithromycin 5mg/kg qd (Max: 250 mg) OR Penicillin V 250mg PO bid 42 National Antibiotic Guidelines . decrease the fever. H. purulent pericarditis occurs after surgery 2. Once a pathogen is isolated and the antimicrobial susceptibilities are known. Etiology: Methicillin-sensitive S.12 g/d) Etiology: S. ACUTE RHEUMATIC FEVER PRIMARY PREVENTION: (See section on Streptococcal Tonsillopharyngitis) Comments: Therapy for acute rheumatic fever is symptomatic to control the inflammation. in the immunocompromised III.000 U IM bid) OR > 27 kg: 1. N. in association with UTI 3. aureus Preferred Regimen: Oxacillin 200mg/kg/day (Max: 4 . and keep cardiac failure in check. pneumoniae (including penicillin-resistant strains). meningitidis.200. SECONDARY PREVENTION (PREVENTION OF RECURRENT ATTACKS) Preferred Regimen: Benzathine penicillin G (every 3 For individuals allergic to penicillin weeks*) Erythromycin 20mg/kg/d bid (Max: 250 mg < 27 kg: 600. CARDIOVASCULAR INFECTIONS Preferred Regimen: Vancomycin 60 mg/kg/d q6h (adjusted based on TDM) DOT: Empirical and determined partly by the nature of concomitant infection. the most specific antimicrobial agent is continued IV for 3-4 weeks. Enterococcus spp. Preferred Regimen: Fluconazole 12mg/kg PO/IV as loading dose. An individual with a previous attack of rheumatic fever in whom GAS pharyngitis develops is at high risk for a recurrent attack of rheumatic fever. then 6mg/kg/d is an acceptable alternative if not critically ill and unlikely to have fluconazole-resistant Candida spp. S. CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION (CLABSI) IN CHILDREN Etiology: Coagulase-negative staphylococci (especially S.. aureus. CARDIOVASCULAR INFECTIONS Comments: Referral to a pediatric cardiologist is important. Successful oral prophylaxis depends on patient adherence (compliance). Other enteric Gram-negative bacteria Preferred Regimen: Vancomycin 60mg/kg/d q6h PLUS Piperacillin-tazobactam 200-300mg/kg/day IV q8h PLUS Aminoglycoside Etiology: Candida spp. and oral agents are more appropriate for patients at low risk for rheumatic fever recurrence. Klebsiella spp.. DOT: up to 2 weeks after clearance of candidemia National Antibiotic Guidelines 43 . Prevention of recurrent episodes of Group A Streptococcus (GAS) pharyngitis is the most effective method to prevent severe RHD. Escherichia coli. epidermidis). Duration of Secondary Rheumatic Fever Prophylaxis Category **Clinical or echocardiographic findings Duration of Last Attack Rheumatic fever with carditis and 10 years or until 40 years of age residual heart disease (persistent (whichever is longer) valvular disease**) Rheumatic fever with carditis but no 10 years or 21 years of age residual heart disease (no valvular (whichever is longer) disease**) Rheumatic fever without carditis 5 years or 21 years of age (whichever is longer) IV. dual lumen hemodialysis catheters (Permacath): S. CARDIOVASCULAR INFECTIONS Comments: • Once the causative organism is identified. septic thrombosis. epidermidis. patients should receive 10–14 days of appropriate systemic therapy. remove catheter and treat for 2 weeks. epidermidis. aureus (MSSA/MRSA). Infection prevention of long-term IV lines include components of both insertion and maintenance bundles: • Hand washing • Maximal sterile barrier precautions during catheter insertion • Use of >0. CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION IN ADULTS Diagnosis: Fever AND: 1) positive percutaneous blood culture and same organism cultured from central venous catheter (CVC) tip OR 2) positive blood cultures simultaneously drawn with CVC positive at least 2 hours earlier than the peripheral vein culture. V.g. peripherally inserted central catheter (PICC): S. Preferred Regimen: Vancomycin 15-20mg/kg IV q8-12h If S. Groshong. S.to 7-day treatment course is reasonable for CLABSI due to coagulase-negative staphylococci if the catheter is removed and blood cultures clear promptly. patients should receive 10-14 days of systemic antibiotic therapy from the date of the first negative blood culture • If the catheter is removed. may “save” catheter and treat for 10-14 days plus antibiotic lock therapy (in the absence of complications) 44 National Antibiotic Guidelines . Prolong to 4-6 weeks if transesophageal echocardiogram positive for vegetation or if there are other complications (e. aureus.). • If the catheter is retained. Hickman.5% chlorhexidine prep with alcohol for skin antisepsis (chlorhexidine–alcohol provides greater protection against short-term catheter-related infections than povidone iodine–alcohol) • Avoidance of femoral vessels • Daily review of line necessity and replacement • Disinfection of hubs • Strict asepsis for dressing changes • Standardized administration set changes NON-TUNNELED central venous catheter (subclavian. osteomyelitis) If S. aureus (MSSA/MRSA) TUNNEL TYPE indwelling venous catheters and ports (Broviac. S. • A shorter 5. Referral to specialist is recommended. epidermidis. Candida sp. internal jugular). targeted therapy should be selected based on susceptibility testing. epidermidis. Pseudomonas sp. Enterobacteriaceae. S. If fungal. Fluconazole 12 mg/kg PO or IV as loading dose. Treat all patients with positive blood cultures for Candida. DOT: up to 2 weeks after clearance of candidemia Comments: Remove venous catheter. remove catheter. Antimicrobial Therapy. epidermidis. Infective Endocarditis in Adults: Diagnosis. Common Preferred Regimen: As above for staphylococcal infections If Candida: An echinocandin (e. Do not insert new catheter over a guidewire. aureus (MSSA/MRSA). Wilson WR. Candida sp. Ophthalmologic consultation recommended when candidemia is suspected to detect early ophthalmic involvement. Aspergillum.g. IMPAIRED HOST (burn. REFERENCES: • Baddour LM. and Management of Complications: A Scientific Statement for National Antibiotic Guidelines 45 . then 6 mg/kg/d is an acceptable alternative if not critically ill and unlikely to have fluconazole-resistant Candida sp. CARDIOVASCULAR INFECTIONS For documented MSSA: Oxacillin 2 g IV q4h OR Cefazolin 2 g IV q8h Comments: If subcutaneous tunnel infected. Rhizopus Preferred Regimen: Vancomycin 15-20mg/kg IV q8-12h PLUS Cefepime 2g IV q8h or Ceftazidime 2g IV q8h OR Vancomycin 15-20mg/kg IV q8-12h PLUS Piperacillin-tazobactam 4.. aureus (MSSA/MRSA). ligation or removal often indicated + antifungal Rx. biopsy of vein recommended to rule out fungal etiology. surgical drainage.. S. Stop antimicrobial agents if possible. anidulafungin 200 mg IV loading dose then 100 mg IV daily). Candida sp. Bayer AS. Corynebacterium jeikeium.5g IV q6-8h OR Cefepime 2g IV q8h or Ceftazidime 2g IV q8h PLUS Amikacin 15 mg/kg qd Comments: Often w/ associated septic thrombophlebitis. neutropenic) Etiology: S. et al. HYPERALIMENTATION Etiology: S. Andes DR. and Kawasaki Disease Committee. Taubert CA. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. 2011 May. 5:16. CARDIOVASCULAR INFECTIONS Healthcare Professionals from the American Heart Association.52(9): e162–193. 49(1):1-45. • Mermel LA. Jul 1 2009. Clin Infect Dis. Endocarditis. and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Gewitz M. et al. Antimicrob Resist Infect Control 2016. Clin Infect Dis. • Pappas PG. Apisarnthanarak A. Council on Cardiovascular Disease in the Young. Circulation 2007. 121:1141- 1152. 46 National Antibiotic Guidelines . Circulation 2010. Alexander M. APSIC guide for prevention of Central Line Associated Bloodstream Infections (CLABSI).116(15):1736-54. 132:1435- 1486. Council on Cardiovascular Surgery and Anesthesia. Tornos P. et al. Kauffman CA. Guidelines from the American Heart Association: A Guideline from the American Heart Association Rheumatic Fever. Epub 2011 Apr 1. Jaggi N. Burns LA. et al. • O’Grady NP. et al. Surgery for Infective Endocarditis. and the Council on Clinical Cardiology. Clin Infect Dis 2016.62: e1-50. Guidelines for the prevention of intravascular catheter-related infections. et al. Bouza E. Circulation 2015. • Ling ML. • Wilson W. • Prendergast BD. Allon M. In neonates. bulging fontanel and seizures. COMMUNITY ACUTE BACTERIAL MENINGITIS • Acute bacterial meningitis is an inflammatory disease of the leptomeninges. If bacterial meningitis is suspected. < 2 MONTHS OLD Etiology: Escherichia coli. nuchal rigidity. influenzae. if this is delayed. Group B Streptococcus (rare) Preferred Regimen: Ampicillin or Cefotaxime IV/IM using the following dose: Age 0-7 days Age >7 days Body weight <2 kg 50mg/kg q12h 50mg/kg q8h Body weight at least 2 kg 50mg/kg q8h 50mg/kg q6h PLUS Amikacin 15mg/kg/d IV/IM q24h or Gentamicin 5mg/kg/d IV/IM q24h Comments: Adjust therapy based on culture. the classic triad of acute bacterial meningitis consists of fever. May use Ceftriaxone if Cefotaxime is not available and the neonate is not jaundiced. Streptococcus pneumoniae. meningitidis (less Chloramphenicol 100mg/kg/d IV q8h (Max: 4g/d) common) National Antibiotic Guidelines 47 . gram stain or antigen test. irritability. Early onset usually due to maternal transmission. • In adults. pneumoniae. and a change in mental status. Klebsiella. common signs and symptoms include fever.5 YRS Etiology: Preferred Regimen: S. Repeat lumbar tap in the neonate is necessary to verify sterilization of the CSF in gram-negative meningitis. or suspected by clinical characteristics and/or CSF markers of inflammation (an abnormal number of white blood cells. Dexamethasone has no role in neonatal meningitis. CENTRAL NERVOUS SYSTEM INFECTIONS I. • Once suspected and awaiting laboratory results. Antibiotic therapy should be started immediately after lumbar puncture or. empiric therapy should be started right away to prevent complications and mortality. elevated protein and low glucose levels) • In children. > 2 MONTHS . signs and symptoms are subtler and may resemble neonatal sepsis. after obtaining blood cultures. the tissues surrounding the brain and spinal cord as proven by a positive bacterial CSF culture. PCR. Ceftriaxone 100mg/kg/d IV q12-24h (Max: 4 g/d) H. CSF analysis and culture should be performed to confirm the diagnosis. OR N. Duration of therapy is dependent on the etiology of bacterial meningitis. poor feeding. There is no single or combination of signs which are diagnostic of bacterial meningitis. Enterobacter. : 20mg/kg/d x 4d (Max: 600 mg) >5 YRS . pneumoniae meningitis. The first dose should be administered within 4 hours of starting antibiotic. Repeat lumbar puncture (LP) is recommended in patients with poor clinical response despite 36 hours of appropriate antibiotic treatment. old at a dose of 0. 18 yrs. repeat LP is not necessary. if patient is improving. with confirmed Hib meningitis should receive rifampin prophylaxis to eradicate the carrier state. It should be started along or shortly before the 1st antibiotic dose. monocytogenes. influenzae is suspected.or cephalosporin-resistant H.: 250mg IM x 1 dose OR Ciprofloxacin 500mg PO x 1 dose >50 YRS Etiology: Preferred Regimen: S. Cefuroxime should not be used for the treatment of bacterial meningitis because of delayed sterilization and a greater incidence of hearing loss.15 mg/kg (max: 10 mg) q6h for 4 days.18 yrs. aerobic For severe penicillin allergy: Gram-negative bacilli Vancomycin 15-20mg/kg IV q8-12h 48 National Antibiotic Guidelines . N. q12h L.18 YRS. For H. influenzae and S. influenzae b meningitis in children less than 5 yrs. Do not start dexamethasone >12h after starting antibiotics. meningitidis. meningitidis Preferred Regimen: >5 yrs. >3-10 yrs. pneumoniae.: 125mg IM x 1 dose. CENTRAL NERVOUS SYSTEM INFECTIONS Comments: Add vancomycin if penicillin. pneumoniae. or those with gram-negative meningitis. Recommended rifampicin dose for prophylaxis: <3yrs old: 10mg/kg/d x 4d. . 18 YRS-50 YRS Etiology: S. Ampicillin 2g IV q4h PLUS Ceftriaxone 2g IV N. Dexamethasone is of proven value for children with H. >15 yrs. Patients <10 yrs.-50 yrs. Ceftriaxone 100mg/kg/d IV q12h Ceftriaxone 2g IV q12h (Max: 4 g/d) OR Chloramphenicol 100mg/kg/d IV q8h (Max: 4 g/d) Comments: Patients with confirmed meningococcal meningitis and not treated with Ceftriaxone should receive either: Rifampicin 10mg/kg/d x 2d (Max: 600 mg) OR Ceftriaxone <15 yrs. meningitides: give same regimen as for patient For adults. Gram negative bacilli including Pseudomonas Preferred Regimen: PEDIATRICS ADULTS Vancomycin 60mg/kg/d IV/IM div q6h Vancomycin 15-20mg/kg IV/IM q8- PLUS Ceftazidime 150mg/kg/d div q8h 12h PLUS Ceftazidime 2g/d div q8h DOT: 3-6 weeks Comments: For household contacts: Hib meningitis: give same regimen as for patient N. L. Gram-negative enteric bacilli: 21d ANATOMIC DEFECTS. Culture negative: 10-14d. dexamethasone should be started before or given with the first dose of antibiotics at 0.000U/kg/d IV/IM q6h Penicillin G 4MU IV/IM q4h PLUS PLUS Ceftriaxone 100mg/kg/d IV/IM Ceftriaxone 2g IV q12h or q12h (Max: 4 g/d) or Chloramphenicol 1g IV/IM q6h National Antibiotic Guidelines 49 . Fusobacterium. • Etiology and treatment depends on the source of infection. BRAIN ABSCESS • Brain abscess is a focal collection of pus within the brain parenchyma. epidermidis. pneumoniae: 10-14d. Bacteroides Preferred Regimen: PEDIATRICS ADULTS Penicillin G 400. influenzae B: 7-10d. monocytogenes: 21d. aureus. II. direct spread of infection or hematogenous spread from a distant site of infection. meningitidis: 7d. N. The etiology may be trauma. NEUROSURGICAL COMPLICATIONS AND OPEN HEAD TRAUMA Etiology: S. IN THE PRESENCE OF DENTAL INFECTION: Etiology: Streptococci (viridans and anaerobic). S. • Imaging studies such as CT scan and MRI are necessary for diagnosis although this cannot determine the etiology.15 mg/kg q6h IV x 2-4 days. CENTRAL NERVOUS SYSTEM INFECTIONS PLUS Aztreonam 2g IV q6-8h or Ciprofloxacin 400mg IV q12h DOT (regardless of age): S. H. 5 cm IN THE PRESENCE OF CHRONIC OTITIS MEDIA. OR MASTOIDITIS Preferred Regimen: PEDIATRICS ADULTS Ceftazidime 150mg/kg/d IV/IM q8h Ceftazidime 2g/d IV/IM q8h PLUS PLUS Metronidazole 7. aerobic streptococci.5mg/kg IV/IM Metronidazole 7. influenzae. H. SINUSITIS. shift to oxacillin. usually 6-8 weeks. aureus is documented. Gram-negative enteric bacilli. IN THE PRESENCE OF ENDOCARDITIS (NATIVE VALVE): Etiology: S. faecalis is documented. aeruginosa Preferred Regimen: PEDIATRICS ADULTS Vancomycin 60mg/kg/d IV q6h Vancomycin 15-20mg/kg IV q8-12h PLUS Ceftriaxone 100mg/kg/d IV/IM PLUS Ceftriaxone 2g IV q12h q12h (Max: 4 g/d) Comments: If methicillin-sensitive S. aspiration of abscess is usually required if lesion is >2. faecalis is documented. 50 National Antibiotic Guidelines . shift to oxacillin. Bacteroides sp. give q8h) Comments: If methicillin-sensitive S. CENTRAL NERVOUS SYSTEM INFECTIONS Chloramphenicol 100mg/kg/d IV/IM q6h DOT: unclear. aureus.5mg/kg IV/IM q6h q6h or 15mg/kg IV/IM q12h or 15mg/kg IV/IM q12h IN THE PRESENCE OF HEAD TRAUMA: Etiology: Streptococci (aerobic and anaerobic). P. Comments: Consult a neurosurgeon. aureus is documented. Gram-negative enteric bacilli Preferred Regimen: PEDIATRICS ADULTS Ceftriaxone 100mg/kg/d IV/IM q12h Ceftriaxone 2g IV q12h PLUS (Max: 4 g/d) PLUS Gentamicin 3-6mg/kg/d IV/IM q24h Gentamicin 3-6mg/kg/d IV/IM q24h (If E. give q8h) (If E. viridans. viridans. influenzae Preferred Regimen: 1st line 2nd line PEDIATRICS Ceftriaxone 100mg/kg/d IV/IM q12h Penicillin G 400.5mg/kg/ IV q6h or 15 Chloramphenicol 100mg/kg/d IV mg/kg IV q12h q6h ADULTS Ceftriaxone 2g IV q12h PLUS Penicillin G 4MU IV q4h Metronidazole 7. S. pneumoniae. give q8h) IN THE PRESENCE OF CONGENITAL HEART DISEASE: Etiology: S.5mg/kg IV q6h or 15 Metronidazole 7. give q8h) (If E. Haemophilus spp. faecalis is documented.5mg/kg IV q6h or 15 PLUS Chloramphenicol 1g IV q6h mg/kg q12h III. faecalis is documented. aureus. SPINAL ABSCESS Etiology: S. H.000U/kg/d IV q6h (Max: 4 g/d) PLUS PLUS Metronidazole 7. Preferred Regimen: PEDIATRICS ADULTS Ceftriaxone 100mg/kg/d IV/IM q12h Ceftriaxone 2g IV q12h PLUS (Max: 4g/d) PLUS Metronidazole 7. aureus Preferred Regimen: PEDIATRICS ADULTS Vancomycin 60mg/kg/d q6h IV PLUS Vancomycin 15-20mg/kg q8-12h PLUS Gentamicin 3-6mg/kg/d IV/IM q24h Gentamicin 3-6mg/kg/day IV/IM q24h (If E. Streptococci Preferred Regimen: PEDIATRICS ADULTS Vancomycin 60mg/kg/d IV q6h Vancomycin 15-20mg/kg IV q8-12h National Antibiotic Guidelines 51 . CENTRAL NERVOUS SYSTEM INFECTIONS IN THE PRESENCE OF ENDOCARDITIS (PROSTHETIC VALVE): Etiology: S.5mg/kg IV q6h or 15 mg/kg IV q12h mg/kg IV q12h NO FOCUS Etiology: S. keratoconjunctivitis. VIRAL INCLUDING. Culture of the CSF is the gold standard for diagnosis. • Findings of herpes simplex virus (HSV) infection in neonates may include the following: herpetic skin lesions over the presenting surface from birth or with breaks in the skin. shift to oxacillin. and measles. Severe signs include jaundice. ENCEPHALITIS • Encephalitis is an inflammation of the brain usually caused by viral infections. including the following: behavioral and personality changes. bulging fontanels. HERPES SIMPLEX Preferred Regimen: PEDIATRICS ADULTS Aciclovir (<12 years): 20mg/kg IV Aciclovir 10 mg/kg IV infused over infused over 1hour q8h 1hour q8h DOT: 14-21 days Comments: Early diagnosis and treatment is necessary. mumps. MEASLES. ARBOVIRUSES Preferred Regimen: Supportive treatment Comments: Children should be immunized with measles vaccine at 9 months. oropharyngeal involvement. or through a ventricular shunt. • Infection with the encapsulated yeast Cryptococcus neoformans can result in harmless colonization of the airways. meningitis or disseminated disease. Cryptococcal 52 National Antibiotic Guidelines . irritability. and varicella vaccines at 12 months. FUNGAL MENINGITIS • Candida may enter the central nervous system by hematogenous spread. photophobia. hepatomegaly and shock. especially in persons with defective cell-mediated immunity. with decreased level of consciousness. INFLUENZA. CENTRAL NERVOUS SYSTEM INFECTIONS Comments: If methicillin-sensitive S. aureus is documented. V. rubella (MMR). A booster of MMR is given at 4-6 years old. The classic presentation is encephalopathy with diffuse or focal neurologic symptoms. ENTEROVIRUSES. at the time of craniotomy. IV. generalized or focal seizures. stiffness. neck pain. seizure. Manifestations of Candida meningitis may be similar to those of acute bacterial meningitis. initiate with 0. CRYPTOCOCCAL MENINGITIS (NON-AIDS) Preferred Regimen: Induction Phase Consolidation phase Amphotericin B Fluconazole 200mg PO qd deoxycholate 0. confusion.25 mg/kg daily. lethargy. radiographic and clinical abnormalities Comments: BUN. but this drug is not available in the Philippines. CANDIDA MENINGITIS Preferred Regimen: Amphotericin B deoxycholate 0.25 mg/kg over 2-6h. DOT: several weeks until resolution of CSF. and coma. The most common symptoms include headache and altered mental status. creatinine and K+ should be monitored at least weekly. personality changes.1 mg/kg/dose IV to a maximum dose of 1 mg over 20-60 min.6-1 mg/kg/d IV over 2-6h Start with test dose of 0. and increase by 0. obtundation. and death may occur from 2 weeks to several years after symptom onset. If tolerated. CRYPTOCOCCAL MENINGITIS ASSOCIATED WITH HIV/AIDS Preferred Regimen: Induction Phase Consolidation phase Suppression (chronic maintenance therapy) Amphotericin B Fluconazole Fluconazole deoxycholate 0. Removal of shunts is recommended. If CSF pressure >25 cm H20. repeat the lumbar tap to drain fluid and control pressure.7-1 mg/kg/d DOT: 10-12 weeks after CSF culture is IV over 2-6h negative DOT: until patient is afebrile OR (for less severely ill) and cultures are negative Fluconazole (approximately 6 weeks) P: 6-12mg/kg/d qd A: 400mg qd DOT: 10-12 weeks after CSF culture is negative Comments: The ideal regimen includes flucytosine in the induction phase. CENTRAL NERVOUS SYSTEM INFECTIONS meningitis is usually fatal without appropriate therapy.7-1 P: 6-12mg/kg/d IV qd P: 3mg/kg/d IV qd mg/kg/d IV over 2-6h A: 400mg IV or po qd A: 200mg PO qd National Antibiotic Guidelines 53 . UptoDate 2016. • Gilbert DN.16(6): 672-679. Pavia AT. Portegies P.. Sanford Guide to Antimicrobial Therapy 2016 • Kaplan SL.com/contents/infections-of-central- nervous-system-shunts-and-other-devices. Consolidation: Begin after successful induction therapy (defined as substantial clinical improvement and negative CSF culture on repeat tap). Freedman DO. Black DB. 24:1-10. O. Hand book of Pediatric Infectious Diseases 2012.. PIDSP J 2011. Jallo GI. Chambers HF. MMWR 2013. 2013. and E. Fekete T.uptodate. Maramba-Lazarte CC. Accessed from http://www. Etiology of neonatal sepsis in five urban hospitals in the Philippines. Flynn PM. Kennedy PGE. Steiner I for the EFNS Task Force. Focus 2008. • Bravo LC. Seaton RA. 12(2): 75-85. EFNS guideline on the management of community meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. Gatchalian SR.2). Swann. REFERENCES: • Baddour LM.uptodate. Infections of central nervous system shunts and other devices. Martin PM.com/contents/bacterial-meningitis- in-the-neonate-treatment-and-outcome on January 13. Gallardo EE. Kim K. UptoDate 2016. Suppression: May stop once CD4 > 100 cells/μL x at least 3 months and with undetectable viral load. Europ J Neurol 2008. Systematic review: neonatal meningitis in the developing world. • Frazier JL. Bojar M. Bunyi MAC. • Centers for Disease Control and Prevention. Bacterial meningitis in children older than one month: Treatment and prognosis.S. • Edwards MS. • Chaudhuri. A. Ong-Lim AT.uptodate. Accessed from http://www. Pagcatipunan MR. Aguilar CY. • Maramba-Lazarte CC. Schwartz BS editors. 54 National Antibiotic Guidelines . Accessed at: www. 2016. Lobo JJ. 2016. Neurosurg. J. Baker CJ. Bacterial meningitis in the neonate: Treatment and outcome. delos Reyes CA. Lim JG. 15: 649-659. Molyneux. • Furyk. Saag MS. Management of Brain Abscesses in Children. CENTRAL NERVOUS SYSTEM INFECTIONS PLUS Fluconazole DOT: at least 8 weeks DOT: at least 1 year P: 6-12mg/kg/d IV qd A: 800mg IV/PO qd DOT: at least 2 weeks Comments: Induction: Defer ART to allow for 5 weeks of antifungal therapy. UptoDate 2016. Recommendations of the Immunization Practices (ACIP). Manila 2012. 62 (No. Gonzales ML. Trop Med Int Health 2011. Section of Infectious and Tropical Diseases. Ahn ES. 5th edition.com/contents/bacterial-meningitis- in-children-older-than-one-month-treatment-and-prognosis on January 13. 2008. pp 28-30. Repeat lumbar tap daily until signs and symptoms of increased intracranial pressure consistently improve. Prevention and Control of Meningococcal Disease. Eliopoulis GM. Etiology: H. Etiology: Herpes simplex virus1 and 2 Preferred Regimen: PEDIATRICS ADULTS Aciclovir 15 mg/kg q8h x 5-7d Valaciclovir 2g PO q12h x 2 doses DOT: 7d Comments: Treatment is generally not recommended in immunocompetent patients. Manifests as marked cheek swelling with trismus and systemic symptoms. influenzae immunization. DENTAL AND ORAL INFECTIONS I. lymphadenopathy. S. DENTAL AND ORAL INFECTIONS A. Paracetamol may be used as an analgesic. pneumoniae Preferred Regimen: 1st line: 2nd line: Ceftriaxone 50mg/kg IV q24h Amoxicillin-clavulanate 45 mg/kg/d (amoxicillin component) PO div bid DOT: 7-14d Comments: There has been a marked decrease in incidence in areas with universal H. fever. One third would have recurrent lesions and are commonly referred to as cold sores. but aspirin should be avoided to prevent Reye syndrome. This may lead to dehydration in young children and may require hospitalization. and oropharyngeal vesicular eruptions leading to difficulty in eating and drinking. B. Herpes Simplex Virus Gingivostomatitis This usually self-limiting disease may cause significant mouth discomfort. influenzae. National Antibiotic Guidelines 55 . Buccal Cellulitis • Seen in children <5 years old • Usually with a history of a recent upper respiratory tract infection or sinusitis. Oral candidiasis Also called oral thrush. Etiology: S. Fluconazole is preferred for moderate to severe disease. Infections may spread through the tissues causing cellulitis and present with fever. etc. 4mL qid OR Miconazole oral U/ml. AIDS. 4mL qid OR Miconazole oral gel gel 2%. Prevotella sp. apply to affected area qid 2%. mutans.000 Nystatin oral suspension 100. this condition is caused by an overgrowth of Candida. malignancy. apply to affected area qid OR Fluconazole 100-200 mg PO qd DOT: 7-14d Comments: Recurrent infections may be the first signs of HIV infection. ODONTOGENIC INFECTIONS A. radiation. pain and malaise. II. DENTAL AND ORAL INFECTIONS C. immunodeficiency.) or intake of antibiotics Etiology: Candida albicans Preferred Regimen: PEDIATRICS ADULTS Nystatin oral suspension 100. Actinomyces. swollen face.000 U/mL. This may be triggered by any condition which would depress the immune system (diabetes. corticosteroids. Fusobacterium. Dentoalveolar infection or peri-apical abscess Abscesses may form because of extension of microorganisms through the root apex. Poryphoromonas and other Anaerobes Preferred Regimen: 1st line 2nd line PEDIATRICS Ampicillin-sulbactam 200-400 mg Clindamycin 10mg/kg PO q8h IV q6h (ampicillin component) OR Amoxicillin-clavulanate 45 mg/kg/d bid (amoxicillin component) ADULTS Ampicillin-sulbactam 3g IV q6h OR Clindamycin 300mg PO q8h Amoxicillin-clavulanate 875/125mg bid 56 National Antibiotic Guidelines . Radiographic evidence of bone destruction may take 10-14 days to develop. Initial IV therapy is preferred and may step down to oral therapy once with clinical improvement in 3-5 days. lymphadenopathy. Acute gingivitis Rarely requires systemic antimicrobial therapy. C. nutritional deficiency. swelling inferior to the mandible. Acute necrotizing ulcerative gingivitis Signs and symptoms includes foul breath. gingival pain. In patients with rapidly advancing disease. Etiology: Oral anaerobes. or osteomyelitis. dysphagia. Antibiotic treatment is only necessary if any of the following are present: acute onset facial or oral swelling. trismus. Comments: Dental consult is needed because deep periodontal scaling or extraction of the tooth is necessary to eliminate the infected pulp. fever >38.: 250-500mg PO q6-8h PLUS Clindamycin 300mg PO/IV q8h OR Metronidazole 30mg/kg/d in div Amoxicillin-clavulanate 875/125mg doses q6h (Max: 4 g/d) bid DOT: 7-10d. or other infections such as herpes or fungi. DENTAL AND ORAL INFECTIONS DOT: about 7-14d. with or without fever. malaise. if systemic antibiotics are necessary Comments: Acute gingivitis in children may be induced by plaque. B. Spirochetes Preferred Regimen: Chlorhexidine 0. severe pain or HIV infection. Spirochetes Preferred Regimen: Penicillin VK 500mg PO q6h PLUS Metronidazole 500mg PO q8h OR Clindamycin 300mg PO/IV q8h OR Amoxicillin-clavulanate 875/125 mg bid DOT: 10d National Antibiotic Guidelines 57 . Antiseptic rinses are adequate in most cases. or associated with puberty. systemic therapy may be necessary. the gingiva is edematous and ulcerated with a pseudomembrane on the interdental papillae. On examination of the oral cavity. until local inflammation has resolved completely. thick ropy saliva. The condition is not contagious.: 50-75mg/kg/d PO q6-8h Metronidazole 500mg PO q8h OR 12 yrs. Etiology: Oral anaerobes.12% oral rinse PEDIATRICS ADULTS Penicillin Penicillin VK 500mg PO q6h PLUS <12 yrs.3oC. blood dyscrasias. Periodontal abscess This condition manifests as a red. D. Usually found in older adolescents and adults. fluctuant swelling of the gingiva. it can usually be controlled with root debridement and plaque control only. Juvenile periodontitis This condition occurs in otherwise healthy children and is localized to the molar and incisor regions. Capnocytophaga Preferred Regimen: <8y old: >8y old: Metronidazole 50mg/kg/d PO q8h Doxycycline 200mg PO DOT: 7d Comments: Affects children 10-20 years old. which is extremely tender to palpation. Anaerobes Preferred Regimen: 1st line 2nd line PEDIATRICS Amoxicillin-clavulanate 45 mg/kg/d Clindamycin 10mg/kg PO q8h (amoxicillin component) bid ADULTS Amoxicillin-clavulanate 875/125mg bid Clindamycin 150-300mg PO q8h DOT: 7d 58 National Antibiotic Guidelines .12% chlorhexidine.5% hydrogen peroxide or 0. DENTAL AND ORAL INFECTIONS Comments: Also called trench mouth or Vincent’s angina. Antibiotic therapy should be followed within a few days by localized gingival curettage by a dentist and oral rinses with 0. Dental consult is necessary. Etiology: Aggregatibacter (Actinobacillus) actinomycetemcomitans. If condition does not respond to conservative management then antibiotics should be started. Fusiform. E. The abscess is always in communication with a periodontal pocket. Deep gingival pocketing and bone resorption occur and may cause tooth loss in this area. Etiology: Streptococcus mutans. DENTAL AND ORAL INFECTIONS Comments: Dental consult is needed because drainage of loculated pus should be performed. rapidly spreading. Etiology: Prevotella. bilateral cellulitis of the submandibular space which includes the sublingual space and the mylohyoid. Treponema denticola Preferred Regimen: Penicillin VK 500mg q6h OR Amoxicillin 500mg q8h DOT: 7d Comments: Mainstays of treatment include saline gargle. Fusobacterium.000. Typically. infected pulpal tissues should be removed by subgingival scaling and root planing. Actinomyces. this may lead to infection of adjacent soft tissues and fascial spaces. dysphagia. maintenance of good oral hygiene. Antibiotic treatment is only necessary for systemic signs such as fever and lymphadenopathy. symmetric. Ludwig’s Angina It is an aggressive. PLUS 400. or osteomyelitis. stiff neck. mouth pain. G. swelling inferior to the mandible. Prevotella sp. F. Antibiotic treatment is only necessary if any of the following are present: acute onset facial or oral swelling. Pericoronitis Microorganisms and debris may be impacted under the soft tissue overlying the crown of the tooth in a third molar or any erupting permanent teeth.000U/kg/day in 4 div doses PLUS Metronidazole 500mg IV q6-8h or Clindamycin 600mg IV q6-8h National Antibiotic Guidelines 59 . Patient may present with fever. trismus.3oC. lymphadenopathy. Etiology: S. but with tender. Porphyromonas sp. After abscess resolution. mutans. drooling and dysphagia. The infection is life- threatening due to the possibility of asphyxia and aspiration pneumonia. there is no lymphadenopathy. If the natural drainage is blocked. fever >38. Poryphoromonas and other anaerobes Preferred Regimen: PEDIATRICS ADULTS Ampicillin-sulbactam 200-400mg IV Ampicillin-sulbactam 3g IV q6h or q6h (ampicillin component) or Penicillin G 2-4 MU IV q4-6h Penicillin G 250. “woody“induration. pain management and local incision and drainage by a dentist. • Chow AW.com. Hand book of Pediatric Infectious Diseases 2012. Philippines 2016. Bloom A (Eds). Submandibular space infection (Ludwig’s Angina) in UpToDate.. VA: Antimicrobial Therapy.pdf on September 7. Katamreddy V. • Pari A. delos Reyes CA. Parthasarthy H. Freedman DO. If complications arise. Calderwoood SB. Broad spectrum coverage is required for these patients. Bloom A (Eds). Immunocompromised patients may have MRSA or gram- negative infections. Feign and Cherry’s Textbook of Pediatric Infectious Diseases. Antimicrobial Resistance Surveillance Program 2015 Annual Report. Martin JT.) • Chow AW. 7th edition. Black DB. Epidemiology. Calderwoood SB. 2012. Antibiotic treatment is only necessary for systemic signs such as fever and lymphadenopathy. empiric antibiotics. Subbareddy V. Schwartz BS editors. Calderwoood SB. REFERENCES: • Antimicrobial Resistance Surveillance Laboratory. Sanford Guide to Antimicrobial Therapy 2016. • Do DHN. Steinbach WJ. 2014. longer courses may be necessary. pathogenesis and clinical manifestations of odontogenic infections in UpToDate.) • Chow AW. Gatchalian SR. Surgery is necessary only if abscesses are identified by imaging. (Accessed on February 23 2017. Comments: Mainstays of treatment include management of the airway. Kim K. • Simos C. Philadelphia. Chambers HF. UpToDate. Maramba-Lazarte CC. pp 140-155. Waltham. Elsevier. and fever and leukocytosis have disappeared. 77(55): 797-802. Ilango P. Pavia AT. Manila: Section of Infectious and Tropical Diseases. Accessed at http://arsp. Waltham. 2016 • Bravo LC.5-40mg/kg/day IV in 3 div doses or Clindamycin 17-25mg/kg/d PO in 3-4 equally div doses DOT: 2-3 weeks until clear evidence of clinical improvement is present. MA. 60 National Antibiotic Guidelines . diagnosis and treatment of odontogenic infections in UpToDate.8 (10): Ze01–4. Pagcatipunan MR. Kaplan SL. • Gilbert DN. Department of Health. 44:57-78. DENTAL AND ORAL INFECTIONS Metronidazole 22. 2016. Complications. Waltham. Infections of the Oral Cavity. (Accessed on February 23 2017. Gonzales ML. UpToDate. Common Dental Infections in the Primary Care Setting. Volume 1. Otolaryngol Clin N Amer 2011. (Accessed on February 23 2017. UpToDate. Inc. Bloom A (Eds). MA. MA. Gingival diseases in childhood—a review. Harrison GJ. Eliopoulis GM. Journal of clinical and diagnostic research 2014. Am Fam Physician 2008.ph/wp-content/uploads/2016/06/2015-ARSP-annual-report- summary_1. Eusterman VD. • Levi ME. Ong-Lim AT. Oral Infections and Antibiotic Treatment. Hotez PJ. 5th edition. Manila. Cherry JD. Gonzalez BE. Saag MS. 4 12-23 months: Rotavirus: 1. Shigella: 0. 20th edition.6.1.Skin pinch goes back very slowly • Some dehydration (when 2 of the following signs are present) . Rotavirus: 7-17% Etiology of acute diarrheas in developing countries expressed in weighted annual incidence per 100 child years (Nelson’s Textbook of Pediatrics.8 Preferred Regimen: IMCI protocol Neonate up to 2 months: Child 2 months to 5 years: Suspected Ciprofloxacin 30mg/kg/d PO Ciprofloxacin 30 mg/kg/d dysentery: div 2 doses x 3d div 2 doses x 3d Suspected Erythromycin 250mg PO qid cholera: _____ x 3d OR Tetracycline 250mg PO qid x 3d National Antibiotic Guidelines 61 . GASTROINTESTINAL TRACT INFECTIONS I. irritable . Carlos et al 1989): Salmonella: 10-15%. Cryptosporidium: 0. Mainstay of treatment is to give fluids.Sunken eyes .Not able to drink or drinking poorly . thirsty . Classification of dehydration status of children 2 months to 5 years of age (IMCI 2014): • Severe dehydration (when 2 of the following signs are present) . and food. ETEC: 9-15%.Drinks eagerly.5-8.2-3. Vibrio cholera 01: 0.8.5.7-5.4.6-12.Lethargic or unconscious . Enterotoxigenic Escherichia coli (ETEC): 0. 2015): <12 months: Rotavirus: 2.Restless. zinc supplements.1.2-1.7- 3.Skin pinch goes back slowly • No dehydration (when there are not enough signs to classify patient’s status as some or severe) Etiology: Community and hospital-based based studies in children < 5 years (Saniel et al 1982-84. ETEC: 0. ACUTE DIARRHEA AND GASTROENTERITIS A.3-3. Lucero et al 1982-83. Shigella: 0. Acute Diarrhea in Children Acute diarrhea is defined as diarrhea lasting less than 14 days.Sunken eyes .1-10.7-2.5 24-59 months: Rotavirus: 0. Gastroenteritis (infectious diarrhea) In adults MILD DIARRHEA (≤3 unformed stools/day. give ciprofloxacin for 3 days. give antibiotic for cholera. For suspected antibiotic- associated colitis. difficile diarrhea has not been well studied. mild disease does not warrant antibiotic treatment since symptoms resolve within 7-10 days after discontinuing precipitating antibiotics. minimal associated symptomatology) Preferred Regimen: Oral Hydration 62 National Antibiotic Guidelines . Immunization of infants starting at 6 weeks of age with either of 2 available live attenuated rotavirus vaccines is recommended to afford protection against severe rotavirus disease. The monovalent human rotavirus vaccine is given as a 2-dose series and the pentavalent human bovine rotavirus vaccine is given as a 3-dose series. Oral vancomycin is not available locally. Probiotic treatment of children with C. For cases of acute diarrhea with dysentery (blood in the stool). B. GASTROINTESTINAL TRACT INFECTIONS Recommendations of Feigin and Cherry: Indication Preferred Regimen: Suspected antibiotic-associated Metronidazole 30mg/kg/d IV or PO div 4 colitis presenting as severe doses x 10-14d OR disease or with prolonged Vancomycin 40mg/kg/d PO div 4 doses symptoms especially for patients with severe disease Suspected nontyphoidal Ciprofloxacin 30mg/kg/d IV div 2 doses x Salmonella in the setting of 10-14d OR Azithromycin 6mg/kg/d PO qd x severe diarrhea in infants less 5d OR Ceftriaxone 75-100 mg/kg/d IV q24h than 6 months of age. x 14d malnourished and immunocompromised children Campylobacter Azithromycin 10mg/kg/d PO x 3d OR Erythromycin 40mg/kg/d PO div 4 doses x 5d Entamoeba histolytica Metronidazole 35-50mg/kg/d PO div 3 doses x 7-10d Giardia Metronidazole 15mg/kg/d PO div 3 doses x 5-7d Cyclospora Trimethoprim-sulfamethoxazole 10 mg TMP/50mg SMX/kg/d PO div 2 doses x 7- 10d Comments: For children with severe dehydration living in an area with reported cases of cholera. Primary spontaneous bacterial peritonitis (SBP) Characterized by a patient with cirrhosis. coli (25-40%). Cryptosporidium Preferred Regimen: Empiric therapy: Specific therapy: Ciprofloxacin 500mg PO q12h OR Entamoeba histolytica: Levofloxacin 500mg PO q24h x 3–5d Metronidazole 500-750mg PO tid x 7- OR Azithromycin 500mg PO q24h for 10d OR Tinidazole 2g PO qd x 3d 3d (preferred for Campylobacter) Vibrio cholera: OR Cotrimoxazole DS PO bid x 3–5d Doxycycline 300mg x 1 dose OR Tetracycline 500mg qid X 3d OR Cotrimoxazole DS PO bid X 3d Shigella species: Cotrimoxazole DS PO bid X 3d OR Ciprofloxacin 500mg PO bid X 3d C... C. E. Shiga-toxin producing) K. most common). difficile (Toxin positive) E. blood or fecal leukocytes) Etiologies: Bacterial: Shigella sp. GASTROINTESTINAL TRACT INFECTIONS MODERATE DIARRHEA (3 . pneumoniae. especially in patients with severe diarrhea or systemic symptoms. reported National Antibiotic Guidelines 63 . E. coli (enterotoxigenic. histolytica. with or without systemic symptoms) Preferred Regimen: Oral or Parenteral Hydration Comments: Try to make specific diagnosis. Enterococcus sp. Anaerobes. enteroaggregative.4 unformed stools/day. Extended spectrum β-lactamase (ESBL) positive Klebsiella sp. pneumoniae (30-50%. and ≥ 250 neutrophils/μl of ascitic fluid. ascites. C.. Klebsiella pneumoniae A: Enterobacteriaceae. Etiology: P: S. S. jejuni. SEVERE DIARRHEA (≥ 6 unformed stools/day ± fever. fever. tenesmus. Enterococci. Group A Streptococcus. oxytoca (Toxin producer). Salmonella sp. Staphylococci (2-4%). Parasitic: Giardia lamblia. Ceftriaxone may cause bile sludge in patients with jaundice or cirrhosis. Antibiotic Prophylaxis: Indications: 1. Start antimicrobials as soon as possible. GASTROINTESTINAL TRACT INFECTIONS Preferred Regimen: PEDIATRICS ADULTS S.000-300. if life- doses OR Ceftriaxone 100mg/kg/d IV threatening infection) OR div 1-2 doses Ampicillin-sulbactam 3g IV q6h OR If penicillin sensitive S. pneumoniae: 1st line: Cefotaxime 200mg/kg/d IV div 4 or 6 Cefotaxime 2g IV q8h (q4h. pneumoniae: Piperacillin-tazobactam 4. resolution of ascites or 25 mg/dL and/or serum sodium < 130 mEq/L) 64 National Antibiotic Guidelines . Do surgical consult..5g IV q6h aqueous Penicillin G 200. ESBL): Meropenem 1g IV q8h WITHOUT DOT: Unclear.g. coli.5mg/kg/d IV div 3 perhaps longer if documented doses OR Monotherapy with the bacteremia following: Piperacillin tazobactam 300mg/kg/d IV div 3 doses (piperacillin component) or Ampicillin-sulbactam 100-200mg/kg/d div 4 doses (ampicillin component Comments: Perform analysis (check bleeding parameters first). BUN > death. Klebsiella species doses x 10d to 3 weeks WITH or (e. Duration of antibiotic therapy depends on clinical course of the patient. Generally managed medically. Probiotics have no use in the adjunctive treatment. (serum creatinine > 1.5g q8h) OR U/kg/d IV in 6 div doses x 10-14d Ceftriaxone 2g IV q24h OR Gram-negative bacilli: Ertapenem 1g IV q24h Cefotaxime 200mg/kg/d IV div 4 or 6 doses x 10d to 3 weeks OR 2nd line: Ceftriaxone 100mg/kg/d IV div 1-2 If resistant E. Treat at 5 days and Gentamicin 3-7. Prophylaxis of SBP • Low protein ascites (< 15 g/L) Norfloxacin 400mg/d PO OR • Advanced liver failure (Child-Pugh score Ciprofloxacin 500 mg/d PO > 9 points with serum bilirubin > 3 DOP for SBP: mg/dL) and/or renal dysfunction Until liver transplantation.000 (or 4-hour infusion of 4.2 mg/dL. Patients with cirrhosis Variceal or upper GI bleeding Norfloxacin 400mg PO q12h x 7d OR Ceftriaxone 1g IV qd x 7d 2. Gram stain and culture of peritoneal fluid to distinguish primary from secondary peritonitis. Maintain fluid and electrolyte balance. GASTROINTESTINAL TRACT INFECTIONS improvement in liver function • Prior episode of SBP to a compensated state. D. Secondary peritonitis Etiology: Usually polymicrobial consisting of anaerobes and facultative gram- negative bacilli: Bacteroides fragilis group, Peptostreptococcus, E. coli, Klebsiella, P. aeruginosa, Enterococcus Preferred Regimen: Metronidazole 22.5-40mg/kg/d IV div 3 doses PLUS Cefotaxime 200mg/kg/d IV div 4 or 6 doses OR Monotherapy with the following antibiotics: Piperacillin tazobactam 300mg/kg/d IV div 3 doses (piperacillin component) OR Meropenem 30-60mg/kg/d IV div 3 doses DOT: Antibiotics are generally given for 5-10d but the primary basis for duration of antibiotic treatment is the patient’s clinical course. Comments: Patient may require either immediate surgery to control the source of contamination and to remove necrotic tissue, blood and intestinal contents from the peritoneal cavity or a drainage procedure if a limited number of large abscesses can be shown. E. CAPD-associated peritonitis Infectious complication of chronic ambulatory peritoneal dialysis (CAPD) PEDIATRICS: Etiology: Preferred Regimen: Gram-positive organisms, Vancomycin 45-60mg/kg/d IV or coagulase negative intraperitoneal in 3-4 doses PLUS Gentamicin staphylococci, S. aureus (30- 3-7.5mg/kg/d IV div 3 doses 45%), Enterobacteriaceae (20-30%) Ventriculo-peritoneal shunt Vancomycin 45-60mg/kg/d IV or peritonitis: intraperitoneal div 3-4 doses Coagulase-positive/negative PLUS for Gram-negative infections Staphylococci Cefotaxime 200mg/kg/d IV div 4 or 6 doses • Gram-negative bacilli OR Ceftriaxone 100mg/kg/d IV div 1 or 2 doses OR National Antibiotic Guidelines 65 GASTROINTESTINAL TRACT INFECTIONS Ceftazidime 200-300mg/kg/d div 3 doses OR Meropenem 30-60mg/kg/d div 3 doses DOT: generally, 10d but the primary basis for DOT is the patient’s clinical course. ADULTS: Etiology: Preferred Regimen: Gram-positive cocci For Gram-positive cocci: (45%), Vancomycin added to the dialysis fluid. Gram-negative bacilli For Gram-negative bacilli: (15%), Cefepime 2g IV q8–12h OR Mixture (1%), Ceftazidime 3g loading dose intraperitoneal (IP), Fungi (2%), then 1-2g IP q24h or 2g IP q48h OR M. tuberculosis (0.1%) Meropenem 1g IV q8h OR Aztreonam 1–2g IV q6–8h OR Ciprofloxacin 400mg IV q12h OR Amikacin 15–20mg/kg IV q24h Add an antifungal only if yeast seen on Gram stain. Comments: A positive Gram stain will help guide initial therapy. If polymicrobic gram-negative flora is cultured, consider possibility of catheter-induced bowel perforation, and/or concomitant underlying GI pathology (e.g., dead bowel). Infection almost always limited to abdominal cavity; complicating bacteremia is rare. Hence, usually treat by adding drugs to dialysis fluid; if bacteremia documented or likely, treat via IV route. The following are the recommendations based on the Consensus Guidelines for Prevention and Treatment of Catheter-related infections and peritonitis in pediatric patients receiving peritoneal dialysis (2012 update): • Empiric diagnosis of PD-related peritonitis can be made if the effluent WBC count > 100/mm3 and at least 50% of the WBCs are polymorphonuclear leukocytes. Effluent should be centrifuged and sediment should be cultured. • Antibiotics for the treatment of bacterial peritonitis should be administered by the intraperitoneal route. Beta lactam antibiotics should be administered continuously. • Center-specific antibiotic susceptibility patterns should guide selection of empiric antibiotic therapy although the ISPD recommends cefepime as empiric treatment. Refer to a specialist for co-management. Higher cure rate is achieved with VP shunt removal. 66 National Antibiotic Guidelines GASTROINTESTINAL TRACT INFECTIONS F. Hepatitis A Etiology: Hepatitis A virus Preferred Regimen: PEDIATRICS ADULTS No antiviral treatment is No antiviral treatment is recommended. recommended Give supportive measures. Comments: P: Hepatitis A vaccine is given intramuscularly as a 2-dose series at a minimum age of 12 months. A second dose is given at least 6 months from the first dose. A: If within 2 weeks of exposure, Hepatitis A vaccination: • Monovalent Hepatitis A vaccine a. 720 ELISA units/ml IM - 2doses 1 month apart b. 1440 ELISA units/ml IM single dose • Booster dose between 6 & 12 months after initiation of primary course is recommended to ensure long term antibody titers. (Handbook on Adult Immunization for Filipinos, 2012) A single dose of immunoglobulin 0.02 mL/kg IM is protective if administered within 2 weeks of exposure, but is not locally available. Immunoglobulin might be preferred over Hepatitis A vaccination among seronegative individuals with significant underlying liver disease (Sanford Guide to Antimicrobial Therapy, 2016). G. Hepatitis B • Patients with Hepatitis B (HBV) are usually asymptomatic. • When symptomatic, common complaints include: fatigue, nausea, anorexia, myalgias, arthralgias, asthenia, weight loss (except where ascites). • There is poor correlation between symptoms and disease stage or transaminase elevation Etiology: Hepatitis B virus PEDIATRICS Preferred Regimen: Refer to a specialist. Comments: Hepatitis B vaccine is given intramuscularly. The first dose is given at birth or within the first 12 hours of life. The minimum interval between doses is 4 weeks. The final dose is administered not earlier than age 24 weeks. Another dose is needed if the last dose was given at age < 24 weeks. National Antibiotic Guidelines 67 GASTROINTESTINAL TRACT INFECTIONS For preterm infants, if born to HBsAg (-) mothers and medically stable, the first dose of HBV may be given at 30 days of chronological age regardless of weight, and this can be counted as part of the 3 dose primary series. Another dose of HBV is needed for those < 2 kg whose 1st dose was received at birth. For infants born to HBsAg (+) mothers, administer HBV and HBIG (0.5ml) within 12hours of life. HBIG should be administered not later than 7 days of age, if not immediately available. For infants born to mothers with unknown HBsAg status, if birth weight is >2 kg, administer HBV within 12h of birth and determine mother’s HBsAg status as soon as possible. If HBsAg (+), administer HBIG not later than 7 days of age. If with birth weight of <2 kg, administer HBIG in addition to HBV within 12h of life. Referral to a specialist is recommended for management of hepatitis cases. ADULTS Preferred Regimen: Refer to a specialist. The following are key indicators for treatment: HBeAg status, HBV viral load (HBV DNA), elevated liver enzymes (ALT level), cirrhosis. For HBeAg+ patients treatment is typically deferred for 3-6 months to observe spontaneous seroconversion from HBeAg+ to negative. [Sanford] Comments: Vaccination: Recombinant Hepatitis B Vaccine (20μg/mL) IM 3 doses at 0,1,6 months Combined Hepatitis A (720 ELISA units) & B (20 μg/mL recombinant) – 3 doses IM at 0, 1, 6 months (Handbook on Adult Immunization for Filipinos, 2012) H. Hepatitis C • Usually asymptomatic (elevated transaminases). • When symptomatic, common complaints include fatigue, nausea, anorexia, myalgias, arthralgias, asthenia, weight loss (except where ascites). • If symptomatic, usually abates in days to weeks; rarely associated with hepatic failure. • 75-85% of persons with acute infection progress to chronic HCV. Etiology: Preferred Regimen: Hepatitis C virus Specialist referral RECOMMENDED. Comments: No recommended prophylaxis; immune serum globulin not effective. 68 National Antibiotic Guidelines GASTROINTESTINAL TRACT INFECTIONS I. Liver Abscess • Fever, right upper quadrant tenderness • Findings consistent with single or multiple abscesses on abdominal ultrasound or CT PEDIATRICS Etiology: Preferred Regimen: 50% polymicrobial Ampicillin-sulbactam 100-200mg/kg/d IV div 4 S. aureus doses (ampicillin component) (Max: 8g) or Streptococcus sp. Piperacillin-tazobactam 300mg/kg/d IV div 3 E. coli doses (piperacillin component) (Daily adult dose 9- K. pneumoniae, 16 g) or Salmonella Ceftriaxone 100mg/kg/d IV in 1-2 doses (daily Anaerobic organisms adult dose: 2-4 g) (Nelson’s Textbook of PLUS Pedia, 2015) Metronidazole 30-50 mg/kg/d IV div 3 doses (daily In developing countries, adult dose: 0.75-2.25 g) for 2-3 weeks then shift to may consider E. oral to complete 4-6 weeks. histolytica and Toxocara For hepatic abscess secondary to E. histolytica: canis Metronidazole 30-50mg/kg/d IV div 3 doses x 10d FOLLOWED BY Intraluminal amoebicides such as Diloxanide (2nd line agent) to cure luminal infection ADULTS Etiology: Preferred Regimen: Enterobacteriaceae Pending determination of bacterial versus (esp. Klebsiella sp.) amoebic liver abscess: Bacteroides sp. Metronidazole 30-40mg/kg/d div 3 doses IV q8h Enterococcus sp. or 500mg PO q6-8h E. histolytica PLUS Fusobacterium Ceftriaxone 1-2g q24h IV or necrophorum Piperacillin-tazobactam 4.5g IV q4-6h or (Lemierre's) Ciprofloxacin 400mg IV q12h OR 750 mg PO or Levofloxacin 750mg PO/IV q24h or Ertapenem 1g IV q24h If amoeba serology is positive: Metronidazole 750mg IV/PO tid x 10d National Antibiotic Guidelines 69 start on anti-MRSA regimen (refer to section on treatment of MRSA infections). Enterobacter cloacae. Other treatment options when laparoscopic or open cholecystectomy is not feasible include cholecystostomy. Klebsiella. Acinetobacter baumannii (Antibiotic management of complicated intra-abdominal infections in adults: The Asian perspective. Annals of Medicine and Surgery.75mg/kg/d IV div 3 doses x 14- Leptospirosis interrogans. Comments: Laparoscopic cholecystectomy is the most common surgical treatment for acute calculous or acalculous cholecystitis in over 95% of pediatric cases. coli. Ceftriaxone may cause bile sludge in patients with jaundice or cirrhosis. 21d OR Amikacin 15-22. leaking surgical anastomosis. 2014) 70 National Antibiotic Guidelines . Enterococcus). intra-abdominal abscess or other like conditions. ischemic bowel. ruptured diverticula. • Contamination of peritoneal cavity by bowel flora due to bowel perforation. Gallbladder infection Etiology: Preferred Regimen: Acute acalculous Piperacillin tazobactam 300mg/kg/d IV div 3 cholecystitis is uncommon in doses (piperacillin component) OR children and usually caused Ampicillin-sulbactam 100-200mg/kg/d div 4 by an infection secondary to doses (ampicillin component) OR Groups A and B Streptococci. ertapenem (or other carbapenem) are sufficiently active alone and metronidazole may be discontinued. Klebsiella pneumoniae. For anaerobic or mixed infections piperacillin-tazobactam.5mg/kg/d div 3 doses x 14-21d Antibiotic therapy should cover for gut luminal flora (E. • Common pathogens: Escherichia coli. Serological tests for amebiasis should be done on all patients. II. GASTROINTESTINAL TRACT INFECTIONS Comments: If MRSA is suspected. Cefotaxime 200mg/kg/d IV div 4-6 doses Gram-negative bacilli (like WITH or WITHOUT Salmonella) and Gentamicin 3. Pseudomonas aeruginosa. J. COMPLICATED INTRA-ABDOMINAL INFECTIONS • Complicated intra-abdominal infection extends beyond the hollow viscus of origin into the peritoneal space and is associated with either abscess formation or peritonitis. ruptured appendix. Biliary complicated intra-abdominal infections Clinical Setting: Preferred Regimen: Community-acquired acute Cefazolin 1–2g IV q8h OR cholecystitis of mild-to. B. 2010).5g IV q6h cholecystitis of severe 2nd line: Metronidazole 500mg IV q8–12h physiologic disturbance. PLUS Ciprofloxacin 400mg IV q12h or Health care–associated Levofloxacin 750mg IV q24h or biliary infection of any Cefepime 2g IV q8–12h severity (IDSA. CID 2010:50).5g IV q8h or Ceftriaxone 1–2g IV q12–24h or Cefotaxime 1–2g IV q6–8h or Ciprofloxacin 400mg IV q12h or Levofloxacin 750mg IV q24h High risk or severity: 1st line: severe physiologic Piperacillin-tazobactam 4. 2nd line: moderate severity Metronidazole 500mg IV q8–12h PLUS Cefazolin 1–2g IV q8h or Cefuroxime 1. Patients undergoing cholecystectomy for acute cholecystitis should have antimicrobial therapy discontinued within 24 hours unless there is evidence of infection outside the wall of the gallbladder (IDSA Complicated Intra-abdominal Infection Guidelines.5g IV q8h OR moderate severity Ceftriaxone 1–2g IV q12–24h Community-acquired acute 1st line: Piperacillin-tazobactam 4. Cefuroxime 1. Meropenem 1g IV q8h National Antibiotic Guidelines 71 . advanced age. Comments: Obtain surgical consult for possible gallbladder removal.5g IV q6h OR disturbance. PLUS Ciprofloxacin 400mg IV q12h or advanced age. Extra-biliary complicated intra-abdominal infections Etiology: Preferred Regimen: Mild-to-moderate 1st line: severity: perforated or Cefoxitin 2g IV q6h OR abscessed appendicitis and Ertapenem 1g IV q24h other infections of mild-to. GASTROINTESTINAL TRACT INFECTIONS A. or Levofloxacin 750mg IV q24h or immunocompromised state Cefepime 2g IV q8–12h Acute cholangitis following 1st line: Meropenem 1g IV q8h bilio-enteric anastamosis of 2nd line: Metronidazole 500mg IV q8–12h any severity. especially for severe disease is sparse: • Mild or moderate peritonitis: clinical trial found comparable clinical outcomes in patients treated for 4 days vs those treated until vital signs and GI continuity had returned (mean of 8 days). and restore anatomic and physiological function to the extent feasible is recommended for nearly all patients with intra-abdominal infection. CID 2010:50) Duration of therapy is variable and clinical trial data. Longer durations of therapy have not been associated with improved outcome. Staphylococcus epidermidis. control ongoing peritoneal contamination by diversion or resection. (IDSA Complicated Intra-abdominal Infection Guidelines. unless it is difficult to achieve adequate source control. GASTROINTESTINAL TRACT INFECTIONS or immunocompromised 2nd line: state Metronidazole 500mg IV q8–12h PLUS Cefepime 2g IV q8–12h or Ceftazidime 2g IV q8h or Ciprofloxacin 400mg IV q12h or Levofloxacin 750mg IV q24h Comments: Antimicrobial therapy of established infection should be limited to 4–7 days. leukocytosis and ileus. Enterococcus sp. S. • Post-Necrotizing pancreatitis. Normalization of serum procalcitonin concentration may assist in customizing the duration of therapy. Preferred Regimen: 1st line 2nd line Piperacillin-tazobactam 4. C. • Severe peritonitis: need source control and resolution of fever. aureus. Candida sp.. infected pseudocyst or pancreatic abscess Etiology: Enterobacteriaceae. All patients had "source control". Anaerobes.5g IV q4. (Sanford Guide to Antimicrobial Therapy 2016) An appropriate source control procedure to drain infected foci. Ciprofloxacin 400mg IV q12h OR 6h OR Meropenem 1g IV q8h Levofloxacin 750mg IV q24h 72 National Antibiotic Guidelines . Some centers continue antibiotics until the serum procalcitonin serum concentration is <0. rising inflammatory markers or persistent fever may be suspected of having infected pancreatic necrosis and would be candidates for antibiotic therapy. Acute pancreatitis • Patients with necrotizing pancreatitis who develop gas in the area of necrosis.25 mg/ml or has decreased by 90% from its peak concentration. Monzon O. • The Sanford Guide to Antimicrobial Therapy 2016. • Kurup A. Moriles R. Antibiotic management of complicated intra-abdominal infections in adults: The Asian perspective. 20th edition. • Cherry JD. • Solomkin JS. Ang C. 2015. Geme J. • Integrated Management of Childhood Illness Chart Booklet. Perit Dial Int. Feigin and Cherry's Textbook of Pediatric Infectious Diseases. 2015. 2014. Clin Infect Dis. Philipp J Microbiol Infect Dis 1984. St. Mate R. REFERENCES: • Carlos C. but that they should be employed when clinical factors point to infected pancreatic necrosis. • Saniel M. Sanvictores E. Alaniz C. Tupasi T. Leano F. J Hepatol 2014. et al. 2012 Jun. Geronimo J.com/. Trajano E. Salazar N. Harrison GJ. et al. Etiology and epidemiology of diarrheas. Sombrero L. 2010. Those with necrosis involving 30% or more of the pancreas are at greatest risk of developing infection. Manila: Philippine Foundation for Vaccination. Hotez PJ.. Pogue JM. et al. Annals of Medicine and Surgery 3 (2014) 85-91 • Lucero M. GASTROINTESTINAL TRACT INFECTIONS PLUS Metronidazole 500 mg IV q8– 12h Comments: Current consensus is that use of prophylactic antibiotics is not advisable in pancreatitis. Villanueva J. Available at: http://webedition. A position statement based on the EASL Special Conference 2013. 2012.sanfordguide. Stanton B. Philipp J Microbiol Infect Dis 1990. Pennsylvania: Elsevier Inc. Schor N. Philadelphia. Crowley AW. The relative importance of various enteropathogen in the etiology of acute diarrhea: a hospital-based study in urban Philippines. et al. 20th edition. SEAMIC Publication (1987). National Antibiotic Guidelines 73 . Etiology of diarrhea in hospitalized children.19(2): 51-53. • Philippine Foundation for Vaccination and the Philippine Society for Microbiology and Infectious Diseases. Philadelphia: Elsevier Inc. Nelson Textbook of Pediatrics. Retrospective analysis of azithromycin versus fluoroquinolones for the treatment of legionella pneumonia. Mat R. Saniel M. • Cherry J. 2015. • Kliegman RM. Leano F. Philadelphia: Elsevier. et al. Geneva: World Health Organization. Kaplan SL. 7th Edition. • Nagel JL. PT. Balis A. 60:1310-1324. et al. 2016. • Warady BA. 39:204-205. Rarus RE. Feigin and Cherry's Textbook of Pediatric Infectious Diseases.50(2):133-164. Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Saniel M. Forbes Z. 2014. Bacterial infections in cirrhosis. Consensus guidelines for the prevention and treatment of catheter- related infections and peritonitis in pediatric patients receiving peritoneal dialysis: 2012 update. Steinbach WJ. Geronimo J. • Kliegman RM. Trajano B. Nelson’s Textbook of Pediatrics.32 Suppl 2: S32-86. March 2014 • Jalan R. Handbook on Adult Immunization for Filipinos 2012. Philadelphia: Elsevier. and is also called meibomianitis. aureus and S. gauze or face towel over the affected area for 10 to 15 minutes. false eye lashes and eye lash extensions. EXTERNAL HORDEOLUM: S. rosacea. may repeat as often as necessary. including methicillin-sensitive and –resistant strains 74 National Antibiotic Guidelines . Treatment involves patient education about disease chronicity and need for long term commitment to lid hygiene with regular application of warm compresses. aureus Preferred Regimen: No antibiotic Comments: Warm moist compress (40-45 degree Celsius) continuously using cotton. mascara. but may include P: Usually. EXTERNAL EYE INFECTIONS A. aureus. B. OCULAR INFECTIONS I. relief. gentle lid massage and lid washing. Hordeolum (Stye) • External hordeolum: External infection of the superficial sebaceous gland (eyelash follicle) • Internal hordeolum: Infection of the meibomian glands. Antibiotic alone to prevent recurrences for 3 to 6 months. INTERNAL HORDEOLUM: S. benefit epidermidis as well as A: Topical antibiotics may provide symptomatic associated seborrhea. gauze pad. Apply artificial tears if with associated dry eyes. dry eye If associated acne rosacea: Doxycycline 100mg PO bid x 2 weeks and then q24h Comments: Do lid margin care with baby shampoo and warm water q24h using a clean washcloth. topical antibiotic ointment of no S. Blepharitis Etiology: Preferred Regimen: unclear. or cotton swab (50:50 mixture). Avoid eyeliner. Topical antibiotic steroid combination during the acute phase for around 2 to 4 weeks. Orbital Cellulitis in Children Etiology: S. influenzae type B. Gram negative bacilli (post- trauma) Preferred Regimen: 1st line 2nd line Vancomycin 45-60mg/kg/d IV in 4 div Linezolid doses (Max: 4g/d) <12 y: 30 mg/kg/d IV in 3 doses PLUS ≥12 y: 1200 mg/d IV in 2 doses Ceftriaxone 100mg/kg/d IV/IM in 1-2 PLUS doses (Max: 4g/d) Cefotaxime 100-200 mg/kg/d IV If with odontogenic source. Can be acute. Anaerobes (odontogenic source). aeruginosa. hemolytic streptococcus or S. OCULAR INFECTIONS Preferred Regimen: PEDIATRICS ADULTS Cloxacillin 100-150mg/kg/d PO For MSSA: Cloxacillin 250-500mg PO q6h div q6h PLUS hot packs For MRSA. Incision and drainage if with pointing abscess. Eikenella corrodens. Streptococci Grp A B. ADD: in 3-4 doses (Max: 2g/d) Metronidazole 30mg/kg/d IV/PO in 4 div doses (Max: 4g/d) OR Vancomycin 45-60 mg/kg/d IV in 4 div doses (Max: 4g/d) PLUS Piperacillin-Tazobactam 240-300 mg/kg/d IV in 3-4 doses (piperacillin component) (Max: 16g piperacillin/d) National Antibiotic Guidelines 75 . Rarely drain spontaneously and may need Incision and Drainage with culture II. pneumoniae. pyogenes. P. community-associated: Cotrimoxazole 800/160mg PO 2 tabs bid For MRSA. catarrhalis uncommon causes: Aeromonas hydrophila. ORBITAL CELLULITIS A. M. aureus. hospital-acquired: Linezolid 600mg PO bid Comments: Topical antibiotic ointment (erythromycin. H. subacute. S. The decision to use an antibiotic-steroid combination will depend on the judgment call of the physician on the degree of inflammation involved. or chronic. tobramycin) or topical antibiotic- steroid ointment (tobramycin-dexamethasone) 3 to 4 times a day. Incision and curettage for chalazion. proptosis. Antibiotics with MRSA coverage should be promptly started. M. pneumoniae. B. anterior lid swelling. Streptococcus sp. catarrhalis. It is best to obtain specimen for culture and sensitivity testing prior to treatment initiation. For confirmed MSSA. aureus to Oxacillin at 62. limited extra-ocular motion. Stage IV: ophthalmoplegia with visual loss.5g PO qd/800mg IV qd) or Levofloxacin ≥ 6 mos. ARSP 2015 showed increased resistance of S. shift to Oxacillin. Anaerobes (odontogenic source). H.5g IV q8h Vancomycin 1g IV q12h PLUS OR Ciprofloxacin 400mg IV q8-12h Ceftriaxone 1g IV q12h PLUS PLUS Clindamycin 600mg IV q8h Metronidazole 1g IV q12h 76 National Antibiotic Guidelines . CT with proptosis. Invasive Aspergillus sp (severe neutropenia. extraocular muscles involved. Stage II: edema.: 10mg/kg/dose q12h ≥ 5 years:10 mg/kg/dose q24h (Max: 500mg) DOT: 7-14 days depending on clinical response Comments: Orbital cellulitis is serious and potentially life threatening. Mucormycosis (in patients with diabetic ketoacidosis). globe displacement. abscess formation & periosteal rupture. Etiology: S. influenzae. OCULAR INFECTIONS For children with serious allergy to PCN and/or cephalosporins: Vancomycin PLUS Ciprofloxacin 20-30mg/kg/day in 2 div doses (Max: 1. CT normal.6%. (Group A). Gram-negative bacilli (post- trauma). Orbital cellulitis is a serious infection with risk of cavernous sinus thrombosis. chemosis. HIV) Preferred Regimen: Stage 1: Amoxicillin-clavulanate 500mg PO tid x 10-14d Stage II – IV: If MRSA is not considered: If MRSA considered: Piperacillin-Tazobactam 4. Stage III: occasional visual loss. to < 5 yrs. S. Orbital Cellulitis in Adults Stage I: preseptal cellulitis. Surgical consultation is recommended. CT with mucosal swelling but no fluid collection. CT subperiosteal abscess. aureus. aeruginosa. Mild infection limited to lacrimal sac and 4 doses PLUS lid: Cephalexin 500mg PO qid OR Ceftazidime 100mg/kg/d IV div Amoxicillin-clavulanate 875mg PO bid OR 3 Cotrimoxazole 2 DS tablets PO bid doses (if Gram-negative dacryocystitis is entertained). aureus Chronic dacryocystitis: S. S. With signs or symptoms of orbital cellulitis: Vancomycin 15-20mg/kg/d IV q8-12h PLUS Ceftriaxone 2g IV q24h or Cefepime 2g IV q6h if pseudomonal infection is suspected Documented MSSA infection: Oxacillin 2g IV q6h OR Cefazolin 2g IV q8h DOT: 7-14d Comments: Ophthalmologic consultation is needed and surgery may be required to do culture studies (to detect MRSA). S. 4-6 weeks if bone changes are suggestive of osteomyelitis. Etiology: Acute dacryocystitis: Alpha –hemolytic streptococci. Surgical debridement is warranted with abscesses or if medical management fails to lead to an improvement in the first 24-36 hours. P. DACRYOCYSTITIS (LACRIMAL SAC) • Can be acute or chronic • Due to obstruction of the lacrimal duct. For serious allergy to penicillins and/or cephalosporins: Vancomycin 1g IV q12h PLUS Ciprofloxacin 400mg IV q12h OR 500 to 750 mg PO bid OR Levofloxacin 500 to 750 mg IV or PO qd Comments: Close consultation with ophthalmology and /or ENT is required. H. III. OCULAR INFECTIONS (if odontogenic source) Option for MRSA if Vancomycin intolerant: Linezolid 600 mg IV q12h DOT: 10-21 days depending on clinical response. Enterobacteriaceae Preferred Regimen: PEDIATRICS ADULTS Vancomycin 40mg/kg/d IV div 3. Empiric systemic antibiotic therapy is based on Gram National Antibiotic Guidelines 77 . influenzae. S. epidermidis. viridans. pneumoniae. Nocardia sp.5% x 1 application OR tetracycline 1% ointment x 1 application DAYS 2 TO 4: N. Adjust therapy based on culture results. Staphylococci. rarely Arachnia fusobacterium. Streptococci. Conjunctivitis of the Newborn by day of onset post-delivery 1ST DAY POST-DELIVERY: CHEMICAL DUE TO SILVER NITRATE PROPHYLAXIS Preferred Regimen: No antibiotic Comments: Chemical prophylaxis is rare since usual prophylaxis involves use of erythromycin ointment 0. Ophthalmologic consult is advised. Irrigate conjunctiva with saline to remove discharge as often as needed. Topical Gentamicin. Referral to ophthalmologist for removal of granules and local irrigation with an antibiotic solution. presence and type of complications.. Treat neonate for concomitant Chlamydia trachomatis infection. Treat the mother and sexual partner. severity of the infection. OCULAR INFECTIONS stain of the aspirate. CONJUNCTIVITIS A. IV. gonorrhoeae Preferred Regimen: Ceftriaxone 25-50mg/kg IV x 1 dose not to exceed 125mg. Candida sp. Treat the mother and sexual partners. Canaliculitis (Lacrimal apparatus) Etiology: Actinomyces. A.5mg/kg q6h x 14d 2nd line: Azithromycin 20mg/kg PO q24h x 3d Comments: Diagnosed by antigen detection. Oral agents may be used for less severe cases. DAYS 3-10: Chlamydia trachomatis Preferred Regimen: 1st line: Erythromycin base or ethylsuccinate syrup 12. age of the child. No topical treatment is needed. (all rare) Comments: Apply hot packs to punctal area qid. Hospitalization may be considered in cases of suppurative bacterial infection with associated lacrimal gland abscess. 78 National Antibiotic Guidelines . Ciprofloxacin 6-8x/d Comments: Hyperpurulent discharge is observed. Topical treatment is inadequate. 2 Preferred Regimen: Aciclovir 60mg/kg/d IV div q8h x 14d Comments: Topical anti-viral therapy under the direction of an ophthalmologist B. topical antibiotic-steroid is given to those with severe symptoms. If symptomatic. Comments: Highly contagious. It is the preferred agent in contact lens wearers. Erythromycin OR Fusidic acid 1 drop tid . qid x 5-7d Comments: Ointment is preferred over drops for children. marked swelling and with membrane formation which can lead to permanent conjunctival scarring (these are cases that have to be referred). OCULAR INFECTIONS DAYS 2-16: Herpes simplex types 1. C. Eye drops: Levofloxacin OR Tobramycin OR pneumoniae. Cold moist compresses as often as needed.qid x 5- S. membranes or epithelial defects. Remove discharge by irrigation with saline. Gonococcal Conjunctivitis Etiology: Preferred Regimen: N. D. If with ocular pain and photophobia. gonorrhoeae A: Ceftriaxone 1g IV/IM x 1 dose PLUS Azithromycin 1g PO x 1 dose for presumptive Chlamydia co-infection PLUS National Antibiotic Guidelines 79 . ointments blur vision for 20 minutes after the dose is administered. viridans. suspect keratitis (rare). However. S. Eye drops: Tobramycin OR Levofloxacin 2 drops Moraxella sp. and those in whom it is difficult to administer eye medications. 7d H. artificial tears may help. influenzae. Viral Conjunctivitis (Pink eye) Etiology: Adenovirus 3 & 7 in children Preferred Regimen: No antibiotic Consider short course topical antibiotic-steroid drops one to two drops every 3 to 4 hours for 7 to 14 days in cases with severe inflammation. Bacterial (non-gonococcal) conjunctivitis Etiology: Preferred Regimen: S. Although adenoviral conjunctivitis is self-limiting. aureus. Fluoroquinolones offer the best spectrum of activity for empiric therapy. those with poor compliance. pneumoniae. Acute bacterial keratitis (no comorbidity) Etiology: Preferred Regimen: S. KERATITIS A. Erythromycin ointment qid x 2-3 weeks or until infection) resolution of symptoms. OCULAR INFECTIONS Chlamydia trachomatis Topical Levofloxacin or Tobramycin or (presumptive co. 5x/d until corneal ulcer heals. 1-2 drops q4h 80 National Antibiotic Guidelines . Varicella zoster opthalmicus Etiology: Varicella zoster virus Preferred Regimen: P: Aciclovir 10mg/kg IV (most effective within 72h from appearance of vesicles) A: Famciclovir 500mg PO tid OR Valaciclovir 1g PO tid OR Aciclovir 800mg PO 5x/d x 10d Apply tobramycin-dexamethasone ointment 2 to 3 times a day to lesions on the eyelids until resolution of lid lesions. Test patient for HIV and syphilis. Herpes Keratitis Etiology: Preferred Regimen: Herpes simplex 1 P and A: and 2 Ganciclovir 0.. and adjunctive therapy. Comments: Ophthalmology consult recommended because it can progress to corneal perforation. C. V. Irrigate conjunctiva with saline to remove discharge as often as needed. Aciclovir 400 mg bid for 12 months may be given to prevent recurrences. Haemophilus sp. 30% recur within 1y. Oral antiviral drugs are not necessary. antimicrobial. then tid x 7d Comments: Serious and often sight threatening so prompt ophthalmologic consultation is essential for diagnosis. S. B.15% or Aciclovir 3% ophthalmic ointment. P: Gram-negative: Tobramycin eye drops S. Treat sex partner. For those aged 12y and older with recurrent infections (>2x a year). aureus. pyogenes. 3% solution Give 1 drop qh x 24-72h then taper based on clinical response Comments: Referral to ophthalmologist is recommended. NEVER patch the eye. Topical steroids are never used in isolation. S. aeruginosa Preferred Regimen: PEDIATRICS ADULTS Tobramycin 0.5% eye aeruginosa. S.3% ophthalmic Ciprofloxacin 0. S. Listeria sp. Comments: Obtain specimen for Gram stain and culture studies and adjust treatment accordingly. E. It is important to try to identify organism from corneal scrapings. Consider systemic antibiotic for large (>6 mm) corneal ulcer. Bacterial keratitis secondary to contact lens use Etiology: P. Enterobacteriaceae. Fungal keratitis Etiology: Preferred Regimen: Aspergillus. NEVER patch the eye. Empiric therapy is not recommended for fungal keratitis. NEVER give topical steroid. OCULAR INFECTIONS Also for children: P. Moraxella spp.5% eye drops Dry cornea / diabetes. Daily National Antibiotic Guidelines 81 . corneal perforation or scleritis due to Pseudomonas aeruginosa and other Gram-negative enteric bacteria. epidermidis. Tobramycin 0. Bacterial keratitis can be a vision-threatening disease: prompt consultation with an ophthalmologist is essential. drops A: Gram-positive: Levofloxacin 0. Candida Refer to ophthalmologist Comments: Obtain specimen for fungal wet mount and cultures. pneumoniae.3% eye drops OR solution 1-2 drops qh x 24h then taper Levofloxacin 0. Discontinue contact lens use.5% eye drops OR based on clinical response. aureus. D. Refer to ophthalmologist immunosuppression: S. Gram-positive: Levofloxacin 0. Fusarium. pyogenes. Hematogenous Etiology: S. wires) Preferred Regimen: Refer to ophthalmologist Comments: Intravitreal administration of antimicrobials is essential. OCULAR INFECTIONS debridement is advised to enhance penetration of anti-fungal agents. Protozoan Etiology: Preferred Regimen: Acanthamoeba sp. massiliense Comments: Ophthalmologic consultation recommended. Keratitis. Refer to ophthalmologist M. pneumoniae or other streptococci. Discontinue contact lens use. BBQ stick. N.g. S. NEVER patch the eye. Treatment regimen is as for extrapulmonary tuberculosis (see National Antibiotic Guidelines on Tuberculosis). G. aureus. (rare). Prolonged course of therapy. Topical cycloplegic (atropine sulfate 1%) one drop 3 times a day until free of pain. Immediate referral to vitreo-retinal surgeon. Avoid topical and subconjunctival steroids. Refer to ophthalmologist Comments: Corneal infection usually associated with trauma or soft contact lens use. walis tingting. Topical broad-spectrum antibiotics to prevent secondary bacterial infection. 82 National Antibiotic Guidelines . pnemoniae or other gram-negative organisms. meningitidis. F. Candida sp. abscessus. Keratitis. Topical cycloplegic (atropine sulfate 1%) one drop 3 times a day until free of pain. Non-tuberculous Mycobacterial (Post-Lasik surgery) Etiology: Preferred Regimen: Mycobacterium chelonae. M. K. Bacillus cereus (heroin use) (locally usually due to penetrating or perforating globe injury by pointed material e. ENDOPHTHALMITIS A. VI. Endophthalmitis. OCULAR INFECTIONS B. Endophthalmitis, Post-cataract surgery Etiology: Early, acute: S. epidermidis, S. aureus, Streptococcus sp., Enterococcus sp., Gram- negative bacilli, Candida albicans Low grade, chronic: Propionibacterium acnes, S. epidermidis, S. aureus (rare), Fungi Preferred Regimen: Refer to ophthalmologist Comments: Immediate ophthalmologic consult is needed. If only light perception or worse, perform immediate vitrectomy. May require removal of lens material. C. Endophthalmitis, Candida • Endogenous: occurs in ~15% of patients with candidemia • Exogenous: occurs following ocular surgery or traumatic injury. Etiology: Preferred Regimen: Candida sp. Chorioretinitis without Fluconazole 800mg PO (12 mg/kg) vitritis loading dose, then 400-800mg (6- 12 mg/kg For fluconazole- qd) OR Voriconazole 400mg IV bid for 2 /voriconazole-susceptible doses loading dose (6 mg/kg), then 300 mg isolates (4 mg/kg) IV/PO bid For fluconazole- Refer to ophthalmologist /voriconazole-resistant isolates With macular involvement Refer to ophthalmologist Chorioretinitis with vitritis Refer to ophthalmologist (Endophthalmitis) Comments: The extent of ocular infection (chorioretinitis with or without macular involvement and with or without vitritis) should be determined by an ophthalmologist. For fluconazole–susceptible isolates, fluconazole is preferred over voriconazole. Vitrectomy should be considered to decrease the burden of organisms and to allow the removal of fungal abscesses that are inaccessible to systemic antifungal agents. National Antibiotic Guidelines 83 OCULAR INFECTIONS D. Endophthalmitis, Post-traumatic Etiology: Bacillus sp., S. epidermis, Gram-negative bacilli, Streptococci, Fungi Preferred Regimen: Refer to ophthalmologist Comments: Vitrectomy often necessary. Consider prophylactic administration of systemic + intravitreal antibiotics in high risk injuries (soil contamination, >24h delay in wound closure, intraocular foreign body). VII. RETINITIS A. Acute Retinal Necrosis • Vision loss, usually in immunocompetent individuals, which progresses rapidly with retinal necrosis, vasculitis and uveitis; frequently results in retinal detachment. • Begins unilaterally but may involve the other eye (up to 50% of cases). Etiology: Varicella-zoster virus, Herpes simplex Preferred Regimen: Aciclovir 10–12mg/kg IV q8h x 7–10d until disease stabilizes, then oral therapy for a min of 6 weeks with: Aciclovir 800mg PO 5x/d OR Valaciclovir 1g PO tid OR Famciclovir 500mg PO tid Comments: Ophthalmology consult imperative. B. Retinitis, Cytomegalovirus (HIV/AIDS) Etiology: Cytomegalovirus (CMV) Preferred Regimen: Refer to ophthalmologist Comments: Watch for Immune Reconstitution Inflammatory Syndrome (IRIS) (e.g., Immune Recovery Uveitis) in those on anti-retroviral therapy (ART). ART should not be delayed owing to concern of IRIS. 84 National Antibiotic Guidelines OCULAR INFECTIONS REFERENCES: • Antibiotic Guidelines 2015-2016. Treatment Recommendations for Adult Inpatients. Available at: http://www.hopkinsmedicine.org/amp/guidelines/antibiotic_guidelines.pdf • Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. Available at: http://aidsinfo.nih.gov/guidelines. • Liu C, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin-Resistant Staphylococcus Aureus Infections in Adults and Children. Clin Infect Dis 2011: 52;1–38. • Pappas P, et al. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016;62(4): e1–50. • The Sanford Guide to Antimicrobial Therapy 2014. Available at: http://webedition.sanfordguide.com/. National Antibiotic Guidelines 85 UPPER RESPIRATORY TRACT INFECTION I. PHARYNGITIS OR TONSILLITIS A. Exudative or diffuse erythematous • Associated cough, rhinorrhea, hoarseness and/or oral ulcers suggest a viral etiology • The Rapid Strep Test may be used to diagnose Group A Streptococcus (GAS) pharyngitis. • Complications of GAS pharyngitis include: o Acute rheumatic fever (ARF) – follows Group A S. pyogenes infection, and is rare after Group C/G infection. The rationale for therapy is to eradicate GAS and prevent ARF. Benzathine penicillin G decreases the rate of ARF from 2.8% to 0.2% in trials. For prevention, start treatment within 9 days of symptom onset. o Post-streptococcal glomerulonephritis in children < 7 years old o Pediatric autoimmune neuropsychiatric disorder associated with Group A Streptococcus infection, or PANDAS o Peritonsillar abscess and suppurative phlebitis are also potential complications. Etiology: Group A, C, G; streptococci; Fusobacterium (in studies) Preferred Regimen: 1st line PEDIATRICS ADULTS Phenoxymethylpenicillin or Penicillin Phenoxymethylpenicillin or Penicillin V 25-50mg/kg/d PO q6h x 10d OR V 500mg q12h or 250mg PO q6h x 10d Amoxicillin trihydrate 50mg/kg/d PO OR q8-12h (Max: 1g/d) x 10d Benzathine Penicillin G 1.2MU IM x 1dose 2nd line PEDIATRICS ADULTS Amoxicillin trihydrate 50mg/kg/d PO Amoxicillin trihydrate 500mg PO q8-12h (Max: 1g/d) x 10d q12h x 10d For penicillin allergy: The primary For penicillin allergy: The primary choice is a macrolide, such as: choice is a macrolide, such as: Erythromycin ethylsuccinate 40 Erythromycin ethylsuccinate 400mg mg/kg/d PO q6h (Max: 1g/d) x 10d OR PO q6-12h x 10d OR Clarithromycin 15mg/kg/d PO div Clarithromycin 250mg PO q12h x 10d q12h x 10d OR OR Azithromycin 500mg x 1 dose and Azithromycin 12 mg/kg PO qd x 5d then 250mg PO qd x 4d or 500mg PO qd x 3d 86 National Antibiotic Guidelines UPPER RESPIRATORY TRACT INFECTION Alternative to the macrolides for Alternative to the macrolides for severe penicillin allergy: severe penicillin allergy: Clindamycin 20-30mg/kg/d PO q8h Clindamycin 300-450mg PO q6-8h x (Max: 1.8g/d) x 10d 10d Comments: Penicillin V should be given on an empty stomach because its absorption is impaired by food. Take 1 hour before or 2 hours after a meal. In throat infections caused by Epstein Barr virus (infectious mononucleosis), Amoxicillin or ampicillin produces a non-allergic maculopapular rash, which does not preclude the future use of penicillins. Cotrimoxazole, tetracyclines and fluoroquinolones are not effective. Resistance of S. pyogenes to macrolides has been reported. ALERT! Co- amoxiclav is not recommended. B. Recurrent pharyngitis • True Group A Streptococci (GAS) infection is difficult to distinguish from GAS carriage with repeated viral pharyngitis. • Tonsillectomy is not recommended to decrease streptococcal infection. Etiology: Group A streptococci Preferred Regimen: 1st line PEDIATRICS ADULTS Phenoxymethylpenicillin or Penicillin Phenoxymethylpenicillin or V 25-50mg/kg/d PO q6h x 10d OR Penicillin V 500mg q12h or 250mg Amoxicillin trihydrate 50mg/kg/d PO PO q6h x 10d OR q8-12h (Max: 1g/d) x 10d Amoxicillin trihydrate 500mg PO q12h x 10d 2nd line PEDIATRICS ADULTS Cefuroxime axetil 20mg/kg/d PO div Cefuroxime axetil 500mg-1g/d PO q12h x 10d OR q12h x 10d OR Co-amoxiclav Co-amoxiclav 500mg/125mg PO <40kg: 25-45mg/kg/d PO div q8h q12h x 10d (amoxicillin component) x 10d; >40kg: 500mg PO q12h or 250mg PO q8h. For more severe infections, may increase dose to 500mg PO q8h. National Antibiotic Guidelines 87 antibiotic options include cephalosporins. 70mL) Comments: GAS is able to enter the epithelial cells. there is varied expert opinion on which therapy is most appropriate. and internalization is associated with the presence of certain fibronectin-binding proteins. Co-amoxiclav. C. component) 400mg amoxicillin/ x 10d 57mg potassium clavulanate/5mL (30mL. Because penicillin does not effectively penetrate epithelial cells. Group A streptococci (33%).Ceftriaxone 2g IV q24h PLUS 24h PLUS Metronidazole 30mg/kg/d Metronidazole 500mg IV/PO q6-8h (Max: 4 g/d) IV q6h 88 National Antibiotic Guidelines . macrolides including azalides (azithromycin). Group C/G Streptococci (9%).5g /d PO q8h (amoxicillin component) x 10d 2nd line PEDIATRICS ADULTS Ceftriaxone 50-75mg/kg/d IV q12. and clindamycin.5mg potassium div q12h clavulanate/5mL (amoxicillin (70mL). However. Streptococcus anginosus group Preferred Regimen: 1st line PEDIATRICS ADULTS Ampicillin-sulbactam 100mg/kg/d Ampicillin-Sulbactam 6-12g/d IV/IM IV/IM q6h (ampicillin component) q6h (ampicillin component) (Max: 4g Step down to: Co-amoxiclav sulbactam/d) 40mg/kg/d PO q8h (amoxicillin Step down to: Co-amoxiclav 750mg- component) x 10d 1. In cases of persistent pharyngitis. Peritonsillar abscess (Quinsy) • Sometimes a serious complication of exudative pharyngitis • Surgical drainage is required in treatment. Etiology: Fusobacterium necrophorum (44%). this internalization may contribute to persistence despite antibiotic therapy. UPPER RESPIRATORY TRACT INFECTION For 3 months and older: Dosing PNF preparations Regimen 15-45 200mg amoxicillin/ mg/kg/d PO 28. Preferred Regimen: 1st line PEDIATRICS ADULTS Ampicillin-sulbactam 100mg /kg/d Ampicillin-sulbactam 6-12g (Max: 4 IV/IM q6h (ampicillin component) g/d) IV/IM q6h (ampicillin Step down to: Co-amoxiclav component) 40mg/kg/d PO q8h (amoxicillin Step down to: Co-amoxiclav 750mg - component) OR Cefuroxime Na 100. There are some reports of beta lactamase production by oral anaerobes.1.5g/d PO q8h (amoxicillin 150mg/kg/d IV q8h component) OR Cefuroxime Na 750mg IV q8h Step down to: Cefuroxime axetil 20- 30mg/kg/d PO q12h PLUS Step down to: Cefuroxime axetil Metronidazole 30mg/kg/d (Max: 500mg PO bid PLUS Metronidazole 4g/d) IV q6h x at least 7d 500mg q8h IV x at least 7d Step down to: Metronidazole 30.Step down to: Metronidazole 500mg 50mg/kg/d PO q8h PO q8h x at least 7d 2nd line PEDIATRICS ADULTS Ceftriaxone 50-75mg/kg/d IV q12. Etiology: Polymicrobial. Streptococcus spp. current hospitalization for 5 days or more.Ceftriaxone 2g IV q24h x 10-14d PLUS 24h x 7d PLUS Metronidazole Metronidazole 500mg IV q8h x at 30mg/kg/d (Max: 4g/d) IV q6h x at least 7d least 7d Comments: If methicillin-resistant S. Bacteroides spp. S. immunosuppressive disease National Antibiotic Guidelines 89 . aureus (MRSA) is suspected (antibiotic therapy in the preceding 90-day. presence of risk factors for healthcare-associated pneumonia. D. aureus. high frequency of antibiotic resistance in the community or in the specific hospital unit. Deep Neck Abscess/ Retropharyngeal Abscess • Surgical drainage is required in treatment. UPPER RESPIRATORY TRACT INFECTION For penicillin allergy: For penicillin allergy: Clindamycin 40mg/kg/d IV q6-8h Clindamycin 600-900mg IV q6-8h Comments: Fusobacterium is resistant to macrolides and are best avoided (not recommended).. It is given at a dose of 0.5 mL IM. • Supportive treatment is critical in management. • Obtain nasal and pharyngeal cultures (special media. cellulitis. Clindamycin or vancomycin is recommended. Community-acquired MRSA have been reported in children without identified risk factors. UPPER RESPIRATORY TRACT INFECTION and/or therapy. Vaccine containing diphtheria toxoid is available in combination with tetanus and pertussis. pseudotuberculosis (animal to human. ulcerans and C. diphtheriae.000 U/kg 150. 14 weeks. Step down should be guided by culture. • Persons recovering from diphtheria should begin or complete active immunization. 12 months (provided there is a minimum interval of 6 months from dose 3) and 4-6 years before school entry. • Culture contacts and treat accordingly. • Ensure adequate airway.000 to Penicillin G crystalline 50. or stay in an intensive care unit). recent or prolonged hospitalization. Routine pediatric immunization should include 5 doses given on ages 6 weeks.000 U/kg/d Step down to: (Max: 1. diphtheriae (human to human). Antibiotics are not the mainstay of treatment. exposure to antibiotics.000 to 50. C. • Patients should be placed in isolation. 10 weeks.000 U/kg/d IV q6h or procaine (Max: 1. and recurrent skin infections. Membranous pharyngitis due to diphtheria • Intensive surveillance and immediate notification to the Department of Health is necessary. E. • Observe standard and droplet precautions (respiratory droplet isolation) for patients and carriers until 2 cultures from both the nose and throat collected 24 hours after completing antibiotics are negative for C. rare) Preferred Regimen: 1st line PEDIATRICS ADULTS Penicillin G crystalline 100.2 MU) IM q12h Phenoxymethylpenicillin 250mg PO Step down to: q6h x 14d Phenoxymethylpenicillin 25- 50mg/kg/d PO q6h x 14d 90 National Antibiotic Guidelines . including subcutaneous abscesses. These cases have a predominance of superficial infections.) Etiology: C. Perform cardiac assessment. • Administer diphtheria toxoid before discharge.2 MU) IV q12h penicillin 25. o Mild or possibly absent: Systemic findings. Vesicular. Penicillin is superior to erythromycin. B1-5 Echo viruses (multiple types).000 U IM x 1 dose Weight >30 kg: benzathine penicillin G 1. palatal petechiae. pharyngeal erythema. Eradication of the organism should be documented 24 hours after completing treatment by 2 consecutive negative cultures from pharyngeal specimens taken 24 hours apart. If follow-up cultures are positive. ulcerative stomatitis.PO q6h x 7-10d 50mg/kg/d (Max: 2g/d) PO q6h x 14d Comments: Antibiotics decrease toxin production. Treatment of carrier state: Weight < 30 kg: benzathine penicillin G 600. cough. Enterovirus 71. 2 Preferred Regimen: For HSV 1 and 2 in immunocompromised host: P: Aciclovir Infants and children < 12y: 10mg/kg q8h x 7-14d as 1-3h IV infusion > 12y: 5 mg/kg q8h x 7-14d as 1-3h IV infusion OR Valaciclovir 12y: 4g/d q12h x 1d A: Aciclovir 400mg PO 5x/d x 5d OR Valaciclovir 500mg bid x 7d Recurrent herpes labialis: P: Valaciclovir Children > 12 y: 4g/d q12h x 1d A: Valaciclovir 500mg bid x 7d National Antibiotic Guidelines 91 . difficulty swallowing. exudates. Herpes simplex virus (HSV) 1.2 million U or oral erythromycin 40 to 50 mg/kg/d F. ulcerative pharyngitis (viral) • More common in patients aged < 3 years • Associated signs and symptoms: o Consistently present: Hoarseness. conjunctivitis. o NO tender cervical lymph nodes Etiology: Coxsackie A9. UPPER RESPIRATORY TRACT INFECTION 2nd line PEDIATRICS ADULTS Erythromycin 40-50mg/kg/d (Max: Erythromycin 500mg qid x 14d 2g/d) IV q6h Step down to: Step down to: Erythromycin ethylsuccinate 500mg Erythromycin ethylsuccinate 40. erythromycin should be given for an additional 10 days. sore throat. decrease spread of organisms. colds. II. 92 National Antibiotic Guidelines . Perform surgical drainage..5g IV q6h or 1g IV q12h. cefpodoxime and cefuroxime are not effective for pharyngeal gonococcal infections. UPPER RESPIRATORY TRACT INFECTION Comments: For vesicular pharyngitis suspected to be caused by coxsackie A9. including: Streptococcus sp. Anaerobes (which outnumber aerobes 10:1) Preferred Regimen: 1st line PEDIATRICS ADULTS Ampicillin-sulbactam 100mg/kg/d Clindamycin 600-900mg IV q8h or q6h IV/IM (ampicillin component) Penicillin G 24 MU/d by continuous Step down to: infusion or div q4-6h IV PLUS Co-amoxiclav 40mg/kg/d PO div q8h Metronidazole 1g loading dose THEN x 10d 0. gonorrhoeae Preferred Regimen: P: Ceftriaxone <45 kg: 125mg IM x 1 dose. toothpicks. or foreign bodies (e. • Complications include infection of the carotid (with possible rupture) and jugular vein phlebitis Etiology: Polymicrobial. For mild infections in immunocompetent host. • Perform MRI or CT scan to identify the abscess.g. PERITONSILLAR ABSCESS • May be due to poor dental hygiene. PARAPHARYNGEAL SPACE INFECTION. supportive therapy is recommended. Supportive therapy is recommended. G. echo viruses and enterovirus. fish bones) • Closely monitor the airway. cefixime. >45 kg: 250mg IM x 1 dose A: Ceftriaxone 250mg IM x 1 dose Comments: Spectinomycin. dental extractions. antiviral therapy is not needed. Gonococcal pharyngitis Etiology: N. a third of patients require intubation. B1-5. ACUTE EPIGLOTTITIS • Requires urgent hospitalization. Etiology: Fusobacterium necrophorum in vast majority. 1-2 months apart. JUGULAR VEIN SUPPURATIVE PHLEBITIS (LEMIERRE’S SYNDROME) • Pulmonary and systemic emboli are common. treat empirically for methicillin- resistant Staphylococcus aureus using vancomycin. 1-2 months apart. o If given between 6 weeks to 6 months: Primary series of 3 doses.Ampicillin-sulbactam 3g IV q6h OR 24h PLUS Piperacillin-tazobactam 4. Note: If not a complication of pharyngitis. and if there is an internal jugular line. Preferred Regimen (A): 1st line: Piperacillin-tazobactam 4. • Erosion into the carotid artery can occur. III. Lemierre described Fusobacterium in 1936. • Have tracheostomy set “at bedside. influenzae Type b immunization is recommended. Ceftriaxone 1g IV q24h PLUS Metronidazole 500mg IV q8h x at least 7d Comments: Clindamycin may be used in pediatric patients with penicillin allergy.5g IV q6h Metronidazole 30mg/kg/d (Max: 4 or 4h infusion of 3. UPPER RESPIRATORY TRACT INFECTION 2nd line PEDIATRICS ADULTS Ceftriaxone 50-75mg/kg/d IV q12. e.” • Use of steroids is controversial and not recommended. May present with life-threatening upper airway obstruction. given IM at a minimum age of 6 weeks with a minimum interval of 4 weeks in between doses.. National Antibiotic Guidelines 93 . • H. Booster dose at 12-15 months. Booster dose at 18 months o If given between 12-59 months.g. give only 1 dose. other anaerobes and Gram (+) cocci are less common etiologies of suppurative phlebitis postpharyngitis.375g q8h OR g/d) IV/PO q6h 2nd or 3rd generation cephalosporins. o If given between 7-11 months: Primary series of 2 doses.5g IV q8h OR Metronidazole 500mg PO/IV q8h PLUS Ceftriaxone 2g IV qd 2nd line: Clindamycin 600-900mg IV q8h Comments: Avoid macrolides: fusobacterium resistance. IV. especially in pediatrics. M. S. pneumonia. H. RHINOSINUSITIS A. V.9mg OR allergy (adult): Cefuroxime 30mg/kg/d div q12h x Type 1: Doxycycline 100mg q12h PO min 10d x 5-7d For patients with severe penicillin Type 2: Cefuroxime 500mg bid x 5-7d allergy (pediatric): Type 1: Clarithromycin 15mg/kg/d div q12h 94 National Antibiotic Guidelines . influenzae.: 30mg/kg/d div q12h high dose Amoxicillin 1g po tid OR ≥3 mos. Acute bacterial rhinosinusitis (ABRS) Etiology: S. use the following formulations: 200/28. aureus. Avoid in patients with history of QT prolongation or with drugs that prolong QT interval. UPPER RESPIRATORY TRACT INFECTION Etiology: H. Tendon rupture can occur during or after therapy.: 20-40mg/kg/d div q8h or Co-amoxiclav 875mg/125mg PO 25-45mg/kg/d div q12h q12h x 5-7d For bid dosing.5mg or 400/57mg 2nd line PEDIATRICS ADULTS Co-amoxiclav Doxycycline 100mg bid x 5-7d ≥3 mos. Anaerobic bacteria. AND <40 kg: 90 mg/kg/d For patients with severe penicillin q12h using 600/42. S. pneumoniae Preferred Regimen: P: 1st line: Ceftriaxone 50-100 mg/kg/d q12-24h IV x 7-10d 2nd line: Ampicillin-Sulbactam 100 mg/kg/d q6h IV x 10d A: 1st line: Ceftriaxone 2g q24h IV infusion x 7-10d 2nd line: Levofloxacin 750mg IV q24h PLUS Clindamycin 600-900mg q6-8h IV x 7-10d Comments: Levofloxacin is generally not recommended in patients < 18y. catarrhalis. influenzae Type b. Some other streptococcal species Preferred Regimen: 1st line PEDIATRICS ADULTS Co-amoxiclav x 10-14d Co-amoxiclav x 10-14d 1-3 mos. Some other streptococcal species. M. catarrhalis if used empirically. influenzae and M. B. deferoxamine therapy – adults only Early diagnosis is key to treatment success. • Rapidly fatal without treatment. Symptoms suggestive of fungal sinusitis (or lateral facial pain or numbness) should increase suspicion. it makes up for this with the added coverage against anaerobic bacteria. influenzae. Acute sinusitis (clinical failure after 3 days) in adults Etiology: S. 2) still symptomatic after 10 days with no antibiotic. catarrhalis. Anaerobic bacteria. Palatal ulcers and/or black eschars and unilateral blindness in immunocompromised or diabetic patients suggests mucor. The same holds true for clindamycin. H. Avoid Trimethoprim-sulfamethoxazole because of increasing resistance. • Diagnosis is by stain of tissue culture isolates. These considerations should be taken into account when prescribing these antibiotics. peripheral neuropathy. The use of erythromycin and Clindamycin as single-drug therapy for ABRS is controversial. S. however. • Diabetics are predisposed to mucormycosis due to microangiopathy and ketoacidosis. erythromycin has poor coverage for Gram (-) bacteria and may not cover for H. consider diagnostic tap/aspirate Preferred Regimen: 1st line or mild/moderate disease: Cefuroxime axetil 500mg q12h PO x 7-10d 2nd line or severe disease: Levofloxacin 750mg qd PO x 5 d C. non-septated hyphae with variation • in diameter and right-angle branching. revealing wide ribbon-like. neutropenia. pneumonia. On its own. Mucormycosis: diabetes mellitus with acute ketoacidosis. Fluoroquinolones are generally not recommended as the serious side effects (tendinopathy. National Antibiotic Guidelines 95 . or 3) symptoms worsen after a typical viral illness that lasted 5 days and had initially improved. UPPER RESPIRATORY TRACT INFECTION Type 2: Cefuroxime30mg/kg/d div q12h x min 10d Comments: Antibiotics for bacterial sinusitis are recommended if: 1) with high ever and purulent nasal discharge or facial pain for > 3 days. aureus. and prolongation of QT interval) outweigh the benefits. Total duration of therapy is based on response. 200mg qid Comments: Amphotericin B lipid complex monotherapy has a 20% success rate vs 69% for other polyenes. UPPER RESPIRATORY TRACT INFECTION • Iron overload also predisposes to mucormycosis. but on transnasal puncture only 38% culture positive. Aspergillus Preferred Regimen: 1st line: Amphotericin B 1-1. If NPO. 2) resolution or stabilization of radiographic abnormalities. D. Polymicrobial in 80%. Posaconazole may be used for secondary prophylaxis for those on immunosuppressive therapy. For 96 National Antibiotic Guidelines . AND 3) resolution of underlying immunosuppression. Resistant to Voriconazole: prolonged use of Voriconazole prophylaxis predisposes to mucormycosis infections. Acute sinusitis in adult hospitalized patients with nasotracheal or nasogastric intubation Etiology: Gram negative bacilli (Pseudomonas. E. Complete or partial response rates with Posaconazole salvage protocols is from 60% to 80%. Continue therapy until 1) resolution of clinical signs and symptoms of infection. Yeasts 18% Preferred Regimen: 1st line: Piperacillin-tazobactam 4. Etiology: Rhizopus sp. 95% have x-ray “sinusitis” (fluid in sinuses). Acinetobacter. Gram positive (Staphylococcus aureus) in 35%. as iron stimulates fungal growth. aureus is suspected. (mucor). Posaconazole (not in the PNDF and) is not included in the FDA- approved indications for posaconazole. 2nd line: Ceftazidime 2g IV q8h PLUS Vancomycin loading dose 25-30mg/kg IV followed by 15mg/kg IV q8h or q12h OR Cefepime 2g IV q12h PLUS Vancomycin loading dose 25-30mg/kg IV followed by 15mg/kg q8h or q12h IV Comments: After 7 days of nasotracheal or nasogastric tubes.5g IV q6-8h OR Meropenem 1g IV q8h Add Vancomycin if methicillin-resistant S. coli common) in 47% of cases.5mg/kg/d OR Liposomal Amphotericin B 5- 10mg/kg/d 2nd line: Posaconazole 400mg PO bid with meals. facial pain or decreased sense of smell PLUS mucopurulence on endoscopy or CT scan changes.g. Comments: Treatment is usually with antibiotic therapy for 3 to 6 or up to 10 weeks with appropriately selected agents. The benefit of antifungal agents for CRS is unproven and not currently recommended. prolonged. damage to the ostiomeatal complex during acute bacterial disease. occult immunodeficiency. Pediatric patients: • Evaluate children for allergy. and adequate medical management. anti-inflammatory agents. LARYNGITIS VIRAL (90 %) Comments: Antibiotics are not indicated in viral laryngitis. antihistamines. and/or odontogenic disease (periodontitis in maxillary teeth) Preferred Regimen: No persuasive evidence of benefit from antibiotics P & A: Otolaryngology consultation is recommended. Etiology: Multifactorial. E. extensive. Chronic rhinosinusitis (CRS): Symptoms > 6 weeks • Defined as drainage. • Culture and sensitivity testing is important. but the efficacy of this approach is controversial. bacterial sinusitis occurs in < 10%. • Functional endoscopic sinus surgery can be considered for children with failed. • Serum IgE levels may be tested if allergy is suspected • Perform CT scan of the maxillary bone if an odontogenic source is suspected. allergy with or without polyps. May need fluconazole if yeast cells seen on Gram stain of sinus aspirate. blockage. DIPHTHERIA IN DEVELOPING COUNTRIES (PEDIATRICS) Comments: See the recommendations for membranous pharyngitis due to diphtheria. e. UPPER RESPIRATORY TRACT INFECTION patients requiring mechanical ventilation with nasotracheal tube for > 1-week. • Adjuvant therapy includes nasal saline washes (twice daily per nostril). VI. National Antibiotic Guidelines 97 . and topical (intranasal) corticosteroids.. availability. treatment involves debridement and application of topical anti-inflammatory agents.12h up to 10-14d Comments: Debridement and dry ear hygiene is crucial in otomycosis. and dosing schedule. Do not use neomycin drops if the tympanic membrane is punctured. OTITIS A. corticosteroids. cost. triamcinolone 0. Control seborrhea with dandruff shampoo containing selenium sulphide OR ketoconazole shampoo plus medium-potency steroid solution (e.1%) Etiology: Usually secondary to seborrhea (chronic) Preferred Regimen: P: Ofloxacin ear drops < 1y: no recommendation 1-12y: 5 drops bid in the affected ear > 12y: 10 drops bid DOT: 7-10d or 3d after cessation of symptoms. A 1:1 white vinegar + rubbing alcohol solution may be instilled in the external ear canal after swimming to restore proper acidic pH to the ear canal and to dry residual water. UPPER RESPIRATORY TRACT INFECTION VII. e. bacterial resistance. because antifungals are ototoxic. A: Ofloxacin ear drops 10 drops/d x 7d Comments: Treatment of choice should be based on factors such as patient allergy. Actinomyces spp.. 98 National Antibiotic Guidelines . Otitis externa • Usually secondary to chronic seborrhea. Place a wick if edema prevents drug delivery. Thorough cleaning with removal of the matted fungal debris is warranted. Phycomycetes Preferred Regimen: P: Clotrimazole 1% solution 2-3 drops q8-12h up to 10-14d OR Gentian violet may be used and is well tolerated (as recommended by the WHO Integrated Management of Childhood Illness [IMCI] guidelines). Fungal otitis externa / otomycosis Etiology: Aspergillus.. Candida spp. risk of ototoxicity... Assess for perforation of tympanic membrane. Clean the canal of detritus. For chronic otitis externa (symptoms 6 weeks to >3 months). A: Clotrimazole 1% solution 2-3 drops q8. B.g.g. 5g IV q6h 2nd line: Piperacillin-tazobactam 4. aureus in 11%. UPPER RESPIRATORY TRACT INFECTION C. A: Ofloxacin ear drops 10 drops 1-2x/d x 7d Comments: Ointments should not be used in the ear. Anaerobes in 2%. Avoid submerging head in water x 7-10 days. D. • Rule out osteomyelitis with a CT or MRI scan. epidermidis in 46%.5g IV q6h +/.Gentamicin or Amikacin qd Comments: Duration of therapy is prolonged for at least 6 weeks and until clinical and radiographical improvement has been achieved. A 1:1 white vinegar + rubbing alcohol National Antibiotic Guidelines 99 . Do not use neomycin drops if the tympanic membrane is punctured. Treatment from other etiologies should be guided by antibiotic susceptibility results. and psoriasis Etiology: S. treat for 4-6 weeks. P. Necrotizing otitis externa • Very high erythrocyte sedimentation rates are typical. • Debridement is usually required. Perform surgical debridement. Pseudomonas sp. If bone is involved. Proteus mirabilis in pediatric patients Preferred Regimen: P: 1st line: Ceftazidime 100-150mg/kg/d IV q8h 2nd line: Piperacillin-tazobactam 300mg/kg/d IV q8h A: 1st line: Piperacillin-tazobactam 4. aeruginosa. Do not use neomycin drops if the tympanic membrane is punctured. Candida in 8% Preferred Regimen: P: Ofloxacin ear drops < 1y: no recommendation 1-12y: 5 drops twice a day in the affected ear > 12y: 10 drops twice a day DOT: 7-10d or 3d after cessation of symptoms. Acute diffuse otitis externa / swimmer’s ear • May also be caused by occlusive devices (earphones). Etiology: P. in 11%. S. Give analgesics for severe pain. Obtain cultures from the ear canal or from surgical debridement. aeruginosa in >95%. contact dermatitis. Primary vaccination involves 3 doses with an interval of 4 weeks in between doses. >5y: 5-7d With anaphylaxis: OR Ceftriaxone 50mg/kg/d IM/IV x Levofloxacin 750mg PO q24h x 5d 3d No anaphylaxis: Cefuroxime axetil 500mg–1g/d PO q12h x 7d OR Ceftriaxone 2g qd IV/IM x 3d 100 National Antibiotic Guidelines . e. Primary vaccination involves 3 doses with an interval of 4 weeks in between doses. Booster is given 6 months after the 3rd dose. >5y: 5-7d 2nd line PEDIATRICS ADULTS With anaphylaxis: No penicillin allergy Clarithromycin 15mg/kg/d PO q12h Co-amoxiclav 875mg/125mg PO No anaphylaxis: q12h x 10d Cefuroxime axetil 30mg/kg/d q12h With penicillin allergy DOT: <2y: 10 d. Bacterial pathogens account for 85% of middle ear infections: S. UPPER RESPIRATORY TRACT INFECTION solution may be instilled in the external ear canal after swimming to restore proper acidic pH to the ear canal and to dry residual water. Acute otitis media (AOM) Prevention includes immunization against invasive pneumococcal disease and Haemophilus influenzae Type B. with an interval of 6 months after the 3rd dose.g. corticosteroids. In children aged 6 months to 3 years. E. there may be 2 episodes of AOM per year. • influenzae Type b conjugate vaccine is given IM in children aged at least 6 weeks. Preferred Regimen: No antibiotic use in the prior month 1st line PEDIATRICS ADULTS Amoxicillin 80-90mg/kg/d PO div Amoxicillin 1g q8h x 10 d (high dose) q12h DOT: <2y: 10 d. For chronic otitis externa (symptoms 6 weeks to > 3 months). M. 2-5y: 7 d. • Pneumococcal conjugate vaccine is given IM in children aged at least 6 weeks. treatment involves debridement and application of topical anti-inflammatory agents. influenzae in 29%. H. pneumoniae in 49%. catarrhalis in 28%.. and 63% are virus-positive. Etiology: Viruses cause up to 6% of middle ear infections. 2-5y: 7 d. Booster is given at age 12-15 months. avoid cephalosporins Trimethoprim-sulfamethoxazole has a high failure rate if etiology is drug-resistant S. Adenoidectomy at time of tympanostomy tubes decreases future hospitalization for AOM. Spontaneous resolution occurred in 90% of patients infected with M. consider analgesic treatment without antimicrobials. Placement of tympanostomy tube is an option for some. DOT: <2y OR severe symptoms regardless of age: 10d. UPPER RESPIRATORY TRACT INFECTION Comments: For patients above 2 years old with no fever and ear pain with a negative or questionable exam. >2 y: 5-7d OR Cefuroxime 30mg/kg/d PO q12h. Clindamycin is not effective against H. catarrhalis. influenzae. influenzae. 50% with H. the child presents with high fever >39oC and/or if with severe otalgia. may give effective oral cephalosporin • If IgE-mediated allergy (e. >2yrs with mild or moderate disease:5-7d OR Ceftriaxone 50mg/kg/d IM x 3d 2nd line: Mild penicillin allergy: Cefuroxime 15mg/kg/d div q12h or Ceftriaxone 50mg/kg IM/IV x 3d Severe penicillin allergy: Levofloxacin 750mg PO bid x 5d National Antibiotic Guidelines 101 . Additional comments for pediatric patients: Co-amoxiclav and Ceftriaxone may be used as a first-line agent if at the onset. Persistent middle ear effusion for 2-3 months after therapy is expected and does not require retreatment. pneumoniae or H. F.g. but 5 days may be inadequate. pneumoniae are resistant to macrolides and 0%-5% are resistant to penicillins. Macrolide resistance of S. appropriate duration of treatment is unclear. tympanocentesis or myringotomy may be necessary. If infection is non-responsive to antimicrobial therapy..9 mg. Up to 50% of S. pneumoniae has been reported. anaphylaxis). For severe disease. For patients allergic to β-lactam drugs: • If history unclear or rash. influenzae and M. There may be favorable results in mostly afebrile patients with waiting for 48 hours before deciding to use antibiotics. DOT: <2yrs: 10 d. pneumoniae Preferred Regimen: 1st line: Co-amoxiclav for ≥3 months and <40 kg: 90mg/kg/d q12h using 600/42. and 10% with S. Acute otitis media (clinical failure after 3 days) Etiology: Drug-resistant S. catarrhalis. pneumoniae (overall 80% resolve within 2-14 days). S. Proteus mirabilis. aureus. Amoxicillin-clavulanate high dose reported successful for penicillin-resistant S. • Consult an otorhinolaryngologist (ENT) for possible mastoidectomy. fever. Give quinolone ear drops tid for 5 days. such as osteomyelitis. Klebsiella sp. aureus. pneumoniae Preferred Regimen: P: Ceftriaxone 100mg/kg/d IV q12h PLUS Oxacillin 150-200mg/kg/d IV q6h or Vancomycin 45-60mg/kg/d IV q6h 102 National Antibiotic Guidelines . P. Do not use neomycin drops if the tympanic membrane is ruptured. Chronic suppurative otitis media (CSOM) • Aural toilet is an essential part of the treatment of CSOM in all patients. Systemic antibiotics should not be routinely given to patients with CSOM either alone or in combination with topical antimicrobials. M. E. aeruginosa. S. Anaerobic: Bacteroides. H. suppurative lateral sinus thrombophlebitis. aeruginosa. pneumoniae resistant to macrolides are usually also resistant to clindamycin. Definition of failure: no change in ear pain. Peptostreptococcus. • Look for complications. Tympanocentesis will allow culture. pyogenes. pneumoniae. S. aeruginosa. Acute mastoiditis • Usually a complication of acute otitis media.. purulent meningitis. Etiology: Aerobic: P. Obtain cultures. Etiology: 1st episode: S. influenzae or M. • Surgery must be performed on all cases of CSOM with suppurative complications. S. bulging tympanic membrane or otorrhea after 3 days of therapy. aureus. influenzae. catarrhalis. S. pyogenes. pneumoniae acute otitis media. coli. H. UPPER RESPIRATORY TRACT INFECTION Comments: Clindamycin not active against H. S. catarrhalis. Comments: Antibiotic treatment as in acute otitis media if there is acute exacerbation. • Diagnosis is by CT or MRI scan. Propionibacterium Preferred Regimen: Daily ear cleansing and drying should be done. or brain abscess. P. G. If secondary to otitis media: S. (2014). obtain cultures. UPPER RESPIRATORY TRACT INFECTION A: 1st line: Obtain cultures. I. 164:425-34.5g IV q8h If caused by a multidrug-resistant Pseudomonas sp: Meropenem 1g IV q8h should be given. are suspected. S. pyogenes. 54: e72-e112. Baltimore. • Chow AW. Philadelphia. MD: Johns Hopkins University Hospital. Brook I.. Chronic or recurrent mastoiditis Etiology: S. ed. PA: Saunders. aeruginosa. influenzae. P. Benninger MS. (2016). Do not use neomycin drops if the tympanic membrane is ruptured. • Harris AM. then: Vancomycin (dose to achieve serum trough levels of 15-20 mcg/mL) PLUS Piperacillin-tazobactam 4. Treatment in pediatric group depends on the patient’s response. S. 7th ed. H. aureus. et al.5mg/kg/d IV q8h If intracranial extension is suspected: Cefepime 150mg/kg/d IV q8h A: Culture ear drainage. et al. eds. Hicks LA. Goldstein EJ. Topical fluoroquinolone ear drops. Infectious Diseases Society of America. pneumoniae. National Antibiotic Guidelines 103 . Brozek JL. (2015) Johns Hopkins ABX Guide. Hicks LA. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Systemic antibiotics should not be routinely given to patients with CSOM either alone or in combination with topical antimicrobials. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. surgical debridement of the auditory canal. Comments: Surgical debridement. then empiric therapy for the first episode: Ceftriaxone 2g IV qd OR Levofloxacin 750mg IV qd 2nd line: Acute exacerbation of chronic otitis media: If Pseudomonas and Staphylococcus spp. Feigin and Cherry's Textbook of Pediatric Infectious Diseases. References • Bartlett JG. Fungi Preferred Regimen: P: Piperacillin-tazobactam 300mg/kg/d IV q6h PLUS Gentamicin 7. Moraxella catarrhalis. May need surgical debridement. Qaseem A. (2012). Annals of Internal Medicine. • Cherry JD. Comments: Antibiotic treatment as in acute otitis media if there is acute exacerbation. Clinical Infectious Disease. Consult with an otorhinolaryngologist (ENT) is recommended. eds.1002/14651858. 20th ed. DOI: 10.com. (2015). Douglas. 375:962-70.7326/M16- 2766. Antibiotics for acute laryngitis in adults.com/. Clinical Practice Guideline for Sinusitis. Red Book: Report of the Committee on Infectious Diseases. Art. Cochrane Database of Systematic Review (3):CD004783. Cardona AF. Clinical Practice Guideline (Update): Adult Sinusitis. Gold. ed. • Macfadyen CA. et al. Elk Grove Village. • Research Institute for Tropical Medicine. DOI: 10.: CD005608.. The New England Journal of Medicine. American Academy of Otolaryngology – Head and Neck Surgery. IL: American Academy of Pediatrics. UPPER RESPIRATORY TRACT INFECTION • Kimberlin. et al.CD004783. Brockmeyer. and Bennett’s Principles and Practice of Infectious Disease. Cochrane Database of Systematic Review.pub4. DM. • Philippine Society of Otolaryngology – Head and Neck Surgery. (2015).1002/14651858. HS. 166. • Rosenfeld RM et al. Annals of Internal Medicine. (2006). H. doi:10. 104 National Antibiotic Guidelines . Antimicrobial Resistance Surveillance Program: 2015 Data Summary Report. Acuin JM. 8th edition. Issue 1. (2016) Nelson Textbook of Pediatrics. Philadelphia. (2006). DW et al. • Libman. Gamble CL. • Kliegman RM. (2016). Acute Sinusitis in Adults.1056/ NEJMcp1601749 • The Sanford Guide to Antimicrobial Therapy 2015. No. (2015). Systemic antibiotics versus topical treatments for chronically discharging ears with underlying eardrum perforations. (2017) Should We Prescribe Antibiotics to This Patient with Persistent Upper Respiratory Symptoms? Grand Rounds Discussion from Both Israel Deaconess Medical Center. doi: 10. Retrieved from: http://arsp.ph/arsp-data-summary- report-2015/ • Reveiz L.sanfordguide. Mandell. 201-208. 30th ed. Pasig City: Philippine Society of Otolaryngology – Head and Neck Surgery. CD005608 • Mandell LA.152 (2S): S1-S39. • Rosenfeld RM et al. PA: Elsevier. Available at: http:// webedition. Head and Neck Surgery. (2013).. absence of controlled data. RSV caused 11% of clinically important respiratory illnesses in military recruits.): Ribavirin for severe disease (e. Human metapneumovirus Preferred Regimen: P (Infants/children <5yrs. 2010). requiring mechanical ventilation). BRONCHIOLITIS/WHEEZY BRONCHITIS (EXPIRATORY WHEEZING) • Respiratory syncytial virus (RSV) is the most important etiology. reducing hospitalization rates by 39-82% among high risk infants (e. • There is a need for surveillance for etiologies of bronchiolitis and bronchitis. Aerosolized ribavirin should only be administered with SPAG 2. Palivizumab is a humanized mouse monoclonal antibody for the prevention of bronchiolitis.2% for asthma and 5.4% for chronic obstructive pulmonary disease. RSV accounts for 10.6% of hospitalizations for pneumonia.g. chronic lung disease. The mainstay of therapy is supportive care. 7. those with congenital heart disease.g. or preterm birth <32 weeks). BRONCHIITIS A. measurement of oxygen saturation and use of supplemental oxygen if needed. II.. It is given at a dose of 15mg/kg IM once every 30 days. which includes hydration. rapid diagnosis uses antigen detection methods. Parainfluenza in 25%. Aerosolized ribavirin is not available in the Philippines A: Antibiotics are not indicated. Acute Bronchitis • A throat swab polymerase chain reaction test may be done to diagnose Mycoplasma or Chlamydophila (formerly Chlamydia) Etiology: Infants or children < 2y: Adenovirus (most common) Children 2-5y: Respiratory syncytial virus. Human metapneumovirus National Antibiotic Guidelines 105 . for a maximum of 5 months (Pediatrics 126: e116. • In adults. toxicity.4% for congestive heart failure in patients >65 years of age.. 11. Ribavirin is not routinely recommended due to the high cost. Parainfluenza 3 virus. Administer at a concentration of 20mg/mL in sterile water by small particle aerosol generator (SPAG) 2 via continuous aerosol administration for over 18-20 hours daily for 3-5d. LOWER RESPIRATORY TRACT INFECTION I. Etiology: RSV in 50%. Comments: Antibiotics not indicated in infants hospitalized with RSV bronchiolitis unless there is evidence of secondary bacterial infection. and 3) convalescence (1-2 weeks). If Mycoplasma is documented. B. • Diagnosis is made through polymerase chain reaction on nasopharyngeal secretions or increased pertussis-toxin antibody titres. Azithromycin 10mg/kg/d q24h for 5d 250mg q24h on d2-5 OR OR 106 National Antibiotic Guidelines . inhaled growth on throat culture for S. with associated sinusitis or heavy Antitussive +/. pneumoniae. parapertussis. Chlamydophila infection Preferred Regimen: PEDIATRICS ADULTS Neonates younger than 1 month: Azithromycin 500mg PO on d1. get a chest x-ray. afebrile during community outbreak: Pertussis (whooping cough) • Presents as 3 stages: 1) catarrhal (1-2 weeks). influenzae. B. Post-nasal drip 4. Mycoplasma infection 5. Gastroesophageal reflux 3. A throat swab polymerase chain reaction test may be done to diagnose Mycoplasma or Chlamydophila (formerly Chlamydia). Comments: Purulent sputum alone not an indication for antibiotic therapy. LOWER RESPIRATORY TRACT INFECTION Adolescent and adults: Usually viral M. Group A Streptococci. bronchodilators. Chlamydophyla pneumoniae in 5% Preferred Regimen: PEDIATRICS ADULTS < 5yrs. Otherwise.: Antibiotics are indicated only Antibiotics are usually not indicated. pneumoniae in 5%. treatment is symptomatic. Asthma 2. Expect cough to last for 2 weeks. Differential diagnoses include the following: 1. Etiology: Bordetella pertussis and occasionally. H. If there is fever or rigors. Peritonsillar abscess (Quinsy) Persistent cough (>14 days). or there is no improvement in 1 week. 2) paroxysmal coughing (2-4 weeks). prefer doxycycline over macrolides due to increasing macrolide resistance. (3) oral corticosteroid. then 250mg q24h on d2–5 OR Erythromycin 500mg PO qid 14d OR Clarithromycin 500mg PO bid x 7d OR Trimethoprim-sulfamethoxazole 160/800 mg 1 tablet PO bid x 14d C.: Trimethoprim-sulfamethoxazole Azithromycin 10mg/kg/d PO on d1 160/800mg PO bid x 14d then 5mg/kg/d PO q24h x 4d OR OR Clarithromycin 7. especially if febrile and/or with low oxygen saturation. Chlamydophila pneumonia in 5%. In the non-outbreak setting. LOWER RESPIRATORY TRACT INFECTION Erythromycin 40mg/kg/d in 4 div Erythromycin estolate 500mg PO qid doses x 14d x14d OR >2 mos. but does not shorten the paroxysmal stage. influenzae. and Moraxella catarrhalis is controversial. • Management of severe ABECB includes: (1) consider a chest x-ray. pneumoniae. H. Treatment is aimed at eradication of nasopharyngeal carriage. Acute bacterial exacerbation of chronic bronchitis (ABECB). • Severe ABECB is characterized by increased dyspnea. Pertussis prophylaxis of household contacts (adults and children): Azithromycin 500mg PO x1 dose on d1. Etiology: Viruses in 20%-50%.5mg/kg PO q12h x Clarithromycin 500mg PO bid x 7d 7d (Max: 1g/d) OR Erythromycin estolate 40mg/kg/d in 4 div doses OR Erythromycin base 40mg/kg/d div q6h x 7-14d (Max: 1-2g/d) OR Trimethoprim-sulfamethoxazole 8/40mg/kg/d in 2 div doses/d x 14d Comments: Treatment may abort or eliminate pertussis in the catarrhal stage. National Antibiotic Guidelines 107 . adults • Almost always in smokers with chronic obstructive pulmonary disease. and (5) non-invasive positive pressure ventilation. (4) tobacco cessation. Tobacco use and air pollution contribute to ABECB. the likelihood of pertussis increased if post-tussive emesis or inspiratory whoop is present. sputum viscosity/purulence and sputum volume. (2) inhaled anticholinergic bronchodilator. Mycoplasma pneumonia in <1% The role of S. taper over 2 weeks. Influenza • Fever. The GOLD COPD 2015 Update states: Antibiotics should be given to patients with exacerbations of COPD who have: (1) three cardinal symptoms. (2) have two of the cardinal symptoms. sputum volume. Acute bacterial exacerbation (bronchiectasis) Etiology: H. pneumoniae (rarely) 108 National Antibiotic Guidelines . Etiology: Influenza A and B Preferred Regimen: P: Oseltamivir Infant 2 weeks-11 months: 3mg/kg bid x 5d ≤15kg: 30mg bid x 5d >15kg to 23kg: 45mg bid x 5d >23kg to 40kg: 60mg bid x 5d >40kg: 75mg bid x 5d A: Oseltamivir 75mg PO bid x 5d Comments: Resistant to Amantadine and rimantidine (100%) E. influenzae. Streptococcus pneumoniae. P. myalgia during influenza season • Complications include influenza pneumonia and secondary bacterial pneumonia due to community-acquired methicillin-resistant and susceptible Staphylococcus aureus. S. D. cough. • Prevention includes annual vaccination. but a recent study on over 80. (increase in dyspnea. LOWER RESPIRATORY TRACT INFECTION Preferred Regimen (A): Mild Moderate infections: Amoxicillin 500mg tid OR Doxycycline 100mg PO bid OR Cefuroxime 500mg PO bid Severe infections: Co-amoxiclav 875/125mg bid OR Azithromycin 500mg q24h x 3d OR Clarithromycin 500mg PO bid OR Levofloxacin 500mg PO q24h DOT: 5-10d Comments: The role of antimicrobial therapy is debated even for severe diseases. aeruginosa. and Haemophilus influenzae. IV antibiotics should only be used if the patient cannot tolerate oral antibiotics. if increased sputum purulence is one of the two symptoms. or (3) require mechanical ventilation (invasive or non-invasive.000 patients show value of antimicrobial therapy in patients hospitalized with severe disease. and sputum purulence. 000-250. PNEUMONIAS AND INFECTIONS OF THE LUNG PARENCHYMA A. Comments: Itraconazole decreases the number of exacerbations requiring corticosteroids with improved immunological markers improved lung function and exercise tolerance. tobacco. decreased immunoglobulins. or other dematiaceous species (Alternaria. bronchiectasis. Allergic bronchopulmonary aspergillosis (clinical manifestation: wheezing. LOWER RESPIRATORY TRACT INFECTION Preferred Regimen: A: Levofloxacin 500mg PO q24h x 7-10d Prevention of exacerbation: Erythromycin 500mg PO bid OR Azithromycin 250mg q24h x 1 year Comments: May be caused by obstruction. A. Higher rates of macrolide resistance in oropharyngeal flora may potentially increase the risk of cardiovascular deaths from macrolide-induced QTc prolongation. electrocardiogram. cystic fibrosis. III. increase lgE levels and isolation of Aspergillus spp. and sputum culture to exclude mycobacterial disease. flavus and others. etc.000 U/kg/d div q4-6h IV infusion over 15-60 min For severe infections: 250. and fibrosis). Cladosporium.000-400. or hearing loss Pre-treatment screening includes baseline liver function tests. liver toxicity. Etiology: Aspergillosis. Community-Acquired Pneumonia (CAP) in Neonates Etiology: Gram (-) bacilli. hearing test. Aspergillus fumigatus (most common)..) Preferred Regimen (A): Treatment of allergic bronchopulmonary aspergillosis: Itraconazole 200mg PO bid x 16 weeks or longer. pulmonary infiltrates.g.000 U/kg/d div q4-6h IV infusion over 15-60 min PLUS Aminoglycoside: Amikacin 15mg/kg/d IV qd or Gentamicin 5mg/kg/d IV qd National Antibiotic Guidelines 109 . Acute asthma attacks associated with allergic bronchopulmonary aspergillosis is treated with corticosteroids. or prior severe or recurrent necrotizing bronchitis (e. dyskinetic cilia. pertussis). Airway colonization is associated with increase blood eosinophils. Group B Streptococci Preferred Regimen: Ampicillin 100-200mg/kg/d IV div q6h OR Penicillin G 100. pneumoniae. no signs of respiratory failure. NO apnea • PCAP D (very severe): Severe dehydration. grunting. respiratory rate of ≥50-≥60/min (3- 12mos. K. If started on Co-amoxiclav 80-90mg/kg/d. given at 6 weeks of age. consider macrolide: Azithromycin 10mg/kg qd PO x 3d or 10mg/kg/d PO on d1 then 5mg/kg/d PO on d2-5 OR Clarithromycin 15mg/kg/d div PO q12h x 7d If with non-response to initial treatment (48-72h). head bobbing. May also consider adding an oral macrolide. >35/min (>5y). pneumoniae in 30%-50%. H. respiratory rate of >60-≤70/min (3-12 mos. S. >35/min (>5y). 6 months after the 3rd dose • Hib Conjugate Vaccine given IM. moderate malnutrition. If started on Amoxicillin 80-90mg/kg/d. apnea. >50/min (1-5 y).). no pallor. with pallor. lethargic/ stuporous/in coma (+ supraclavicular/intercostal/subcostal retractions. 110 National Antibiotic Guidelines . NO grunting. cyanosis). irritable (+ intercostal/subcostal retractions. Community-Acquired Pneumonia (CAP) in Infants and Children up to 5 years Pediatric CAP (PCAP) classification: • PCAP A/B (non-severe): No or mild dehydration. given at 6 weeks of age. cyanosis. Primary vaccination includes 3 doses with an interval of 4 weeks in between doses. awake.) • PCAP C (severe): Moderate dehydration. and a booster. 2. LOWER RESPIRATORY TRACT INFECTION Comments: Recommendation for immunization: • Pneumococcal Conjugate Vaccine given IM. severe malnutrition. consider the following: 1. Primary vaccination includes 3 doses with an interval of 4 weeks in between B. aureus. 3. Non-typeable H. head bobbing. admit for IV antibiotics. no malnutrition. with pallor. ≥40-≤50/min (1-5yrs. Consider other diagnosis. 4.). influenzae type b in 10%-30%. respiratory rate >70/min (3-12 mos. shift to Co-amoxiclav 90 mg/kg/d div PO q12h (amoxicillin component). >50/min (1-5 y). Etiology: S. influenzae Preferred Regimen: PCAP A or B: If with complete Hib vaccination: Amoxicillin 80-90mg/kg/d div q12h PO x 5d If with no Hib vaccination or incomplete or unknown vaccination history: Co-amoxiclav 80-90mg/kg/d PO (amoxicillin component) div q8h (4:1 preparations) or div q12h (7:1 preparations) For children >40 kg: 500/125mg PO q8h (Max: 2g/d of amoxicillin) OR Cefuroxime 20-30mg/kg/d PO div q12h If allergic to Amoxicillin. ≥30-≤35/min (>5 yrs.).). longer courses of 2 to 3 weeks may be required for more severe disease (pleural empyema or pulmonary abscesses). Physical examination may show rales. and wheezes in the context of a child who does not appear ill (“walking pneumonia”). pharyngitis. intact GI absorption c. Responding to initial treatment b. pneumoniae. Etiology: Children (>5 years) and adolescents: S. LOWER RESPIRATORY TRACT INFECTION PCAP C: If with complete Hib vaccination: Penicillin G 200. with malaise. Admit to critical care unit. Clinical presentation may be indistinguishable from viral pneumonia. pneumoniae Preferred Regimen: Erythromycin 50mg/kg/d PO div q6-8h x 10-14d OR Clarithromycin suspension 15mg/kg/d div q12h x 10d OR Azithromycin 10mg/kg PO qd x 3d or 10 mg/kg/d PO on d1 then 5mg/kg/d PO on d2-5 Comments: Treatment choices when atypical pathogens are suspected.5 mg clavulanate per 5mL granules/powder for suspension. Complaints are related to slowly progressive systemic symptoms over 3 to 7 days. rhonchi. 70 mL Switch from IV to oral form 2-3 days after initiation of treatment in patients who are: a. Available Co-amoxiclav preparations in the formulary are the following: 4:1 500 mg amoxicillin (as trihydrate) + 125 mg potassium clavulanate per tablet 7:1 875 mg amoxicillin (as trihydrate) + 125 mg potassium clavulanate per tablet 200 mg amoxicillin (as trihydrate) + 28. 70 mL 400 mg amoxicillin (as trihydrate) + 57 mg potassium clavulanate per 5mL granules/powder for suspension. and headache. Free from pulmonary/ extrapulmonary complications Although the total course of therapy is usually 7 to 10 days for uncomplicated pneumonia. National Antibiotic Guidelines 111 .000 U/kg/d IV div q6h OR Ampicillin 200mg/kg/d IV div q6h If with no Hib vaccination or incomplete or unknown vaccination history: Ampicillin-sulbactam 100mg/kg/d IV div q6h OR Cefuroxime 100mg/kg/d IV div q8h OR Ceftriaxone 100mg/kg/d IV div q12h PCAP D: Refer to Specialist. refer to specialist for antibiotic guidance. Able to feed. followed by cough that is irritative and nonproductive (lasting for 2-4 weeks). Comments: Equal efficacy between oral Amoxicillin and IV penicillin if feeding is tolerated. C. M. pneumoniae. • Chest X-ray: multilobar infiltrates. pneumoniae. active malignancies. Fluoroquinolones are not recommended as first line treatment option for low risk CAP. Sputum gram stain and culture is not necessary. unstable coronary artery disease. Among noninvasive S. M. congestive heart failure class II-IV. LOWER RESPIRATORY TRACT INFECTION C. H. MODERATE-RISK CAP: • Unstable Vital Signs: RR>30/min.meningitis breakpoints. no evidence of pleural effusion Etiology (Potential pathogens): S. influenzae. C. Temp>36˚C or<40˚C) • No altered mental state of acute onset • No suspected aspiration • No or stable co-morbid conditions • Chest X ray: localized infiltrates. pneumoniae: 5-7d or 3-5d if using Azithromycin Comments: The recommendation to use Amoxicillin as first-line drug for low-risk CAP in patients with no co-morbid illness is based on the 2015 ARSP data.Azithromycin 500mg PO qd OR Clarithromycin 500mg PO bid DOT: For S. catarrhalis Enteric Gram (-) bacilli (among those with co. particularly for multi-drug resistant tuberculosis. neurologic disease in evolution. renal failure on dialysis. pneumoniae. Community-Acquired Pneumonia (CAP) in Adults LOW-RISK CAP: • Stable vital signs (RR <30/min.morbid illness) Preferred Regimen: Without co-morbid illness: Amoxicillin 1g PO tid OR Azithromycin 500mg PO qd OR Clarithromycin 500mg PO bid With stable co-morbid illness: Co-amoxiclav 1g PO bid OR Cefuroxime axetil 500mg PO bid +/. It is recommended that they be reserved as potential second-line agents for the treatment of pulmonary tuberculosis. DBP>60mmHg. pneumoniae isolates. decompensated liver disease. only 1% (n=246 non-invasive isolates) were reported as penicillin-resistant using non. pleural effusion 112 National Antibiotic Guidelines . uncompensated COPD. SBP>90mmHg. Temp < 36˚C or > 40˚C • Altered mental state of acute onset • Suspected aspiration • Unstable/Decompensated comorbid condition: uncontrolled diabetes mellitus. PR > 125/min. PR<125/min. Legionella pneumophila. M. Choose antibiotics based on available micro. Shift from IV to oral therapy once the patient is clinically improving. pneumoniae. pneumoniae. Enteric Gram (-) bacilli. infections with anaerobes should be considered.biological data. C. Enteric Gram (-) bacilli.5g IV q6h or Cefepime 2g IV q8-12h or Meropenem 1g IV q8h PLUS Levofloxacin 750mg IV qd or Ciprofloxacin 400mg IV q8-12h If MRSA pneumonia is suspected.5g IV q8h or Ceftriaxone 2g IV q24h PLUS Azithromycin 500mg PO qd or Clarithromycin 500mg PO bid or Levofloxacin 750mg PO qd DOT: 7-10d may be adequate (or 3-5d for azalides). Caution should be taken especially in elderly with cardiovascular diseases. pneumoniae. Azithromycin and fluoroquinolones can cause prolongation of QT interval. aeruginosa: Ceftriaxone 2g IV q24h OR Ertapenem 1g IV q24h PLUS Azithromycin 500mg IV qd OR Levofloxacin 750mg IV qd Risk for P. Comments: For those at risk of aspiration. or use an oral agent from the same drug class. catarrhalis. M. aeruginosa: Piperacillin-tazobactam 4. H. M. M. Because of increasing resistance of gram (-) bacilli to fluoroquinolones.5g IV q6h or Cefepime 2g IV q8-12h or Meropenem 1g IV q8h PLUS Azithromycin 500mg IV qd PLUS Gentamicin 5-7mg/kg IV qd or Amikacin 15mg/kg IV qd OR Piperacillin-Tazobactam 4. pneumoniae. LOWER RESPIRATORY TRACT INFECTION Etiology (Potential Pathogens): S. Blood culture. influenzae. H. Anaerobes (among those with risk of aspiration). aureus. influenzae. sputum gram stain and culture are necessary HIGH-RISK CAP: Any of the clinical feature of Moderate-risk CAP plus any of the following: severe sepsis and septic shock or need for mechanical ventilation Etiology (Potential Pathogens): S. aeruginosa Preferred Regimen: No risk for P. pneumophila. add: Vancomycin 25-30mg/kg loading dose then 15-20mg/kg IV q8-12h OR Linezolid 600mg IV q12h National Antibiotic Guidelines 113 . monotherapy with fluoroquinolone is not recommended. L. Anaerobes (among those with risk of aspiration) Preferred Regimen: Ampicillin-Sulbactam 1. pneumoniae. aureus or P. pneumoniae. aeruginosa if with concomitant bacteremia. P.5g IV q6h or Cefuroxime sodium 1. A longer duration of up to 28d may be given for S. catarrhalis. S. C. aeruginosa if with concomitant bacteremia. Severe underlying bronchopulmonary disease 3. even if associated with a pulmonary source. H. Chronic use of steroids >15mg/d for at least 2 weeks Empiric therapy for MRSA among hospitalized patients with severe CAP is indicated in any of the following conditions: 1. empyema. Use of Linezolid or Clindamycin monotherapy for MRSA bacteremia. S. requirement for intensive care unit 2. aureus or P. necrotizing or cavitary infiltrates 3. Empyema ACUTE EMPYEMA Etiology: S. influenzae Preferred Regimen: 1st line 2nd line PEDIATRICS Clindamycin 25-40mg/kg/d IV div q6-8h Clindamycin 600mg q8h IV PLUS Ceftriaxone 50-100mg/kg/dose PLUS q24h IV infusion over 10-30 min Ceftriaxone 2g q24h IV ADULTS Vancomycin 40mg/kg/d IV div q6h PLUS Vancomycin 15mg/kg IV q8-12h Ampicillin-sulbactam 100mg/kg/d IV PLUS div q6h Ampicillin-sulbactam 1. aureus. History of chronic or prolonged (>7 days within the past month) use of broad- spectrum antibiotic therapy. 2. A longer duration of up to 28 days may be given for S. pneumoniae. pyogenes. Comments: Risk factors for P. LOWER RESPIRATORY TRACT INFECTION DOT for all regimens: 7-10 days may be adequate. aeruginosa infections: 1. S. is not recommended.5g IV q6h OR OR Vancomycin 40mg/kg/d IV div q6h PLUS Vancomycin 15mg/kg IV q8-12h Ceftriaxone 50-100mg/kg/dose IV q24h PLUS PLUS Ceftriaxone 2g IV q24h PLUS Metronidazole 30 mg/kg/d IV div q6h Metronidazole 500mg IV q6h DOT: 2-4 weeks based on clinical response to drainage and antimicrobial therapy 114 National Antibiotic Guidelines . D. Malnutrition 4. Treatment should be modified according to culture/sensitivity results once available. Anaerobes of the upper respiratory tract Preferred Regimen: P: 1st line: Clindamycin 25-40mg/kg/d IV div q6-8h PLUS Ceftriaxone 50-100mg/kg/dose q24h IV infusion over 10-30 min 2nd line: Vancomycin 40mg/kg/d IV div q6h PLUS Ceftriaxone 50- 100mg/kg/dose q24h IV infusion over 10-30 min PLUS Metronidazole 30mg/kg/d IV div q6h A: Clindamycin 600mg IV q8h OR Ampicillin-sulbactam 3g IV q6h OR Ceftriaxone 2g IV q24h PLUS Metronidazole 500mg IV q6h or 1g IV q12h OR Piperacillin-tazobactam 4. Comments: Rule out the possibility of tuberculosis. aureus. S. Gram positive cocci. CHRONIC EMPYEMA Etiology: Mostly anaerobic organisms Mycobacterium tuberculosis Preferred Regimen: Refer to specialist. pneumoniae. Streptococcus melliri. Comments: Do surgical intervention if with failure to improve after 7d of appropriate antibiotics. Lung Abscess Etiology: S. Treatment should be guided by culture results. LOWER RESPIRATORY TRACT INFECTION Comments: Treatment includes systemic antibiotic and drainage. F. Pneumonia. anaerobic or aspiration with or without lung abscess Etiology: Anaerobes. E.5g IV q8h (for mixed infections with resistant Gram- negative aerobes) DOT: 4-6 weeks. Gram-negative bacteria Preferred Regimen: 1st line PARENTERAL ORAL Clindamycin 600mg IV q8h PLUS Clindamycin 300-450mg PO tid Ceftriaxone 2g IV q24h for suspected OR Gram-negative infection Amoxicillin-clavulanic acid 1g PO bid OR Ampicillin-sulbactam 3g IV q6h National Antibiotic Guidelines 115 . G. • VAP in children is pneumonia where the patient is on mechanical ventilation for >2 calendar days on the date of event. even if associated with a pulmonary source. pneumoniae Preferred Regimen: Refer to recommendations for moderate or high-risk CAP in adults and ADD: Vancomycin 15 mg/kg IV q8-12h OR Linezolid 600mg IV q12h Comments: Use of Linezolid monotherapy for methicillin-resistant S. laboratory and imaging parameters) that occurs on or after the 3rd day of admission to an inpatient location. with day of ventilator placement being day 1 and the ventilator was in place on the date of the event or the day before. H. LOWER RESPIRATORY TRACT INFECTION 2nd line PARENTERAL ORAL Piperacillin-Tazobactam 4. Hospital-acquired pneumonia (HAP) and Ventilator-associated pneumonia (VAP) in PEDIATRICS • HAP in children is pneumonia (diagnosed by a combination of clinical. pneumonia Preferred Regimen: Refer to recommendations for moderate or high-risk CAP in adults and ADD: Vancomycin 40-60mg/kg/d IV q6-8h for documented MRSA infections OR Linezolid 600mg IV q12h 116 National Antibiotic Guidelines . aureus. Etiology: S. is not recommended. Pneumonia with concomitant/post-influenza Patients with active influenza or with history of influenza within 2 weeks of development of CAP Etiology: S. aureus. longer (up to 2-3 months) for lung abscess. S. aureus bacteremia. S.5g IV q8h Co-amoxiclav 1g PO bid OR Ceftriaxone 2g q24h IV PLUS Metronidazole 500mg IV q6h OR Ertapenem 1g IV q24h DOT: Up to 3-4 weeks. depending on clinical response. add Vancomycin. E. Home infusion therapy (including antibiotics) 4. aeruginosa. The recommendations for empiric therapy here are based on national antimicrobial resistance data. aureus Preferred Regimen: Piperacillin-Tazobactam 300mg/kg/d q6h OR Meropenem 300mg/kg/d q6h (120mg/kg/d q8h if with meningitis) (Max: 2-4g/d) OR Cefepime 100mg/kg/day q8h (150mg/kg/d q8h for Pseudomonas) Comments: For infections with MDR Gram (-) bacilli that are highly resistant to several classes of antimicrobial agents. K. Acinetobacter spp. National Antibiotic Guidelines 117 . Immunosuppressive disease and/ or therapy Etiology: Viral and fungal pathogens in immunocompromised hosts (patients on chronic immunosuppressants. LOWER RESPIRATORY TRACT INFECTION Etiology: P. Klebsiella spp. Residence in a nursing home or extended care facility 3. pneumoniae (extended spectrum beta-lactamase and carbapenemase-producing Klebsiella strains). solid organ and bone marrow transplant recipients) Comments: Refer to a specialist. baumanii. aureus is suspected.. Burkholderiacepacia. Etiology (Multi-drug resistant (MDR) pathogens): P. pneumoniae. Family member with MDR pathogen 7. Chronic dialysis within 30 days 5. A. coli.. Proteus spp. Home wound care 6. Enterobacter spp. Stenotrophomonas maltophilia. referral to a specialist is warranted. Risk factors for MDR pathogens: • Antimicrobial therapy in preceding 90 days • Current hospitalization of 5 days or more • High frequency of antibiotic resistance in the community or in the specific hospital unit • Presence of risk factors for HCAP: 1.. K. aeruginosa.. Methicillin-resistant S. Hospitalization for 2 days or more in the preceding 90 days 2. Serratia marcesens Preferred Regimen: Ceftazidime 100-150mg/kg/d q8h IV infused over 15-30 minutes PLUS Aminoglycoside: Amikacin 15mg/kg/d IV qd or Gentamicin 5mg/kg/day IV qd Comments: Choice should be based on current antimicrobial susceptibility pattern in the institution. If S. LOWER RESPIRATORY TRACT INFECTION I. Hospital-acquired pneumonia (HAP) and Ventilator-associated pneumonia (VAP) in ADULTS Risk Factors for multidrug-resistant (MDR) VAP/HAP, methicillin-resistant S. aureus (MRSA) VAP/HAP, and Pseudomonas VAP/HAP: • Prior IV antibiotic use within 90 days Additional Risk factors for MDR VAP • Septic shock • ARDS Preceding VAP • At least 5 days hospitalization before VAP onset • Acute Renal Replacement therapy prior to VAP onset High Risk for Mortality • Need for ventilator support due to pneumonia • Septic shock EMPIRIC TREATMENT FOR HAP HAP is defined as a pneumonia not incubating at the time of hospital admission and occurring 48h or more after admission and not associated with ventilation NOT AT HIGH RISK OF MORTALITY AND NO FACTORS INCREASING THE LIKELIHOOD OF MRSA Preferred Regimen: Piperacillin-Tazobactam 4.5g IV q6h OR Cefepime 2g IV q8h OR Meropenem 1g IV q8h Comments: All hospitals should generate their own antibiogram and empiric treatment be guided by the local distribution of pathogens and their antimicrobial susceptibilities. Antibiotic therapy should be de- escalated or modified based on the culture and susceptibility results. Do sputum GS/CS and blood culture to determine etiology of HAP. NOT AT HIGH RISK OF MORTALITY BUT WITH FACTORS INCREASING THE LIKELIHOOD OF MRSA Preferred Regimen: Piperacillin-Tazobactam 4.5g IV q6h OR Cefepime 2g IV q8h OR Meropenem 1g IV q8h OR Aztreonam 2g IV q8h PLUS Vancomycin loading dose of 25-30mg/kg then 15- 20mg/kg IV q8-12h with goal to target trough level to 15-20 mg/mL OR 118 National Antibiotic Guidelines LOWER RESPIRATORY TRACT INFECTION Linezolid 600mg IV q12h HIGH RISK OF MORTALITY AND WITH RISK FACTOR FOR MDR Preferred Regimen: Piperacillin-Tazobactam 4.5g IV q6h or Cefepime 2g IV q8h or Meropenem 1g IV q8h or Aztreonam (for Penicillin Allergy) PLUS Levofloxacin 750 mg IV qd or Amikacin 15-20 mg/kg IV qd PLUS Vancomycin loading dose of 25-30 mg/kg then 15-20mg/kg IV q8-12h with goal to target trough level to 15-20mg/mL or Linezolid 600mg IV q12h DOT: 7 days may be longer depending on clinical radiologic and laboratory improvement EMPIRIC TREATMENT OF VAP VAP is defined as pneumonia occurring >48h after endotracheal intubation and associated with ventilation Preferred Regimen: Piperacillin-Tazobactam 4.5g IV q6h or Cefepime 2g IV q8h or Meropenem 1g IV q8h or Aztreonam 2g IV q8h PLUS Levofloxacin 750mg IV qd or Amikacin 15-20mg/kg IV q24h PLUS Vancomycin loading dose of 25-30mg/kg then 15-20mg/kg IV q8-12h with goal to target trough level to 15-20 mg/mL or Linezolid 600mg IV q12h DOT: 7 days may be longer depending on clinical radiologic and laboratory improvement Comments: In patients with suspected VAP, include coverage for S. aureus, Pseudomonas aeruginosa and other gram negative bacilli in all empiric regimens (gram positive coverage + β lactams-based gram-negative antibiotics with antipseudomonal activity + non-β lactam based antibiotics with antipseudomonal activity). All hospitals should generate their own antibiogram and empiric treatment be guided by the local distribution of pathogens and their antimicrobial susceptibilities Initial treatment should cover for MRSA, Pseudomonas aeruginosa and other gram (-) bacilli. Therapy should be modified based on culture and susceptibility results If culture results show carbapenem resistance or MDR where Colistin is to be used, referral to ID physician is required. Use procalcitonin levels and clinical criteria to guide discontinuation of therapy for both HAP and VAP PATHOGEN-SPECIFIC TREATMENT FOR ADULT AND PEDIATRICS Choice of antibiotic should be based on the results of susceptibility testing Etiology: Methicillin-resistant S. aureus National Antibiotic Guidelines 119 LOWER RESPIRATORY TRACT INFECTION Preferred Regimen: P and A: Vancomycin 40-60mg/kg/dq6h with goal to target trough level to 15-20mg/mL OR Linezolid 30mg/kg/d IV/PO div q8h (up to 12 yrs) or 600mg IV/PO q12h (age>12 y) Etiology: P. aeruginosa Preferred Regimen: P: 1st line: Ceftazidime 100-150mg/kg/d IV div q8h PLUS Amikacin 15mg/kg/d IV or Gentamicin 5-7mg/kg/d IV qd OR Cefepime 150mg/kg/d div q6h 2nd line: Piperacillin-tazobactam 300mg/kg/d IV div q6h OR Meropenem 60mg/kg/d IV div q8h (120mg/kg/d if with meningitis) (Max: 2- 4g/d) OR Ciprofloxacin 20-30mg/kg/day IV div q12h (Max: 1.2 g/d) PLUS Amikacin 15mg/kg/d IV or Gentamicin 5-7mg/kg/d IV qd A: Piperacillin-Tazobactam 4.5g q6h by extended infusion OR Ceftazidime 2g IV q8h OR Cefepime 2g IV q12h or q8h OR Meropenem 1g IV q8h OR Levofloxacin 750mg IV or Ciprofloxacin 400mg IV q8h PLUS Amikacin 15mg/kg/d IV or Gentamicin 5-7mg/kg/d IV qd OR Aztreonam 2g IV q6h for beta-lactam allergy Comments: Choice of antibiotic should be based on upon the results of susceptibility testing. Aminoglycoside monotherapy should be avoided. For patients with VAP/HAP due to P. aeruginosa not in septic shock or at high risk for death and for whom the results of antibiotic susceptibility testing are known, monotherapy with a beta- lactam is preferred. For patients with HAP/VAP due to P. aeruginosa in septic shock or at high risk of death when results of antibiotic testing is available, use combination therapy using 2 antibiotics to which the isolate is susceptible. Use Meropenem only if organism is resistant to all other beta-lactams. Etiology: Acinetobacter species Preferred Regimen: P: Meropenem 60mg/kg/d IV div q8h PLUS Amikacin 15mg/kg/d IV div q8h or Gentamicin 5mg/kg/d IV qd For carbapenem-resistant strains: Ampicillin-sulbactam 100-200mg/kg/d IV div q6h (ampicillin component) or Piperacillin-tazobactam 300mg/kg/d IV div q6-8h PLUS Amikacin 15mg/kg/d IV or Gentamicin 5-7mg/kg/d IV qd 120 National Antibiotic Guidelines LOWER RESPIRATORY TRACT INFECTION For MDR Acinetobacter: Ciprofloxacin 20-30mg/kg/d IV div q12h A: Meropenem 1g IV q8h PLUS Ampicillin-sulbactam 3g IV q6h MDR strain sensitive only to colistin: Combine Colistin with Meropenem Comments: In patients with HAP/VAP caused by Acinetobacter species that is sensitive only to polymyxins, use IV colistin plus Meropenem. Do not use adjunctive rifampicin in patients caused by Acinetobacter species that is sensitive only to colistin. Do not use Tigecycline in patients with HAP/VAP due to Acinetobacter species. The combination of colistin and Meropenem is preferred than tigecycline. Refer to Specialist, if use of Colistin is indicated Etiology: Klebsiella pneumoniae Preferred Regimen: P: 1st line: Meropenem 60mg/kg/d IV div q8h OR Imipenem 60-100mg/kg/day IV div q6h 2nd line: Ciprofloxacin 20-30mg/kg/d IV div q12h OR Piperacillin-tazobactam 300mg/kg/d IV div q8h A: Ceftriaxone 2g IV q24h OR Levofloxacin 750mg IV q24h OR Piperacillin-Tazobactam 4.5g IV q8-6h Regimen for ESBL-producing organisms: Ertapenem 1g IV q24h Comments: Consider patient specific factors such as allergies and co morbidities in choosing an antibiotic. Consider prolonged infusion of carbapenem Etiology: Carbapenem-resistant gram negatives Preferred Regimen: Refer to Specialist Etiology: Achromobacter Preferred Regimen: P: 1st line: Ceftazidime 100-150mg/kg/d IV div q8h PLUS Cotrimoxazole 8mg/kg/d PO div q12h 2nd line: Piperacillin-Tazobactam 300mg/kg/d IV div q6-8h or Meropenem 60mg/kg/d IV div q8h PLUS Cotrimoxazole 8mg/kg/d PO div q12h A: 1st line: Piperacillin-tazobactam 4.5g IV q8-6h OR Meropenem 1g q8h IV 2nd line: Cotrimoxazole 8-10mg/kg/d PO div q6h or q8h (TMP component) National Antibiotic Guidelines 121 LOWER RESPIRATORY TRACT INFECTION Comments: For Meropenem, if with meningitis, increase dose to 120 mg/kg/day div q8h Etiology: Burkholderia cepacia Preferred Regimen: P: 1st line: Meropenem 60mg/kg/d IV div q8h PLUS Amikacin 15mg/kg/d IV or Gentamicin 5-7 mg/kg/d IV qd 2nd line: Ceftazidime 100-150mg/kg/d IV div q8h or Piperacillin-Tazobactam 300mg/kg/d IV div q6-8h or Ciprofloxacin 20-30 mg/kg/d IV div q12h or Cotrimoxazole 8mg/kg/d PO div q12h PLUS Amikacin 15 mg/kg/d IV or Gentamicin 5-7 mg/kg/d IV qd A: 1st line: Meropenem 1g IV q8h OR Ciprofloxacin 400mg IV q12h 2nd line: Cotrimoxazole 8-10 mg/kg/day PO div q6h or q8h (TMP Component) Etiology: Burkholderia pseudomallei Preferred Regimen: P: 1st line: Ceftazidime 150 mg/kg/d IV div q8h OR Meropenem 60mg/kg/d div IV q8h x 7-14d PLUS Cotrimoxazole 8 mg/kg/d PO div q12h (TMP component) x 12- 24 weeks. Some eradication regimens use: Amoxicillin-clavulanate 90 mg/kg/d PO div q8h (amoxicillin component) OR Doxycycline 4mg/kg/d div q12h PLUS Cotrimoxazole 8 mg/kg/d PO div q12h (TMP component) x 12-24 weeks A: 1st line: Ceftazidime 2g IV q6h x 10-14d OR Meropenem 1g IV q8h x 10-14 d Followed by oral therapy: Cotrimoxazole 6-8mg/kg bid (TMP component) plus Folic acid 5mg qd OR Doxycycline 100mg bid OR Amoxicillin-clavulanate 625mg PO tid (for pregnant or sulfa allergy) DOT: 6 months for osteomyelitis and CNS infection, 3 months for other infections Etiology: Escherichia coli Preferred Regimen: P: 1st line: Ceftriaxone 100 mg/kg/d IV div q12-24h PLUS Amikacin 15mg/kg/d IV or Gentamicin 5mg/kg/d qd IV 2nd line: Meropenem 60mg/kg/d IV div q8h PLUS Amikacin 15mg/kg/d IV or Gentamicin 5mg/kg/d IV qd 122 National Antibiotic Guidelines National Antibiotic Guidelines 123 . Philadelphia. • Research Institute for Tropical Medicine.sanfordguide. Joint Statement of PSMID. 46 th ed. eds. (2007) 44 (Supplement 2): S27-S72. Inc.com/. • Philippine Academy of Pediatric Pulmonologists. Fluoroquinolones or Aminoglycosides ESBL strains A: Ertapenem 1g IV q24h Etiology: Enterobacter Preferred Regimen: P: 1st line: Cefepime 100-150mg/kg/d div q8-12h OR Meropenem 60mg/kg/d IV div q8h OR PLUS Amikacin 15mg/kg/d IV or Gentamicin 5-7mg/kg/d IV qd 2nd line: Cotrimoxazole 8mg/kg/day PO div q12h OR Ciprofloxacin 20-30mg/kg/d IV div q12h PLUS Amikacin 15mg/kg/d IV OR Gentamicin 5-7mg/kg/d IV qd A: Piperacillin-Tazobactam 4. Red Book: Report of the Committee on Infectious Diseases. • Kliegman RM. PA: Elsevier. IL: American Academy of Pediatrics. Cephalosporins. Elk Grove Village. PAFP and PCR. 8 th ed. Manila: Philippine Society of Microbiology and Infectious Diseases. Douglas and Bennett’s Principles and Practice of Infectious Diseases. (2016) Nelson Textbook of Pediatrics. • Kimberlin. LOWER RESPIRATORY TRACT INFECTION Pansensitive Strains: A: Choices include: Piperacillin-Tazobactam. 20th ed. • Task Force: Diagnosis. (2014). Empiric Management and Prevention of Community-Acquired Pneumonia in Immunocompetent Adults 2016 Update. CID 2016:63 • Mandell. eds.5g IV q6h OR Cefepime 2g IV q8h OR Meropenem 500mg-1g IV q8h References • Antibiotic Guidelines 2015-2016.org/amp/ guidelines/antibiotic_guidelines. Antimicrobial Resistance Surveillance Program: 2015 Data Summary Report.. 2012 PAPP Update in the Evaluation and Management of Pediatric Community. et al. Retrieved from: http://arsp. et al.pdf • Cherry JD. 7th ed. Quezon City: Philippine Academy of Pediatric Pulmonologists.. Available at: http://webedition. Available at: http://www. PCCP.ph/arsp-data-summary- report-2015/ • The Sanford Guide to Antimicrobial Therapy 2016. et al. 30th ed.hopkinsmedicine. (2015).com. Treatment Recommendations for Adult Inpatients. Philadelphia. • Mandell LA. 2015.Acquired Pneumonia. DW et al. Inc. PA: Saunders. ed. • Management of Adults with Hospital-acquired and Ventilator associated Pneumonia. Feigin and Cherry's Textbook of Pediatric Infectious Diseases.. 2016 Clinical Practice Guideline by the Infectious Diseases Society of American Thoracic Society. Clin Infect Dis. 1st line ORAL PARENTERAL Cloxacillin 50-100mg/kg/d in 4 doses Oxacillin (Max: 2g/d) Mild to moderate infections: OR 100-150mg/kg/d IV/IM in 4 doses Cephalexin (Max: 4 g/d) Mild to moderate infections: Severe infections: 150-200mg/kg/d 25-50mg/kg/d in 3-4 doses IV/IM in 4-6 doses (Max: 12 g/d) OR Severe infections: Cefazolin 75-100mg/kg/d in 3-4 doses (Max: Mild to moderate infections: 4g/d) 50mg/kg/d IV/IM in 3-4 doses (Max: 3g/d) Severe infections: 100-150mg IV/IM in 3-4 doses (Max: 6g/d) DOT: 5-10d 2nd line ORAL PARENTERAL Clindamycin 10-30mg/kg/d PO in 3-4 Clindamycin 25-40mg/kg/d IV in 3-4 doses (Max: 1.: 30mg/kg/d in 3 doses DOT: 7-10d ≥12 yrs.: 1200mg/d in 2 doses Severe infections: Same (Max: 1. Note: needle aspiration is inadequate. boils.: 1200mg/d in 2 doses Mild to moderate infections: Severe infections: Same <12 yrs. aureus: Methicillin sensitive (MSSA). Preferred Regimen: Incision and drainage is the mainstay of therapy.7g/d) OR Cotrimoxazole 8-12mg/kg/d in 2 Vancomycin 40-60 mg/kg/d IV in 4 doses (TMP component) (Max: doses (Max: 4 g/d) OR 320mg/d) OR Linezolid Doxycycline 2-4mg/kg/d in 1-2 doses Mild to moderate infections (Max: 200mg/d) OR <12 yrs.: 30mg/kg/d in 3 doses Linezolid ≥12 yrs.8g/d) OR doses (Max: 2. furuncles Etiology: S. and boil or abscess is <5 cm in 124 National Antibiotic Guidelines .2g/d) DOT: 7-10d Comments: May treat patients with incision and drainage only and in outpatient setting if there is no diabetes or immunosuppression. SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS I. SKIN INFECTIONS A. Methicillin resistant (MRSA) Community-associated MRSA is of increasing concern for effective management. Skin abscess. limited recent clinical experience. Recurrent furunculosis Etiology: S.. Systemic agents should be used in patients who are toxic. face. nose. or • Those with SIRS and hypotension Doxycycline is not recommended for age <8 yrs. Preferred Regimen: Treat as for furuncles and boils For decolonization: If patient and physician wish to attempt decolonization. boils) in an otherwise healthy host.SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS diameter. or who have associated cellulitis. associated septic phlebitis. bacteriostatic. Oral therapy PLUS I&D may be effective in abscess >5 cm in diameter and in multiple abscesses. Patient should have no active skin infections and is otherwise a healthy host. hand and genitalia). Empirical antibiotic therapy using parenteral agents (in absence of specific culture and sensitivity data select an agent with activity against MRSA) follow up culture and sensitivity results. look for complications and consider: Incision and drainage: culture abscess and blood. is as effective as use of National Antibiotic Guidelines 125 .g... involving multiple sites of infection) or rapid progression in presence of cellulitis. or white blood cell count >12. and inguinal area skin. aureus (MSSA and MRSA) infection presenting as recurrent furunculosis (abscesses. B.g. Avoid systemic antibiotics. presence of systemic inflammatory response syndrome (SIRS). such as temperature >38°C or <36°C.. If no response after 2-3 days with oral antibiotics. lack of response to I&D alone.000 or <4000 cells/μL. e. An antibiotic active against MRSA is recommended for any of the following: • Patients with carbuncles or abscesses who have failed initial recommended antibiotic treatment against MSSA • Those with markedly impaired host defenses.g. Antibiotic therapy is recommended for abscesses with the following conditions: severe or extensive disease (e. associated comorbidities or immunosuppression. who have extensive disease. Mupirocin ointment in anterior nares and under fingernails bid x 7d PLUS Chlorhexidine 4% shower daily x 7d One report indicates that bleach baths (tub of warm water with ¼ cup of 6% sodium hypochlorite (household bleach) for 15 minutes. tachypnea >24 breaths per minute. extremes of age abscess in areas difficult to drain (e. tachycardia >90 beats per minute. throat. Nares-only culture missed 48% of colonized individuals. Need to culture multiple sites. aeruginosa. Hot packs for comfort. particularly the CA-MRSA. is usually self-limited and no treatment is indicated. 1st line: Topical antibiotic therapy for mild cases of folliculitis. Hot tub folliculitis is almost always caused by P. SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS chlorhexidine shower body washes. Systemic therapy in cases of large and multiple lesions should be treated with Penicillinase resistant antibiotics (Cloxacillin or cephalexin). C. Preferred Regimen: Usually self-limiting. PVL is a virulence factor of S. Recommended intranasal preparation of mupirocin is not available locally. aureus Systemic antibiotics is recommended for the treatment of active infection ONLY and is not routinely recommended for decolonization. no therapy indicated. Some local experts use topical mupirocin for nasal decolonization. Could use mupirocin ointment if staphylococcal etiology. Incision and drainage is the mainstay of therapy. aeruginosa (from exposure to inadequately chlorinated swimming pools. Intermittent bathing with chlorhexidine 4% or dilute bleach baths/6% sodium hypochlorite (1/4 cup of bleach in a quarter-filled bathtub or 13 gallons water or 1 tsp bleach in 1 gallon of water) for 15 minutes 3x a week can be used to significantly reduce skin load of S. aureus (most common). Topical decolonization is considered if patient has 2 or more episodes in 1 year or other household members develop infection. 126 National Antibiotic Guidelines . whirlpools and hot tubs). Only a modest positive effect in a prospective. aureus which correlates with chronic recurrent furunculosis. P. Oral agents: Cloxacillin 50-100mg/kg/d in 4 doses (Max: 2g/d) OR Cephalexin Mild to moderate infections: 25-50mg/kg/d in 3-4 doses. Folliculitis Etiology: S. randomized single-blinded controlled trial. Aeromonas hydrophila (following water exposure). produce a toxin named Panton- Valentin leukocidin (PVL) and are associated with severe infections. Comments: Some strains of MRSA. Severe infections: 75-100mg/kg/d in 3-4 doses (Max: 4 g/d) DOT: 7-10 days Comments: Folliculitis is infection of the hair follicle with purulent exudate in the epidermis. aureus producing an exfoliative toxin. Impetigo and ecthyma Etiology Preferred Regimen Streptococcus sp. C. Staphylococcal scalded skin syndrome Etiology: Result of colonization of skin or mucosa by strain of S. G are less DOT: 7-12d common) Methicillin-susceptible Cloxacillin 50-100mg/k/d in 4 doses Staphylococcus aureus bullous (Max: 12 g/d) OR impetigo: Cephalexin Mild to moderate infections: 25-50 mg/kg/d in 3-4 doses Severe infections: 75-100mg/kg/d in 3-4 doses (Max: 4 g/d) DOT: 7d Suspected or confirmed Clindamycin 30-40mg/k/d in 3-4 doses methicillin-resistant (Max: 1. Preferred Regimen: 1st line: Oral Agent: Cloxacillin 50-100mg/kg/d in 4 doses (Max: 2g/d) Parenteral Agents: Oxacillin Mild to moderate infections: 100-150mg/kg/d IM/IV in 4 doses (Max: 4g/d) Severe infections: 150-200mg/kg/d in 4-6 doses (Max: 12g/d) OR Cefazolin Mild to moderate infections: 50mg/kg/d IM/IV in 3-4 doses (Max: 3g/d) Severe infections: 100-150 mg in 3-4 doses (Max: 6 g/d) DOT: 7-10d for MSSA 2nd line (if MRSA is suspected): Oral agent: Clindamycin PO 10-30mg in 3-4 doses (Max: 1.8 /d) Parenteral agents: Clindamycin 25-40mg/kg/d in 3-4 doses (Max: 2.8 g/d) OR Staphylococcus aureus bullous Cotrimoxazole 8-12mg/kg/d in 2 doses impetigo: (TMP component) (Max: 320mg/d) OR National Antibiotic Guidelines 127 . Pathogen may be MSSA or MRSA.SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS D.7g/d) OR Vancomycin 40-60mg/kg/d IV in 4doses (Max: 4g/d) E. (Group A Mupirocin ointment 2% tid OR causes honey crust impetigo) Fusidic acid 2% cream bid (Group B. child care groups. ecthyma heals with scarring. Oral therapy for ecthyma and impetigo should be a 7-day regimen with an agent active against S. with the dried discharge forming honey- colored crusts on an erythematous base. SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS Doxycycline 2-4mg/kg/d in 1-2 doses (Max: 200mg/d) DOT: 7d Comments: Impetigo can be either bullous or nonbullous. aureus unless cultures yield streptococci alone (when oral penicillin is the recommended agent). and S. and those with non-bullous impetigo in multiple family members. These lesions may rupture. aureus. Erysipelas Etiology: Streptococcus pyogenes (Groups A. or both in combination. Impetigo begins as erythematous papules that rapidly evolve into vesicles and pustules that rupture. erythematous ulcers with adherent crusts. Gram stain and culture of the pus or exudates from skin lesions of impetigo and ecthyma are recommended to help identify whether S. creating crusted. often surrounded by a collar of the roof’s remnants. often with surrounding erythematous edema. Topicals can be used for patients with limited number of lesions and appropriate for those with mild. resulting in circular. G) is the major cause 128 National Antibiotic Guidelines . no more than 3 areas of impetigo or an area of infection <5 cm. Unlike impetigo. F. Most frequently occurs in children in hot. B. aureus that produce a toxin that cleaves the dermal-epidermal junction to form fragile. An antibiotic active against MRSA is recommended for the following: • Patients who have failed initial recommended antibiotic treatment against MSSA • Those with markedly impaired host defenses • Those with SIRS and hypotension Echthyma is a consequence of neglected impetigo. humid environments. aureus and/or a GABHS is the cause. Streptococcus pyogenes infection manifests as “honey crust” lesions or “punched out” ulcers (ecthyma). thin roofed vesicopustules. Oral antibiotics are indicated for patients with more extensive areas of infection (those with multiple lesions) if infection is not resolving or is worsening. Nonbullous impetigo can be caused by β-hemolytic streptococci or S. localized areas of impetigo. or athletic teams. Lesions begin as vesicles that rupture. or those with systemic symptoms. aureus and/or streptococci may be the cause. C. erythematous erosions. Bullous impetigo is caused by strains of S. with Severe infections: Erythromycin 20mg/kg/d IV in 4 doses (Max: 4g/d) (DOC) OR Vancomycin 40-60mg/kg/d IV in 4 doses (Max: 4g/d) Treat IV until afebrile.000-150. ≥12 yrs. These infections cause rapidly spreading areas of erythema. National Antibiotic Guidelines 129 . sometimes exhibiting blebs filled with yellowish fluid. 5 days for Azithromycin For erysipelas involving the face: 1st line: Vancomycin 40-60 mg/kg/d IV in 4 divided doses (Max: 4 g/d) 2nd line: Linezolid Mild to moderate infections: <12 yrs.5 g/d) OR Cephalexin Mild to moderate infections: 25-50mg/kg/d in 3-4 doses Severe infections: 75-100mg/kg/d in 3-4 doses (daily adult dose: 4 g/d) If penicillin allergic: Azithromycin (Children ≥6 months): 10 mg/kg PO on d1 (Max: 500 mg/d) followed by 5 mg/kg on d2-5 qd (Max: 250 mg/d) OR Clindamycin 30-40 mg/kg/d PO in 3-4 doses (Max: 1.SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS Preferred Regimen: 1st line: Penicillin is the drug of choice except in patients with penicillin allergy Parenteral Agents: Penicillin G Mild to moderate infections: 100.: 30mg/kg/d in 3 doses. then may shift to oral agents as outpatient. longer if patient is bacteremic Comments: Erysipelas is an unusual type of streptococcal infection involving the skin and sometimes the adjacent mucous membranes. It is an elevated erythematous lesion. Oral agents: Penicillin VK 25-30mg/kg/d in 3-4 doses (Max: 2 g/d) OR Amoxicillin 25-50mg/kg/d in 3 doses (Max: 1. oral agents are used also as out-patient therapy for less ill patients. which may crust over after rupture.000 U/kg/d in 4 doses (Max: 8 MU/d) Severe infections: 200.000-300.: 1200mg/d in 2 doses Severe infections: same DOT: 7-10 days.8 g/d) DOT: 7-10 days or until the patient is afebrile for 3-5 days.000 U/kg/d in 6 doses (Max: 24 MU/d) OR Cefazolin Mild to moderate infections: 25-50mg/kg/d in 3 doses (Max: 3g/d) Severe infections: 100-150mg/kg/d in 3 doses (Max: 6 g/d) If penicillin or cephalosporin allergic. sometimes accompanied by lymphangitis and inflammation of the regional lymph nodes. S. aureus) ORAL PARENTERAL Cloxacillin 50-100 mg/kg/d PO in 4 Oxacillin doses (Max: 2 g/d) Mild to moderate infections: 100- 150mg/kg/d IV/IM in 4 doses (Max: 4 g/d) Severe infections: 150-200mg/kg/d IV/IM in 4-6 doses (Max: 12 g/d) OR Cefazolin Mild to moderate infections: 50mg/ kg/d in 3 doses (Max: 3g/d) Severe infections: 100-150mg in 3 doses (Max: 6g/d) DOT: 7-10d is recommended but should be individualized on the basis of the patient’s clinical response 2nd line (For suspected/confirmed MRSA): ORAL PARENTERAL Clindamycin 30-40mg/kg/d in 3-4 Clindamycin 25-40mg/kg/d IV in 3-4 doses (Max: 1. If erysipelas-like on the face. must treat as if MRSA is present. aureus erysipelas of the face can mimic streptococcal erysipelas of an extremity. If in doubt. Sudden onset of rapidly spreading red edematous tender plaque- like skin on the face in an otherwise healthy host. Cellulitis (purulent) Etiology: Most cases of cellulitis are attributed to S. tenderness. And Staph. Preferred Regimen: 1st line (empiric therapy to cover for S. G. The skin surface may resemble an orange peel (peau d’orange) due to superficial cutaneous edema surrounding hair follicles and causing skin dimpling because the follicles remain tethered to the underlying dermis. aureus is present. can clinically distinguish between red indurated demarcated inflamed skin of erysipelas (S.8g/d) OR doses Max: 2. Bedside ultrasound may be helpful in detection of deep S. and warmth. Usually.7g/d) OR Vancomycin 40-60mg/kg/d IV in 4 130 National Antibiotic Guidelines .) is rare. If S. pyogenes) from the abscess of S. look for loculated purulence. SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS swelling. aureus abscess(es). aureus. Mixed infection (Strep. treat for both. Community-associated MRSA can mimic erysipelas. need incision and drainage. Dual infection is rare. aureus. .: 30mg/kg/d in 3 doses doses (Max: 200mg/d) ≥12 yrs. Group A. Cellulitis (non-purulent) Etiology: Usually caused by beta-hemolytic streptococci (e. and adults: 1200mg/d in 2 doses Severe infections: same DOT: 7-10 days is recommended but should be individualized on the basis of the patient’s clinical response Comments: Cellulitis refers to infection involving the deeper dermis and subcutaneous fats.SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS Cotrimoxazole 8-12mg/kg/d in 2 doses (Max: 4g/d) OR doses (TMP component) (Max: Linezolid 320mg/d) OR Mild to moderate infections: Doxycycline 2-4mg/kg/d in 1-2 <12 yrs. G streptococci) and MSSA Preferred Regimen: 1st line (empiric therapy to cover both Strep and Staph) ORAL PARENTERAL Cephalexin Cefazolin Mild to moderate infections: Mild to moderate infections: 50mg/kg/d 25-50mg/kg/d in 3-4 doses in 3 doses (Max: 3g/d) Severe infections: 75-100mg/kg/d in Severe infections: 100-150mg in 3 doses 3-4 doses (Max: 4g/d) OR (Max: 6g/d) OR Amoxicillin-clavulanic acid Ampicillin-sulbactam 7:1 formulation: 25-45mg/kg/d in 2 Mild to moderate infections: 100- doses (amoxicillin component) 200mg/kg/d in 4 doses (Max:4 g/d) (Max: 1.g. C.75 g/d) Severe infections: 200mg/kg/d in 4 4:1 formulation: 20-40 mg/kg/d PO doses (ampicillin component) (Max: 8 in 3 doses (amoxicillin component) g/d) (Max: 1.g. cellulitis associated with purulent drainage or exudate in the absence of a drainable abscess). An antibiotic active against MRSA is recommended for the following: • Patients with carbuncles or abscesses who have failed initial recommended antibiotic treatment against MSSA • Those with markedly impaired host defenses • Those with SIRS and hypotension H. empirical therapy for S. (e. For purulent cellulitis.5g) National Antibiotic Guidelines 131 . B. aureus is recommended and empirical therapy for infection due to β-hemolytic streptococci is likely unnecessary. 7 g/d) OR Cotrimoxazole 8-12 mg/kg/d in 2 Vancomycin 40-60 mg/kg/d IV in 4 doses doses (TMP component) (Max: 4 g/d) OR (Max: 320mg/d) Linezolid PLUS Mild to moderate infections: Amoxicillin 25-50 mg/kg/d in 3 doses <12 yrs.g. I.5 g/d) OR ≥12 yrs.. An antibiotic active against MRSA is recommended for the following: • Patients who have failed initial recommended antibiotic treatment against MSSA • Those with markedly impaired host defenses • Those with SIRS and hypotension Trimethoprim-sulfamethoxazole and doxycycline should not be used as a single agent in the initial treatment of cellulitis because their activity against β-hemolytic streptococci is not well defined.g. may combine Cotrimoxazole or a tetracycline with a β-lactam (e. Empirical coverage for CAMRSA is recommended in patients who do not respond to B-lactam therapy and may be considered in those with systemic toxicity. amoxicillin). 132 National Antibiotic Guidelines .. and adults: 1200 mg/d in 2 Doxycycline 2-4 mg/kg/d in 1-2 doses doses (Max: 200 mg/d) Severe infections: same PLUS Amoxicillin 25-50 mg/kg/d in 3 doses (Max: 1. gram-positive cocci. and fungi. 2nd line (For suspected/confirmed MRSA): ORAL PARENTERAL Clindamycin 30-40mg/kg/d in 3-4 Clindamycin 25-40 mg/kg/d IV in 3-4 doses (Max: 1. gram- negative bacilli. SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS DOT: 7-10d is recommended but should be individualized on the basis of the patient’s clinical response.8 g/d) OR doses (Max: 2.: 30 mg/kg/d in 3 doses (Max: 1. If coverage for both β-hemolytic streptococci and CA-MRSA is desired. Non-infected burns Etiology: Wide spectrum of potential pathogens: e.5 g/d) DOT: 7-10d is recommended but should be individualized on the basis of the patient’s clinical response Comments: Non-purulent cellulitis is defined as cellulitis with intact skin and no evidence of purulent discharge. Resolves spontaneously. S.SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS Preferred Regimen: 1st line: Silver sulfadiazine cream (mixture of silver nitrate and sodium sulfadiazine) 2nd line: Topical antimicrobials Stage I (epidermis) and II A and B wounds (partial thickness. Steven Johnson's Syndrome. Burns with secondary infections Etiology: S. probably due to margination of WBCs in the wound rather than bone marrow suppression. E. epidermidis. Not facial burns for fear of eye irritation or injury.. Preferred Regimen: 1st line 2nd line Oxacillin Vancomycin 40-60mg/kg/d IV in 4 Mild to moderate infections: 100-150 doses (Max: 4g/d) PLUS mg/kg/d IV/IM in 4 doses (Max: 4g/d) Meropenem 60-120mg/kg/d in 3 div Severe infections: 150-200mg/kg/d doses (Max: 6g/d) IV/IM in 4-6 doses (Max: 12g/d) OR PLUS Vancomycin 40-60mg/kg/d IV in 4 Ceftazidime doses (Max: 4g/d) PLUS Mild to moderate infections: 90. Transient leukopenia. aureus. Hyponatremia and hypochloremia can occur Rarely. Activity vs Gram-negative bacteria less broad than silver sulfadiazine cream. Turns skin black. J. Silver nitrate solution Messy. Fungi (rare) and Herpes virus (rare). E.5% solution Anti-tetanus prophylaxis is indicated Comments: Silver sulfadiazine Minor adverse effects: Sulfonamide allergy. Cefepime 150mg IV/IM in 3 doses (Max: 3g/d) Mild to moderate infections: 100mg Severe infections: 200-300mg IV/IM in 2 doses (Max: 4g/d) in 3-4 doses (Max: 6g/d) Severe infections: 100-150mg in 2-3 doses (Max: 6g/d) National Antibiotic Guidelines 133 . Some believe drug impairs re-epithelialization of the burn wound. S. silver is toxic to keratinocytes and fibroblasts. Methemoglobinemia can occur. faecalis. coli. Enterobacter sp. superficial and deep): Silver nitrate 0. aeruginosa. P. pyogenes. 5g/d) PLUS Ceftazidime Mild to moderate infections: 90-150mg IV/IM in 3 doses (Max: 3 g/d) Severe infections: 200-300mg IV/IM in 3 or 4 doses (Max: 6 g/d) OR Piperacillin-Tazobactam Severe infections: 240-300mg/kg/d in 3-4 doses (piperacillin component) (Max: 16g/d) Lower dose is recommended for patients <6 months of age: 150-300mg/kg/d in 3-4 doses (piperacillin component) (Max: 16 g/d) 134 National Antibiotic Guidelines . Streptococcus sp. aureus toxic shock syndrome (TSS). aureus. An antibiotic active against MRSA is recommended for the following: • Patients who have failed initial recommended antibiotic treatment against MSSA • Those with markedly impaired host defenses • Those with SIRS and hypotension K. coli. Gram positive cocci and gram-negative bacteria esp.7g/d) PLUS Amikacin 15 -22. Gram positive cocci.150mg/kg/d IV/IM in 4 doses (Max: 4g/d) Severe infections: 150-200mg/kg/d IV/IM in 4-6 doses (Max: 12g/d) 2nd line: Clindamycin 25-40mg/kg/d in 3-4 doses (Max: 2. Other complications of concern in critically ill burn patient: S. Gram positive organisms prevail in the early postburn period: Staph (CONS and S. mixed flora Preferred Regimen: 1st line: Oxacillin Mild to moderate infections: 100. P. aureus and MRSA were the most common causes of burn infections in patients with relatively small burns <30% of BSA. Micrococcus. Strep. These then are replaced by fungi (Candida) and gram-negative bacteria: P. aeruginosa. Puncture wound Etiology: S. Pediococcus. and Enterococcus. Enterobacter cloacae. aureus).5mg/kg/d in 1-3 doses (max 1. SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS Comments: Ideal care is in dedicated burn unit. suppurative phlebitis. pneumonia. aeruginosa were common causes in patients with extensive burns>30% of BSA. E. Klebsiella pneumonia and Serratia marcescens. Acinetobacter are also found more often in patients with more severe burns and comorbidities.. including S. 5g/d) National Antibiotic Guidelines 135 .5g) OR Ciprofloxacin 20-30mg/kg/d PO in 2 doses (Max: 1. Use clindamycin instead of oxacillin if anaerobes or MRSA are suspected. post-trauma Etiology: Polymicrobic (microbial flora dependent on nature of the trauma): S. Streptococcus sp. Pseudomonas sp.: 30mg/kg/d in 3 doses 25-50mg/kg/d in 3-4 doses ≥12 yrs. C.g. (water exposure). add amikacin and ceftazidime or piperacillin-tazobactam.. If P. Enterobacteriaceae. Any evidence of deep infection. L. C. perfringens. afebrile patient 1st line 2nd line (For suspected/confirmed MRSA): Oral agents Doxycycline 2-4mg/kg/d in 1-2 doses Cloxacillin 50-100mg/kg/d in 4 (Max: 200mg/d) OR doses (Max: 2g/d) OR Linezolid Cephalexin Mild to moderate infections: Mild to moderate infections: <12 yrs. is a strong indication for exploration and addition of an anti-pseudomonal agent. Aeromonas sp. MRSA). tetani. aeruginosa infection is highly considered (e. (aerobic and anaerobic). Wound infection. wound is associated with nail through rubber-soled footwear). mild or moderate. Acinetobacter species Preferred Regimen: Uncomplicated.75g/d) 4:1 formulation: 20-40mg/kg/d PO in 3 doses (amoxicillin component) (Max: 1. especially if it persists or develops more than 72h after injury and particularly in children. and adults: 1200mg/d in 2 doses Severe infections: Severe infections: Same 75-100mg/kg/d in 3-4 doses (Max: 4 g/d) If Gram-negative bacilli are suspected: PLUS Amoxicillin-clavulanic acid Mild to moderate infections 7:1 formulation: 25-45mg/kg/d PO in 2 doses (amoxicillin component) (Max: 1.SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS Lower dose is recommended for patients <6 months of age: 150-300mg/kg/d in 3-4 doses (piperacillin component) (Max: 16g/d) Comments: Refer to WHO prevention and management of wound infection. aureus (MSSA. afebrile patients) 1st line 2nd line Clindamycin 30-40mg/kg/d in 3-4 Linezolid doses (Max: 1. C.8g/d) OR Mild to moderate infections: Cotrimoxazole 8-12mg/kg/d in 2 <12 yrs. SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS Complicated. G) Preferred Regimen: Mild to moderate infections (without sepsis. Obtain culture and sensitivity. severe. may have inducible resistance to clindamycin. Give tetanus prophylaxis and vaccine if indicated.: 30mg/kg/d in 3 doses doses (TMP component) 136 National Antibiotic Guidelines . M. S. (Group A. An antibiotic active against MRSA is recommended for the following: • Patients who have failed initial recommended antibiotic treatment against MSSA • Those with markedly impaired host defenses • Those with SIRS and hypotension If S. aureus. Streptococcus sp. B. non-GU tract surgery) Etiology: skin flora. check gram stain. febrile patient 1st line 2nd line Parenteral agents Parenteral agents Piperacillin-Tazobactam Meropenem Severe infections: 240-300mg in Severe infections: 60-120mg/kg/d in 3 3 doses (piperacillin doses (Max: 6g/d) PLUS component) (Max: 16 g/d). make sure lab checks if using the latter. Post-operative wound infection (non-GI tract. and adults: 1200mg/d IV in 2 4 div doses (Max: 4g/d) doses Severe infections: same PLUS Ciprofloxacin 20-30mg/kg/d IV in 2 -3 doses (Max: 1. aureus are erythromycin-resistant in vitro. effective and does not appear to cause arthropathy.2g/d) Comments: Debridement of wound may be indicated. Vancomycin 40-60mg/kg/d IV in 4 div Lower doses are recommended doses (Max: 4g/d) for patients <6months of age: OR 150-300mg/kg/d in 3-4 doses Linezolid (piperacillin component) (Max: Mild to moderate infections: 16g/d) PLUS <12 yrs.: 30mg/kg/d IV in 3 doses Vancomycin 40-60mg/kg/d IV in ≥12 yrs. Ciprofloxacin has been used most extensively in children and adolescents and appears to be well tolerated. g. An antibiotic active against MRSA is recommended for the following: • Patients who have failed initial recommended antibiotic treatment against MSSA • Those with markedly impaired host defenses or • Those with SIRS and hypotension. and adults: 1200mg/d in 2 doses Mild to moderate infections: same Severe infection: with sepsis.2g/d) PLUS Metronidazole 30mg/kg/d in 3-4 doses (Max: 4 g/d) Comments: Surgical site infections require prompt and wide opening of the surgical incision. aureus (MSSA. Bacteroides species: e. MRSA). if source control is incomplete or in immunocompromised patients.. Antimicrobial therapy is recommended for deep incisional surgical site infections if systemic signs of sepsis are present. N. Coliform species: e. E.7g/d) Linezolid Mild to moderate infections: <12 y: 30 mg/kg/d IV in 3 doses ≥12 y and adults: 1200 mg/d IV in 2 doses Severe infections: same PLUS Ciprofloxacin 20-30mg IV in 2-3 doses (Max: 1. febrile patients 1st line 2nd line Parenteral agents Vancomycin 45-60mg/kg/d IV in 3-4 Clindamycin 25-40mg/kg/d IV in 3-4 doses (Max: 4g/d) OR doses (Max: 2.SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS (Max: 320mg/d) ≥12 yrs.. Other anaerobic bacteria Preferred Regimen: Mild infections 1st line 2nd line Amoxicillin-clavulanic acid Amoxicillin-clavulanic acid Mild to moderate infections Mild to moderate infections 7:1 formulation: 25-45mg/kg/d PO 7:1 formulation: 25-45mg/kg/d PO in in 2 doses (amoxicillin component) 2 doses (amoxicillin component) National Antibiotic Guidelines 137 . fragilis.g. Post-operative wound infection (GI tract or GU tract surgery) Etiology: skin flora. antimicrobial therapy should cover gram-positive organisms. GI and vaginal flora. B. In patients who have had clean operations. coli. S. 75g/d) 4:1 formulation: 20-40mg/kg/d PO 4:1 formulation: 20-40 mg/kg/d PO in in 3 doses (amoxicillin component) 3 doses (amoxicillin component) (Max: 1.: 30mg/kg/d in 3 doses 16g/d) PLUS ≥12 yrs.Linezolid IV 300mg/kg/d in 3-4 doses (Max: <12 yrs. An antibiotic active against MRSA is recommended for the following: 138 National Antibiotic Guidelines . aureus (MRSA) is suspected PLUS: PLUS: Clindamycin 30-40mg/kg/d in 3-4 Cotrimoxazole 8-12mg/kg/d in 2 doses (Max: 1. obtain culture and sensitivity. aureus (MRSA) is suspected If S. antimicrobial therapy should cover both gram-positive and gram-negative organisms.75g/d) (Max: 1. and adults: 1200mg/d in 2 Vancomycin 40-60mg/kg/d IV in 3-4 doses doses (Max: 4g/d) PLUS OR Meropenem 60-120mg/kg/d IV in 3 Ceftriaxone 100mg/kg/d IV in 1 or 2 doses (Max: 6g/d) doses (Max: 4g/d) PLUS Metronidazole 30mg/kg/d IV in 3-4 doses (Max: 4g/d) PLUS Vancomycin 40-60mg/kg/d IV in 3-4 doses (Max: 4g/d) OR Cefotaxime 100-200mg/kg/d IV in 3- 4 doses (Max: 12g/d) PLUS Metronidazole 30mg/kg/d IV in 3-4 doses (Max: 4g/d) PLUS Vancomycin 40-60mg/kg/d IV in 3-4 doses (Max: 4g/d) Comments: In patients who have had procedures on the GI or GU tract. and pack wound. If with skin incision.5g) If S. usually remove sutures to drain wound.8g/d) doses (TMP component) (Max: 320mg/d) Severe infection 1st line 2nd line Piperacillin-Tazobactam IV Vancomycin 40-60mg/kg/d IV in 3-4 Severe infections: 240-300mg/kg/d doses (Max: 4g/d) PLUS in 3 doses (piperacillin component) Meropenem 60-120mg/kg/d IV in 3 (daily adult dose: 16 g/d). SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS (Max: 1. Lower doses (Max: 6g/d) doses are recommended for OR patients <6 months of age: 150.5g) (Max: 1. abscessus. CAT. DOG AND MAMMAL BITE A. aureus. Enterococcus Preferred Regimen: 1st line 2nd line Penicillin G Clindamycin 25-40mg/kg/d IV in 3-4 Mild to moderate infections: doses (Max: 2.5mg/kg IV/IM in 1-3 Severe infections: 200.000 doses (Max: 1. soil contaminated Etiology: S. Fusobacterium sp. Nocardia asteroids.000.000-300. EF-4.. Bite wound from cat Etiology: Pasteurella species.5g) in 2 doses (Max: 1g/d) or Parenteral agent Doxycycline 2-4mg/kg/d PO/IV in 1-2 Ampicillin/sulbactam doses (Max: 200mg/d) National Antibiotic Guidelines 139 . Actinomyces. Aspergillus.7g/d) in 2 doses (amoxicillin component) OR (Max: 1. Nocardia otitidis-caviarum. Anaerobes. Wound infection. Enterobacter cancerogenus. Group A Strep Preferred Regimen: 1st line 2nd line Oral agent Clindamycin Amoxicillin-clavulanic acid 30-40 mg/kg/d PO in 3-4 doses (Max: Mild to moderate infections 1.8g/d) or 25-40 mg/kg/d IV in 3-4 7:1 formulation: 25-45mg/kg/d PO doses (Max: 2.5g/d) II. aureus. GABHS. M. M.150. gram negative enterics.7g/d) 100.. Bacteroides sp.000U/kg/d in 4 doses PLUS (Max: 8MU/d) Amikacin 15-22.75g/d) Metronidazole 30mg/kg/d in 3-4 4:1 formulation: 20-40mg/kg/d PO doses (Max: 4g/d) PLUS in 3 doses (amoxicillin component) Cefuroxime axetil 20-30mg/kg/d PO (Max: 1.SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS • Patients with carbuncles or abscesses who have failed initial antibiotic treatment • Those with markedly impaired host defenses • Those with SIRS and hypotension O. fortuitum.5mg/kg IV/IM in 1-3 doses (Max: 1. S.5g/d) U/kg/d in 6 doses (Max: 24MU/d) PLUS Amikacin 15-22. Capnocytophaga sp.. (http://www.g. Dog bite Only 5% of dog bite wounds get infected. diabetes). Staphylococcus aureus. Capnocytophaga sp. Fusobacterium sp. Preemptive early antimicrobial therapy for 3-5 days is recommended for patients who are immunocompromised. Etiology: Pasteurella canis.ph/sites/default/files/basic-page/ao2014-0012 pdf) 140 National Antibiotic Guidelines . P. have advanced liver disease. refer to: DOH AO 2014- 0012. 80% get infected. multocida infection develops within 24 h. are asplenic. Consider rabies and tetanus post-exposure prophylaxis and vaccination. Cephalexin and clindamycin..doh. Treat only if the bite is severe or patient presents with co-morbidity (e. EF-4. have moderate to severe injuries. especially to the hand or face. or have injuries that may have penetrated the periosteum or joint capsule. multocida is resistant to dicloxacillin.. irrigation and debridement are most important. have preexisting or resultant edema of the affected area. Many strains appear susceptible to azithromycin but no clinical data. P. Culture and treat empirically. SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS Mild to moderate infections: 100- 200mg/kg/d in 4 doses (Max: 4g/d) Severe infections: 200mg/kg/d in 4 doses (ampicillin component) (Max: 8g/d) Comments: Cleaning. B.gov. Observe for osteomyelitis. Bacteroides sp. Preferred Regimen: 1st line 2nd line Amoxicillin-clavulanic acid 875/125mg Clindamycin 300mg PO qid PO bid or 500/125mg PO tid Ampicillin/sulbactam 3g IV q6h Comments: For rabies post-exposure prophylaxis and vaccination.. tendon sheath) and require careful evaluation.5g) Clindamycin 30-40mg/kg/d PO in 3-4 doses Parenteral agent (Max: 1. Resistant to clindamycin. X-rays should be obtained. nafcillin/oxacillin. Bacteroides sp. Peptostreptococcus sp. Staphylococcus aureus (29%). (41%).g. Eikenella sp.: Susceptible to fluoroquinolones and beta-lactam-beta lactamase inhibitor combinations. Potential risk of transmitting blood-borne pathogens if injury contaminated with another's blood. bone.2g/d) Comments: Cleaning. Human bite Etiology: Viridans streptococcus (100%). (82%). ampicillin-sulbactam. joint. Staphylococcus epidermidis (53%).SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS C.g.7g/d) Mild to moderate infections: OR 100-200mg/kg/d in 4 doses (Max: 4g/d) Metronidazole 30mg/kg/d in 3-4 Severe infections: 200mg/kg/d in 4 doses (Max: 4g/d) doses (ampicillin component) (Max: PLUS 8g/d) Ciprofloxacin 20-30mg/kg/d PO in 2 doses DOT: 5 days (Max: 1.. For bites inflicted by hospitalized patients.5g/d) or 20-30mg/kg/d IV in 2-3 doses (Max: 1. For clenched fist or hand injuries. X-ray would evaluate for fracture or foreign body. Eikenella sp. Clenched fist (and other hand) bite wounds pose risk for deep infections (e. irrigation and debridement are most important. e. cephalexin/ cefazolin. Corynebacterium sp.8g/d) or 25-40mg/kg/d IV in Ampicillin/sulbactam 3-4 doses (Max: 2. (15%). (26%) Preferred Regimen: 1st line 2nd line Oral agent Piperacillin-tazobactam Amoxicillin-clavulanic acid Severe infections: 240-300mg/kg/d Mild to moderate infections in 3 doses (piperacillin component) 7:1 formulation: 25-45mg/kg/d PO in 2 (daily adult dose: 16 g/d). Lower doses (amoxicillin component) doses are recommended for (Max: 1. TMP/SMX and erythromycin. Review tetanus immunization status.. consider aerobic Gram-negative bacilli. metronidazole.75g/d) patients <6 months of age: 150-300 4:1 formulation: 20-40mg/kg/d PO in 3 mg/kg/d in 3-4 doses (Max: 16g/d) doses (amoxicillin component) For penicillin allergy: (Max: 1. National Antibiotic Guidelines 141 . Rat bite Etiology: Spirillum minus. perfringens (most common).000-150. Clostridium sp.000U/kg/d in 4 doses 50 mg/kg/d PO in 3-4 doses (Max: 2g/d) (Max: 8MU/d) Severe infections: Severe infections: 20mg/kg/d IV in 4 doses (Max: 4g/d) 200. Streptobacillus moniliformis Preferred Regimen: Prophylaxis 1st line 2nd line Amoxicillin 25-50mg/kg/d in Doxycycline 2-4mg/kg/d in 1-2 doses 3doses (Max: 1.8g/d) or 25-40mg/kg/d IV in 3-4 doses doses (Max: 200mg/d) (Max: 2.: C. Group A streptococci.7g/d) DOT: 10-14d Comments: Rabies post-exposure prophylaxis and vaccination is not indicated for rat bites.5g/d) (Max: 200mg/d) DOT: 3d Rat bite fever 1st line 2nd line Penicillin G Erythromycin Mild to moderate infections: Mild to moderate infections: 100. SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS D.7g/d) dose is recommended for patients Penicillin PLUS clindamycin is <6 months of age: 150-300 mg/kg/d recommended for treatment of in 3-4 doses (Max: 16g/d) documented group A streptococcal 142 National Antibiotic Guidelines . Necrotizing fasciitis/gas gangrene Etiology: S.000-300. septicum. C.000U/kg/d in 6 doses OR (Max: 24MU/d) Clindamycin OR 30-40mg/kg/d PO in 3-4 doses (Max: Doxycycline 2-4mg/kg/d in 1-2 1. C. tertium Preferred Regimen: 1st line 2nd line Vancomycin 40-60mg/kg/d IV in 4 Cefotaxime 100-200mg/kg/d in 3-4 doses (Max: 4 g/d) PLUS doses (Max: 12g/d) PLUS Piperacillin-Tazobactam Clindamycin Severe infections: 240-300mg/kg/d 30-40mg/kg/d PO in 3-4 doses (Max: in 3-4 doses (piperacillin 1. E.8g/d) or 25-40mg/kg/d IV in 3-4 component) (Max: 16 g/d) Lower doses (Max: 2. aureus (CA-MRSA). Streptococcus sp. S. drainage and debridement (include aerobic and anaerobic cultures if available in your setting) and resect all nonviable tissue. Hyperbaric oxygen (HBO) is not recommended.000 U/kg/d in 6 doses (Max: 24MU/d) PLUS Clindamycin 30-40 mg/kg/d PO in 3-4 doses (Max: 1. aureus. Historically. X-ray. Pyomyositis Etiology: S.5-2 h (Max: 12g/d) or 100-150mg/kg/d IV div q4-6h (Max: 12g/d) DOT: 2-3 weeks OR Cefazolin Mild to moderate infections: 50mg/kg/d in 3 doses (Max: 3g/d) National Antibiotic Guidelines 143 .000-300. aureus was not associated with necrotizing fasciitis.7g/d) 100-150mg/kg/d IV/IM in 4 doses OR (Max: 4g/d) Vancomycin 40-60mg/kg/d IV in 4 Severe infections: doses (Max: 4g/d) Individual doses ≥1 150-200mg/kg/d IV/IM in 4-6 doses g should be infused over 1. CT scan may show gas in involved tissue. (Group A and others). Anaerobic bacteria (rarely Clostridium species) Preferred Regimen: 1st line 2nd line Oxacillin Clindamycin 25-40mg/kg/d in 3-4 Mild to moderate infections: doses (Max: 2. F.7g/d) DOT: 10d Comments: Incision for exploration. Gram-negative bacilli (rare). Infection extends into the fascial plane between muscle and subcutaneous fat with resulting necrotizing fasciitis. but CA-MRSA is now different and can cause the disease. Diagnosis is easily made by gram stain of necrotic tissue.000-150. Usually gas gangrene is preceded by a traumatic wound or surgery with contamination by Clostridial spores.SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS necrotizing fasciitis and clostridial myonecrosis Penicillin G Mild to moderate infections: 100.000 U/kg/d in 4 doses (Max: 8MU/d) Severe infections: 200.8g/d) or 25-40mg/kg/d IV in 3-4 doses (Max: 2. 5g/d) or 20-30mg/kg/d IV in 2-3 doses (Max: 1. Decubitus ulcer Etiology: Streptococcus sp. both may 144 National Antibiotic Guidelines . B. SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS Severe infections: 100-150mg/kg/d in 3 doses (Max: 6g/d) Comments: Magnetic resonance imaging (MRI) is the recommended imaging modality for establishing the diagnosis. Lower dose is or 4 doses (Max: 6g/d) recommended for patients <6 OR months of age: 150-300mg/kg/d in 3. An antibiotic active against MRSA is recommended for the following: • Patients who have failed initial recommended antibiotic treatment against MSSA • Those with markedly impaired host defenses • Those with SIRS and hypotension An agent active against enteric gram-negative bacilli should be added for infection in immunocompromised patients or following open trauma to the muscles (aminoglycosides). Appropriate cultures (blood and abscess) should be obtained.2g/d) Comments: Debride necrotic tissue and use moist wound dressing. elevate leg if venous stasis. Computed tomography (CT) scan and ultrasound studies are also useful. Remove pressure if decubitus ulcer.7g/d) PLUS Severe local infection: Ceftazidime Piperacillin-Tazobactam Mild to moderate infections: 90- Severe infections: 240-300mg/kg/d in 150mg IV in 3 doses (Max: 3g/d) 3-4 doses (piperacillin component) Severe infections: 200-300mg IV in 3 (Max: 16g/d).. G. aeruginosa. Anaerobic streptococci. P. fragilis Preferred Regimen: 1st line 2nd line Superficial infection: Clindamycin 25-40mg/kg/d IV in 3-4 Silver sulfadiazine 1% cream doses (Max: 2. S. Do not use povidone iodine or chlorhexidine. evaluate for revascularization if arterial insufficiency. aureus. Enterobacteriaceae. Ciprofloxacin 4 doses (Max: 16g/d) 20-30mg/kg/d PO in 2 doses (Max: 1. Epidermophyton floccosum Preferred Regimen: 1st line 2nd line Terbinafine 1% cream for Tinea Topical: corporis. T. and Imidazoles (clotrimazole. interdigital Tinea pedis. mentagrophytes. (Max: 500mg/d) followed by 5mg/kg on d2-5 qd (Max: 250mg/d) OR Complete resolution may take 2-6 Rifampicin 20mg/kg/d in 1-2 doses months. Systemic: apply bid x 2 weeks. TINEA CRURIS.5mg/d 20-40 kg: 125mg/d National Antibiotic Guidelines 145 . also bone biopsy. Needle aspiration from the ulcer margin is acceptable. Tinea cruris. H. eyes and viscera (liver. ketoconazole. Tinea pedis (athlete’s foot) Etiology: Trichophyton rubrum. as the lymphadenitis Children ≥6 months: 10mg/kg PO on d1 spontaneously resolves. III. (Max: 600mg/d) OR Cotrimoxazole 8-12mg/kg/d in 2 doses (TMP component) (Max: 320mg/d) DOT: 7-10d Comments: Self-limited regional lymphadenitis. Best method is surgically obtained deep tissue specimen for histology and culture. TINEA PEDIS A. Terbinafine <20 kg: 62. Disease manifestations can include involvement of the central nervous system. If osteomyelitis is suspected. Tinea cruris (jock itch). Tinea corporis. TINEA CORPORIS. and spleen). for plantar Tinea pedis. apply bid x etc. Cat scratch disease Etiology: Bartonella henselae Preferred Regimen: 1st line 2nd line Lymphadenitis in Lymphadenitis in immunocompromised patient: immunocompetent patient: Azithromycin No therapy.) apply bid x 2-4 weeks 1 week. The optimal duration of therapy is not known but may be several weeks for systemic disease.SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS damage granulation tissue and fibroblasts. Genuino RF. repeat in 14 days Comments: Fine. these infections can often be cured with topical therapy alone. B. Serious but rare cases of hepatic failure have been reported in patients receiving terbinafine and should not be used in those with chronic or active liver disease. chest. underarms. SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS >40 kg: 250mg/d Fluconazole 3-6mg/kg once a week x 2-4 weeks Comments: Redder margins than centers create impression of a ring. but larger randomized trials with good follow-up rates are needed to confirm these findings.5% shampoo. Systemic therapy can be reserved for severe or refractory infection. Skin may appear lighter than surrounding healthy skin. upper arms. scaly rash with patches of discolored skin with sharp borders commonly found on back. recurrent infection. can use 2-3 times a week for maintenance/prevention Selenium sulfide 2. Rule out erythrasma. 146 National Antibiotic Guidelines . or in immunocompromised patients. It appears to be as effective as 25% sodium thiosulfate and ketoconazole cream. 2016 unpublished) showed that 50% Akapulco lotion was superior to placebo for tinea versicolor (mycologic cure and decrease in clinical activity). and Salud-Gnilo CM. Akapulco lotion (Senna alata extract): a meta-analysis (Tababa EJL. Tinea versicolor (Pityriasis versicolor) Etiology: Malassezia furfur Preferred Regimen: 1st line 2nd line Limited disease: Itraconazole 5-10mg/kg/d PO in 2 Ketoconazole 2% shampoo daily for 3 doses x 7d days. in African Americans. either hypo or hyper- pigmentation. daily application while bathing for 1 to 2 weeks. Opposed to Tinea capitis. can use 2-3 times a week for maintenance/prevention Extensive disease: Fluconazole 3-6mg/kg x 1 dose. and neck. 5mg PO in 1 dose x 2 x 8-12 weeks (Max: 150 mg PO every weeks week for adults) 20-40 kg: 125mg PO in 1 dose x 2 Griseofulvin (microsize formulation) weeks 10-20 mg/kg/d (child) until hair >40 kg: 250mg PO in 1 dose x 2 weeks regrows. • Pruritus may persist for 2 weeks after mites are gone. raised. other species elsewhere) Preferred Regimen: 1st line 2nd line Terbinafine Itraconazole 5mg/kg/d x 4 weeks P (age>2y). Scabies • Mite infestation of the skin that causes intense itching which is worse at night. weight-based dosing Fluconazole 6mg/kg/d PO every week <20 kg: 62. May require 30 g. National Antibiotic Guidelines 147 . Sometimes. scaly patches often sharply defined. Serious but rare cases of hepatic failure have been reported in patients receiving terbinafine and should not be used in those with chronic or active liver disease. Wash and dry linens to prevent re-infection. Comments: Treat close contacts. • Antihistamines may help reduce itching.SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS C. Durations of therapy are for T. D. mites or eggs from scrapings of burrows are visible. treat for approximately twice as long for M. • Diagnosis is based on history and distribution of skin lesions. Safe for children age >2 months. Leave on 8-14 h. canis. Repeat in 1-2 weeks. Tinea capitis (ringworm) Etiology: Trichophyton tonsurans. tonsurans. All agents have similar cure rates (60-100%) in clinical studies. • Secondary streptococcal infections can occur. Etiology: Sarcoptes scabiei (mite) Preferred Regimen: Permethrin 5% cream Apply to entire skin from chin down to and including toes and under fingernails and toenails. Comments: Itchy. red. Microsporum canis (North America. Reapply to hands after handwashing. minimum dose is 125 units) is recommended for post-exposure prophylaxis in susceptible persons at greater risk for complications (immunocompromised such as HIV. initiate treatment quickly (<24h of rash) with aciclovir. Pavia AT. Freedman DO. 148 National Antibiotic Guidelines . chronic cutaneous or pulmonary diseases: Aciclovir 80mg/kg/d PO in 4 doses (Max: 3200mg/d) (start within 24h of rash) OR Valaciclovir 60mg/kg/d PO in 3 doses (Max: 1g/dose in 3 doses) DOT: 5 days Comments: Aciclovir slowed development and reduced number of new lesions and reduced duration of disease in children. The recommended IGIV dose for post-exposure prophylaxis to varicella is 400 mg/kg. chickenpox: Child age 2-12 y Mild to moderate disease: no treatment For patients at increased risk of moderate or severe varicella. If VZIG is not available. time to healing. Saag MS. 20 (1): 21-23. et al. The Sanford Guide to Antimicrobial Therapy 2014. administered once IV.] body weight IM up to a max of 625 units. malignancies. Colbourne M. pregnancy. Puncture wounds. 6th ed. 44th edition. Prevention. Gonzales. the titer of any specific lot of IGIV is uncertain because IGIV is not tested routinely for IGIV anti-varicella anti-bodies. Gatchalian.. Although licensed IGIV preparations contain anti-varicella antibodies. Susceptible children should receive vaccination. Cherry J. Varicella-zoster virus infections Clinical syndromes: • Chickenpox • Shingles (single dermatomal or multiple dermatomes) • Disseminated VZV disease/organ involvement Etiology: Varicella-zoster virus Preferred Regimen: Immunocompetent host. If varicella develops. Pagcatipunan. • Feigin R. 2009 • Gilbert DN. Handbook of Pediatric Infectious Disease an Easy Guide 5th ed. Aciclovir decreased duration of fever. Ong-Lim. post-exposure prophylaxis Varicella-zoster immune globulin (VZIG) (125 units/10 kg [22 lbs. • Bravo. Textbook of Pediatric Infectious Diseases. SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS E. REFERENCES • Baldwin G. and symptoms. Chambers HF. Black. 1999. IGIV can be used. and steroid therapy) as soon as possible after exposure (<96 h). In Pediatrics in Review. delos Reyes. Eliopoulos GM. Schwartz B. Maramba-Lazarte. Some would treat presumptively with aciclovir in high-risk patients. p27.Resistant Staphylococcus aureus Infections in Adults and Children CID 2011: 52 (1 February) • MIMS Philippines 1/2016. Issue 64. • Wolff. • Stevens DL.SKIN AND SOFT TISSUE INFECTIONS IN PEDIATRIC PATIENTS • Liu C. Gilchrest.808-820. K. et al. 30th edition. Am Acad Pediatr 2015. and Lefell. Salud-Gnilo.. 147th edition. Clinical Practice Guidelines by the Infectious Diseases Society of America for the Treatment of Methicillin. USA: McGrawhill Hill. B.. Goldsmith L. Bisno AL. Report of the Committee on Infectious Diseases. Practice Guidelines for the diagnosis and management of skin and soft tissue infections: 2014 Update by Infectious Diseases Society of America.. 87:581-583. Puncture wounds of the foot: can infective complications be avoided? J Royal Society Med 1994. (2008) Fitzpatrick’s Dermatology in General Medicine. Senna alata (Akapulko) extract versus topical antifungals for treatment of superficial fungal skin infections: A systemic review and meta- analysis (Unpublished) • Topical antibiotics: very few indications for use: BPJ. National Antibiotic Guidelines 149 . Genuino RF. IDAS Practice Guidelines for SSTIs CID: 1-43. Bayer A. Paller.. et al. A. • Tababa EJL. S. Cosgrove SE. • Red Book 2015. D. Makover R. 7th Edition. O’Donnell AM. • Pennycook A. Katz. Cambers HF. Empirical antibiotic therapy (in absence of specific culture and sensitivity data select an agent with activity against MRSA): Clindamycin 600mg IV q8h for patients without signs and symptoms of sepsis/ bacteremia OR Vancomycin 15mg/kg q12h (trough concentrations of 5-10 μg/mL are adequate for infections of moderate severity. aureus. shift to another first-line antibiotic. carbuncles and abscesses. 2 DS tabs in obese patient. Methicillin-sensitive (MSSA).. Skin abscess. furuncles • These include purulent skin lesions. or if C/S results not yet available. ABSCESS A. boils. Outpatient.g. follow up exudate culture and sensitivity (C/S) results and shift to culture-guided antibiotic therapy. or systemic inflammatory response syndrome: Incision and drainage PLUS one of the following: Clindamycin 300-450mg (higher dose in obese patient. for severe infections or if bacteremia is present. 1st line: Outpatient setting. Methicillin-resistant (MRSA) Preferred Regimen: Incision and drainage is the mainstay of therapy. furuncles. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS I. • See also Recurrent Furunculosis (decolonization) Etiology: S. such as boils. • Community-associated MRSA is of increasing concern for effective management. Note: needle aspiration is inadequate. 15-20 mg/kg q8-12h targeting troughs of 15-20 μg/mL recommended) 150 National Antibiotic Guidelines . BMI>40) PO bid x 5-10d OR Doxycycline 100 mg PO q12h x 5-10d (may also be effective for community-acquired MRSA infections) If no response after 2-3d. no diabetes or immunosuppression. boil or smaller abscess (<2 cm in diameter): Incision and drainage only are usually effective. Inpatient: Incision and drainage: culture abscess and blood. e. acute bacterial skin and skin structure infection (ABSSSI). Hot packs are helpful. larger (>2 cm in diameter within an area of erythema of ≥5 cm) or multiple abscesses. No need for antimicrobial therapy. BMI>40) PO tid x 5-10d OR Cotrimoxazole 160/800mg (1 DS tab. 5% vs 73. a beta-lactam is the preferred agent: Oral agents: Cloxacillin 500mg PO qid or Cephalexin 500mg PO tid. refer to the latest report (2016) of the Antimicrobial Resistance Surveillance Program at: http://arsp. and prescribed antibiotics for 10 days regardless of abscess size. One double-strength (DS) tab of Cotrimoxazole bid as effective as two DS tabs bid.qid Parenteral agents: Oxacillin 1g IV q4h or Cefazolin 1g IV q8h For MRSA infections: Linezolid 600 mg IV/PO q12h Comments: Avoid fluoroquinolones. • Need to culture multiple sites. There was a higher rate of clinical cure in the two groups with antibiotics but the study did not break down treatment outcomes for those with abscesses ≤2 cm vs 2–5 cm. the patient should have no active skin infections and is otherwise healthy. NOTE: For data on the prevalence of MRSA in the Philippines and the increasing resistance of MRSA to Cotrimoxazole. Use of antibiotics for a single abscess ≤ 2 cm should be weighed against the fairly high proportion of adverse events. recurrent Clinical setting for decolonization • If the patient and physician wish to attempt decolonization. Nares- only culture missed 48% of colonized individuals. and inguinal area skin. throat.pdf B. National Antibiotic Guidelines 151 .ph/wp- content/uploads/2017/06/2016_annual_report_summary. aureus (MSSA and MRSA) presenting as recurrent furunculosis (abscesses.com. For abscesses >2 cm in diameter. Mupirocin ointment in anterior nares and under fingernails bid x 5-7d PLUS Chlorhexidine 4% shower qd x 5-7d. a large randomized controlled trial of incision & drainage plus Cotrimoxazole vs incision & drainage alone showed a higher rate of clinical cure among the former group (80. Furunculosis.g.6%.. Preferred Regimen: Treat as for furuncles and boils For decolonization: Avoid systemic antibiotics. nose. • Does not apply to people who inject drugs (PWID). boils) in an otherwise healthy host. Etiology: S. respectively). Lower dosage range of Cotrimoxazole (1 DS instead of 2 DS) and clindamycin (150-300 mg instead of 450 mg) found to be associated with treatment failure in obese patients (BMI >40). Cotrimoxazole or placebo was added to incision & drainage. Another large double-blind randomized controlled trial was conducted for single abscesses ≤5 cm where Clindamycin. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS 2nd line: For documented MSSA infection. e. In a prospective randomized trial of combined topical and systemic therapy. Etiology: Pasteurella canis. Fusobacterium sp.ph/sites/default/files/basic- page/ao2014-0012. refer to: DOH AO 2014-0012. Go to: http://www. at 3 months. Culture and treat empirically. In vitro sensitivity to fluoroquinolones has been observed. aureus Preferred Regimen: 1st line: Amoxicillin/clavulanate 875/125mg PO bid or 500/125mg PO tid 2nd line: Cefuroxime axetil 500mg PO q12h OR Doxycycline 100mg PO bid If culture is positive for only P. B. diabetes.g.gov. Dog bite • Only 5% of dog bite wounds get infected.pdf 152 National Antibiotic Guidelines .. • Observe for osteomyelitis Etiology: Pasteurella multocida. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS Comments: There is no "gold standard" regimen for decolonization. Cephalexin and Clindamycin. Preferred Regimen: 1st line: Amoxicillin/clavulanate 875/125mg PO bid or 500/125 mg PO tid OR Ampicillin/sulbactam 3g IV q6h 2nd line: Clindamycin 300mg PO qid Comments: For rabies post-exposure prophylaxis and vaccination. II. BITES A. multocida. e. Cat bite • 80% of cat bites get infected. can switch to Penicillin G IV or Penicillin VK PO. Comments: P. multocida is resistant to Dicloxacillin. 32% of patients not treated.doh. aureus.. cultures were negative for MRSA in 74% for treated vs. Bacteroides sp. Many strains appear susceptible to Azithromycin but no clinical data. S. S. Treat only if the bite is severe or patient presents bad comorbidity. Optimal regimen and duration of treatment are uncertain.. EF-4 Capnocytophaga sp. Pasteurella multocida infection develops within 24h. S. bone. For bites inflicted by hospitalized patients. (82%). until MRSA is Levofloxacin excluded: ADD Vancomycin 1g IV q12h (or 1. (15%). Review tetanus status. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS C. • Potential risk of transmitting blood-borne pathogens if injury contaminated with another's blood. S. aureus (29%).375 g q8h). epidermidis (53%). Cefoxitin. Corynebacterium sp. >100 kg) Comments: Cleaning. • Resistant to: Clindamycin. usually 3-24 h): parenteral therapy is required. • X-ray would evaluate for fracture or foreign body.5g q12h if wt.. Cotrimoxazole and erythromycin. consider aerobic Gram-negative bacilli. Eikenella sp. irrigation and debridement are most important. Prophylaxis: clavulanate 875/125mg PO bid x 3d Doxycycline 100mg PO bid x 3d National Antibiotic Guidelines 153 .g.g. Streptobacillus moniliformis (USA) Preferred Regimen: 1st line 2nd line Prophylaxis: Amoxicillin. (26%) Preferred Regimen: 1st line 2nd line: Early (wound not yet infected): A carbapenem can be used in place Amoxicillin-Clavulanate 875/125 mg PO of Ampicillin-Sulbactam. (41%). Cephalexin/Cefazolin. Eikenella sp. joint. Rat bite Etiology: Spirillum minus (Asia). Peptostreptococcus sp. Clenched fist (and other hand) bite wounds pose risk for deep infections (e. • Susceptible to: fluoroquinolones and beta-lactam / beta-lactamase inhibitor combinations: e. Bacteroides sp. D.5 to 3 g IV q6h OR Piperacillin-Tazobactam (4. Clindamycin PLUS Ciprofloxacin OR For serious infections. Ampicillin-Sulbactam 1. Nafcillin/oxacillin. Metronidazole. bid x 5d or Piperacillin-Tazobactam if Later (signs of infection. Ampicillin-Sulbactam. Human bite Etiology: Viridans streptococcus (100%).5 g q8h If the patient is penicillin allergic: or 4-hr infusion of 3.. tendon sheath) and require careful evaluation. advanced maternal age. pyogenes (Group A or B). Coagulase-negative staphylococci (e. surgical I&D of an abscess. • Poor breastfeeding technique and incomplete emptying are contributing factors. continue breast feeding during the antibiotic therapy. primiparity. Bacteroides species. breastfeeding difficulties • May present with or without abscess. Corynebacterium sp.. obtain culture before starting empiric therapy.3 div doses Comments: If baby can latch on and the mother is comfortable. e. S. If possible. lugdunensis) Preferred Regimen: If MRSA is not present: If MRSA is present or possible: Outpatient Cloxacillin 500mg PO qid OR Clindamycin 300mg PO qid OR Cephalexin 500mg PO qid Cotrimoxazole 160/800mg 1-2 tabs PO bid Inpatient Oxacillin 2g IV q4h Vancomycin 30mg/kg/d IV in 2. III. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS Rat bite fever: Rat bite fever: Penicillin G 2MU IV q4h OR Erythromycin 500mg PO qid OR Doxycycline 100mg PO bid x 10-14d Clindamycin 300mg PO qid x 10-14d Comments: Rabies post-exposure prophylaxis and vaccination are not routinely indicated for rat bites. discuss with pediatrician age-specific risks to infant of drug exposure through breast milk. Continued breast feeding does not pose a risk to the infant. On occasion. • S. 154 National Antibiotic Guidelines . Postpartum Mastitis • Postpartum mastitis occurs in approximately 10% of nursing mothers. Etiology: S. • Risk factors (same for MRSA and MSSA) include: mother employed outside the home.g. MASTITIS A.g. aureus (MRSA or MSSA).. Breast feeding should resume once pain is tolerable. aureus is most common etiology but other pathogens are possible. feeding can be temporarily interrupted. Consider consultation with an expert for bites secondary to wild rodents. coli. Discontinue breastfeeding only if the breast is too painful for breast feeding. E.. S. If not subareolar. most likely anaerobes: ADD Metronidazole 500mg IV/PO tid 2nd line: For granulomatous mastitis due to Corynebacterium sp: Doxycycline 100mg PO bid x 3-4 weeks Comments: Consider inflammatory carcinoma in older women without clear abscess. • Invasive infection is characterized by pathogens at a sufficient concentration. • Treatment may require surgical debridement of infected necrotic tissue. or a breast mass is detected radiographically. depth. Need pretreatment aerobic and anaerobic cultures. Bacteroides sp. Selected coagulase-negative staphylococci. and /or topical medications. indicated for abscess. National Antibiotic Guidelines 155 . invasion of adjacent unburned tissue. 1. The ideal care is in a dedicated burn unit. aureus. Corynebacterium sp. Preferred Regimen: 1st line: If MRSA is not present: If MRSA is present or possible: Outpatient Cloxacillin 500 mg PO qid OR Clindamycin 300 mg PO qid OR Cephalexin 500 mg PO qid Cotrimoxazole 160/800 mg 1-2 tabs PO bid Inpatient Oxacillin 2 g IV q4h Vancomycin 1 g IV q12h. Non-puerperal mastitis Etiology: S.-rare.5 g IV q12h if patient weight >100 kg If subareolar & odoriferous. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS B. either by ultrasound guided needle aspiration or surgical. Drainage. application of skin grafts and/or skin substitutes. IV. especially if microcalcification. (less often). sepsis • An Infected burn wound is characterized by bacteria in the wound and wound eschar at high concentration (>105/g tissue). or sepsis syndrome. BUIRNS A. and surface area to cause suppurative separation of eschar or graft loss. Infected burn wound. Peptostreptococcus. can cause distinctive granulomatous inflammation. • Critically ill patients may have suspected burn wound sepsis. probably Staphylococcus. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS Etiology: S. pyogenes; Enterobacter sp.; S. aureus; S. epidermidis; E. faecalis; E. coli; P. aeruginosa; Fungi (rare) and Herpes virus (rare) Preferred Regimen: 1st line 2nd line Vancomycin loading dose of 25- Meropenem 1g IV q8h or 30mg/kg IV, then 15mg/kg IV q8-12h Cefepime 2g IV q8h PLUS PLUS Piperacillin-Tazobactam 4.5g Vancomycin loading dose of 25- q6h 30mg/kg IV, then 15mg/kg IV q8-12h If with IgE-mediated allergy to beta If Candida infection suspected: lactams: ADD Fluconazole 6mg/kg IV qd Could use Aztreonam 2g IV q6h If ESBL- or carbapenemase- producing multi-drug resistant gram- negative bacillus: The only alternative is Colistin PLUS Meropenem. Comments: Patients should undergo quantitative wound cultures, blood cultures, and then empiric antimicrobial therapy while awaiting results. Other complications of concern in critically ill burn patients include S. aureus toxic shock syndrome (TSS), suppurative phlebitis, and pneumonia. V. CELLULITIS A. Diabetes mellitus and erysipelas • Patients with diabetes mellitus peripheral neuropathy commonly suffer from inflammation of the skin and subcutaneous tissue. • The patient may have contiguous skin ulceration and/or atherosclerotic peripheral vascular disease. Etiology: Streptococcus. sp. (Group A, B, C, G); S. aureus; Enterobacteriaceae Anaerobes (poor prognosis if present). 156 National Antibiotic Guidelines SKIN AND SOFT TISSUE INFECTIONS IN ADULTS Preferred Regimen: 1st line 2nd line Early or mild infection: For hospitalized patient with severe Clindamycin 300-450mg (higher dose disease, forced to use broad- in obese patient, BMI >40) PO tid x 5- spectrum therapy that targets both 10d or Cotrimoxazole 160/800 mg 1- S. aureus and Enterobacteriaceae: 2 tabs PO bid PLUS Piperacillin-Tazobactam 4.5g IV q8h Penicillin VK 500mg PO qid or PLUS Cephalexin 500mg PO qid Vancomycin 1g IV q12h or Linezolid 600mg IV/PO bid Can substitute Piperacillin- tazobactam for carbapenem: Ertapenem 1g IV q24h or Meropenem 1g IV q8h Comments: Assess the adequacy of arterial blood supply. Surgical debridement for cultures may be required to determine or assess for contiguous osteomyelitis and the presence of necrotizing fasciitis. The likelihood of contiguous osteomyelitis is increased if one can probe to the bone. The likelihood of contiguous osteomyelitis is low if MRI is negative. Other alternatives to a carbapenem: Levofloxacin, Piperacillin-Tazobactam. B. Facial erysipelas This is characterized by the sudden onset of rapidly spreading red edematous tender plaque-like skin on the face in an otherwise healthy host. Etiology: Streptococcus sp. (Groups A, B, C, G); S. aureus Preferred Regimen: 1st line: For severe infection: Vancomycin 1g IV q12h PLUS Piperacillin-Tazobactam 4.5g IV q8h If weight >100 kg, increase dose to 1.5g IV q12h 2nd line: Linezolid 600mg IV q12h Comments: S. aureus erysipelas of the face can mimic streptococcal erysipelas of an extremity. If there are erysipelas-like lesions on the face, treat as if MRSA is present. The usual duration of treatment is 7-10d, longer if the patient is bacteremic. National Antibiotic Guidelines 157 SKIN AND SOFT TISSUE INFECTIONS IN ADULTS C. Acute bacterial skin and skin structure infections (ABSSSI) • This section focuses on the treatment of uncomplicated cellulitis, erysipelas in extremities and other ABSSSI in the non-diabetic patient. • This is characterized by an acute onset of rapidly spreading red edematous, tender plaque-like area of skin usually on the lower leg, often febrile. It may be associated with lymphangitis or lymphadenitis. • The portal of entry is frequently a fungal infection between the toes (Tinea pedis). • If the facial skin is involved, see Facial erysipelas. • Erysipelas is characterized by red indurated demarcated inflamed skin (S. pyogenes), and is distinguishable from abscesses due to S. aureus. Dual infection is rare. Bedside ultrasound may be helpful in detecting deep S. aureus abscess. If in doubt, treat for both. Community-associated MRSA can mimic erysipelas; look for loculated purulence. Etiology: S. pyogenes (Groups A, B, C, G); S. aureus (rare) Preferred Regimen: 1st line: Inpatient parenteral therapy: Penicillin G 1-2 MU IV q6h If history of penicillin skin rash and nothing to suggest IgE-mediated allergic reaction: Cefazolin 1g IV q8h OR Ceftriaxone 2g IV qd If history/evidence of past IgE-mediated allergic reaction (anaphylaxis), then may be forced to use: Vancomycin 15mg/kg IV q12h 2nd line: Linezolid 600mg IV/PO bid. Give IV until afebrile. Stepdown to Penicillin VK 500mg PO qid ac and hs (outpatient) x 10d of total therapy. Outpatient therapy for less-ill patients: Penicillin VK 500mg PO qid OR Amoxicillin 500 mg PO q8h If history of Penicillin skin rash and nothing to suggest an IgE-mediated reaction (anaphylaxis, angio-neurotic edema): Cephalexin 500mg PO bid x 10d If documented past history of IgE-medicated allergic reaction to beta-lactam antibiotics: Azithromycin 500mg PO x 1 dose then 250mg PO qd x 4d OR Linezolid 600 mg PO bid x 10d If clinically unclear whether infection is due to S. pyogenes or S. aureus, get cultures and start empiric therapy: Amoxicillin OR Penicillin VK OR Cephalexin 158 National Antibiotic Guidelines SKIN AND SOFT TISSUE INFECTIONS IN ADULTS for S. pyogenes and Clindamycin for S. aureus (MRSA). See Comment re Cotrimoxazole. For suspected S. aureus (fluctuance or positive gram stain): MSSA (outpatient): Cloxacillin 500mg PO qid MSSA (inpatient): Oxacillin 2g IV q4h MRSA (outpatient): Doxycycline 100mg PO bid OR Clindamycin 300-450mg PO bid OR Cotrimoxazole DS 1 tab PO bid MRSA (inpatient): Vancomycin 1g IV q12h Comments: Treatment also includes leg elevation to reduce local edema. Mixed infection (Strep. and Staph.) is rare. If S. aureus is present, need incision and drainage. Usual duration of therapy is 7-10d. Some treat until the patient is afebrile for 3-5d. Treat Tinea pedis if present. Stasis dermatitis due to venous insufficiency can masquerade as bacterial cellulitis/erysipelas; condition is often bilateral, chronic and patient afebrile. Systemic antibiotics offer no additional benefit. Do not use a fluoroquinolone, Cotrimoxazole or a Tetracycline for reasons of resistance and/or clinical failures. D. Purulent cellulitis • This is associated with purulent drainage or exudate, in the absence of a drainable abscess Etiology: S. aureus: predominantly MRSA; also MSSA Rare: beta-hemolytic streptococci Preferred Regimen: 1st line: Non-severe: Clindamycin 300-450mg (higher dose in obese patient, BMI >40) PO tid x 5-10d OR Cotrimoxazole 160/800mg (1 DS tab; 2 DS tabs in obese patient, BMI >40) PO bid x 5-10d OR Doxycycline 100mg PO q12h x 5-10d may also be effective for community acquired MRSA infections Inpatient: Empirical antibiotic therapy (in absence of specific culture and sensitivity data, select an agent with activity against MRSA): Clindamycin 600mg IV q8h for patients without signs and symptoms of sepsis/bacteremia OR Vancomycin 15 mg/kg q12h (trough concentrations of 5-10 μg/ mL are adequate for infections of moderate severity; for Severe infections or if bacteremia is present, 15-20 mg/kg q8-12h) National Antibiotic Guidelines 159 SKIN AND SOFT TISSUE INFECTIONS IN ADULTS 2nd line: For MRSA infection: Linezolid 600 mg PO q12h Severe infections: Linezolid 600mg IV q12h For documented MSSA infection, use a beta-lactam agent: Oral agents: Cloxacillin 500 mg PO qid OR Cephalexin 500 mg PO tid-qid Parenteral agents: Oxacillin 1g IV q4h OR Cefazolin 1g IV q8h Comments: Culture of blood, exudate, and/ or bullae is needed when there are signs of systemic toxicity, extensive skin involvement, or underlying comorbidities. Empiric therapy for infection due to beta-hemolytic streptococci may not be necessary since MRSA is the dominant organism (59%). Others: MSSA (17%) and beta- hemolytic streptococci (2.6%). I&D with culture of the exudate and blood is beneficial. E. Seawater, brackish water-associated, contaminated skin wounds • Individuals at highest risk of life-threatening infection: cirrhosis due to alcohol or chronic viral hepatitis, alcoholism, hemochromatosis, diabetes mellitus, thalassemia major, chronic renal disease, and lymphoma Etiology: Vibrio vulnificus; Vibrio alginolyticus; Vibrio damsel Preferred Regimen: 1st line (Severe infections/sepsis or those at risk for life-threatening infections): Vancomycin 15-20 mg/kg IV q 8-12h OR Piperacillin-Tazobactam 4.5 g IV q8h 2nd line: Ciprofloxacin 750mg PO bid or 400mg IV bid OR Levofloxacin 750mg IV/PO qd DOT: based on clinical response. Comments: Due to the potential severity of disease empiric therapy for wound and septic patients should include drugs active against V. vulnificus when risk factors are present (e.g. sepsis and septic shock in immunocompromised patients including hematological disease, malignancy, and liver disease. Roughly 75% of patients have bullous skin lesions. VI. HERPES INFECTION A. Herpes zoster, shingles • Effective treatment of shingles is most evident in patients >50 y. • Must begin treatment within 3d of onset of rash. 160 National Antibiotic Guidelines SKIN AND SOFT TISSUE INFECTIONS IN ADULTS • Immunization results in 25-fold decrease in infection rate. and disseminated VZV disease/organ involvement. Varicella zoster virus • Clinical syndromes include: chickenpox. • There should be increasing recognition of increased risk of stroke in the 6 months after an episode of H. Treatment must be begun within 72 h. However. to decrease discomfort during acute phase of infection. Toxicity of both drugs are similar.) improved quality of life measurements. • Emerging data suggests VZV may cause vasculopathy of cerebral. Etiology: Herpes zoster virus (Varicella zoster virus) Preferred Regimen: 1st line: Immunocompetent: Aciclovir 800mg PO 5x/d x 7-10d PLUS Prednisone in patients age >50 yrs. and other arteries (suggested as possible cause of Giant Cell arteritis). temporal. shingles (single dermatomal or multiple dermatomes) [see also Herpes zoster (shingles)]. 8 out of 15 patients improved with IV aciclovir 10 mg/kg q8h x 14d followed by oral valaciclovir 1 g 3x/d for 1 month. Aciclovir-resistant VZV occurs in HIV-positive patients previously treated with aciclovir. Day 1-7: 30mg PO bid Day 8-14: 15mg PO bid Day 15-21: 7. Prednisone added to aciclovir (in patients aged >50 yrs. The role of antiviral drugs in the treatment of PHN is unproven.5mg PO bid Immunocompromised: Not severe: Aciclovir 800mg PO 5x/d x 7d Severe (>1 dermatome. trigeminal nerve or disseminated): Aciclovir 10-12mg/kg IV (infusion over 1hr) q8h x 7-14d 2nd line: Immunocompetent: Valaciclovir 1g PO tid x 7d Immunocompromised (not severe): Valaciclovir 1g PO tid x 7d Comments: Valaciclovir reduced post-herpetic neuralgia (PHN) more rapidly than aciclovir in patients age >50 y. B. National Antibiotic Guidelines 161 . zoster. Oral antivirals during clinical infection may have a protective effect. Does not decrease incidence of post-herpetic neuralgia. Herpes zoster is a common manifestation of immune reconstitution following ART in HIV-infected children. philvaccine. nausea. perianal area. • May have associated toxic shock syndrome as defined by hypotension.5g IV q8h PLUS Vancomycin 15-20mg/kg IV q8-12h If Type II necrotizing fasciitis or clostridial necrotizing fasciitis is suspected: Penicillin G 4MU IV q4h PLUS Clindamycin 600-900mg IV q8h (to block toxin production) 162 National Antibiotic Guidelines . Available at: www. and maybe erythroderma. pneumonia: Aciclovir 800mg PO 5x/d or 10 mg/kg IV q8h x 5d Immunocompromised: Aciclovir 10-12mg/kg (500 mg/M2) IV (infused over 1 hour) q8h x 7d 2nd line: Valaciclovir 1g PO tid x 5d Prevention. fast moving. If a varicella-susceptible mother is exposed and develops respiratory symptoms within 10d after exposure. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS Etiology: Varicella-zoster virus (VZV) Preferred Regimen: 1st line: Immunocompetent host. chickenpox: Aciclovir 800mg PO 5x/d x 5-7d (start within 24h of rash) OR Valaciclovir 1g PO tid x 5d Pregnancy (3rd trimester). Necrotizing fasciitis • Infection causing necrosis extending to fascial plane(s): usually involving an extremity. pyogenes) [Type II]—acute or subacute. Group A Streptococcus (GAS. but Aciclovir decreases incidence and severity of varicella pneumonia. MRSA. Typically. gas is present in the involved tissue. cyanotic skin. Clostridium perfringens. C. respiratory failure. post-exposure prophylaxis: Refer to PSMID-PFV Adult Immunization Schedule 2015. diarrhea. genitals (“Fournier’s gangrene”) • Necrosis manifests by a decrease in pain and dusky. Etiology: Mixed aerobic-anaerobic bacteria [Type I]: most common. Preferred Regimen: 1st line: If Type I necrotizing fasciitis is suspected: Piperacillin-Tazobactam 4. often with blood-filled bullae. start Aciclovir. S. Vibrio vulnificus.org/vaccination-schedules/adult-immunization-schedule Comments: Varicella pneumonia is associated with a 41% mortality in pregnancy. renal failure. vomiting. Klebsiella spp. Use of IVIG is supported by a small controlled study and a retrospective review. tertium to Penicillin and Metronidazole is variable in published studies. Comments: X-ray. IDSA classification. Urgent surgical debridement and antibiotics are the mainstay of therapy. or pain). non-purulent secretions. e. IDSA Guidelines do not recommend hyperbaric oxygen. For necrotizing fasciitis caused by MRSA: Linezolid 600mg IV q12h. purulent secretions. CT scan. Early exploratory surgery is recommended to establish diagnosis (include aerobic and anaerobic cultures) and resect all non-viable tissue. Type II necrotizing fasciitis: presents with and without TSS and/or rhabdomyolysis. More data is needed. is recommended. National Antibiotic Guidelines 163 . warmth. resistance to Clindamycin and third-generation cephalosporins is common. aureus suspected Penicillin allergy manifested as anaphylaxis or angioneurotic edema: Levofloxacin 750mg IV qd or Ciprofloxacin 400mg IV q12h PLUS Metronidazole 500mg IV q6h PLUS Vancomycin if S. Diabetic Foot Infections (DFI) • This manifests in diabetic patients with any foot wound with: signs of inflammation (redness. undermining of wound edges. • The use of a validated classification system for DFI.g. aureus suspected For streptococcal (Type II) necrotizing fasciitis: If with penicillin allergy: Vancomycin 1g IV q12h For clostridial necrotizing fasciitis: Susceptibility of C. or additional secondary signs (e. swelling.g. D. friable or discolored granulation tissue. Some lots of intravenous immunoglobulin (IVIG) have antibodies against streptococcal toxins.. or MRI may show gas in involved tissue.. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS If MRSA is suspected: Vancomycin 15-20mg/kg q8-12h (target trough concentrations 15-20μg/ mL) 2nd line: For Type 1 necrotizing fasciitis: Meropenem 1g IV q8h PLUS Vancomycin 15-20mg/kg q8-12h (target trough concentrations 15-20μg/ mL) Penicillin allergy manifested as skin rash only and unable to tolerate carbapenem: Cefepime 1-2g q8-12h PLUS Metronidazole 500mg IV q6h PLUS Vancomycin if S. foul odor). tenderness. Vancomycin and Meropenem expected to have activity in vitro. For moderate to severe infections. aeruginosa is Cefepime) PLUS Metronidazole suspected) PLUS Vancomycin (for 500mg IV q8h PLUS Vancomycin 15- MRSA coverage) 15-20mg/kg IV q8. Comments: Management requires multi-specialty collaboration (for diabetes control. Treatment regimen is determined by the severity of infection (may be mild in afebrile patients. Preferred Regimen: 1st line 2nd line Mild to moderate DFI: Mild to moderate DFI: Clindamycin 300mg PO/IV qid OR Levofloxacin 750mg PO/IV qd Cotrimoxazole 160/800mg 1-2 tabs PO bid x 1-2 weeks Severe DFI: Meropenem 1g IV q8h PLUS Severe DFI: Vancomycin 15-20mg/kg IV q8-12h x Piperacillin-Tazobactam 4. potential contamination by bowel or vaginal flora).. including MRSA. VII. send specimens from deep tissue. The patient is febrile. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS Etiology: Aerobic gram-positive cocci. obtained by biopsy or curettage after the wound has been cleansed and debrided. Avoid swab specimens. debridement and other surgical interventions by orthopedic/vascular/general surgeons). • Gastrointestinal tract (including oropharyngeal and esophageal) and non- genitourinary tract surgery (e. "clean" surgery). Orthopedic consultation and management is needed when osteomyelitis is being considered. Plain x-ray of the affected foot and/or MRI may be necessary to determine the extent and depth of infection.g. 2-3 weeks OR 8hr IV (for Gram-negative bacilli Ceftazidime 1-2g IV q8h (or coverage. with neutrophilia.g. Surgical debridement is usually necessary for moderate to severe DFI.. especially if P. This may be extended for 4-6 weeks (or even longer) if there is residual infected bone following debridement of necrotic bone. are most common.5g IV q6. infectious diseases. or severe in febrile patients). WOUND INFECTION A. Aerobic gram-negative bacilli and anaerobes are common secondary organisms. 20mg/kg IV q8-12h x 2-3 weeks 12h x 2-3 weeks DOT may be as short as one week for osteomyelitis if all infected and necrotic bone and soft tissue are resected and there is clinical improvement. 164 National Antibiotic Guidelines . Post-operative wound infections • Non-gastrointestinal tract and non-genitourinary tract surgery (e. coliform species (e. S. C. aureus suspected: Vancomycin in the primary regimen. MRSA). afebrile). aureus. febrile Linezolid 600mg IV q12h PLUS patient): Vancomycin 1g IV q12h (1.. fragilis). non-genitourinary tract surgery: skin flora. B. NON-GU TRACT SURGERY: Mild infection (without sepsis. (Group A. Bacteroides sp (e. S.5mg Vancomycin 1g IV q12h extended release. febrile patient): Severe infection (sepsis. if antimicrobial needed: afebrile patient): Clindamycin 300-450mg PO tid OR Clindamycin 300-450mg PO tid Cotrimoxazole 160/800mg 1-2 tabs PO bid Severe infection (sepsis.5g Ciprofloxacin 400mg IV q12h or q12h if weight >100 kg) Levofloxacin 750mg IV q24h PLUS Metronidazole 500mg IV q6h GI TRACT OR GU TRACT SURGERY: Mild infection: Meropenem 1g q8h PLUS Amoxicillin-Clavulanate 1000/62. ADD Clindamycin 300-450mg PO OR Cotrimoxazole 160/800mg 1-2 tabs PO bid Severe infection: Piperacillin-Tazobactam 4.g. coli). SKIN AND SOFT TISSUE INFECTIONS IN ADULTS Etiology: Non-gastrointestinal tract. and other anaerobic bacteria Preferred Regimen: 1st line 2nd line NON-GI TRACT. gastrointestinal and vaginal flora. aureus (MSSA. Mild infection (without sepsis..5 g IV q8h OR Parenteral third-generation cephalosporin PLUS Metronidazole 500mg IV q6h OR Ertapenem 1 g IV q24h PLUS Vancomycin 1 g IV q12h FOR SUSPECTED MSSA OR MRSA POSTWOUND INFECTION (GRAM STAIN SHOWS GRAM POSITIVE COCCI): Oral: Clindamycin 300-450mg PO tid Oral: Minocycline 100mg PO q12h OR Cotrimoxazole DS 1-2 tabs PO bid OR Doxycycline 100mg PO bid OR IV: Vancomycin 1 g IV q12h Linezolid 600mg PO/IV q12h National Antibiotic Guidelines 165 . Streptococcus sp. G) Gastrointestinal tract (GIT) or genitourinary tract (GUT) surgery: skin flora. E. B. 2 tabs PO bid Can substitute Linezolid for If S.g. In the absence of systemic response.000 S. B. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS Comments: If the infection is on the skin incision. the rate of resistance of S. potential contamination by bowel or vaginal flora).. Surgical debridement may be indicated. mild or moderate. The patient is febrile. febrile patient: 1st line: Piperacillin-Tazobactam 4. aureus is Clindamycin-sensitive but Erythromycin-resistant. 85% were susceptible to Tetracycline. aureus isolates. If S. C. Etiology: Polymicrobic (Microbial flora dependent on nature of the trauma): S. aureus/ Streptococcus sp. with neutrophilia. or severe in febrile patients). Infected wound.. 2nd line: Minocycline 100mg PO bid OR Linezolid 600mg PO bid Complicated.. and 88. MRSA). See IDSA Guidelines for the assessment and management of infected surgical wounds. Streptococcus sp. Iraq Preferred Regimen: Uncomplicated. post-trauma • Non-gastrointestinal tract and non-genitourinary tract surgery (e. Open and drain the wound if S.1 % in 2015.g. and pack the wound. remove sutures to drain wound. • Gastrointestinal tract (including oropharyngeal and esophageal) and non- genitourinary tract surgery (e. aureus to tetracycline was 9. Treatment regimen is determined by the severity of infection (may be mild in afebrile patients.3% (by Eucast breakpoint) or 97. If Gram-negative bacilli are suspected: add a fluoroquinolone.1 % in 2014 and 7. especially in soldiers infected in Afghanistan. Based on a 2011 global survey of approximately 5. For MRSA. wounds with <5 cm erythema and no induration or necrosis may be treated with opening and dressing changes only. afebrile patient: 1st line: Clindamycin 300-450mg PO tid OR Cotrimoxazole DS 1-2 tabs PO bid Regimen focuses on S. In the Philippines.g. 94% of MSSA were susceptible to Tetracycline and >98% were susceptible to Minocycline. aureus (MSSA. severe. perfringens.2% (by CLSI breakpoint) were susceptible to Minocycline. Enterobacteriaceae. approximately. tetani. (water exposure). obtain culture and sensitivity. (aerobic and anaerobic). Pseudomonas sp. "clean" surgery).5g q8h PLUS Vancomycin 1g IV q12h 2nd line: Meropenem 1g IV q8h PLUS Vancomycin 1g IV q12h or Linezolid 600mg IV/PO q12h PLUS Ciprofloxacin 400mg IV q12h or Levofloxacin IV 750mg IV q24h 166 National Antibiotic Guidelines . C. aureus suspected on GIT or GUT Surgery. watch out for inducible Clindamycin resistance.. Acinetobacter sp. Aeromonas sp. aureus is erythromycin-resistant in vitro. for intertrigo. and paronychia Preferred Regimen: 1st line: Topical therapy for 3-5d Clotrimazole 1% cream.. Ensure that the microbial laboratory checks this if clindamycin is being considered. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS Comments: If S. Acute paronychia usually caused by mixed bacterial infections and may require I&D if the abscess is present. inducible resistance to clindamycin is also possible. gyms. farmer. Ketoconazole 2% cream applied bid 2nd line: If topical treatment does not work: Fluconazole 100-200mg PO q week until normal nail anatomy restored Alternatives: Itraconazole 200mg PO bid x 1 week x 3 consecutive months OR Terbinafine 250 mg PO od x 3 months Comments: Maintain dry skin surface (e... Chronic paronychia may require referral to hand surgeon if medical treatment is ineffective B. of dermatophytes of the following genera: Epidermophyton. pet shop workers) • Environmental exposure (e. contact sports. lab worker.g. veterinarian. VIII. balanitis. gardening. erosion interdigitalis blastomycetica. Miconazole 2% cream. diaper dermatitis) and control hyperglycemia if present.g. FUNGAL SKIN INFECTIONS A. locker rooms. diaper dermatitis. Clinical settings Common types of candida skin infections include: intertrigo. perianal dermatitis. Microsporum and Trichophyton National Antibiotic Guidelines 167 . Tinea corporis/cruris Check for history of: • Current and previous topical and/or systemic treatment • Occupational exposure (e. affected family members) Etiology: Certain spp. Cutaneous candidiasis Etiology: Candida albicans Other Candida spp. pets).g. and lateral aspects of the feet • Vesicobullous: may have purulent exudate. but larger randomized trials with good follow-up rates are needed to confirm these findings. very pruritic. respectively). Tinea pedia can trigger an “id” reaction on the hands -multiple. Trichophyton interdigitale. minute deep-seated vesicles on the fingers and palms. A meta-analysis showed that 50% Akapulco lotion was superior to placebo for Tinea versicolor (mycologic cure and decrease in clinical activity). multifocal or inflammatory disease. applied for 28d. soles. Another RCT showed comparable efficacy between clotrimazole 1% od and ketoconazole 2% bid. Acremonium. or with extensive and/or disabling. 168 National Antibiotic Guidelines . especially common in the 3rd and 4th web spaces • Moccasin-style: powdery plaques with mildly erythematous base on heels. Rare: Epidermophyton floccosum. Candida. uncomplicated noninflammatory lesions. C. Tinea pedis May manifest as: • Inter-digital. It appears to be as effective as 25% sodium thiosulfate and ketoconazole cream. Fusarium Preferred Regimen: 1st line: Terbinafine 1% cream qd x 2-4 weeks (recommended) OR Ketoconazole 2% cream bid x 3-6 weeks OR Clotrimazole 1% bid x 2-4 weeks 2nd line: Terbinafine 250mg PO x 2 weeks Fluconazole 150mg PO q1wk x 4 weeks Comments: A randomized controlled trial showed faster response with topical terbinafine compared to topical clotrimazole after 1 week of treatment (84. Avoid tight-fitting clothes/underwear. solution bid x 2-4 weeks 2nd line: Topical therapy ineffective or intolerant to topical medications.8%. If secondary bacterial infection is suspected. powder. Trichophyton mentagrophytes. obtain bacterial cultures and start adequate antibiotic coverage.6% vs 55. usually on the instep Etiology: Trichophyton rubrum. deeper infection with hair follicle involvement: Terbinafine 250mg PO qd x 2-4 weeks OR Itraconazole 200mg PO qd x 2-4 weeks or 200mg bid x 7d OR Fluconazole 50- 100mg PO qd or 150mg once weekly x 2-3 weeks Comments: Topical antifungals preferred for localized. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS Preferred Regimen: 1st line: Terbinafine 1% cream bid x 3-4 weeks (recommended) OR Ketoconazole 2% cream qd or bid x 2-4 weeks OR Clotrimazole 1% cream. May progress to a chronic phase resembling hand eczema. Clin Inf Diseases 2011. 2015. Clinical Practice Guidelines by the Infectious Diseases Society of America for the treatment of Methicillin resistant Staphylococcus aureus infections in adults and children. Miller LG. Clin Inf Diseases 2012. References • Antimicrobial Resistance Surveillance Program. Bisno AL. Bayer A. 4:132-73. Comia PB. SKIN AND SOFT TISSUE INFECTIONS IN ADULTS Topical or systemic corticosteroids: may be considered in cases of extensive or severe inflammatory tinea pedis. Berendt AR. • Bartlett JG. A placebo-controlled trial of antibiotics for smaller skin abscesses. Topical or systemic antibiotics: may be needed in cases of secondary Gram-negative toe web infection. 52:1-38. Manila: Department of Health. 376:2545-55. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America. et al. Immergluck L. • Lipsky BA. • Liu C. Cosgrove SE. et al. National Antibiotic Guidelines 169 . 59: 147-59. Clin Inf diseases 2014. • Daum RS. • The Sanford Guide to Antimicrobial Therapy. 2012 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Treatment of Diabetic Foot Infections. Johns Hopkins ABX Guide (@2000 – 2016). New Engl J Med 2017. Editor in Chief. et al. Chambers HF. 2016. • Stevens DL. et al. and malodorous urine. malaise. URINARY TRACT INFECTION IN CHILDREN In children. Urinary Tract Infection (UTI) is defined by the presence of a single pathogen in urine culture accompanied by clinical findings in the history. vomiting. back.5-10mg/kg qd >7d 1200 . Group B Streptococcus Preferred Regimen: Infants <2 months: Cefotaxime PLUS Age Weight Dose <7d 50mg/kg/dose q12h >7d <1200g 50mg/kg/dose q12h >7d >1200g 50mg/kg/dose 8h >1 month 100-200 mg/kg/d q6h Amikacin Age Weight Dose 0-4 weeks <1200g 7. suprapubic pain. physical examination and diagnostic evaluation. The following recommended antimicrobial treatments for selected pathogen-specific conditions are based on evidence of clinical effectiveness.5mg/kg qd <7d 1200 . diarrhea. antibiotic therapy may be adjusted accordingly. Patients usually have no systemic signs or symptoms.2000g 7. Enterobacter. urgency. Infants and children who have bacteriuria and fever >38°C OR those presenting with fever <38°C with loin pain/tenderness and bacteriuria should be worked up for acute pyelonephritis. cost effectiveness and local patterns of drug resistance reported the past two years. frequency. Enterococcus.2000g 7. incontinence. occasionally. coli. Klebsiella. Once the sensitivity pattern of a specific pathogen has been obtained from the urine culture requested.5mg/kg qd >7d >2000g 10 mg/kg qd DOT: 10-14 days 170 National Antibiotic Guidelines . A. Etiology: E. or flank pain. and. URINARY TRACT INFECTIONS I.5mg/kg qd <7d >2000g 7. • Acute cystitis: condition that indicates urinary bladder involvement where infants and children may present with any or all of the following symptoms of dysuria. Acute Uncomplicated UTI • Acute pyelonephritis: Condition that indicates renal parenchymal involvement where infants and children may present with fever with any or all of the following symptoms: abdominal. nausea. “there are insufficient data to answer the question on which type of antibiotic and which duration is most effective to treat symptomatic lower UTI. Clinical response is expected in 24-48 hours. Early onset is usually due to maternal transmission. Antibiotic coverage should be re- assessed if still unwell in 24-48h. Request for a kidney and urinary bladder ultrasound and if abnormal. Enterobacter. Klebsiella. Early antibiotic therapy is necessary to prevent renal damage. IV therapy is preferred for seriously ill children and for those who cannot take oral therapy. DOT (IV/PO): 7-14d Comments: Oral therapy is equally effective to IV therapy. use adult dose. According to a Cochrane review on antibiotics for lower urinary tract infection in children (August 2012). Citrobacter Preferred Regimen: Oral: >2 months to 18 years Amoxicillin-clavulanate: <40 kg: 20-40mg/kg/d q8h (amoxicillin component) or 25-45mg/kg/d q12h using the 20mg/5mL or 400mg/5mL >40 kg: 500-875mg q8h (Max: 2g/d) OR Cefuroxime >3mos . Switch to oral therapy once patient has been afebrile for 24h and able to take oral medications. refer to a pediatric nephrologist for further work-up. URINARY TRACT INFECTIONS Comments: If there are signs of sepsis. Etiology: E. Nitrofurantoin should NOT be used for pyelonephritis and renal sepsis due to poor serum concentrations.12years: 20-30 mg/kg/d PO q12h Adolescent: Cefuroxime 250-500mg PO q12h OR Nitrofurantoin (only for cystitis) 5-7mg/kg/d q6h (Max: 400 mg/d) Parenteral: Ampicillin-Sulbactam 100-200mg/kg/d q6h (ampicillin component) IM or IV infusion over 10-15 min OR Cefuroxime 75-150mg/kg/d q8h (Max dose: 6 g/d). For those >40 kg. treat as neonatal sepsis. Obtain renal ultrasound within 6 weeks for 1st UTI in children <6 months old.” National Antibiotic Guidelines 171 . coli. Use ceftriaxone if cefotaxime is not available and the neonate is not jaundiced. Adjust therapy based on culture. Cephalosporins are not useful if Enterococcus is suspected. This review found that 10-day antibiotic treatment is more likely to eliminate bacteria from the urine than single-dose treatments. Refer to specialist for drainage. Etiology: Enterobacteriaceae.5-10mg/kg qd >7d 1200 . Comments: Use cefotaxime instead of ceftriaxone in jaundiced patients. Oxacillin 100-200mg/kg/d q6h PLUS S.5mg/kg/d x 1 dose or q8h (Max: 24 g/d) Comments: Use Vancomycin if MRSA is suspected.2000g 7. Adjust antibiotics depending on results of culture. Perinephric abscess Etiology: Preferred Regimen: Enterobacteriaceae. URINARY TRACT INFECTIONS B. pediatric nephrologist and pediatric urologist. Cephalosporins are not active against Enterococcus. aeruginosa.5mg/kg qd >7d >2000g 10 mg/kg qd Infants and children: 15-22.5mg/kg qd <7d 1200 . UTI. 172 National Antibiotic Guidelines . C. P.5mg/kg qd <7d >2000g 7. If Pseudomonas is suspected. aureus Amikacin 15-22. use ceftazidime instead of cefotaxime.2000g 7. recurrent catheter related or with co-morbids These patients require a referral to a pediatric infectious disease specialist.5mg/kg/d as single daily dose or q8h (Max: 24 g/d) DOT: 7-14 days depending on response. Enterococcus Preferred Regimen: Ceftriaxone PLUS Age Weight Dose <7d 50mg/kg/dose q24h >7d <2000g 50mg/kg/dose q24h >7d >2000g 50-75mg/kg/dose q24h Infants & children: 50-100 mg/kg/dose q24h AND/OR Amikacin Age Weight Dose 0-4 weeks <1200g 7. saprophyticus (5-15%) Preferred Regimen: 1st line: 2nd line: Nitrofurantoin macrocrystals Cefuroxime 250mg bid x 7d OR 100mg qid x 5d OR Fosfomycin 3g Cefixime 200mg bid x 7d OR x 1 dose sachet in 3-4 oz (or 90. frequency. but are efficacious in 3-day regimens. coli (75-90%). otherwise healthy premenopausal female Etiology: E. The treatment is the same for otherwise healthy elderly women with AUC. Amoxicillin/ampicillin and cotrimoxazole are not recommended for empiric treatment given the high prevalence of resistance to these agents. Amoxicillin-clavulanate 625mg bid x 120ml) water 7d Comments: Empiric treatment is the most cost-effective approach.g. National Antibiotic Guidelines 173 . Nitrofurantoin monohydrate/ macrocrystals (100mg bid) are not locally available. S. Hospital acquired UTI Preferred Regimen: Ceftazidime 30-50mg/kg IV q8h (Max: 6 g/d) OR Amikacin 15mg/kg IV q24h (Max: 24g/d) Comments: Choice should be based on current antimicrobial susceptibility pattern in the institution E. Prophylaxis for Recurrent UTI Preferred Regimen: Nitrofurantoin 1-2mg/kg/d (up to 100 mg/d) PO in 1-2 div doses Comment: Refer to an infectious disease specialist or nephrologist II.. Fluoroquinolones are considered as reserved drugs because of propensity for collateral damage (e. urinalysis and urine culture not pre-requisites. Uncomplicated UTI Acute uncomplicated cystitis (AUC) • Acute dysuria. selection for drug-resistant bacteria). URINARY TRACT INFECTION IN ADULTS A. URINARY TRACT INFECTIONS D. urgency in a non-pregnant. E. Consider giving initial IV/IM dose of antibiotic followed by oral regimen in patients not requiring hospitalization. nausea/vomiting.5g q6-8h Comments: Urine analysis. Indications for hospitalization/parenteral regimen: 1. with or without signs or symptoms of cystitis in an otherwise healthy premenopausal female Etiology: As for AUC. culture and susceptibility tests should be done. Asymptomatic bacteriuria (ASB) presence of bacteria in the urine without signs and symptoms of UTI Diagnosis: • In women: 2 consecutive voided urine specimens with the same organism in quantitative counts ≥100. URINARY TRACT INFECTIONS Acute uncomplicated pyelonephritis • Fever. gram stain. Routine urologic evaluation and imaging not recommended unless still febrile after 72 hr. Blood cultures are not routinely done unless septic. Tailor antibiotic regimen once culture result available. flank pain. coli is predominant. concern re compliance 4. signs of sepsis 2. presence of possible complicating conditions Switch to oral regimen once afebrile for 24-48 hr. and able to take oral medicines.5g q6h (when GS shows g+ cocci) Reserved for multidrug-resistant organisms: Ertapenem 1g q24h (if ESBL rate >10%) Piperacillin-tazobactam 2. Post-treatment urine culture not recommended if clinically responding to treatment.25-4. inability to take oral medications/hydration 3. as well as other Enterobacteriaceae Preferred Regimen: Oral 1st line: Ciprofloxacin 500mg bid x 7-10d OR Levofloxacin 750mg qd x 5d 2nd line: Cefuroxime 500 mg bid x 14d OR Cefixime 400 mg qd x 14d OR Amoxicillin-clavulanate 625 mg tid x 14d (when GS shows Gram+ cocci) Parenteral 1st line: Ceftriaxone 1-2g q24h Amikacin 15mg/kg q24h Ciprofloxacin 400mg q12h Gentamicin 3-5mg/kg q24 h +/- Levofloxacin 250-750mg q24h Ampicillin 2nd line: Ampicillin-sulbactam 1.000 cfu/mL 174 National Antibiotic Guidelines . costovertebral angle tenderness. RECURRENT UTI IN WOMEN • ≥3 episodes of acute uncomplicated cystitis documented by urine culture in 1 year or ≥ 2 episodes in a 6-mo. When indicated. clean-catch voided urine with one bacterial species in a quantitative count ≥100.000 cfu/mL • In both men and women: a single catheterized urine specimen with one bacterial species in a quantitative count ≥100 cfu/mL. period Etiology: Similar to cystitis Preferred Regimen: Treat as acute episode for uncomplicated UTI Prophylaxis: TMP-SMX 40/200mg or Nitrofurantoin 50-100 mg at bedtime for 6-12 mos (continuous prophylaxis) OR TMP-SMX 40-80/200-400mg or Nitrofurantoin 50-100 mg x 1 dose (post-coital) OR TMP-SMX 320/1600mg x 1 dose at symptom onset National Antibiotic Guidelines 175 . odor and color of urine not relevant to decision to treat Etiology: Similar to acute uncomplicated cystitis Preferred Regimen: No screening and treatment DO NOT TREAT ASB in: recommended except in: • healthy adults • pregnant women • non-pregnant women • persons undergoing invasive • patients with diabetes mellitus genitourinary tract procedures • elderly patients (likely to cause mucosal bleeding) • persons with spinal cord injury • persons with indwelling urinary catheter • persons with HIV • persons with urologic abnormalities Comments: Antibiotics do not decrease asymptomatic bacteriuria or prevent subsequent development of UTI. pyuria. A 7-day regimen is recommended. If urine culture not possible. URINARY TRACT INFECTIONS • In men: single. treatment should be culture-guided. B. significant pyuria (>10 wbc/hpf) or a positive gram stain of unspun urine (>2 microorganisms/oif) in two consecutive midstream urine samples may be used to screen for ASB. The optimal screening test is a urine culture. Screen for urologic abnormalities in the ff: • No response to treatment • Gross hematuria/persistent microscopic hematuria • Obstructive symptoms • History of acute pyelonephritis • History of or symptoms suggestive of urolithiasis • History of childhood UTI • Elevated serum creatinine • Infection with urea-splitting bacteria (Proteus. Avoid amoxicillin-clavulanate in those at risk of pre-term labor because of potential for neonatal necrotizing enterocolitis. For post-menopausal women. Cranberry juice and products can be used. intra-vaginal estriol nightly x2 weeks then twice-weekly for at least 8 months. UTI IN PREGNANCY ACUTE UNCOMPLICATED CYSTITIS IN PREGNANCY Etiology: E. coli (70%). ACUTE PYELONEPHRITIS IN PREGNANCY Etiology: Similar to acute cystitis in pregnancy 176 National Antibiotic Guidelines . Avoid cotrimoxazole especially during the first and third trimesters because of risk of teratogenicity and kernicterus. if possible. Fluoroquinolones are contraindicated. Morganella. Document clearance of bacteriuria with a repeat urine culture 1-2 weeks post-treatment. because of potential for birth defects and hemolytic anemia. but pre-treatment urine must be submitted for culture and susceptibility. Group B Streptococcus Preferred Regimen: Cefalexin 500mg qid x 7d Nitrofurantoin macrocrystals 100mg qid x 7d Cefuroxime 500mg bid x 7d Fosfomycin 3g single-dose sachet Cefixime 200mg bid x 7d Amoxicillin-clavulanate 625mg bid x 7d Comments: Start empiric antibiotic immediately. Providencia) C. Other Enterobacteriaceae. Comments: Radiologic or imaging studies not routinely indicated. URINARY TRACT INFECTIONS Others: Lactobacilli is not recommended. Use nitrofurantoin from the 2nd trimester to 32 weeks only. adjust treatment accordingly. Choice of regimen is based on culture/susceptibility test result. Follow up with monthly urine culture until delivery. Blood cultures are not routinely done unless septic. ASYMPTOMATIC BACTERIURIA (ASB) IN PREGNANCY Etiology: Similar to acute cystitis in pregnancy Preferred Regimen: Cefalexin 500mg qid x 7d Fosfomycin 3g single-dose sachet Cefuroxime 500mg bid x 7d Amoxicillin-clavulanate 625mg bid x Nitrofurantoin macrocrystals 100mg qid 7d x 7d Comments: Treat ASB to reduce the risks of symptomatic UTI and low birth weight neonates and preterm infants. Screen all pregnant women for ASB once between the 9th and 17th week. URINARY TRACT INFECTIONS Preferred Regimen: Parenteral: 1st line: Ceftriaxone 1-2 g q24 h OR Ceftazidime 2 g q8 h 2nd line: Ampicillin-sulbactam 1. The standard urine culture/susceptibility is the test of choice. Ultrasound of KUB reserved for failure to respond to treatment. Do follow-up urine culture 1-week post-treatment and monitor every trimester till delivery. Note caveats for use of nitrofurantoin and amoxicillin-clavulanate. Urinalysis is inadequate for ASB screening. preferably during the 16th week.5g q6h (when GS shows gram+ cocci) Oral: Cefalexin 500mg to complete 14d Cefuroxime 500mg bid to complete 14d Cefixime 200mg bid to complete 14d Amoxicillin-clavulanate 625mg bid to complete 14d Comments: Urinalysis. Test of cure with a urine culture post-treatment is essential. Recommended duration of treatment is 14d. gram stain and culture/susceptibility tests should be done. and based on culture/susceptibility result. National Antibiotic Guidelines 177 . Indications for admission: pre-term labor and other indications as listed above for acute uncomplicated pyelonephritis. Switch to oral regimen when afebrile x 48 hrs. functional or anatomic abnormalities of the urinary tract. Start with parenteral broad-spectrum antibiotic for severely ill patients. P. Repeat urine culture 1-2 weeks post -treatment. aeruginosa and enterococci Preferred Regimen: Parenteral: Amikacin 15mg/kg q24h Ertapenem 1g q24h Gentamicin 3-5mg/kg q24h Meropenem 1g q8h Piperacillin-tazobactam 2. culture and susceptibility prior to start of treatment. Ancillary diagnostic tests such as imaging of the urinary tract (CT or ultrasound) are often warranted. coli). P. • Cut-off for significant bacteriuria in cUTI is 100. aeruginosa and enterococci Preferred Regimen: Amikacin 15mg/kg IV q24h Piperacillin-tazobactam 4.g. CATHETER-ASSOCIATED UTI (CAUTI) Etiology: more varied and may include drug – resistant organisms (e.000 cfu/mL.presence of an underlying disease that interferes with host defense mechanisms . Etiology: more varied and may include drug – resistant organisms (e.any condition that increases the risk of acquiring [persistent] infection and/or treatment failure. ESBL- producing E.5g q6-8h Oral: Ciprofloxacin 500-750mg bid Levofloxacin 500-750mg qd Amoxicillin-clavulanate 625mg tid or 1g bid DOT: 7-14d Comments: Always obtain urine for gram stain. COMPLICATED UTI • Significant bacteriuria plus clinical symptoms occurring in the setting of: .. URINARY TRACT INFECTIONS D. and then switch to an oral regimen/de-escalate when there is clinical improvement. ESBL- producing E.. Referral to a specialist often warranted E. such as in catheterized patients.g IV q8h Ertapenem 1g IV q24h Ampicillin 1-2g IV q6h Meropenem 1g IV q24h (for susceptible enterococcal infections) Cefepime 1-2g IV q8-12h Levofloxacin 750mg IV/PO q24h Ceftazidime 1-2g IV q8h 178 National Antibiotic Guidelines . and adjust regimen as needed based on culture result. .25-4. coli).g. may be lower in certain clinical situations. female. Treat also presence of pyuria not helpful in those at risk for dissemination (e. DO NOT obtain urine for culture if asymptomatic. if still needed.. treat with oral surgical procedure. differentiating colonization from neutropenic patients). odorous or cloudy urine alone is not an indication for initiating antibiotics. SYMPTOMATIC CYSTITIS Etiology: Most common etiologic agent: C. indwelling urinary catheter) usually adequate to clear candiduria. 10-14 days of antibiotic treatment for patients with delayed response Comments: Pyuria. colony count and and post-procedure.6mg/kg x 1-7d Comments: Do ultrasound or CT of kidneys if candiduria persists in immunocompromised patients. and taking Fluconazole 400mg (6 mg/kg) pre- antibiotics. cephalosporin or fluoroquinolone use) DOT: 7 days w/ prompt resolution of signs and symptoms. krusei or glabrata): AmB deoxycholate 0. replace with a new catheter and obtain urine for gram stain and culture/susceptibility test prior to initiating treatment. more often in the elderly. CANDIDURIA ASYMPTOMATIC CANDIDURIA Etiology: Preferred Regimen: Candida sp. National Antibiotic Guidelines 179 .g. URINARY TRACT INFECTIONS (for mild infections with no previous 3rd gen. Choice of empiric antibiotics is institution-specific depending on the local susceptibility patterns and severity of illness. Whenever possible. F. infection. remove indwelling catheter. w/ Exceptions: When undergoing indwelling urinary device. w/ prior urologic procedure. in urine almost always No treatment indicated represents colonization. Comments: Elimination of risk factors (ex.3-0. diabetic. albicans Preferred Regimen: Fluconazole 200-400mg PO qd x 2 weeks For fluconazole-resistant Candida (C. 5g IV q6-8h DOT: 2 weeks. Vancomycin 15mg/kg q12 h 2nd line: TMP-SMX DS bid OR Piperacillin-tazobactam 4. BACTERIAL PROTATITIS • Most cases of bacterial prostatitis are preceded by a urinary tract infection. • Risk factors: urinary tract instrumentation. fungus ball). krusei or C. treat as if bloodstream infection is present. URINARY TRACT INFECTIONS PYELONEPHRITIS Etiology: Most common etiologic agent: C. blood cultures. P. gonorrhoeae and C. ABP WITH RISK OF STD Etiology: N. glabrata): AmB deoxycholate 0.. Comments: Do CBC. albicans Preferred Regimen: Fluconazole 200 mg PO qd x 2 wks. or urethritis (usually due to sexually transmitted pathogens) ACUTE BACTERIAL PROSTATITIS (ABP) WITHOUT RISK OF STD Etiology: Enterobacteriaceae. urinalysis and urine culture.6 mg/kg x 2 wks. trachomatis Preferred Regimen: Ceftriaxone 250mg IM x 1 dose PLUS Doxycycline 100mg bid or Azithromycin 500 mg PO qd DOT: 2 weeks 180 National Antibiotic Guidelines . coli resistance to TMP-SMX is high so TMP-SMX cannot be 1st line empiric treatment despite its high prostatic concentration.g. For fluconazole-resistant Candida (C. aeruginosa Preferred Regimen: 1st line: Ciprofloxacin 500mg PO or 400mg IV bid OR Levofloxacin 500-750 mg IV/PO qd If enterococcus is suspected/documented: Ampicillin 1-2g IV q4h. If disseminated disease suspected. extend to 4 weeks if patient still symptomatic. Caveat: E. urethral stricture. Comments: Consider surgical intervention to relieve obstruction if any (e.3-0. enterococcus. G. g. National Antibiotic Guidelines 181 . Drain abscess. >3 mos. enterococcus. Consider genitourinary imaging. or 3. COMPLICATED ABP (E. suppressive treatment.. ABP WITH RISK OF ANTIBIOTIC-RESISTANT PATHOGENS Etiology: Fluoroquinolone-resistant Enterobacteriaceae and Pseudomonas. treat intermittently for symptomatic episodes.g. ESBL or AmpC beta lactamase-producing Enterobacteriaceae Preferred Regimen: 1st line: Ertapenem 1g IV qd OR Meropenem 1g IV q8h (for Pseudomonas) 2nd line: Cefepime 2g IV q12h Comments: Consider a 4-week regimen. aeruginosa Preferred Regimen: 1st line: Ciprofloxacin 400 mg IV q12h OR Levofloxacin 750 mg IV q24h 2nd line: Ceftriaxone 1-2g IV q24h PLUS Levofloxacin 750 mg IV q24h OR Ertapenem 1g IV q24h OR Piperacillin-tazobactam 4.. prostatectomy if all other options have failed. enterococci.5g IV q8 h DOT: 4 weeks Comments: Obtain blood cultures. P. URINARY TRACT INFECTIONS Comments: Fluoroquinolones not recommended for gonococcal infection.) • Hallmark: relapsing UTI Etiology: Enterobacteriaceae. aeruginosa Preferred Regimen: 1st line: Ciprofloxacin 400 mg IV q12h OR Levofloxacin 750 mg IV q24h 2nd line: TMP-SMX DS bid DOT: 4-6 weeks Comments: If refractory. bacteremia or suspected prostatic abscess) Etiology: Enterobacteriaceae. options are: 1. CHRONIC BACTERIAL PROSTATITIS (CBP) • Prolonged urogenital symptoms (e. Switch to oral regimen once bacteremia has cleared and abscess is drained. P. 2. • Research Institute of Tropical Medicine. 2012. VA: Antimicrobial Therapy. • Gilbert DN. Accessed at http://arsp. et al. Bunyi MAC.com.50 (5): 625- 663 • Hsueh P. 114 -123 • Lipsky BA. Journal of Infection (2011) 63. Muntinlupa: Research Institute of Tropical Medicine. Treatment of Bacterial Prostatitis. Naber KG. Schwartz BS editors.11(1):10-16. 2016 • Bay AG. Urinary Tract infection in Children: Diagnosis. 2015. Cardenas DD. • Shaikh N. 2007.86(10):940-946. Byren I. Lobo JJ. 2016. 182 National Antibiotic Guidelines . Treatment and Long-Term Management. Department of Health. Diagnosis.nice. Hand book of Pediatric Infectious Diseases 2012. Hoban D. 5th edition. Accessed on July 13. Eliopoulis GM. 2013. • Gupta K.pdf on September 7. Aguilar CY. Quezon City: Philippine Society of Microbiology and Infectious Diseases. PIDSP Journal 2010. • Hooton TM. Carmeli Y. Gonzales ML. imaging and prognosis. Clin Infect Dis 2011.org. NICE guideline 54 accessed on 7/13/15 at nice. 52: e103 -e120. Philippines 2016. et al. Urinary Tract Infection in Children: Diagnosis. Am Family Phys 2012. Treatment and Long-term Management. Pagcatipunan MR. Hoberman. Available at: http://guidance. Urinary tract infections in infants older than one month and young children: acute management. • Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract Infections in Adults 2013 Update. Anacleto F. UpToDate last updated August 25. 2015. Lim JG. Freedman DO. Black DB. Kim K.uk/cg54 • NICE Clinical Guidelines 54.ph/wp-content/uploads/2016/06/2015-ARSP-annual-report- summary_1. Clin Infect Dis 2010. Chambers HF. • Bravo LC. URINARY TRACT INFECTIONS REFERENCES: • Antimicrobial Resistance Surveillance Laboratory. Antimicrobial Resistance Surveillance Program 2014 Annual Report. Saag MS. • Roberts KB. Inc. Ong-Lim AT. Revised AAP Guideline on UTI in Febrile Infants and Young Children. 2016.. 12(2): 75-85. Clinical and Laboratory Profile of Urinary Tract Infection Among Children at The Outpatient Clinic of A Tertiary Hospital. delos Reyes CA. • Maramba-Lazarte CC. 50:1641. • National Institute for Health and Care Excellence. and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Antimicrobial Resistance Surveillance Program 2015 Annual Report. Hoey CT. Pavia AT. Prevention. Etiology of neonatal sepsis in five urban hospitals in the Philippines. Sanford Guide to Antimicrobial Therapy 2016. et al. PIDSP J 2011. Consensus review of the epidemiology and appropriate antimicrobial therapy of complicated urinary tract infections in Asia-Pacific region. Clin Infect Dis 2010. Gallardo EE. Bradley SF. Hooton TM. Maramba-Lazarte CC. Manila. Manila: Section of Infectious and Tropical Diseases. Gatchalian SR.org. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases.uk/cg54. • Individual with asthma. Comments: Tablets should be taken after meals. • If patient is less than 2 years of age. Guidelines for the Implementation of the National Filariasis Elimination Program. and tenderness of nodules. headache. Brugia malayi. • Treatment is contraindicated in individuals with severe cardiac and kidney diseases.gov. These worms occupy the lymphatic system. please refer to the website. including the lymph nodes. Treat asthma first before taking antifilarial drugs. bancrofti infections. REFERENCES: • Department of Health. and Brugia timori. 2009 National Antibiotic Guidelines 183 . adenitis. seizure disorders or severe malnutrition should be treated with caution. Precautions: • Treatment of pregnant women should be deferred until after delivery.ph. Preferred Regimen: Day 1: Diethylcarbamazine (DEC) 6mg/kg div 3 doses (after meals) PLUS Albendazole 400mg Day 2 to Day 12: DEC 6mg/kg div 3 doses DEC is free and only available at the DOH Central office and government health facilities in endemic areas. malaise. Adverse Reactions • Localized: Pain. refer to specialist. DOH PUBLIC HEALTH PROGRAMS (FILARIASIS) FILARIASIS (Selective Treatment) For patients (+) for microfilariae in nocturnal blood examination (NBE) or Immunochromatographic test (ICT) Etiology: Roundworms of the Filarioidea type. myalgia and hematuria occur due to death of microfilariae. in chronic cases. Total cumulative DEC dose of 72 mg/kg for W. www. Lymphatic filariasis is caused by the worms Wuchereria bancrofti. For more information regarding the mass drug administration of the program of the DOH. Usually begins from 2-4 days after the first dose of DEC. Do not initiate treatment when patient has asthma attack. these worms lead to the syndrome of elephantiasis. inflammation. • Systemic: Fever. lymphangitis due to death of adult filarial worms. Usually begin from few to 48 hours after taking DEC and are usually self-limited.doh. Manila: National Filariasis Elimination Program National Center for Disease Prevention and Control. 2009. . his/her family members or other treatment partner with orientation counseling to indicate: • The need for regular treatment (e. When untreated it can cause permanent and progressive damage to the affected organs. Leprosy is a curable infection.g. Step 3: Before the start of treatment. Preferred Regimen: Monthly Treatment: Daily Treatment: Duration of Treatment Day 1 Days 2-28 PEDIA Multibacillary (MB) Regimen (10-14 years old) Rifampicin 450 mg Clofazimine 50 mg 12 blister packs to be taken Clofazimine 150 mg qod monthly within a maximum Dapsone 50 mg Dapsone 50 mg period of 18 months. DOH PUBLIC HEALTH PROGRAMS (LEPROSY) LEPROSY a chronic disease caused by Mycobacterium leprae that affects the skin. is curable by multidrug therapy (MDT). provide the patient. Regular intake of medication and monthly checkups are important). peripheral nerves. 184 National Antibiotic Guidelines . the following steps must be taken: Step 1: Determine which type of MDT is required: PB or MB. upper respiratory tract mucosa and eyes. *Note: Lapses in taking MDT should be < 3 month CHILD PB Regimen (10-14 years old) Rifampicin 450 mg Dapsone 50 mg 6 blister packs to be taken Dapsone 50 mg monthly within a maximum period of 9 months *Note: Lapses in taking MDT should be < 1 month ADULT PB Regimen (15 years old and above) Rifampicin 450 mg Dapsone 50 mg 6 blister packs to be taken Dapsone 50 mg monthly within a maximum period of 9 months *Note: Lapses in taking MDT should be < 1 month Comments: When it has been determined that a leprosy patient needs MDT. *Note: Lapses in taking MDT should be <3 months ADULT (MB) Regimen (15 years old and above) Rifampicin 600 mg Clofazimine 50 mg 12 blister packs to be taken Clofazimine 300 mg Dapsone 100 mg monthly within a maximum Dapsone 100 mg period of 18 months. Step 2: Determine which dose level is required: adult or pediatric. The treatment of leprosy should still be continued during lepra reactions. National Antibiotic Guidelines 185 . 2016. Clofazimine can be spaced out as required. Rifampicin 300mg once a month (Day 1) + dapsone 25 mg per day (Day 2 - 28) A patient with a high baseline average bacillary index (BI of +4 to +6) may need more than 12 months of treatment. REFERENCES: • Department of Health. Operational Manual. Lepra reactions may occur before. (e. A poor response to treatment is defined as a less than +1 reduction in average BI after 12 months of MBMDT. • World Health Organization. Step 4: Give the first dose of treatment and explain how to take treatment at home. Geneva: World Health Organization. DOH PUBLIC HEALTH PROGRAMS (LEPROSY) • The possibility of complication of leprosy which may need other treatment • That the health center or clinic is always ready to see them if they have any problems. 2016. and after treatment. during. 2016. Global Leprosy Strategy 2016–2020: Accelerating towards a leprosy-free world. Manila: Department of Health. Pediatric dose under 10 years of age: Rifampicin: 10mg/kg BW once a month Clofazimine: 1mg/kg BW daily and 6 mg/kg BW monthly Dapsone: 2mg/kg BW daily The standard child blister pack may be divided so that the appropriate dose is given to children under 10 years old. This decision may only be taken by specialists at referral units.g. Treatment rapidly kills the leprosy bacilli and renders the patient non-infectious. National Leprosy Control Programme Manual of Procedures. These complications should be detected and treated early. Response to malaria treatment must be monitored with daily blood film microscopy until the end of administration of the first line drugs. DOH PUBLIC HEALTH PROGRAMS (MALARIA) MALARIA The objectives of antimalarial treatment are to prevent severe malaria and. among others. malariae UNCOMPLICATED Preferred Regimen: INFANTS: <6 mos: Quinine 10mg salt/kg q8h X 7d PLUS Clindamycin 10mg/kg bid x 7d 6-11 months: Artemether–Lumefantrine (AL) (20mg/120mg) combination (Coartem) On d1. then 1 tab bid for d2-3 CHILDREN AND ADULTS 1st line: Artemether–lumefantrine (AL) (20mg/120mg per tab) combination Weight Day 1 Day 2 and 3 5 to <15 kg 1 tab followed by 1 tab after 8h 1 tab bid 15 to <25 kg 2 tabs followed by 2 tabs after 8h 2 tab bid 25 to <35 kg 3 tabs followed by 3 tabs after 8h 3 tab bid >35 kg &adults 4 tabs followed by 4 tabs after 8h 4 tab bid PLUS Primaquine (15 mg/tab) 0. The second line drug is administered when asexual forms of the parasite are detected in blood films during this specified period. For adults >60 kg: 3 tabs 2nd line: P: Quinine sulfate 10mg salt/kg q8h x 7d PLUS Clindamycin 10mg/kg bid x 7d A: Quinine sulfate 10mg salt/kg q8h x 7d PLUS Clindamycin 10mg/kg bid x 7d OR Tetracycline 3mg/kg body weight od x 7d OR Doxycycline 250mg qid x 7d AND Primaquine (15mg/tab) 0. Plasmodium falciparum or P. 1 tab followed by 1 tab after 8h. Recurrence of asexual parasitemia with the first line drugs must also be immediately reported to the Department of Health. For adults >60kg: 3 tab. compliance to guidelines and treatment with highly effective drugs are critical. 186 National Antibiotic Guidelines . The National Malaria Program aims to eliminate the disease by 2030. thus. for patients residing in endemic areas. then weekly until the 28th day after the start of treatment. to interrupt transmission via anopheline vectors.25mg base/kg on d1 (pediatric and adult). A.25mg-base/ kg on d1 (pediatric and adult). nail. Watch out for fever. particularly on the second and third days of treatment. Obtain past medical and family histories of G6PD deficiency before administration of primaquine. consider alternatives. Repeat administration of the first dosage in the event of vomiting within one hour of administration. joint pain. Low blood levels with resultant treatment failure could potentially result from inadequate fat intake. its absorption is enhanced by co- administration of fat. Avoid sun exposure. • It may reduce the efficacy of oral contraceptive pills. Consider other contraceptive options. • May cause increased intracranial pressure.5 units/gram of hemoglobin. dissolved in 5% NaHCO3. or tiredness. or changes in vision. Do not give primaquine to patients with G6PD deficiency.4mg/kg/dose. tooth or gum discoloration may occur. If the G6PD status cannot be documented when required withhold primaquine administration. Do not give AL to infants less than 6 months or less than 5 kg. and renal dysfunction. hemoglobinuria in G6PD deficiency neutropenia. The normal G6P level for adults is 5.25 mg- base/kg on Day 1 if patient can National Antibiotic Guidelines 187 . WHO 2015) tolerate oral medicines AND Primaquine (15 mg/tab) 0. • Skin. and cookies). • May cause photosensitivity. buko or suman sa latik. Considering that lumefantrine is highly lipophilic. Watch out for headache. • Diarrhea may occur. eye. SEVERE 1st line Pediatrics Adults For children < 20 kg: 3mg/kg bw per Artesunate IV or IM 2.5 to 20. Diluted in Shift to oral artemether- 5mL D5W IV drip or IM (anterior lumefantrine once patient can thigh. • May cause autoimmune reactions. Precautions when using doxycycline: • Avoid during pregnancy unless benefit outweighs risks. Do not give primaquine to infants below 1 year old. dose IV or IM Artesunate powder Give 3 IV/IM doses 12 hours apart. Closely monitor infants for side effects such as methemoglobinemia. blurred vision. rash. hemolytic anemia. DOH PUBLIC HEALTH PROGRAMS (MALARIA) Comments: Advise patients to take AL with milk or fat-containing food (gata or coconut milk. falciparum malaria should be done.. continue the application of AS using one to two thirds of the initial dose as maintenance dose until the patient can tolerate oral medication at which point. and 5 mg/kg on d3 B. hyperpyrexia. convulsions. severe anemia.g. 2nd line Pediatrics Adults Parenteral quinine dihydrochloride Parenteral Quinine Dihydrochloride Infusion Infusion ≤7y: 10 mg salt/kg in IV drip for 4h as 20 mg salt/kg in 500 mL D5W or 0.9NaCl or D5W IV drip for 4h q8h 10mL/kg D5W or 0. acute renal failure. then 10 mg salt/kg IV NaCl for 4h IV drip (total dose not to drip q12h as maintenance dose exceed 2.000 mg). then 10 mg salt/ kg 8y-16y: 15 mg salt/kg IV drip for 4h in in 0.9 NaCl (infusion as maintenance dose rate must not exceed 5mg/kg/h) as loading dose. CONGENITAL AND NEONATAL MALARIA Preferred Regimen: Chloroquine 10mg/kg on d1. For adults > 60 kg: 3 tab. and is not recommended for older children and adults. DOH PUBLIC HEALTH PROGRAMS (MALARIA) tolerate oral medicines (pediatric and adult). bleeding. See above for “Precautions when using doxycycline” Artesunate suppository is a last-resort drug. hypoglycemia. e. treatment with AL and Primaquine according to schedule for uncomplicated P. If referral is impossible. pulmonary edema and respiratory failure. then 10 mg salt/kg IV Shift to oral artemether- drip for 4h q8h as maintenance dose lumefantrine once patient can PLUS Clindamycin 10mg/kg bid x 7 d tolerate PLUS Clindamycin 10 mg/kg bw bid x 7d OR Tetracycline 3 mg/kg bw od x 7d OR Doxycycline 250 mg qid x 7d 2nd line for (for pre-referral to hospital) Artesunate suppository (pediatric) 10 mg/kg Comments: Concomitant management of complications of severe P. falciparum in adults.9 loading dose. ovale UNCOMPLICATED 188 National Antibiotic Guidelines . Plasmodium vivax or P.2. 4 tabs followed by 4 tabs after 8h. then 4 tabs bid for d2-3 PLUS Primaquine tablet 0. Indonesia Papua New Guinea. and 5 mg/kg BW on d3 OR Artemether–Lumefantrine for 3 days (see regimen for uncomplicated vivax malaria) PLUS Primaquine 0. DOH PUBLIC HEALTH PROGRAMS (MALARIA) Preferred Regimen: 1st line: Chloroquine 10mg/kg on d1-2. Myanmar and Thailand. vivax or P.25mg base/kg/day x1 dose for d1-14 (pediatric and adult) 2nd line: P: Artemether–lumefantrine (20mg/120 mg) combination Weight Day 1 Day 2 and 3 5 to < 15 kg 1 tab followed by 1 tab after 8h 1 tab bid 15 to < 25 kg 2 tabs followed by 2 tabs after 8h 2 tab bid 25 to < 35 kg 3 tabs followed by 3 tabs after 8h 3 tab bid PLUS Primaquine tablet 0.75mg/kg/d on d1-14 (Max: 30–45 mg/d) (do not give if patient is G6PD deficient) Comments: Chloroquine and primaquine-tolerant vivax is known to exist in nearby countries particularly in East Timor. ovale and refers to infections resulting from activation of hypnozoites. then 5mg/kg on d3 (pediatric and adult) PLUS Primaquine 0. Recrudescence refers to persistence or re-appearance of parasitemia in a patient National Antibiotic Guidelines 189 . Do not give primaquine to patients with G6PD-deficiency.75 mg/kg once a week for 8 weeks. Patients with mild deficiency may receive a dose of 0. Relapse is associated with P. vivax) Preferred Regimen: Chloroquine 10mg/kg BW for d1-2. Relapse must be distinguished from recrudescence. Its occurrence within 28 days of an initial infection/diagnosis is unlikely. If recurrence of parasitemia is within 28 days after the start of chloroquine.25mg-base/kg starting on d1 (pediatric and adult) A: Artemether–Lumefantrine (20mg/120mg) combination on d1. the patient is treated with AL.25mg- base/kg on d1-14 (pediatric and adult) Comments: Primaquine should be taken with meals (causes abdominal discomfort taken on an empty stomach). RELAPSE (laboratory confirmed) (relapse refers to recurrence of parasitemia due to hypnozoites of P. Shift to oral artemether-lumefantrine once patient can tolerate oral medicines. PLUS Clindamycin 10 mg/kg bid x 7 d A: Artesunate IV or IM 2. Give for at least 24 hours.9 NaCl (infusion rate must not exceed 5mg/kg/h) as loading dose. It is counted as the same case. Diluted in 5ml D5W IV drip or IM (anterior thigh. Plasmodium knowlesi Preferred Regimen: P: Artemether–Lumefantrine (20 mg/120 mg) combination Weight Day 1 Day 2 and 3 5 to < 15 kg 1 tab followed by 1 tab after 8h 1 tab bid 15 to < 25 kg 2 tabs followed by 2 tabs after 8h 2 tab bid 25 to < 35 kg 3 tabs followed by 3 tabs after 8h 3 tab bid 190 National Antibiotic Guidelines . DOH PUBLIC HEALTH PROGRAMS (MALARIA) within 28 days of the initial diagnosis it is an indication of treatment failure. then 10 mg salt/kg IV drip q12h as maintenance dose 8y-16y: 15 mg salt/kg IV drip for 4h in 10mL/kg D5W or 0.4 mg/kg/dose. 4 tabs followed by 4 tabs after 8h. SEVERE Preferred Regimen: P: 1st line: For children <20kg – 3mg/kg bw per dose IV or IM Artesunate powder dissolved in 5% NaHCO3. then 10 mg salt/kg IV drip for 4h q8h as maintenance dose. SHIFT TO: P: Artemether–Lumefantrine (20 mg/120 mg) combination Weight Day 1 Day 2 and 3 5 to < 15 kg 1 tab followed by 1 tab after 8h 1 tab bid 15 to < 25 kg 2 tabs followed by 2 tabs after 8h 2 tab bid 25 to < 35 kg 3 tabs followed by 3 tabs after 8h 3 tab bid PLUS Primaquine tablet 0. then 4 tabs bid for days 2 and 3 PLUS Primaquine tablet 0. to complete three days of treatment IF PATIENT CAN TOLERATE ORAL MEDICATIONS.25 mg-base/kg starting on d1 (pediatric and adult) Comment: Management is similar to that of severe falciparum malaria.25 mg-base/kg starting on day 1 (pediatric and adult) A: Artemether–Lumefantrine (20 mg/120 mg) combination on day 1. WHO 2015) 2nd line: Parenteral Quinine dihydrochloride Infusion <7y: 10 mg salt/kg in IV drip for 4h as loading dose. C. 25 mg-base/kg starting on days 1-14 (pediatric and adult) A: Artemether–Lumefantrine (20mg/120mg) combination on d1. then 4 tabs bid for days 2 and 3 Comments: Definite diagnosis for P.25mg- base/kg starting on d1-14 (pediatric and adult) Plasmodium falciparum and P. P. By microscopy. knowlesi is by PCR.25mg- base/kg starting on d1 National Antibiotic Guidelines 191 . malariae Preferred Regimen: P: Artemether–Lumefantrine (20 mg/120 mg) combination Weight Day 1 Day 2 and 3 5 to < 15 kg 1 tab followed by 1 tab after 8h 1 tab bid 15 to < 25 kg 2 tabs followed by 2 tabs after 8h 2 tab bid 25 to < 35 kg 3 tabs followed by 3 tabs after 8h 3 tab bid PLUS Primaquine tablet 0. then 4 tabs bid for d2-3 PLUS Primaquine tablet 0. malariae or even P. 4 tabs followed by 4 tabs after 8h. falciparum. DOH PUBLIC HEALTH PROGRAMS (MALARIA) A: Artemether–Lumefantrine (20 mg/120 mg) combination on day 1. vivax. then 4 tabs bid for d2-3 PLUS Primaquine tablet 0. vivax with/ without P. and infrequently. 4 tabs followed by 4 tabs after 8h. vivax with/ without P. malariae Preferred Regimen: P: Artemether–Lumefantrine (20 mg/120 mg) combination Weight Day 1 Day 2 and 3 5 to < 15 kg 1 tab followed by 1 tab after 8h 1 tab bid 15 to < 25 kg 2 tabs followed by 2 tabs after 8h 2 tab bid 25 to < 35 kg 3 tabs followed by 3 tabs after 8h 3 tab bid PLUS Primaquine tablet 0. it is usually mistaken for P. D. Mixed Infections Plasmodium falciparum and P. 4 tabs followed by 4 tabs after 8h.25 mg-base/kg on day 1 A: Artemether–Lumefantrine (20mg/120mg) combination on d1. but give it 2 weeks after delivery in a single dose: 0. shift to oral clindamycin as soon as patient tolerates it at the same dose to complete 7 days. antimalarials such as chloroquine. If patient can already tolerate oral meds.25mg/kg. LACTATING: ADD Primaquine 0.25 mg base/kg/d (taken as a single dose) for d1-14 PREGNANT AND LACTATING WOMEN A. Plasmodium falciparum UNCOMPLICATED Preferred Regimen: PREGNANT: Quinine sulphate 10mg/kg q8h x 7d PLUS Clindamycin 10mg/kg bid x 7d LACTATING: ADD Primaquine 0. malariae Preferred Regimen: P and A: Chloroquine tablet 10 mg/kg on d1-2. single dose after 7 days of clindamycin. quinine and primaquine are secreted in the breast milk in amounts that are not harmful to the infant and in insufficient amounts to provide protection against malaria.25 mg/kg. SEVERE Preferred Regimen: PREGNANT: Quinine dihydrochloride 20 mg/kg infused over 4h (in 500 mL 5% dextrose water or 0. give it as the last resort for pregnant women during the 1st trimester with patient’s informed consent when Quinine is not available. single dose on day 1 to the above regimen Comments: Withhold primaquine during the entire period of pregnancy. then 5 mg/kg body weight on d3 PLUS Primaquine 0. falciparum.75 mg per kg body weight. but must give it 2 weeks after delivery in single dose at 0. give AL only if the patient is on the 2nd and 3rd trimester according to the guidelines for uncomplicated P. shift to oral quinine sulphate (10 mg/kg q8h) to complete 7 days at the same dose PLUS Clindamycin 10 mg/kg IV bid.25mg/kg until G6PD status is ascertained.9% saline) as loading dose and 10 mg/kg q8h infused over 2-4 hours as maintenance dose. DOH PUBLIC HEALTH PROGRAMS (MALARIA) Plasmodium vivax and P. Comments: If Quinine Plus is not available. For lactating mothers. While AL is contraindicated during the first trimester. Withhold Primaquine during the entire period of pregnancy. to the above regimen. 192 National Antibiotic Guidelines . 75 mg/kg on day 3 PLUS Primaquine 0.75 mg/kg/ day (maximum of 30-45 mg/d) for 14 days. but give it 2 weeks after delivery at 0. See www. but give it 2 weeks after delivery at 0.5-0. but give it 2 weeks after delivery at 0.5 mg/kg/day for 14 days. and 5 mg/kg on d3 LACTATING: Chloroquine tab 10mg/kg on d1-2. C. give primaquine only if their infant is confirmed to be non-G6PD-deficient.5 mg/kg on d3 LACTATING: ADD Primaquine 0.ph/newbornscreening for a list of newborn screening coordinators. Plasmodium malariae Preferred Regimen: PREGNANT: Chloroquine tab 10mg/kg on d1-2. Plasmodium ovale Preferred Regimen: PREGNANT: Chloroquine tab 10mg/kg on d1-2.25mg/kg. DOH PUBLIC HEALTH PROGRAMS (MALARIA) B. and 0.5 mg/kg on d3 LACTATING: ADD Primaquine 0. and 0. Comments: Withhold primaquine during the entire period of pregnancy.25mg/kg X 1 dose on d 1 to the above regimen National Antibiotic Guidelines 193 . RELAPSE Preferred Regimen: PREGNANT: Chloroquine 150mg base/tab 2 tabs per week for 8 weeks LACTATING: ADD Primaquine 0.25 mg/kg/day for 14 days.25mg/kg body weight per day (mmax:30-45 mg/ day) beginning d1-14 to the above regimen Comments: Withhold primaquine during the entire period of pregnancy.gov. Plasmodium vivax ACUTE Preferred Regimen: PREGNANT: Chloroquine tab 10mg/kg on d1-2. D. single dose on d1 to the above regimen Comments: Withhold primaquine during the entire period of pregnancy. For breastfeeding women. and 0.25mg/kg body weight per day beginning day 1 to 14 to the above regimen.doh. National Malaria Control Program: Manual of Operations. Personal protective measures are just as important. even if chemoprophylaxis requirements were strictly complied with. 4 tabs bid on d2-3 PLUS Primaquine PREGNANT: withhold until delivery Post-partum/lactating women: 0. REFERENCES • Department of Health. (2014). • World Health Organization. • However. 3 tabs bid on d2-3 > 35 kg: 4 tabs on day 1 and 8 h after. x 1 dose on d1 to the above regimen Use Artemether–Lumefantrine (20mg/120mg) combination only if quinine + clindamycin is not available. 5th edition.25mg/kg.25 mg/kg/day on days 1-14 CHEMOPROPHYLAXIS • Chemoprophylaxis may be given to any individuals (Filipinos and foreigners alike) traveling to an endemic area within the country. Mixed Infections Preferred Regimen: PREGNANT: Quinine sulphate 10mg/kg q8h x 7d PLUS Clindamycin 10mg/kg bid x 7d LACTATING: ADD Primaquine 0. Geneva: WHO 194 National Antibiotic Guidelines . chemoprophylaxis alone does not give 100% protection against infection with the Plasmodium parasite. (2015). 3rd edition. DOH PUBLIC HEALTH PROGRAMS (MALARIA) Comments: Withhold primaquine during the entire period of pregnancy. Guidelines for the Treatment of Malaria. but give it 2 weeks after delivery in a single dose of 0. and if the patient is on the second or third trimester. The following is the recommended dosage schedule: <35 kg:3 tabs on d1 and 8 h after.75 mg/kg. E. Indications of hospital referral: • Presence of complications. Preferred Regimen: Praziquantel 40 mg/kg/d div 2-3 doses x 1d Dose is increased to 60 mg/kg in neuroschistosomiasis. Follow up treatment of confirmed cases 1 month later because praziquantel does not kill developing worms. Praziquantel should be given on a full stomach. or glomerulonephritis • CNS schistosomiasis (patients with seizures. For more information regarding the mass drug administration of the program of the DOH. Clinical Practice Guidelines for the Diagnosis. vomiting. Treatment and Prevention of Schistosoma japonicum Infections in the Philippines: 2013 Update. Supportive treatment may be given to relieve adverse reactions as appropriate. diarrhea. abdominal discomfort. such as headache. fever and urticaria. and less commonly.gov. japonicum. National Antibiotic Guidelines 195 . REFERENCES: • Department of Health. Instruct them afterwards to watch out for these reactions for 24 hours. www. Observe patients for 1 to 3 hours for possible adverse reactions. or signs of increased intracranial pressure or diffuse encephalitis). dizziness. DOH PUBLIC HEALTH PROGRAMS (SCHISTOSOMIASIS) SCHISTOSOMIASIS (Selective Treatment (Passive or Active Surveillance)) Supported by a positive result on kato katz for Schistosoma japonicum ova by stool exam and or rectal imprint Etiology: Schistomes.doh. focal neurologic deficit. development of portosystemic collateral blood vessels. please refer to the website. splenomegaly with hypersplenism. the most common in the Philippines being S.ph. nausea. such as periportal fibrosis. cor pulmonale. Praziquantel is free and only available at the DOH Central office and government health facilities in endemic areas. Comments: This regimen may also be given for hepato-intestinal schistosomiasis and pulmonary schistosomiasis. Etiology: N. lack of improvement Cefotaxime 0. G. trachomatis. fever >38. including any combination of endometritis. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) I. presence Recommended IM/PO Regimen of tubo-ovarian abscess.5mg/kg q8h maintenance dose.0g IM x 1 dose PLUS after 48h of oral antibiotic) Doxycycline 100mg PO bid x 14d 1st line: WITH or WITHOUT Cefoxitin 2g IV q6 PLUS Metronidazole 500mg PO bid x 14d Doxycycline 100mg PO q12h x 14d OR Clindamycin 900mg IV q8h PLUS Gentamicin 2mg/kg IV/IM loading dose. S. Pelvic Inflammatory Disease Pelvic inflammatory disease (PID) comprises a spectrum of inflammatory disorders of the upper female genital tract. H. M. followed by 1. vaginalis. hominis. salpingitis.5˚C. Cytomegalovirus (CMV). pregnancy. agalactiae. Pelvic Infections A. U. tubo-ovarian abscess. C. Ceftriaxone 250mg IM/IV x 1 dose HIV infection. genitalium Preferred Regimen: PARENTERAL REGIMEN OUTPATIENT REGIMEN (if with uncertain diagnosis. Enterobacteriaceae. and pelvic peritonitis. urealyticum. gonorrhoeae. Single daily dosing (3–5mg/kg) can be used THEN Doxycycline 100mg PO q12h x 14d 2nd line: Ampicillin-sulbactam 3g IV q6h PLUS Doxycycline 100mg PO q12h x 14d Comments: Presumptive treatment should be initiated in sexually active young women and other women at risk for STDs if: • with pelvic or lower abdominal pain • no cause for the illness other than PID can be identified 196 National Antibiotic Guidelines . nausea OR and vomiting precluding use of oral medications. influenzae.5-1. M. Bacteroides. Enteric Gram-negative rods. and syphilis. Single daily dosing (3–5 mg/kg) can be substituted PLUS Doxycycline 100mg PO bid x 14d DOT (IV/PO): at least 21 days. Women who do not respond to IM/oral therapy within 72 hours should be re- evaluated to confirm the diagnosis and should be given intravenous therapy. α-hemolytic streptococci. Tubo-ovarian Abscess • late manifestation of PID.to 6-cm abscess has a 20% chance of requiring surgical intervention. coli. aerobic streptococci Non-sexually active: E. Peptococcus. Etiology: Sexually active: E. B. An abscess larger than 10 cm has a 60% chance. Useful clinical features that suggest the presence of a pelvic abscess are pain. bacterial vaginosis. Bacteroides fragilis. The recommended 3rd generation cephalosporins are limited in their coverage of anaerobes. continue treatment until satisfactory response for at least 24 h before switching to outpatient regimen. a 7. Comments: Ultrasonography of the pelvis is valuable in confirming the presence of an abscess. Other Bacteroides spp.to 9-cm abscess has a 35% chance. Metronidazole should be considered with third-generation cephalosporins. anaerobes Preferred Regimen: PARENTERAL REGIMEN OUTPATIENT REGIMEN Cefoxitin 2g IV q6h PLUS Continuing oral therapy should Doxycycline 100mg PO q12h x 14d OR consist of: Doxycycline 100mg PO bid OR Clindamycin 900mg IV q8h PLUS Clindamycin 450mg PO qid x 14d Gentamicin 2mg/kg IV/IM loading dose. adnexal tenderness (for >7 days) and an erythrocyte sedimentation rate greater than 30 mm/hr. coli. Peptostreptococcus.5 mg/kg q8h maintenance dose. uterine tenderness or adnexal tenderness Screen for trichomoniasis. National Antibiotic Guidelines 197 .. persistent fever. For inpatient regimens. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) • one or more of the following minimum clinical criteria are present on pelvic exam: cervical motion tenderness. followed by 1. and a 4. hepatitis. Etiology: N. Continuing oral therapy should consist of: Doxycycline 100mg PO bid x 14d OR Clindamycin 450mg PO qid x 14d 2nd line: Ampicillin-sulbactam 3g IV q6h PLUS Doxycycline 100mg PO q12h x 14d Comments: The diagnosis is made by having a high index of suspicion. Single daily dosing (3–5 mg/kg) can be used. pleuritis. C. Perihepatitis or Fitz-Hugh-Curtis syndrome Classic manifestation is severe right upper abdominal pain (lasts about 48 h) that often radiates to the shoulder. trachomatis Preferred Regimen: TREATMENT SIMILAR AS WITH PID PARENTERAL REGIMEN OUTPATIENT REGIMEN 1st line: Recommended IM/PO Regimen Cefoxitin 2g IV q6h PLUS Ceftriaxone 250mg IM once OR Doxycycline 100mg PO q12h x 14d Cefotaxime PLUS WITH or WITHOUT Doxycycline 100mg PO bid x 14d Metronidazole 500mg PO bid x 14d WITH or WITHOUT OR Metronidazole 500mg PO bid x 14d Clindamycin 900mg IV q8h PLUS Gentamicin 2mg/kg IV/IM loading dose. appendicitis. nephrolithiasis. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) Patient with tubo-ovarian abscess should have at least 24 hours of inpatient treatment that includes anaerobic coverage. and pancreatitis. Perihepatitis frequently mimics cholelithiasis. Clinical response should be noted in 72 hours and pelvic ultrasound should be repeated to note any further increase in the size of the abscess. followed by 1. C. 198 National Antibiotic Guidelines . subphrenic abscess. ectopic pregnancy.5 mg/kg q8h maintenance dose. gonorrhoeae. perforated peptic ulcer. abdominal trauma. Epididymitis Clinical syndrome consisting of pain. trachomatis. OR give as single agent if no risk for chlamydia and gonorrhea Age >35 years: Levofloxacin 750mg IV/PO qd x 10-14d 2nd line: Age ≤ 35 years: Levofloxacin 500mg PO qd x 10d Age > 35 years: Ampicillin-sulbactam 3g IV q6h OR Ceftriaxone 2g IV q24h OR Piperacillin-tazobactam 4. Enterobacteriaceae (occasional) Age > 35 years: Enterobacteriaceae Preferred Regimen: 1st line: All: Bed rest. • Gram or methylene blue or gentian violet (MB/GV) stain of urethral secretions demonstrating ≥2 WBC/oif • Positive leukocyte esterase test on first-void urine. mobile ovary in a child with mumps or one of the exanthems suggests oophoritis. swelling. Oophoritis • inflammation of the substance of the ovaries. tender. gonorrhoeae. and analgesics. the oocytes in particular Etiology: Mumps virus. smooth.25g q8h Comments: All suspected cases of acute epididymitis should be evaluated for objective evidence of inflammation by one of the following point-of-care tests. and inflammation of the epididymis that lasts <6 weeks Etiology: Age ≤ 35 years: N. scrotal elevation. Cytomegalovirus Preferred Regimen: Treatment is palliative Paracetamol Ibuprofen P: 10-15 mg/kg/dose PO q4-6h P: 5-10mg/kg/dose PO q6-8h A: 500 mg/dose PO q4h A: 400-800mg/dose PO q6-q8h Comments: The presence of an enlarged. boggy. Age ≤35 years: Ceftriaxone 250mg IM x 1 dose PLUS Doxycycline 100mg PO bid x 10d (for cases likely caused by chlamydia and gonorrhea) Add Levofloxacin 500mg PO qd or Ofloxacin 300mg PO bid x 10d if patient is a man who practices insertive anal sex since he will also be at risk for enteric organisms. National Antibiotic Guidelines 199 . E.5g IV q6h or 4-hr infusion of 2. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) D. C. 25g IV q6h or 4. especially Prevotella bivia. gonorrhoeae or C. Prevotella bivia. Pelvic Vein Suppurative (Septic) Thrombophlebitis Infection of ovarian or deep pelvic veins. Enterobacteriaceae Preferred Regimen: If low prevalence of MDR GNB: Piperacillin-tazobactam 2. other anaerobes. (Groups A. Chlamydia trachomatis. Enterobacteriaceae. usually postpartum (either vaginal or C- section delivery).. can complicate postpartum endometritis or pelvic inflammatory disease. No clear role for surgery on infected veins. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) • ≥10 WBC/hpf on a spun first void urine Men who have acute epididymitis confirmed or suspected to be caused by N. trachomatis and for N. Discontinue antibiotic(s) when WBC and differentials are normal and patient is afebrile for 48 hrs. (Group A. Streptococcus sp. B). C. Streptococcus sp. All men with acute epididymitis should be tested for other STDs. including HIV. perfringens. gonorrhoeae by NAAT. B). G. Tests should be done for C. Treatment is a combination of effective antibiotics and anticoagulation (Coumadin x 6 weeks). Ureaplasma urealyticum (less common). Urine is the preferred specimen for NAAT testing in men. F. trachomatis should be advised to abstain from sexual intercourse until they and their partners have been adequately treated and symptoms have resolved. Septic Abortion Etiology: Bacteroides sp.. Carbapenem ensures adequate therapy versus ESBL producing aerobic GNB. Etiology: Bacteroides sp. Preferred Regimen: 1st line 2nd line Cefoxitin 2g IV q6–8h OR Meropenem 1g IV q8h OR Ampicillin-sulbactam 3g IV q6h OR Ertapenem 1g IV q24h OR High Dose Penicillin 5 MU IV q6h 200 National Antibiotic Guidelines .5 gm IV q8h OR Ceftriaxone 2g IV qd PLUS Metronidazole 500mg IV q8h If high prevalence (≥ 20%) of MDR GNB: Meropenem 1g IV q8h Comments: Diagnosis: CT scan or MRI. I. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) PLUS Doxycycline 100mg PO q12h x Piperacillin-tazobactam 4.25g q8h) PLUS Doxycycline 100mg PO q12h x 7d OR Clindamycin 450–900mg IV q8h PLUS (Ceftriaxone 2g IV q24h or Gentamicin 5mg/kg qd) Comments: Curettage. Streptococcus sp. Prevotella bivia). anaerobes) Preferred Regimen: For Candida: National Antibiotic Guidelines 201 . Mycoplasma. Gardnerella sp. Clindamycin + Ceftriaxone is preferred to ensure activity versus Group B Strep (one-third of isolates are Clindamycin resistant). Laparotomy is indicated. (40%). (GBS)....5g IV q6h Ceftriaxone 2g IV q24h or Gentamicin (or 4-hr infusion of 2.25g q8h) 5mg/kg qd PLUS Doxycycline 100mg PO q12h Comments: For vaginal delivery: Ampicillin plus gentamicin. Amnionitis/ chorioamnionitis Etiology: Group B Streptococci. Preferred Regimen: 1st line 2nd line Cefoxitin 2g IV q6–8h OR Meropenem 1g IV q8h OR Ampicillin-sulbactam 3g IV q6h OR Ertapenem 1g IV q24h OR Clindamycin 450–900mg IV q8h PLUS Piperacillin-tazobactam 4. supportive therapy. and hysterectomy should be considered if there is deterioration or no response.5g IV q6h 7d (or 4-hr infusion of 2. Balanitis Etiology: Candida sp.g. H.g. Escherichia coli. Pathogenic anaerobes (e. For Cesarean section: should include anaerobic coverage such as clindamycin or metronidazole to decrease the risk of post-partum endometritis. Other bacteria (e. and intensive cardiovascular monitoring. Clindamycin + Ceftriaxone is preferred to ensure activity versus Group B Strep (one-third of isolates are Clindamycin resistant). T. M. when present. C. urethral pruritus. gonorrhoeae. The following are the recommendations: Etiology: N. gonorrhoeae. II. Antibiotic coverage for N. C. genitalium. gonorrhoeae. trachomatis. Ureaplasma. Urethritis Characterized by urethral inflammation which may due to infectious or non- infectious causes. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) Mild cases: Topical azoles such as Clotrimazole or Miconazole 3-7d Unresponsive and more severe cases: Fluconazole 150mg PO x 1 dose OR Itraconazole 200mg PO bid x 1d For anaerobes or Gardnerella: Metronidazole 2g x 1 dose Comments: Group A streptococcal balanitis has been reported after oral sex. Symptoms. Preferred Regimen: PEDIATRICS ADULTS <45kgs and <8years of age: 1st line: Ceftriaxone 125mg IM x 1 dose PLUS Ceftriaxone 250mg IM x 1 dose PLUS Erythromycin base OR (Azithromycin 1g PO x 1 dose OR ethylsuccinate 50mg/kg/d PO in 4 Doxycycline 100mg PO q12h x 7d) div doses (Max: 2g/day) x 14d 2nd line: (if ceftriaxone is not >45kgs but <8years of age: available) Ceftriaxone 250mg IM x 1 dose PLUS Cefixime 400mg PO x 1 dose PLUS Azithromycin 1g PO x 1 dose Azithromycin 1g PO x 1 dose 202 National Antibiotic Guidelines . Urethritis and Cervicitis A. Do not aspirate because it is likely to cause recurrences. mucopurulent or purulent discharge When diagnostic work-up has not yet been done and cause is not known. Bartholinitis and Bartholin abscess Etiology: N. trachomatis) Comments: Risk factors similar to other sexually transmitted diseases. C. vaginalis. J. may include dysuria. trachomatis and anaerobes for at least 2weeks (see recommendations for N. C. Recurrent infection: marsupialization or fistulization. mucoid. gonorrhoeae. trachomatis. Anaerobes and facultative organisms Preferred Regimen: Incise and drain. trachomatis. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) >45kgs and >8years of age: Other Second line Regimen: Ceftriaxone 250mg IM x 1 dose PLUS Cefotaxime 500mg IM EITHER Azithromycin 1g PO x 1 dose OR Doxycycline 100mg PO bid x 7d Alternatives to Azithromycin or Doxycycline: Erythromycin base 500mg PO qid x 7d OR Erythromycin ethylsuccinate PO 800mg qid x 7d OR Levofloxacin 500mg PO qd x 7d OR Ofloxacin 400mg PO bid x 7d Comments: If symptoms are present and no evidence of urethral inflammation. genitalium. Ureaplasma. (Alternative Regimen: Metronidazole 500mg PO bid x 7d) Comments: Azithromycin should be administered to men initially treated with doxycycline. Nongonococcal Urethritis Confirmed in symptomatic men when staining of urethral secretions without Gram-negative or purple diplococci Etiology: C. B. M. Use combination therapy even if NAAT is negative for Chlamydia. To minimize transmission and reinfection. NAAT testing for Chlamydia and gonorrhea might identify the infection. T. vaginalis with Metronidazole 2g PO x 1 dose. Preferred Regimen: 1st line 2nd line Azithromycin 1g PO x 1 dose OR Erythromycin base 500mg PO qid x 7d Doxycycline 100mg PO bid x 7d OR Erythromycin ethylsuccinate 800mg PO qid x 7d OR Levofloxacin 500mg PO od x 7d OR Ofloxacin 300mg PO bid x 7d PERSISTENT AND RECURRENT NGU Preferred Regimen (A): Azithromycin 1g PO x 1 dose if initially treated with Doxycycline Treat for T. vaginalis. men treated for NGU should be instructed National Antibiotic Guidelines 203 . Comments: Women with a new episode of cervicitis should be assessed for signs of PID and should be tested for C. Women treated for cervicitis should be instructed to abstain from sexual intercourse until they and their partner(s) have been adequately treated. trachomatis. Chlamydial Infections Etiology: C. Treatment of cervicitis in pregnant women does not differ from not pregnant women. M. trachomatis Preferred Regimen: 1st line PEDIATRICS ADULTS <45 kg: Azithromycin 1g PO x 1 dose OR Erythromycin 50mg/kg/d q6h x14d Doxycycline 100mg PO bid x 7d ≥45 kg but who are aged <8 Years: Pregnant Women: Azithromycin 1g PO x 1 dose Azithromycin 1g PO x 1 dose Aged ≥8 years: Azithromycin 1g PO x 1 dose OR Doxycycline 100mg PO bid x 7d 204 National Antibiotic Guidelines . C. Cervicitis Diagnostic signs: 1) a purulent or mucopurulent endocervical exudate visible in the endocervical canal or on an endocervical swab specimen. Etiology: C. genitalium Preferred Regimen: Azithromycin 1g PO x 1 dose OR Doxycycline 100mg PO bid x 7d Consider concurrent treatment for gonococcal infection if patient is at risk for gonorrhea or lives in a community where the prevalence of gonorrhea is high. gonorrhoeae. for 7 days after single-dose therapy or until completion of a 7-day regimen and symptoms resolved). and 2) sustained endocervical bleeding easily induced by gentle passage of a cotton swab through the cervical os.g. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) to abstain from sexual intercourse until they and their partner(s) have been adequately treated (e.. trachomatis and N. N. gonorrhoeae. D. Men who receive a diagnosis of NGU should be tested for HIV and syphilis. Data are limited on the effectiveness and optimal dose of azithromycin for the treatment of chlamydial infection in infants and children who weigh <45 kg. UNCOMPLICATED INFECTIONS OF THE PHARYNX (MORE DIFFICULT TO ERADICATE THAN UROGENITAL OR ANORECTAL SITES) National Antibiotic Guidelines 205 . URETHRA. gonorrhoeae UNCOMPLICATED INFECTIONS OF THE CERVIX. Onsite. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) 2nd line PEDIATRICS ADULTS <45 kg: Erythromycin base 500mg PO qid x 7d Azithromycin 20mg/kg/d PO qd x OR 3d Erythromycin ethylsuccinate 800mg PO qid x 7d OR Levofloxacin 500mg PO qd x 7d OR Ofloxacin 300mg PO bid x 7d Pregnant Women: Amoxicillin 500mg PO tid x 7d OR Erythromycin base 500mg PO qid x 7d OR Erythromycin base 250mg PO qid x 14d OR Erythromycin ethylsuccinate 800mg PO qid x 7d OR Erythromycin ethylsuccinate 400mg PO qid x 14d Comments: Diagnostic test (not routinely recommended): NAAT. directly observed single dose therapy with azithromycin should be available for persons whose adherence is a concern. Tissue culture. swabs from inner eyelid (if conjunctivitis) Doxycycline and quinolones should not be given to pregnant women. and Direct Fluorescent Antibody Test. E. Gonococcal Infections Etiology: N. AND RECTUM. Specimen: Women: first-catch urine or swab specimens from the endocervix or vagina Men: first-catch urine or urethral swab Infants and Children: nasopharyngeal swab (if pneumonia). DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) Preferred Regimen: 1st line PEDIATRICS ADULTS Ceftriaxone 25–50 mg/kg IV/IM x 1 Ceftriaxone 250mg IM x 1 dose PLUS dose (Max: 125mg IM) Azithromycin 1g PO x 1 dose 2nd line PEDIATRICS ADULTS Cefixime 8 mg/kg/d PLUS Cefixime 400mg PO x 1 dose PLUS Azithromycin 10-12mg/kg/d Azithromycin 1g PO x 1 dose GONOCOCCAL CONJUNCTIVITIS Preferred Regimen: P: Cefixime 8 mg/kg/d PLUS Azithromycin 10-12mg/kg/d A: Ceftriaxone 1g IM x 1 dose PLUS Azithromycin 1g PO x 1 dose DISSEMINATED INFECTION Preferred Regimen: P: Ceftriaxone 50 mg/kg IV/IM (max: 1g) qd x 7d A: 1st line: Ceftriaxone 1g IV/IM q24h PLUS Azithromycin 1g PO x 1 dose 2nd line: Cefotaxime 1g IV q8h PLUS Azithromycin 1g PO x 1 dose OPHTHALMIA NEONATORUM Preferred Regimen (P): Ceftriaxone 25-50mg/kg IV/IM x 1 dose (Max: 125mg) OR Spectinomycin 25mg/kg IM x 1 dose (Max: 75 mg) DISSEMINATED GONOCOCCAL INFECTION (DGI) AND GONOCOCCAL SCALP ABSCESSES IN NEONATES Preferred Regimen: Ceftriaxone 25–50mg/kg/d IV/IM x 1 dose x 7d OR Cefotaxime 25mg/kg IV/IM q12h x 7d if meningitis is documented: DOT: 10-14d Comments: Gram’s stain and Culture – endocervical (women) or urethral (men) swab specimens NAAT . Because of the emerging resistance data for gonococcal infections and reduced effectiveness of some medicines. vaginal swabs. good practice 206 National Antibiotic Guidelines . urethral swabs (men). and urine (from both men and women).endocervical swabs. . No data exist regarding the use of dual therapy for treating children with gonococcal infection. Etiology: Prevotella sp. Ureaplasm. All persons who receive a diagnosis of gonorrhoea should be tested for other STDs. For Gonococcal meningitis and endocarditis. including chlamydia. Porphyromonas. National Antibiotic Guidelines 207 . Fluoroquinolones are not recommended for gonococcal urethritis. long Gram-positive rods). Complete immunization for hepatitis B and HPV. III. and peptostreptococci). gonorrhoeae. Medication for gonococcal infection should be provided on site and directly observed. Prevotella.g. or meningitis and is a rare complication of neonatal gonococcal infection.. or joint aspirate provide a presumptive basis for initiating treatment for N. Numerous fastidious anaerobes Preferred Regimen: P: <45 kg: Metronidazole 15mg/kg/d PO div q12h x 7d A: 1st line: Metronidazole 500mg PO bid x 7d 2nd line: Clindamycin 300mg PO bid x 7d Comments: Gram stain is used to determine the relative concentration of lactobacilli (e. Bacterial Vaginosis A polymicrobial clinical syndrome resulting from replacement of the normal hydrogen peroxide producing Lactobacillus sp. Positive Gram-stained smears of exudate. then consider Cefixime but with test of cure one week later. Peptostreptococci. DGI might present as sepsis. CSF. Mycoplasma.. G. Mobiluncus sp. and HIV. Oral cephalosporins are no longer recommended except if ceftriaxone is not available. Gonococcal ophthalmia is strongly suspected when intracellular gram-negative diplococci are identified on Gram stain of conjunctival exudate.g. increase Ceftriaxone to 1–2 g IV every 12–24 hours. arthritis. Porphyromonas. Persons treated for gonorrhea should be instructed to abstain from sexual activity for 7 days after treatment and until all sex partners are adequately treated. Gram-negative and Gram-variable rods and cocci (e. vaginalis.g.. in the vagina with high concentrations of anaerobic bacteria. syphilis. and curved gram- negative rods (e. Mobiluncus) characteristic of BV. vaginalis.. Vaginal Discharge A. G. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) dictates that the choice of treatment depends on reliable local data on antimicrobial susceptibility. coli. Trichomonas Rapid Test (dipstick).pH of vaginal fluid >4. Herpes simplex virus. white discharge that smoothly coats the vaginal walls. Trichomoniasis Most infected persons have minimal or no symptoms. epididymitis. Treatment of partner is recommended.clue cells on microscopic examination . Enteric bacteria including Shigella species Preferred Regimen: <45kgs. B. or prostatitis. E. trachomatis. T.5 .a fishy odor of vaginal discharge before or after addition of 10% KOH (Whiff test). .homogeneous. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) Amsel’s Diagnostic criteria: at least 3 of the following symptoms or signs must be present: . Etiology: T. Prepubertal Etiology: Group A Streptococci. 208 National Antibiotic Guidelines . < 8 years of age: Ceftriaxone 125mg IM x 1 dose PLUS Erythromycin 50mg/kg/d div q6h x 14d >45kgs but <8years of age: Ceftriaxone 250mg IM x 1 dose PLUS Azithromycin 1g PO x 1 dose >45kgs and > 8 years of age: Ceftriaxone 250mg IM x 1 dose PLUS EITHER Azithromycin 1g PO x 1 dose OR Doxycycline 100mg PO bid x 7d C. Some infected men have symptoms of urethritis. N. Vaginitis. or yellow-green with or without vulvar irritation. gonorrhoeae. give 2g orally for 5 days. If single dose metronidazole regimen fails. malodorous. vaginalis. and some infected women have vaginal discharge that might be diffuse. C. thin. vaginalis Preferred Regimen: 1st line 2nd line Metronidazole 2g PO x 1 dose Metronidazole 500mg PO bid x 7d Pregnant women: Metronidazole 2g PO x 1 dose Women with HIV Infection: Metronidazole 500mg PO bid x 7d Comments: Diagnostic Tests: Wet-mount microscopy NAAT. one or more painful genital ulcers ii. curdy) vaginal discharge. and abnormal (thick. 1 supp x 1d Comments: Diagnostic Tests: Wet preparation (saline. 10% KOH) or Gram stain of vaginal discharge which demonstrates budding yeasts. Genital. external dysuria. IV. no evidence of T. vaginalis Preferred Regimen: 1st line 2nd line Clotrimazole 1% cream 5g Fluconazole 150mg PO x 1 dose intravaginally qd x 7–14d OR Miconazole 1. hyphae. Candidiasis Typical symptoms include pruritus. swelling. or Perianal Ulcers A. ducreyi Preferred Regimen: Azithromycin 1g PO x 1 dose OR Ceftriaxone 250mg IM x 1 dose OR Ciprofloxacin 500mg PO bid x 3d OR Erythromycin base 500mg PO tid x 7d Comments: Criteria for probable diagnosis: i. or pseudohyphae. Culture.200mg vaginal suppository. Chancroid Painful genital ulcer plus tender suppurative inguinal adenopathy suggests the diagnosis of chancroid Etiology: H. dyspareunia. A diagnosis of Candida vaginitis is suggested clinically by the presence of external dysuria and vulvar pruritus. pain. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) D. pallidum infection by darkfield examination of ulcer exudate or by a serologic test for syphilis performed at least 7 days after onset of ulcers iv. Negative HSV PCR test or HSV culture performed on the ulcer exudate National Antibiotic Guidelines 209 . vaginal soreness. Anal. and redness. regional lymphadenopathy iii. Etiology: T. risk of disease transmission. PCR. 210 National Antibiotic Guidelines .tid OR Valaciclovir 500mg PO bid OR Famciclovir 500mg PO bid Episodic Therapy (A): Aciclovir 400mg PO tid x 5d OR Aciclovir 800mg PO bid x 5d OR Aciclovir 800mg PO tid x 2d OR Valaciclovir 500mg PO bid x 3d OR Valaciclovir 1g PO qd x 5d OR Famciclovir 125 mg PO bid x 5d OR Famciclovir 1g PO bid x 1d OR Famciclovir 500mg x1 dose. then 250mg bid x 2d HIV-infected Adults: Aciclovir 400mg PO tid x 5-10d OR Valaciclovir 1g PO bid x 5- 10d OR Famciclovir 500mg PO bid x 5-10d Comments: Suppressive therapy reduces: 1. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) Sex partners of patients who have chancroid should be examined and treated if they had sexual contact with the patient within 10 days prior to patient’s onset of symptoms. Genital HSV Infections Etiology: HSV1 and HSV2 FIRST CLINICAL EPISODE Preferred Regimen: Aciclovir 400mg PO bid x 7-10d OR Aciclovir 200mg PO 5x/d x 7-10d OR Valaciclovir 1g PO bid x 7-10d OR Famciclovir 250mg PO tid x 7-10d For children < 45 kg: Aciclovir 80mg/kg/d PO div q6-8h (Max: 1. HSV serology. frequency of recurrences by 70%–80% 2.2g/day) x 7-10d Valaciclovir 40mg/kg/d div q12h x 7-10d Comments: Diagnosis: Viral culture. Extend treatment if healing is incomplete after 10 days. RECURRENT GENITAL HERPES Preferred Regimen: Suppressive Therapy (A): Aciclovir 400mg PO bid OR Valaciclovir 500mg PO qd OR Valaciclovir 1g PO qd OR Famciclovir 250mg PO bid Pregnant Women: Aciclovir 400mg PO tid OR Valaciclovir 500mg PO bid HIV-infected Adults: Aciclovir 400–800mg PO bid. B. followed by oral antiviral therapy to complete at least 10 days. Impaired renal function warrants dose adjustment. SEVERE DISEASE Preferred Regimen: Aciclovir 5–10mg/kg IV q8h x 2-7d or until clinical improvement is observed. slowly progressive ulcerative lesions on the genitals or perineum without regional lymphadenopathy. Effective episodic treatment of recurrent herpes requires initiation of therapy within 1 day of lesion onset or during the prodrome. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) Safety and efficacy have been documented among patients receiving daily therapy with aciclovir for as long as 6 years and with valaciclovir or famciclovir for 1 year. C. NEONATAL HERPES Preferred Regimen: Aciclovir 20mg/kg IV q8h x 14d if disease is limited to the skin and mucous membranes. Treatment is recommended starting at 36 weeks of gestation. Comments: HSV encephalitis requires 21 days of intravenous therapy. Granuloma Inguinale (Donovanosis) Characterized by painless. Etiology: Klebsiella granulomatis (formerly known as Calymmatobacterium granulomatis) Preferred Regimen: 1st line 2nd line Azithromycin 1g PO q week OR 500 Doxycycline 100mg PO bid for at least 3 mg qd for at least 3 weeks and until weeks and until all lesions have all lesions have completely healed completely healed OR Ciprofloxacin 750mg PO bid orally for at least 3 weeks and until all lesions have completely healed OR Erythromycin base 500mg PO qid for at least 3 weeks and until all lesions have completely healed OR National Antibiotic Guidelines 211 . Valaciclovir 500mg qd is less effective than other regimen in those with ≥10 recurrences per year. or for 21 days for disseminated disease and involving the central nervous system. L3 Preferred Regimen: 1st line: Doxycycline 100mg PO bid x 21d 2nd line: Erythromycin base 500mg PO qid x 21d Comments: Persons with a clinical syndrome consistent with LGV. puplosquamous rash often involving palms of hands and soles of feet 212 National Antibiotic Guidelines . should be presumptively treated for LGV. including proctocolitis or genital ulcer disease with lymphadenopathy.000 U/kg IM. L2. Comments: Gentamicin 1 mg/kg IV q8h can be added if improvement is not evident within the first few days of therapy. Lymphogranuloma Venereum Etiology: C. D.4 MU x 1 2nd line: Doxycycline 100mg PO bid x 14d OR dose Tetracycline 500mg qid x 14d OR Ceftriaxone 1g IV/IM q24h x 10-14d OR Azithromycin 2g PO x 1 dose SECONDARY SYPHILIS Clinical Presentation.4MU IM x 1 50. up to the dose adult dose of 2. Special diagnostic tests: culture. Syphilis Etiology: Treponema pallidum PRIMARY SYPHILIS Clinical Presentation: presence of chance Preferred Regimen: PEDIATRICS ADULTS Benzathine penicillin G 1st line: Benzathine penicillin G 2. NAAT (if available) E. Fever. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) Trimethoprim-sulfamethoxazole one double-strength (160 mg/800mg) tablet PO bid for at least 3 weeks and until all lesions have completely healed. trachomatis serovars L1. immunofluorescent test. Infants and children aged ≥1 month with primary and secondary syphilis should be evaluated for sexual abuse. Test all patients with syphilis for HIV For primary and secondary syphilis. 12. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) Preferred Regimen: PEDIATRICS ADULTS Benzathine penicillin G 1st line: Benzathine penicillin G 2. Failure of nontreponemal test titers to decline fourfold within 6–12 months after therapy for primary or secondary syphilis might be indicative of treatment failure.4MU IM x 1 50. secondary.latent syphilis of less than one-year duration Preferred Regimen: PEDIATRICS ADULTS Benzathine penicillin G 1st line: Benzathine penicillin G 2. up to the dose adult dose of 2. or tertiary disease. Quantitative nontreponemal serologic tests should be repeated at 6. A CSF examination should be performed if 1. clinical and serologic evaluation should be performed at 6 and 12 months after treatment. up to the dose adult dose of 2. Doxycycline and tetracycline cannot be given to pregnant women.4 MU x 1 2nd line: Doxycycline 100mg PO bid x 14d OR dose Tetracycline 500mg qid x 14d OR Ceftriaxone 1g IV/IM q24h x10-14d OR Azithromycin 2g PO x 1 dose Comments: Characterized by serore activity without other evidence of primary. EIAs.000 U/kg IM. immunoblots). LATENT SYPHILIS (EARLY LATENT SYPHILIS) a.4 MU x 1 2nd line: Doxycycline 100mg PO bid x 14d OR dose Tetracycline 500mg qid x 14d OR Ceftriaxone 1g IV/IM q24h x10-14d OR Azithromycin 2g PO x 1 dose Comments (For Primary and Secondary Syphilis): Diagnostic tests: • Definitive diagnosis: Darkfield examinations • Presumptive diagnosis: Nontreponemal tests (VDRL or RPR) Treponemal tests (FTA-ABS or TPHA. Early Latent Syphilis . National Antibiotic Guidelines 213 .4MU IM x 1 50.000 U/kg IM. and 24 months. a sustained (>2 weeks) fourfold increase or greater in titer is observed. Latent syphilis of less than unknown duration Preferred Regimen: PEDIATRICS ADULTS Benzathine penicillin G 50.000 U/kg 1st line: Benzathine penicillin G 7.000 units/ kg up intervals to the adult total dose of 7. up to the adult dose of 2. an initially high titer (≥1:32) fails to decline at least fourfold within 12–24 months of therapy 3.4 MU IM each buttock at 1-week intervals (total 150. MU total. Late Latent Syphilis .2 IM. In a person with neurologic signs or symptoms. b. Pregnant women and those who are allergic to penicillin should be desensitized and treated with penicillin. administered as 3–4 MU IV q4h or continuous infusion x 10-14d Comments: Diagnosis of neurosyphilis depends on a combination of CSF cell count or protein and a reactive CSF-VDRL in the presence of reactive serologic test results and neurologic signs and symptoms. NEUROSYPHILIS Preferred Regimen (A): Aqueous crystalline penicillin G 18–24 MU/d.4 MU. administered as 3 doses of 2.2 MU total. CONGENITAL SYPHILIS Preferred Regimen: Proven or Highly Probable Congenital Syphilis 214 National Antibiotic Guidelines .4 MU IM each at 1-week interval Comments: Tertiary syphilis refers to gummas and cardiovascular syphilis but not to neurosyphilis. a reactive CSF-VDRL is considered diagnostic of neurosyphilis. administered as 3 doses of administered as 3 doses at 1-week 2. signs or symptoms attributable to syphilis develop.2 MU) 2nd line: Doxycycline 100mg PO bid x 30d OR Tetracycline 500mg PO qid x 30d TERTIARY SYPHILIS Preferred Regimen (A): Benzathine penicillin G 7. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) 2. Benzathine penicillin G 50. positive darkfield test or PCR of lesions or body fluid(s). OR 3. particularly if follow-up is uncertain and the neonate has a reactive nontreponemal test. administered as 50.000 U/ kg/dose IM x 1 dose for 10-15d Possible Congenital Syphilis: Aqueous crystalline penicillin G 100. mother received recommended treatment <4 weeks before delivery. PE consistent with congenital syphilis.000 U/kg/d.g. National Antibiotic Guidelines 215 . mother was treated with erythromycin or an inappropriate regimen (e. mother was not treated. inadequately treated.000–150. Congenital Syphilis unlikely: No treatment is required.000 U/kg/ dose IV q12h during the first 7 days of life and q8h thereafter for a total of 10 – 15d OR Procaine penicillin G 50. RPR <1:4). Possible Congenital Syphilis: Any neonate who has a normal physical examination and a serum quantitative nontreponemal serologic titer equal to or less than fourfold the maternal titer and one of the following: 1.000 units/kg IM x 1 dose OR Do not treat but do close serologic follow-up every 2–3 months for 6 months for infants whose mother’s nontreponemal titers decreased at least fourfold after appropriate therapy for early syphilis or remained stable for low-titer.000 U/kg IM x 1 dose Congenital Syphilis less likely: Benzathine penicillin G 50.g.000 U/kg/ dose IV q12h during the first 7d of life and q8h thereafter for a total of 10d OR Procaine penicillin G 50. nonpenicillin G) OR 3. OR 2. or has no documentation of having received treatment.000–150. VDRL <1:2. Comments: Proven or Highly Probable Congenital Syphilis Any neonate with: 1. OR 2.. latent syphilis (e.000 U/kg as a single IM injection might be considered.000 U/ kg/dose IM x 1 dose for 10d OR Benzathine penicillin G 50. nontreponemal serologic titer fourfold higher than the mother’s titer. but infants with reactive nontreponemal tests should be followed serologically to ensure the nontreponemal test returns to negative. administered as 50.000 U/kg/d. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) Aqueous crystalline penicillin G 100. Anogenital Warts A. number. tangential shave excision. SYPHYLIS IN PREGNANCY Preferred Regimen: Penicillin is the only drug recommended for treatment of pregnant women with syphilis.75%) cream B. and 2. Comments: All pregnant women should be screened for syphilis early in pregnancy. Give the same dose as in non-pregnant women appropriate for the stage of syphilis. mother was treated during pregnancy. and treatment was administered >4 weeks before delivery. Pregnant women allergic to penicillin should be desensitized and treated with penicillin V. mother’s nontreponemal serologic titer remained low and stable before and during pregnancy and at delivery (VDRL <1:2. mother has no evidence of reinfection or relapse Congenital Syphilis unlikely: Any neonate who has a normal physical examination and a nontreponemal serologic titer equal to or less than fourfold the maternal titer and both of the following are true: 1. Patient-Applied: Imiquimod 5% (or 3. Treatment of anogenital warts should be guided by wart size. treatment was appropriate for the stage of infection. curettage. Provider–Administered: Cryotherapy with liquid nitrogen or cryoprobe OR Surgical removal either by tangential scissor excision. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) Congenital Syphilis less likely: Any neonate who has a normal physical examination and a serum quantitative nontreponemal serologic titer equal to or less than fourfold the maternal titer and both of the following are true: 1. laser. RPR <1:4). and 216 National Antibiotic Guidelines . mother’s treatment was adequate before pregnancy and 2. HPV and genital warts Etiology: Human papillomavirus Preferred Regimen: A. or electrosurgery (electrocautery or electrocoagulation) OR Trichloroacetic acid (TCA) Comments: The aim of treatment is removal of the wart and amelioration of symptoms. Genital lesions should be treated to prevent spread to sexual contacts. Molluscum contagiosum Preferred Regimen: Curettage OR Cryotherapy with liquid nitrogen OR Electrodessication OR Chemical agents (podophyllin. Scabies Etiology: Sarcoptes scabiei Preferred Regimen: Permethrin 5% cream applied to all areas of the body from the neck down and washed off after 8–14h OR Ivermectin 200ug/kg PO. B. Bedding and clothing National Antibiotic Guidelines 217 . at least 25% within 3 months. Genital lesions have a potential carcinogenicity. patient preference. cost of treatment. and provider experience. however recurrence rate is high. convenience. Lesions in healthy individuals are self-limited and may not necessitate treatment. cantharidin. neutropenia and potential permanent as well as nephrotoxicity. Therapeutic methods are effective in 22 to 94% in clearing exophytic genital warts. silver nitrate. 25% to 50% trichloroacetic acid. adverse effects. VI. repeated in 2 weeks Comments: Infants and young children should be treated with permethrin. tretinoin. Pediculosis Pubis Persons with pubic lice usually seek medical attention because of pruritus or because of lice or nits on pubic hair. tincture of iodine or potassium hydroxide) OR Imiquimod Comments: Physical destruction is the most effective and rapid means of curing molluscum contagiosum. Etiology: Pubic Lice Preferred Regimen: Permethrin 1% cream rinse applied to affected areas and washed off after 10 minutes B. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) anatomic site. Infants and young children aged <10 years should not be treated with lindane. Ectoparasitic Infections A. 2015 Report on the Committee of Infectious Diseases • The Sanford Guide to Antimicrobial Therapy 2014. 2015. Douglas. MMWR Recomm Rep 2010. • Feigin RD.al. et.. Textbook of Pediatric Infectious Diseases.sanfordguide. 3 • CDC. 2015: Vol.com) • WHO guidelines for the treatment of Treponema pallidum (syphilis) 29 August 2016 • WHO guidelines for the treatment of Chlamydia trachomatis 29 August 2016 • WHO guidelines for the treatment of Neisseria gonorrhoeae 28 August 2016 218 National Antibiotic Guidelines . Philadelphia: Saunders Elsevier. 64. either machine-washed. MMWR Recomm Rep June 5. (http://webedition. or dry cleaned) or removed from body contact for at least 72hours. 2014 • Mandell. DOH PUBLIC HEALTH PROGRAMS (SEXUALLY TRANSMITTED INFECTIONS) should be decontaminated (e. machine-dried using the hot cycle. Persons with scabies should be advised to keep fingernails closely trimmed to reduce injury from excessive scratching. RR-12). References • Antibiotic Guidelines 2013-2014. 30th Edition. 8th Edition • Red Book. No. John Hopkins Medicine • Carlos C. and Bennett’s Principles and Practice of Infectious Diseases: 2- Volume Set. Sexually transmitted diseases treatment guidelines.g. 44th Edition Sanford Guide 2015. Treatment Recommendations for Adult Inpatients.59(No. Antimicrobial Resistance Surveillance Program 2014 Report • CDC Sexually Transmitted Diseases Treatment Guidelines. 7th edition. Web Edition. • Pediatric FDC dispersible tablet: Contains isoniazid 50 mg and rifampicin 75 mg. Bedaquiline (Bdq). Kanamycin (Km). HRZE) Continuation phase BODY (No. +/- pyrazinamide 400 mg. Ethambutol (E). local availability of SDFs is poor. +/-ethambutol 275 mg per tablet. A. • Adult FDC tablet: Contains isoniazid 75 mg and rifampicin 150mg. whether bacteriologically confirmed or clinically diagnosed) Miliary TB without dissemination or with dissemination not involving meningitis. +/. Linezolid (Lzd). bones. New (no treatment or had undergone previous treatment for less than a month. Cycloserine (Cs). Anti-TB drugs in fixed-dose combination (FDC) preparation. CATEGORY I Etiology: Pulmonary TB. joints Extrapulmonary TB (EPTB). Pyrazinamide (Z). Isoniazid (H). HR) WEIGHT HRZ E (100 mg) HR 4-7 kg 1 1 1 8 – 11 kg 2 2 2 12 – 15 kg 3 3 3 16-24 kg 4 4 4 25 + kg Adult dose and preparations National Antibiotic Guidelines 219 . New (whether bacteriologically confirmed or clinically diagnosed) EXCEPT CNS. or expected to have significant drug interactions. co-morbid conditions requiring dose adjustments (especially liver. These drugs will only be used in certified PMDT centers. DOH PUBLIC HEALTH PROGRAMS (TUBERCULOSIS) TUBERCULOSIS (TB) The available anti-TB drugs are: • First Line anti-TB drugs: Rifampicin (R). joints Preferred Regimen: PEDIATRICS (<15Y): Intensive phase (2 mos. bones. Single-drug formulations (SDF) are still recommended for the following situations: adverse reactions or at risk for adverse reactions. Capreomycin (Cm). Clofazimine (Cfz). Give the entire daily dose once a day. of tablets) (4 mos. However. Para-aminosalicylic Acid (PAS) and Imipenem (Imp). and Streptomycin (S) • Second line anti-TB drugs: Levofloxacin (Lfx).pyrazinamide 150 mg per tablet. Moxifloxacin (Mfx). Prothionamide (Pto). kidney diseases). 000 Ethambutol 20 (15 – 25) 1. Fixed dose combination (FDC) should be used even for children.000 25 (20 – 30) 2. Anti-TB treatment shall be done through a patient-centered. A patient’s anti-TB regimen shall be comprised of at least four (4) first-line drugs. 220 National Antibiotic Guidelines . All patients should be weighed monthly for possible dose adjustments.37 kg 2 2 38 – 54 kg 3 3 55 – 70 kg 4 4 > 70 kg 5 5 Drug Dosage per kg body weight (if using single-drug formulations) PEDIATRICS ADULTS ANTI-TB Drug Dose (mg/kg Max dose/d Dose (mg/kg Max BW) (mg) BW) dose/d(mg) Isoniazid 10 (10 – 15) 300 5 (4 – 6) 400 Rifampicin 15 (10 – 20) 600 10 (8 – 12) 600 Pyrazinamide 30 (20 – 40) 2.200 15 (15 – 20) 1. HR) HRZE HR 30 . Refer to Table below on Summary of treatment regimens for EPTB. Directly-Observed Treatment (DOT) to foster adherence. hepatic or renal impairment. HRZE) Continuation phase BODY WEIGHT (No. of tablets) (4 mos. Anti-TB treatment regimen shall be based on anatomical site and bacteriologic status including drug resistance and history of prior treatment. Single drug formulation should be used for specific subsets of patients such as those with hypersensitivity reactions to rifampicin and other anti-TB drugs: drug reactions. as well as the presence of co-morbid conditions.200 Comments: ALL children being treated for TB should be weighed at least once every month to allow for adjustment of dosage(s). DOH PUBLIC HEALTH PROGRAMS (TUBERCULOSIS) ADULTS: Intensive phase (2 mos. 37 kg 2 2 38 – 54 kg 3 3 55 – 70 kg 4 4 > 70 kg 5 5 Comments: Referral to relevant specialties is recommended for EPTB. CATEGORY IA Etiology: Extra-pulmonary TB (EPTB). HRZE) Continuation phase BODY WEIGHT (No. 15 mg for weeks 9-10 and 5 mg for week 11. HRZE) Continuation phase BODY WEIGHT (No. • TB meningitis: Dexamethasone 0. of tablets) (4 mos. New: CNS. C. of tablets) (4 mos. HR) HRZE HR 30 .4mg/kg/24h with a reducing course over 6-8 weeks • TB pericarditis: Prednisolone 60 mg for the first 4 weeks. Refer to Table below on Summary of treatment regimens for EPTB. previously treated drug-susceptible TB (whether bacteriologically confirmed or clinically diagnosed) • Relapse • Treatment After Failure • Treatment After Lost to Follow-up (TALF) • Previous Treatment Outcome Unknown • Other National Antibiotic Guidelines 221 . DOH PUBLIC HEALTH PROGRAMS (TUBERCULOSIS) B. 30 mg for weeks 5- 8. CATEGORY II 2HRZES/ 1HRZE/5HRE Etiology: PTB or EPTB. bones or joints Preferred Regimen: PEDIATRICS (<15Y): Intensive phase (2 mos. Use of corticosteroids as adjunctive therapy is recommended ONLY for patients with TB meningitis and/or TB pericarditis. HR) HRZ E (100 mg) HR 4 .24 kg 4 4 4 25 + kg Adult dose and preparations ADULTS: Intensive phase (2 mos.7 kg 1 1 1 8 – 11 kg 2 2 2 12 – 15 kg 3 3 3 16 . 37 kg 2 2 2 38 – 54 kg 3 3 3 55 – 70 kg 4 4 4 > 70 kg 5 5 5 *Add streptomycin 15 mg/kg BW/d during the first 2 months of the intensive phase. For patients with BW <50 kgs and those >60 yrs. consider streptomycin dosing of 500-700mg or 10mg/kg/d. They should immediately be referred to the nearest MDR-TB facility (or other private or government facility with Xpert/MTB/Rif service) for Rifampicin susceptibility testing (Xpert). of tablets) (5HRE) WEIGHT HRZES* HRZE HRE 30 . not to exceed 1 g/d. DOH PUBLIC HEALTH PROGRAMS (TUBERCULOSIS) Preferred Regimen: PEDIATRICS (<15Y): Intensive phase (2HRZES* + Continuation phase BODY 1HRZE) (No. Category II regimen should only be given among SUSCEPTIBLE retreatment cases. old. of tablets) (5HRE) WEIGHT HRZ E (100 mg) HRE+ 4 . Comments: All retreatment patients are considered as Presumptive DR-TB and should therefore be tested using Xpert MTB/ Rif Test before initiating Category II treatment regimen (except if there is no sputum specimen. not to exceed 1 g/d. Xpert MTB/Rif test shall be done first and result be made available before starting on any second-line drugs.24 kg 4 4 4 25 + kg Adult dose and preparations *Add streptomycin 15 mg/kg BW/d during the first 2 months of the intensive phase. ADULTS: Intensive phase (2HRZES* + Continuation phase BODY 1HRZE) (No. 222 National Antibiotic Guidelines .7 kg 1 1 1 8 – 11 kg 2 2 2 12 – 15 kg 3 3 3 16 . or there is no access to Xpert services). not to exceed 1 g/d. not to exceed 1 g/d. renal and ocular toxicity.7 kg 1 1 1 8 – 11 kg 2 2 2 12 – 15 kg 3 3 3 16 . Baseline history and PE for any risk factors for hepatic.37 kg 2 2 2 38 – 54 kg 3 3 3 55 – 70 kg 4 4 4 > 70 kg 5 5 5 *Add streptomycin 30 mg/kg BW/d during the first 2 months of the intensive phase. CATEGORY IIA 2HRZES/ 1HRZE/9HRE Etiology: EPTB. Those with risk behavior for HIV or coming from Category A/B HIV areas should be offered PICT 3. RBS or OGTT) for all TB patients 5. bones or joints. ADULTS: Intensive phase (2HRZES* + Continuation phase BODY 1HRZE) (No. occupational history. DOH PUBLIC HEALTH PROGRAMS (TUBERCULOSIS) D. previously treated drug-susceptible TB (whether bacteriologically confirmed or clinically diagnosed) .24 kg 4 4 4 25 + kg Adult dose and preparations *Add streptomycin 30 mg/kg BW/d during the first 2 months of the intensive phase. sexual history. Baseline visual acuity and color perception for all TB patients National Antibiotic Guidelines 223 . of tablets) (5HRE) WEIGHT HRZ E (100 mg) HRE+ 4 . Screening for DM (using FBS.CNS. Preferred Regimen: PEDIATRICS (<15Y): Intensive phase (2HRZES* + Continuation phase BODY 1HRZE) (No. Baseline ALT/crea at the minimum for >60y/o and those with risk factors for liver or kidney disease 4. personal/ social personal (including smoking and alcohol use) 2. of tablets) (5HRE) WEIGHT HRZES* HRZE HRE 30 . Comments: Pre-treatment recommendations for patients starting Category II regimens: 1. the priority is to treat TB. Standard TB regimen for HIV- associated TB is the same as the general population. ARV should be initiated after the 2nd week of TB treatment. DOT shall be done throughout the treatment duration to ensure adherence. Cotrimoxazole prophylaxis (sulfamethoxazole 800mg/ trimethoprim 160 mg daily) for Pneumocystis jiroveci pneumonia regardless of CD4 count. 224 National Antibiotic Guidelines . or loss of weight shall undergo sputum collection for Xpert testing. Standard Regimen Drug Resistant (SRDR) Etiology: Rifampicin-resistant TB or Multidrug-resistant TB (MDR-TB) Preferred Regimen: Shorter Treatment Regimen: Moxifloxacin-Kanamycin-Prothionamide- Clofazimine-Pyrazinamide-Ethambutol-Isoniazid high dose (MfxKmPtoCfzEZH) • Strictly provided to MDR/RR-TB only. DOH PUBLIC HEALTH PROGRAMS (TUBERCULOSIS) E. XDR-TB Regimen Preferred Regimen: Treatment shall be individualized based on DST result and history of previous treatment and managed only by PMDT center. INDIVIDUAL CONDITIONS/SPECIAL SITUATIONS A. Refer to the treatment centers/ satellite treatment centers for DR-TB management. PEOPLE LIVING WITH HUMAN IMMUNODEFICIENCY VIRUS (HIV) Preferred Regimen: In HIV-related TB. Comments: All newly diagnosed PLHIV should be screened for active TB. F. PLHIV without these symptoms should undergo chest x-ray or clinical assessment to rule out EPTB. All PLHIV with cough of any duration. ARV should be given after the Intensive Phase of TB treatment. • Treatment duration for 9-11 months. fever. Conventional Treatment Regimen: • Provided to patients who do not qualify for the Shorter Treatment • Treatment duration for 20-24 months. night sweats. For patients with TB meningitis. Comments: Since second-line drugs (SLDs) come in single dose formulations. Avoid the use of nevirapine because of drug-drug interactions. D. PREGNANCY Preferred Regimen: Standard TB regimen for pregnant is the same as the general population. Pyridoxine (Vitamin B6) at 10-25 mg/d. National Antibiotic Guidelines 225 . Supplemental Pyridoxine should be given at 5-10 mg/d to the infant who is taking isoniazid or whose breastfeeding mother is taking isoniazid. it is important to note that RIF should be reintroduced last. Pregnant patients taking Isoniazid should be given Pyridoxine (Vitamin B6) at 10-25 mg/d. EXCEPT streptomycin (an ABSOLUTE contraindication). DOH PUBLIC HEALTH PROGRAMS (TUBERCULOSIS) Should there be cutaneous reactions observed in HIV-infected individuals. E. First line anti-TB drugs are safe for pregnant women. NEW MILIARY TB AND MILIARY TB WITH DISSEMINATION Preferred Regimen: Treat as Category I: 2HRZE/4HR Comments: In the absence of meningitis or bone and joint involvement. BREASTFEEDING/LACTATING WOMEN Preferred Regimen: Standard TB regimen for breastfeeding/Lactating women is the same as the general population. DIABETIS MELLITUS Preferred Regimen: Same as general population Comments: Glucose control should be optimal. Efavirenz is the preferred NNRTI for PLHIV on TB treatment. Breastfeeding/Lactating women should be given Pyridoxine (Vitamin B6) at 10-25mg/d. Comments: Always ascertain whether or not a woman is pregnant before she starts TB treatment. B. the effective treatment regimen for NEW miliary TB cases is Category I. referral to specialist is recommended for difficult to control diabetes C. DOH PUBLIC HEALTH PROGRAMS (TUBERCULOSIS) Comments: Breastfeeding woman afflicted with TB should receive a full course of TB treatment. LIVER DISEASE / HISTORY OF LIVER DISEASE Preferred Regimen: Treatment should be interrupted and generally modified or alternative regimen used for those with alanine aminotransferase (ALT) elevation >3x the upper limit of normal (ULN) in the presence of hepatitis symptoms/or jaundice. The more advanced the liver disease. In lactating mothers on TB treatment. ORAL CONTRACEPTIVES Preferred Regimen: Category I: Category I: 2HRZE/4HR Comments: Rifampicin interacts with oral contraceptive (OC) medications with a risk of decreased protective efficacy against pregnancy. CHRONIC LIVER DISEASE Preferred Regimen (For compensated liver cirrhosis): 2HRSE/6HR. For decompensated liver cirrhosis: Refer to a specialist because use of possible SLDs is warranted. I. Advise a woman receiving OC while on Rif treatment that she has the following options: 1. 9HRE Comments: Patients undergoing prolonged ethambutol treatment should undergo regular ophthalmologic screening (visual acuity and red/green color discrimination). the fewer number of hepatotoxic drugs should be used. Use another form of contraception G. 2HSE/10HE. Take an OC pill containing a higher dose of estrogen (50 u) following consultation with a clinician 2. treatment should be interrupted even in the absence of symptoms. the safest option is the 226 National Antibiotic Guidelines . When it is necessary to treat TB during acute hepatitis. most anti-TB drugs will be found in breast milk in concentrations equal to only a small fraction of the therapeutic dose in infants. H. ACUTE VIRAL HEPATITIS Preferred Regimen: It is possible to defer TB treatment until acute hepatitis has been resolved. Refer to the appropriate specialist. If ALT is elevated 5x the ULN. F. J. It is recommended that anti-TB medications be taken after hemodialysis. Anti-TB medications should be administered immediately AFTER hemodialysis or ANYTIME during peritoneal dialysis. K. or 900 mg 3x per week R: 600 mg od. Moderate quality evidence National Antibiotic Guidelines 227 . or 600 mg 3x per week Z: 25-35 mg/kg/dose 3x per week (NOT daily) E: 15-25 mg/kg/dose 3x per week (NOT daily) S: 12-15 mg/kg/dose 2 or 3x per week Comments: Noting the recommendations cited. Same adjustments are made for those receiving second line drugs. RENAL FAILURE (with reduced renal function or receiving hemodialysis) Preferred Regimen: H: 300 mg od. High quality evidence Bone and Joints 2 HRZE / 10 HR STRONG recommendation. Thrice weekly instead of daily pyrazinamide and ethambutol is recommended. KNOWN CHRONIC KIDNEY DISEASE Preferred Regimen: 2HRZE/4HR modified in dosage and frequency based on creatinine clearance. If the hepatitis has not been resolved. SE should be continued for a total of 12 months (12SE). it is possible to give a 4-drug FDC (HRZE) 3x per week and then give a 2-drug FDC (HR) for the rest of the week during the Intensive Phase. SDFs are preferred over FDCs to facilitate proper dose adjustments. Moderate quality evidence Lymph node 2 HRZE / 4 HR STRONG recommendation. Continuation Phase may proceed with 4HR. a Continuation Phase of 6 months HR is given (3SE/6HR). Once the hepatitis has resolved. Summary of treatment regimens for Extra-pulmonary TB Site Regimen Recommendation/ Level of Evidence Central Nervous System 2 HRZE / 10 HR STRONG recommendation. Refer all patients to a specialist. DOH PUBLIC HEALTH PROGRAMS (TUBERCULOSIS) combination of streptomycin and ethambutol for 3 months. another safe option is 2HRZ/4HR. Otherwise. Comments: Please refer to the Table below on Dose Adjustments for Patients with Kidney Disease. DOH PUBLIC HEALTH PROGRAMS (TUBERCULOSIS) Pericardium 2 HRZE / 4 HR STRONG recommendation. kg/d (max 3x/week after 3x/week 2 g/d) dialysis Ethambutol 15 (15-20) GFR > 15-25 15-25 mg/kg. mg/kg. 2 HRZE / 4 HR STRONG recommendation. kg/d (max ml/min: 3x/week after 3x/week 1. 3x/week. 3x/week 228 National Antibiotic Guidelines . Moderate quality evidence Gastrointestinal. tract Low quality evidence Dose Adjustments for Patients with Kidney Disease Reference Dose Adjustment dose Anti TB Drug (normal GFR ≥ GFR ≤ Peritoneal renal 30 30 Hemodialysis Dialysis function) ml/min ml/min Isoniazid 5 (4-6) None After dialysis None mg/kg/d (max 300 mg/d) Rifampicin 10 (8-12) None After dialysis None mg/kg/d (max 600 mg/d) Pyrazinamide 25 (20-30) None 25-35 25-35 mg/kg. 3x/week. Moderate quality evidence Liver 2 HRZE / 4 HR STRONG recommendation. 25-35 mg/ mg/kg.2 g/d) None dialysis GFR < 70 ml/min: 15-25 mg/kg. Low quality evidence Pleura 2 HRZE / 4 HR STRONG recommendation. 15-25 mg/ 70 mg/kg. Peritoneum Moderate quality evidence Kidney and Genitourinary 2 HRZE / 4 HR STRONG recommendation. mg/kg. National Antibiotic Guidelines 229 . • CPG for the Diagnosis. Cruz. 2014. 2010. 5 th edition. Switzerland: WHO. Prevention and Control of Tuberculosis in Adult Filipinos – 2016 Update. Manila: DOH. DOH PUBLIC HEALTH PROGRAMS (TUBERCULOSIS) REFERENCES • WHO Treatment of Tuberculosis Guidelines. Treatment. Geneva. Sta. Manila: Philippine Coalition Against Tuberculosis (PhilCAT). 4th edition. 2016. • National Tuberculosis Control Program Manual of Procedures. or in patients with known MRSA colonization or at high risk for this (e.. Stevens-Johnson syndrome).500 mL). adding a second agent with appropriate in vitro activity may be necessary. or when there is excessive blood loss (>1. This can be done by adding cefazolin to vancomycin in the non-allergic patient. a dose should be given within an hour prior to incision. Rapid infusion of vancomycin may result in hypotension and other signs and symptoms of histamine release (red man syndrome). For patients currently given therapeutic antibiotic(s) for infection remote to surgery site and when the antibiotic regimen is appropriate also for prophylaxis. 1. intraoperative supplementary dose(s) may be required. B. When gram-negative bacteria are a concern (as shown by local surveillance data). aminoglycoside. It is also an alternative when patients have a history of an immediate type of allergic reaction to beta-lactams (anaphylaxis. laryngeal edema. urticaria or pruritic rash occurring immediately after a beta-lactam dose) or exfoliative dermatitis (e. local swelling. Adults: A. 230 National Antibiotic Guidelines . 2. or aztreonam). SURGICAL PROPHYLAXIS ANTIBIOTIC PROPHYLAXIS TO PREVENT SURGICAL INFECTIONS GENERAL COMMENTS: I.to 2-hour infusion times. A single dose of antimicrobial with a long enough half-life to achieve activity throughout the operation is sufficient for prophylaxis under most circumstances.g. dose is started 2 hours before surgical incision. Timing is crucial. C.. The antibiotic chosen must cover the expected pathogens for the operative site and take into account local resistance patterns. E. bronchospasm.g. fluoroquinolone. The use of vancomycin is discouraged but may be justifiable in centers where rates of post-operative infection with methicillin-resistant Staphylococcus aureus (MRSA) are high. Intravenous antimicrobial must be started within 60 minutes before surgical incision. Effective prophylaxis requires antimicrobial serum and tissue concentrations above the minimum inhibitory concentration (MIC) for the probable organisms associated with the specific procedure at the time of incision and throughout the duration of the procedure. vancomycin has no activity against gram-negative organisms. Unlike beta-lactams. Post-procedure doses are generally not needed. Surgical prophylaxis is recommended only when the potential benefits exceed the risks and the anticipated costs. 1. hence.. Exceptions: Vancomycin and fluoroquinolones require 1. D.g. hypotension. use vancomycin with another gram-negative antibiotic (e. 3. For procedures lasting more than two half-lives of the prophylactic agent. hemodialysis patients). In patients intolerant of or allergic to beta- lactams. Re-dosing interval is measured from time of the preoperative dose. and those colonized with MRSA. Pediatric Patients: A. in high-risk patients. and bid for 5 days post-surgery • Permanent pacemakers in patients with positive nasal culture • Heart transplant for S. prolonged hospital stay. For CLEAN SURGERIES. body >90kg: 1. Prophylaxis beyond 24 hours is not recommended No prophylaxis is needed for cardiac catheterization. carotid and brachiocephalic procedures without insertion of prosthetic grafts. Exception: procedures where there are severe consequences of infection (e. National Antibiotic Guidelines 231 . Fluoroquinolones should not be used because of the potential for toxicity. data in the pediatric population are limited and recommendations have largely been extrapolated from studies in adults. and increased health care cost. Cardiovascular Surgery Surgery: Regimen: • Reconstruction of abdominal Cefazolin 2g x 1 dose for <120kg or aorta 3g IV >120kg OR • Leg vascular procedures that Cefuroxime 1. cardiac procedures). Vancomycin may be preferred in hospitals with increased frequency of MRSA. aureus. However. increased morbidity and mortality. The principles mirror those for antibiotic prophylaxis in adults. Improper antimicrobial prophylaxis leads to excessive surgical wound infection rate (up to 52% in most studies). II.g.5g IV x 1 dose • Lower extremity amputation for Consider intranasal mupirocin the ischemia evening before surgery. B. The risks of pre-surgical prophylaxis include Clostridium difficile infection and allergic reactions. on the day of • Cardiac surgery surgery. RECOMMENDED ANTIBIOTIC PROPHYLAXIS REGIMEN BY SURGICAL PROCEDURE A.5g IV x 1 dose involve a groin incision • Any vascular procedure with If allergic to beta-lactams: insertion of prosthesis/foreign Vancomycin <90kg: 1g IV x 1 dose. it is recommended to stop prophylaxis either after removal of the retrosternal drainage catheters or just give a 2nd dose after coming off bypass. SURGICAL PROPHYLAXIS F. C. and intravascular central line insertion (tunneled/untunneled). no prophylaxis is recommended as a general rule. Recommendations are generally the same as for adults except for dosing. prosthetic implants. • Implanted cardiac defibrillators Comments: Single infusion just before surgery is as effective as multiple doses. For prosthetic heart valves. C. laparoscopic cholecystectomy No prophylaxis Biliary. non-functioning gallbladder. SURGICAL PROPHYLAXIS B. Gastroduodenal/Biliary Surgery Surgery: Regimen: Gastroduodenal. acute cholecystitis. diabetes. immune-suppression. Ceftriaxone (2g IV) x 1 dose pancreaticoduodenectomy (Whipple procedure) Low risk. includes Cefazolin 2g IV (3g if wt. pregnancy.5 g IV OR Ampicillin-Sulbactam 3g IV If with beta-lactam allergy: Clindamycin 900mg IV PLUS Gentamicin 5mg/kg IV OR Aztreonam 2g IV OR Ciprofloxacin 400mg IV Oral (At 1 pm. Ceftriaxone is recommended for centers where there is increasing resistance of Enterobacteriaceae to 1st and 2nd generation cephalosporins. obstructive jaundice or common duct stones.>120kg) PLUS Metronidazole 0.5g IV 1h prior to procedure Comments: Gastroduodenal (PEG placement) high-risk conditions include: marked obesity. open OR Cefoxitin 2 g IV cholecystectomy Endoscopic retrograde If without obstruction: No cholangiopancreatography Prophylaxis If with obstruction: Ciprofloxacin 500-750mg PO or 400mg IV 2h prior to procedure OR Piperacillin-tazobactam 4. >120kg) OR percutaneous endoscopic gastrostomy Cefoxitin 2 g IV OR (high risk only). 2 pm and 11 pm of preop day): Neomycin 1g PLUS Erythromycin base 1g PO 232 National Antibiotic Guidelines . cancer. obstruction. Avoid using ceftriaxone in neonates. Biliary high-risk factors include: age >70 years. gastric bleeding. includes high risk laparoscopic Cefazolin 2g IV (3g if wt. anticipated bile spillage or procedure duration >2h. decreased gastric acid or decreased motility.> 120 kg) cholecystectomy. Colorectal surgery Regimen: Parenteral: Cefazolin 2g IV (3g if wt.5g IV OR Cefoxitin 2g IV OR Ceftriaxone 2g IV PLUS Metronidazole 0. does not require prophylaxis except when there is placement of prosthetic material.5g IV National Antibiotic Guidelines 233 .>120kg) elective craniotomy 2nd line: Vancomycin ≤90 kg: 1g IV. SURGICAL PROPHYLAXIS Small bowel surgery without obstruction Cefazolin 2g IV (3 g if wt. Head and Neck Surgery Regimen: Cefazolin 2g IV x 1 dose PLUS Metronidazole 0. NPO after midnight. such as thyroidectomy.5g IV Comments: Prevention of surgical site infection includes a combination of: • Mechanical bowel preparation • Oral antibiotic • IV antibiotic Cefazolin and Metronidazole can be given together in same IV bag. e.5g IV PLUS Metronidazole 0. Do bowel preparation at 10am using 4L polyethylene glycol electrolyte solution PO over 2h. Clear liquid diet only. uncontaminated head and neck surgery. non-implant. 2. Neurosurgical Procedures Surgery: Regimen: Clean.>120 kg) with obstruction As for colorectal parenteral regimen Appendectomy for uncomplicated Cefoxitin 2g IV OR appendicitis Cefazolin 2g IV (3g if wt. Wound infection rates can still be high though even with prophylaxis. D. On the pre-operative day: 1.>120 kg) PLUS Metronidazole 0. E.5g IV OR Clindamycin 900mg IV once Clean.g. 3. or Ampicillin-sulbactam 3g IV OR naso/oropharynx) Cefuroxime 1.5 g IV OR Clindamycin 600-900mg IV x 1 dose ± Gentamicin 5mg/kg IV x 1 dose Comments: The efficacy of prophylaxis is best established for head and neck cancer surgery. >90 kg: 1. Clean. Prophylaxis is not indicated for tonsillectomy and functional endoscopic sinus procedures. 1st line: Cefazolin 2g IV (3 g if wt. Need to repeat cefazolin dose 4 hours after the initial pre-op dose. contaminated Clindamycin 900mg IV x 1 dose OR (cross sinuses. SURGICAL PROPHYLAXIS CSF shunt surgery. in high-risk patients. Episiotomy for vaginal Antibiotic prophylaxis is NOT recommended for birth uncomplicated vaginal birth with or without an episiotomy G. >90 kg: 1. Obstetric/Gynecologic Surgery Surgery: Regimen: Vaginal or abdominal 1st line: Cefazolin 2g IV OR Cefoxitin 2g IV OR hysterectomy Ampicillin-sulbactam 3g IV 2nd line: Clindamycin 900mg IV PLUS Gentamicin 5mg/kg IV x 1 dose Caesarean section for 1st line: Cefazolin 2g IV premature 2nd line: Clindamycin 900mg IV PLUS rupture of membranes Gentamicin 5mg/kg IV x 1 dose or active labor Administer before skin incision. F. and those colonized with MRSA.5g IV OR Clindamycin 900mg IV 234 National Antibiotic Guidelines . Ophthalmic Surgery Regimen: Topical neomycin-polymyxin B–gramicidin OR fluoroquinolone given as 1 drop q5-15 min x 5 doses within the hour before start of procedure.5mg intracameral OR Cefuroxime 1mg intracameral Comments: Most available data involve cataract procedures. Optional at the end of procedure: Cefazolin 100mg by subconjunctival injection OR Cefazolin 1-2. H. Orthopedic Surgery Surgery: Regimen: Total joint replacement 1st line: Cefazolin 2g IV pre-op (TJR). 1st line: Cefazolin 1-2g IV once OR intrathecal 2nd line: Vancomycin ≤90 kg: 1g IV. spinal 2nd line: Vancomycin ≤90 kg: 1g IV. >90 kg: 1.5g pumps IV OR Clindamycin 900mg IV once Comments: Vancomycin may be preferred in hospitals with increased frequency of MRSA. Vancomycin may be preferred in hospitals with increased frequency of MRSA. and thoracotomy Video-assisted thoracoscopic surgery J. plates. lung Clindamycin 900mg IV x 1 dose resection. implantation of internal fixation devices (screws. For TJR (other than hip). repair. aureus. finish the initial antibiotic infusion before the tourniquet is inflated. and those colonized with MRSA I. advanced age. wires) Clean operations of Prophylaxis not indicated hands. Thoracic Surgery Surgery: Regimen: Noncardiac procedures. Urologic Surgery/ Procedure Surgery: Regimen: Cystoscopy • Prophylaxis generally not necessary if urine is sterile. in high-risk patients.) • Treat patients with UTI based on urine c/s prior to procedure Cystoscopy with Ciprofloxacin 500mg PO OR manipulation Levofloxacin 500mg PO Transrectal prostate Ciprofloxacin 500mg PO 12h prior to biopsy and biopsy repeated 12h after 1st dose National Antibiotic Guidelines 235 . Cefazolin 2g IV x 1 dose OR including lobectomy.. anatomic abnormalities. Antibiotic-impregnated bone cement in addition to intravenous antibiotic is commonly practiced for joint replacements. May give a fluoroquinolone or cotrimoxazole for those with potentially adverse host factors (e. nails. immunocompromised state. hip fracture Consider intranasal mupirocin if colonized with S. etc.g. feet and arthroscopy w/o implantation of foreign materials Comments: Stop prophylaxis within 24h of surgery. SURGICAL PROPHYLAXIS procedures. Ampicillin-sulbactam 3g IV x 1 dose OR pneumonectomy. 4-10. Treat UTI with targeted therapy before procedure if possible. Others Surgery: Regimen: Breast surgery.9 2 Aztreonam 30mg/kg 1. 50mg/kg 0. Cefazolin 1-2g IV x 1 dose OR herniorrhaphy Ampicillin-sulbactam 3g IV x 1 dose OR Clindamycin 900mg IV x 1 dose Recommended Doses for PEDIATRIC PATIENTS (beyond the Newborn Period) and REDOSING INTERVALS for Commonly Used Antimicrobials for Surgical Prophylaxis Antibiotic Dose for Pediatrics Half-Life in Redosing Adults with Interval (From Normal Renal Initiation of Function Preoperative (hours)* Dose) (hours) ** Ampicillin. etc. fulguration.3-2. Cystoscopy with manipulation: Procedures include ureteroscopy. which should ideally be based on susceptibility of prevailing organisms.7-1. biopsy.9 NA Ciprofloxacin 10mg/kg 3-7 NA Clindamycin 10mg/kg 2-4 6 Fluconazole 6mg/kg 30 NA 236 National Antibiotic Guidelines . K.1 2 Ceftriaxone 50-75mg/kg 5.4 4 Cefazolin 30mg/kg 1. Transrectal prostate biopsy: Screening stool culture pre-procedure for colonization with fluoroquinolone-resistant organisms is increasingly used to guide the choice of prophylaxis. TURP. SURGICAL PROPHYLAXIS Comments: Cystoscopy: Modify antimicrobial to target urinary pathogens based on local resistance patterns.2 4 Cefuroxime 50mg/kg 1-2 4 Cefoxitin 40mg/kg 0.2-2. Increasing cotrimoxazole and/or fluoroquinolone (FQ) resistance among enteric gram-negative bacteria has been a concern.3 2 Sulbactam (ampicillin component) Ampicillin 50mg/kg 1-1.8-1. Black DB. Infants 2-9 mos: 0.hopkinsmedicine.8-3 NA Metronidazole 15mg/kg 6-10 NA Neomycin 15mg/kg 2-3 NA * The maximum pediatric dose should not exceed the usual adult dose. • Katzung BG. cefazolin or cefoxitin) used for long procedures. the dosing weight (DW) can be determined as follows: DW = IBW + 0. redosing during surgery is recommended at an interval of approximately two times the half-life of the agent in patients with normal renal function. • Antibiotic Guidelines 2015-2016. Masters SB.0904. Pediatric patients weighing more than 40 kg should receive weight-based doses unless the dose or daily dose exceeds the recommended adult dose. et al. ** For antimicrobials with a short half-life (e. Chambers HF.4 (actual wt. 35(6): 605-627. • Gilbert DN. Am J Health Syst Pharm 70:195.7-1. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. Treatment Recommendations for Adult Inpatients. Freedman DO. Umscheid CA. 13th edition Mc Graw Hill 2015:883 National Antibiotic Guidelines 237 . Schwartz BS editors.2017. – IBW) References: • Anderson DJ.. Pavia AT. Recommended redosing intervals marked as “not applicable” (NA) are based on typical case length.pdf • Bratzler DW. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. et al. Saag MS. et al. Bratzler DW. 2017. SURGICAL PROPHYLAXIS Gentamicin*** 2. Centers for Disease Control and Prevention guideline for the prevention of surgical site infection. JAMA Surg.org/amp/guidelines/antibiotic_guidelines.1001/jamasurg. • Berrios-Torres SI. Eliopoulis GM. for unusually long procedures.2 2 Tazobactam 80mg/kg (piperacillin Children >9 mos component) and <40kg: 100mg/kg Vancomycin 15mg/kg 4-8 NA Oral Antibiotics for Colorectal Surgery in Conjunction with Mechanical Bowel Preparation Erythromycin base 20mg/kg 0.g. Healthcare Infection Control Practices Advisory Committee. Available at: http://www. 2017. Kim K.5mg/kg based 2-3 NA on dosing weight Metronidazole 15mg/kg 6-8 NA Piperacillin. Basic and Clinical Pharmacology. *** In general. Trever AJ editors. redosing may be needed. Dosing is based on the patient’s actual body weight. If actual body weight is more than 20% above ideal body weight (IBW). Published online May 3. Infect Control Hospital Epidemiol 2014. gentamicin for surgical antibiotic prophylaxis should be limited to a single dose given preoperatively. Sanford Guide to Antimicrobial Therapy 2016. 2013. doi:10. Available at: www. Accessed 14 November 2016. 2008 Apr.int/gpsc/ssi-prevention-guidelines/en/. Edinburgh: SIGN.who. Best practice policy statement on urologic surgery antimicrobial prophylaxis.who.int/gpsc/ssi-prevention-guidelines/en/. • WHO recommendations for prevention and treatment of maternal peripartum infections. SURGICAL PROPHYLAXIS • Research Institute for Tropical Medicine. Geneva: World Health Organization. Accessed 14 November 2016. et al.179(4):1379-90. Antibiotic prophylaxis in surgery. • Wolf JS Jr1. • World Health Organization 2016 Global Guidelines on the Prevention of Surgical Site Infections. 2008. J Urol. www. Antimicrobial Resistance Surveillance Program 2015 Annual Report • Scottish Intercollegiate Guidelines Network (SIGN). 2015 238 National Antibiotic Guidelines .