Antibiotic Guidelines (2005)

BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSIT
Dhaka, Bangladesh
October 2005
Antibiotic Guidelines
BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSIT
Dhaka, Bangladesh
October 2005
ISBN : 984-32-2715-8
Published by :
Bangabandhu Sheikh Mujib Medical University
Shahbag, Dhaka, Bangladesh
All rights reserved by the BSMMU
First Edition: October, 2005
Price: Tk. 50.00
Printed by:
Asian Colour Printing
130, DIT Extension Road
Fakirerpool, Dhaka-1000
Tel: 9357726, 8362258
,
Acknowledgement
All teachers of BSMMU who actively participate in preparing this guidelines.
Committee to prepare the manual
I. Prof. M. A. Mannan
Pro-Vice Chancellor (Hospital)
2. Prof. Md. Salehuddin
Department of Ophthalmology
3. Prof. Md. Ruhul Amin Miah
Department of Microbiology
4. Prof. M. Jalilur Rahman
Department of Hematology
5. Prof. M. Anwar Hussain
Department of Obstetrics & Gynecology
6. Prof. Motiur Rahman Molla
Department of Maxillofacial Surgery
7. Prof. Zahidul Haq
Department of Surgery
8. Prof. N asim Akhter Chowdhury
Department of Medicine
9. Dr. Hossain Imam Al Hadi
Department of Otolaryngology
10. Prof. Mir Misbahuddin
Department of Pharmacology
Chairman
Member
Member
Member
Member
Member
Member
Member
Member
Member Secretary
PREFACE
Antibiotics are an expensive sector of modem medicine. In
Bangladesh, we spend about forty percent of our pharmacy budget
of more than Taka four thousand crores on antibiotics alone. No
doubt antibiotics are essential medicines. They selectively kill
organisms that are sensitive to them. As a result, if used for
prolonged periods, not only such use is uneconomic, but they also
produce unwanted side efects and may encourage the overgrowth of
resistant organisms. As antibiotic resistance is increasing, antibiotic
abuse carries collective penalties for the individual patient and for
the community. Therefore, antibiotics should be used careflly.
Owing to geographical diferences in bacterial sensitivity, each
hospital has its own antibiotic guideline. Therefore, this booklet is
published on treatment guideline that may help our doctors
overcome the above mentioned problems and thereby improve the
quality of teatment.
Our antibiotic guideline is mainly based on empirical treatment that
we are using in BSMMU Hospital. This guideline will be reviewed
and updated periodically because of continuing changes in the patter
of bacterial resistance to antibiotic. In this booklet common diseases
are highlighted and their appropriate therapeutic recommendations are
mentioned. Microbiological statistics of our hospital is presented,
though inadequate, may be helpfl for our doctors for proper selection
of the antibiotic.
Constructive criticism and usefl suggestions for improving the
quality and contents of this booklet are welcomed from its users.
I thank the chairman and members of the committee and contributing
faculty members for their active support and help without which this
publication on the safe use of antibiotics would not have been seen
the light of the day.

(Prof. M.A. Hadi)
Vice Chancellor
Contents
Principles of antimicrobial therapy in infectious disease
Collection of sample for culture
Microbiological statistics
Desirable serum antibiotic levels
Treatment of specifc diseases
Acne vulgaris
Alveolar abscess
Alveolar osteitis (dry socket)
Amoebiasis
Bite wounds
Breast abscess/mastitis
Bronchiectasis
Bronchitis
Chancroid
Cellulitis
Cerebral abscess
Cholecystitis (acute)
Cholera
Conjunctivitis
Coreal ulcer
Cystitis (acute uncomplicated)
Dysentery (bacillary)
Eczema (infected)
Enteric fever
Febrile neutropenia
Genital herpes
Giardiasis
Gingivitis
Pyogenic liver abscess
Mastoiditis
4
10
24
25
26
27
27
28
29
30
31
32
33
34
35
36
36
37
38
39
39
40
40
41
42
43
4
4
44
Meningitis
Neonatal sepsis
Otitis exter a
Otitis media (acute suppurative)
Oral thrush (candidiasis)
Peptic ulcer (due to helicobacter pylori)
Pericoronitis
Periodontal abscess
Spontaneous bacterial peritonitis
Pharyngitis
Pneumonia
Prostatitis
Pyelonephritis (acute)
Sepsis in neuropathic foot in diabetes mellitus
Sinusitis
Syphilis
Tonsillitis
Tuberculosis
Urethritis (acute, for males)
Urinary tract infections
Vaginal candidiasis
Vaginal trichomoniasis
Vaginosis (bacterial)
Wounds (infected)
Guideline for use of antibiotics in renal failure
Use of antibiotics in liver disease
Antibiotics in pregnancy
Drug present in breast milk
Management of anaphylactic shock
Antibiotic prophylaxis in surgery
Antibiotic prophylaxis for nonsurgical conditions
Antimicrobial agents associated with photosensitivity
Hospital infection control team
Index
45
47
47
48
49
49
50
50
51
51
52
55
55
56
56
57
58
58
62
62
63
6
6
65
66
67
78
70
71
72
80
84
85
89
ANTIBIOTIC GUIDELINE
PRINCIPLES OF ANTIMICROBIAL THERAPY IN
INFECTIOUS DISEASE
Selection of antimicrobial agent depends on the following factors:
Agent:
identification of possible agent- identify/suspect
knowledge on possible organism in particular situation
aware about situation
possible load and virulence
sampling to identify agent
Host and environment:
identification of host and environmental factors
site of infection
immunological status
nutritional status
precondition affecting susceptibility- congenital heart disease,
presence of foreign body, steroid, susceptible disease, liver/renal
impairment, heart/respiratory failure
Choice of antibiotic:
empiric and specific
which drug to choose- pharmacokinetic properties
choosing combination preparation
Monitoring response:
clinical
estimation of drug level
development of resistance/ superinfection
Representative specimen collection before starting therapy
It is important to obtain adequate and representative specimens from
all potentially infected sites prior to the initiation of antimicrobial
therapy. Appropriate antimicrobial therapy is based on definitive
identification of pathogenic organisms, which usually requires
culture. Once antimicrobial therapy has been started, cultures often
are rendered sterile, even though viable organisms may remain in the
host. It is also important to avoid or minimize contamination by
surface contaminants and commensals when collecting specimens.
Initial empirical choice based on the most likely pathogens and
susceptibilities
In most cases, it may be impossible to determine the exact nature of
the infecting organisms before institution of antimicrobial therapy.
Initial therapy must therefore be empirical - to make a rational choice
from the many currently available antimicrobial agents, the clinician
must be able to predict or "guess" infecting microorganism(s) and the
antimicrobial susceptibility thereof. In these cases, the use of
"bacteriological statistics" i.e. an awareness of those microorganisms
most likely to cause infection in a given clinical setting, in
conjunction with the local antibiotic resistance patters, may be
particularly helpful in choosing an empiric antimicrobial agent.
Subsequent need to adjust antimicrobial therapy in light of the
sensitivity results
Since different organisms vary in their susceptibility to antimicrobial
agents, it is imperative that we have some means for determining the
antimicrobial susceptibility of the infecting organism(s). Once the
pathogen has been isolated, susceptibility testing to be done.
Monitoring therapeutic response
In many patients, it is possible to monitor the therapeutic response on
clinical grounds alone. Thus the subsidence of fever, the retur of
well-being, and the disappearance of both local and systemic signs of
infection in the patient, all signify an appropriate response. No further
formal monitoring is necessary in most cases.
An apparent failure to respond clinically may be due to either
inefectiveness of antimicrobial agent(s) (due to resistance or
inappropriate route of administration) or to other reasons e.g. a
localised infection that requires surgical drainage, or a superinfection
etc. Careful reassessment is recommended when considering changes
of antimicrobial therapy.
In certain situations, measurement of antimicrobial activity may be
useful in predicting clinical response, e.g. determination of serum
bactericidal activity (Schlichter test) in cases of infective
endocarditis.
2
Assays for drugs with narrow therapeutic:toxic ratio
For antibiotics such as the aminoglycosides and vancomycin, the
measurement of their concentrations in serum/plasma or other body
fluids is often useful to avoid excessive levels which are associated
with toxicity, yet ensure that adequate (therapeutic) levels ae
achieved.
Pharmacokinetic properties of antibiotics
Knowledge of the pharmacodynamic and kinetic properties of
antibiotics is imperative in choosing the correct antibiotic and correct
dose.
Time dependant killing: (penicillins, cephalosporins, macrolides).
The time that the antibiotic exceeds the mimi mal inhibitory
concentration (MIC) is crucial in predicting clinical outcome and
cure. Concentrations of members of this group of antibiotics are
required to be above the MIC for at least 50% of the dosing interval.
If the bacterium is more resistant, the MIC is higher with subsequent
reduction in time that the antibiotic concentration exceeds the MIC
and therefore higher dosages of the drug may be required.
Concentration dependant antibiotics: (quinolones, aminoglyco
sides). The more the antibiotic concentration exceeds the MIC, the
more killing will take place (irrespective and independent of the time
the concentration exceeds the MIC). For this group of antibiotics a
ratio of concentration: MIC 10 is required. This implies that a dose
regimen should be chosen which results in a serum or tissue
concentration of at least 10 times the MIC. Failure to achieve this
concentration at the site of infection will lead to clinical and
bacteriological failure, and is likely to induce resistance to the entire
class of antibiotic.
3
COLLECTION OF SAMPLE FOR CULTURE
URNE SAMPLE
Collection:
1. Male: Cleaning the urethral meatus with plain tap water (free skin
retracted), allow to dry and at least 30 ml of mid stream urine
(MSU) should be collected in sterile container. It is better to
collect the first MSU passed at the beginning of the day.
2. Female: The vulva is cleaned by cotton plug soaked with water
Labia is separated and moring mid stream urine (MSU)
should be collected in a wide mouth sterile container.
3. Children:
(a) Sterile adhesive bag:
(b) Suprapubic tap: Tap by fngers on the suprapubic region

1
hour after feed (one tap per second) for 10 seconds; 1 minute
interval repeat the procedre.
4. Suprapubic aspiration: Occasionally necessary in acute
retention of urine or unconscious patient.
5. Urethral catheterization: Rarely used in children or unconscious
patients. Fresh sterile catheter should be used. Urine sample
should be collected directly from the catheter, never from
collecting bag.
6. Ureteric cathelerization: In operation theatre during urological
surgery/ examination, when necessary.
7. Genitourinary tuberculosis : 3 consecutive early moring
urine specimen (EMU) or 24 hours urine in a container containing
1 % boric acid.
4
Tansport:
All specimens should be processed in the laboratory within 2 hours of
collection; if delay is unavoidable more than 2 hours use one of the
following.
a) Refrigerate the urine at 4
C in the same container.

b) Collect and transport in a container with boric acid (O.lg/
10 ml of urine).
Any way delay should not be longer than 18 hours after collection.
STOOL SAMPLE
Administration of drugs or antidiarrheal substances (mineral oil,
barium, bismith, magnesium, antibiotics) should be terminated at
least one week before stool collection.
- Stool container should be
a) Clean, dry, leak proof, disinfectant free and wide
necked container.
b) A light plastic box or a especially designed glass jar
attached spoon with the stopper.
- Amount of stool that is to be collected
a) About a spoonful specimen is sufficient
b) Transfer a portion of stool that contain mucous, pus,
blood, if present.
- Send the specimen to the lab as early as possible.
- If transport delay is unavoidable place specimen in
Transport medium Cary - Blair media.
Procedure of transport:
a) With the help of cotton swab, a portion of stool is
taken.
b) Insert the swab in the container of sterile Cary-Blair
transpoi medium.
c) Breaking off the swab stick to allow the bottle top to
be replaced lightly.
5
- For infants or other patients if necessary 'Rectal Swab' may be collected.
a) Moisten the swab with normal saline & introduce the swab
into rectum (one inch into the anal canal) and kept for 10
seconds, tum the swab several times with a circular
movement. Care should be taken to avoid unnecessary
contamination of the specimen with bacteria from anal skin.
- Precaution
a) Avoid contaminating the faeces with urine or water
b) Never store in the incubator
c) Never store in the refrigerator
ENDOMETRIUM
- Curetting / scrapings / small tissue samples of endometrium should
collected aseptically, avoiding lower genital tract contamination
and transported in sterile saline.
- Send immediately to laboratory.
THROAT SWAB
Swab should be collected in the moring before any mouthwash, food
or drink. Mouth of the patient should be widely opened, neck flexed.
Hold the head fixed. Keep the tongue down with a tongue depressor.
Oral cavity should be properly illumnated with good light source. A
sterile cotton swab (supplied from dept.) is rubbed vigorously over
one tonsil, then uvula, other tonsil, the posterior wall of the pharynx
and over any other inflamed area. Care should be taken not to touch
the tongue, buccal surface or lips. Place the swab stick in the sterile
container tube. It is preferable to take two swabs from the same
patient. Specimen should be dispatched to the laboratory as soon as
possible.
6
WOUND SWAB
Sample should be collected from the base of the ulcer or nodule
following removal of overlying debris or by surgical biopsy of deep
tissues without contact with the superficial layer of the lesion. If
possible two swabs should be collected. Specimens should be placed
in sterile container capped properly and send to the laboratory as
easily as possible.
SPUTUM COLLECTION
Patient instruction
- Collect early moring specimen before breakfast or mouthwash.
- Rinse mouth with water before collection.
- Remember that saliva and naso pharyngeal discharge are not sputum.
Collect only the exudative material brought up from lungs after a
deep production cough in a dry wide necked leak-proof container.
- Send the container as early as possible. Never refrigerate such sample.
If pulmonary tuberculosis is suspected
- Collect a series of three to six single early moring sputum on
successive days.
- If not possible the 151 sample at spot and 2nd early morning sample.
- If a patient produces very little sputum, 24-48 hours pooled
specimen is needed to yield a positive culture.
CONJUNCTIVAL SWAB
The conjunctival swab should be taken with a thin sterile cotton swab
moistened with sterile trypticase soy !broth sterile normal saline.
Conjunctival swab is collected across the lower tarsal conjunctiva and
fornix from medial to lateral canthus-taking care not to touch the lid margin.
Chlamydial infections: Specimen includes scrapings from conjunctiva.
Mycotic infections: Specimen consists of scrapings from the base of
edge of coreal ulcer.
7
CSF
Collection and transport
- Approximately 5-10 m of CSF (in adult patient) should be
collected in two sterile tubes (Screw-Capped).
Collect about I m of CSF in tube No. I (for culture) and rest of the
portion in tube no. 2 (for other tests).
- The specimen should be delivered to the laboratory immediately as
early as possible.
Do not refrigerate the sample.
- If tuberculus meningitis is suspected, 3r
d
tube is kept in the
refrigeration undisturbed to see whether a pellicle or coagulum forms.
ASPIRATED FLUIS
Exudates from pleural, peritoneal, pericardial or synovial spaces must be
aspirated with aseptic technique. Specimen should be placed in a sterile
screw cap tube and sealed properly and transferred to the laboratory
within 20 minutes of collection (syringe transport not recommended).
CERVICAL SWAB/ HVS
Genital specimen from women
- All specimens should be collected during pelvic examination using
a speculum.
- The speculum should be moistened with warm water before use, but
antiseptics or gynecological exploration should not be used.
- After inserting the speculum, cervical mucus should be wiped off
with a cotton wool ball.
- A sampling swab should be then be introduced into the cervical
canal and rotated for at least 10 seconds before withdrawal.
- Specimen should be transported in Amies and Stuart transport media.
For urethral discharge and genital ulcer the patient should be referred
to Microbiology Department.
8
METHODS OF COLLECTION OF BLOOD FOR CULTURE
- Asepsis of blood culture bottle top
Timing of sample collection:
a) At spike of febrile illness
b) Before antibiotic use
c) If antibiotic already started blood should be collected just
before next dose of antibiotic.
Optimal volume of blood culture:
a) For adult minimum 5-1 0 ml
b) For children 1-3 m.
c) For neonate I m!.
After collection immediately inoculate blood into culture bottle (Bed
side inoculation) and send to laboratory within one hour.
9
ANTIBIOTIC GUI DELINE
"DESIRABLE" SERUM ANTIBIOTIC LEVELS (MG/L)
Peak Trough
Increased risk of
toxicity
Gentamicin 6 - 12 < 1.5 Trough> 2
Tobramycin 6 - 12 < 1.5 Trough> 2
Netilmicin 6 - 1 2 < 1.5 Trough> 2
Amikacin 15 - 30 < 1.5 Trough> 5
Vancomycin 20 - 40 5 - 1 0 Trough> 1 0
TREATMENT OF SPECIFIC DISEASES
24
ANTI BI OTIC GUIDELINE
ACNE VULGARIS
In case ofcomedonal, blackheads, whiteheads, earliest form with no
infammation
There is excessive sebum production and gland obstruction. Goal is
prevention, reduction in the number of new comedones and creates an
environment unfavorable to Propionibacterium acnes.
Drug of choice
Tretinoin Apply cream (0.05% ) locally once daily
Tretinoin is an acid form of retinal. It is a keratolytic agent that reduces
follicular hyperkeratosis by stimulating the turover of epithelial cells. Benefit
is seen after 2 months. It has initnt activity and may promote UV -induced
skin cancer. The drug should be avoided in sunny weather and in pregnancy.
Tretinoin may initially be applied for short intervals of time and the strength
and duration gradually increased. It should not be used in combination with
other keratolytics. Topical corticosteroid should not be used to teat acne.
In case ofmild inflammatory acne, small papules or pustules
There is proliferation of P acnes and desquamation of follicular cells.
Drug of choice
Azelaic acid Apply cream (20%) locally twice daily for up to 6 mon
i
hs
or
Erythromycin Apply cream (3%) locally twice daily
pl us
Azithromycin 500 mg orally after taking meal daily for 4 days a week for 6 weeks
Azelaic acid inhibits the growth of Propiollibacterium spp. And reduces
keratinization. Improvement usually occurs within 4 weeks. Topical
application of azelaic acid may produce a transient skin irritation that
disappears on continued treatment. It should not be applied to the eys, mouth,
or other mucous membranes.
Erythromycin and azithromycin are macrolid antibiotics with wide spectrum
of activity. Oral administration of azithromycin is preferred over erythromycin
due to its less gastrointestinal adverse efects though there may be diarrhea,
nausea and abdominal pain. Azithromycin should be avoided in patient of liver
disease due to high hepatic excretion.
26
In case ofinflammator acne, comedones, papules or pustules
There is proliferation of P acnes and desquamation of follicular cells.
Drug of choice
Erythromycin plus
Benzoyl peroxide plus
Apply cream (3%) locally twice daily
Apply cream (5%) locally twice daily
Doxycycline 100 mg oral ly in empty stomach twice daily for 4-5 months
Banzoyl peroxide has mild keratolytic properties. Topical application of
benzoyl peroxide may produce skin irritation, particularly on beginning
treatment. Caution is required when applying it near the eyes, the mouth and
other sensitive areas.
Administration of doxycycline in empty stomach ensures better absorption.
Oral erythromycin may be used as an alterative to doxycycline. However,
resistance to erythromycin is increasing so it is usually reserved for those
patients in whom other antimicrobials are unsuitable.
ALVEOLAR ABSCESS
Alveolar abscess is the continuation of periapical abscess. It is caused
by Streptococcus, Peptococcus, Bacteroides and Fusobacterium.
Drug of choice
Amoxycil l i n
or
Flucloxacillin
plus
Metronidazole
500 mg orally 8 hourly for 5 - 7 days
250-500 mg orally 6 hourly for 5 - 7 days
200-400 mg orally 8 hourly for 5 - 7 days
Drainage of pus is important.
ALVEOLAR OSTEITIS (Dry socket)
Alveolar osteitis is the most frequent painful complication of
extraction. Pathogens are mainly anaerobes.
Drug of choice
Cefradine
plus
Metronidazole
500 mg orally 8 hourly for 5-7 days
200-400 mg orally thrice daily for 5 days
Warm saline mouth rinses. Soket dressing is required.
27
ANTIBIOTIC GUI DELI NE
AMOEBIASIS
Amoebiasis (amoebic dysentery) is a protozoan parasite infection
caused by Entamoeba histolytica. It exists in two forms: the hardy
infective cyst and the more fragile potentially pathogenic tropozoite.
The disease spreads between humans by its cysts. The parasite is now
known to consist of two separate species: E. dispar (non-pathogenic)
and E histolytica (pathogenic). Cysts of these two species are
morphologically identical, distinguishable only by molecular
techniques, isoenzyme studies or monoclonal antibody typing. Only
E histolytica can give rise to amoebic dysentery or extraintestinal
amoebiasis (amoebic liver abscess).
Drug of choice
Metronidazole
or
Tinidazole
or
Secnidazole
400-800 mg (35 mg/kg/day in children) orally thrice
daily for 5-1 0 days
2 g once daily orally for 3 days
2 g (30 mg/kg in children) single dose orally
Both metronidazole and tinidazole are efective against topozoites. Tinidazole
has longer duration of action over metonidazole. In both the cases the patient
may complain nausea, vomiting, diarrhea, furred tongue and an unpleasant
metallic taste in the mouth. Rashes, urticaria and angioedema may occur.
Peripheral neuropathy occurs if treatment is prolonged and epileptiform
seizures if the dose is high. Follow-up stool examination is always necessary
because no regimen is completely efective in eradicating intestinal infection.
Use of chemoprophylactic agent is not advised.
BI LIARY SEPSIS
Drug of choice
Ci profloxacin
plus
Gentamicin
plus
Metronidazole
28
500 mg orally 1 2 hourly for 1 0- 1 4 days
80 mg intravenously 8 hourly for 1 0- 1 4 days
200-400 mg orally thrice daily for 5 days
BI TE WOUNDS
Bites may be by cat, dog, rat, snake, bee, horet, insect, bat, monkey.
Microorganisms involved are Pasteurella multocida (cats and dogs),
Eikenella corrodens (humans), Staphylococcus aureus, Streptococcus
spp. , andor oral anaerobes.
In case of dog bites
Only 5% of the dog bites become infected. Prophylaxis may be
worthwhile.
Drug of choice
Local wound
cleaning
plus
Co-amoxiclav
plus
All post-exposure treatment should begun with immediate,
thorough cleaning of all wounds with soap and water. Then treat
with 70% ethanol or an iodine tincture. Where possible, wounds
should be kept open or only sutured to secure apposition
375 / 625 mg orally after meal 8 hourly. Duration of treatment
depends on the clinical condition
Rabies vaccine 1 ml intramuscularly at the deltoid region, one each on days
0, 3, 7, 1 4 and 28
plus
Human rabies 20 I U/kg body weight given once on day O. I f anatomically
immune globulin feasible, the half dose should be infiltrated around the wound(s),
the rest should be administered intramuscularly in the gluteal area
There are several types of rabies vaccine available in the drug store. The dosage
schedule of each vaccine varies. So, please check the dose schedule of rabies
vaccine from the supplied patient information leaflet and administer accordingly.
Corticosteroid should not be used because in mouse model, it increases the
mortality rate and shorten the incubation period.
Rabies postexposure prophylaxis , which is highly effective if given prompt/yo
Combination therapy may be superior to therapy with a single agent. Because
immunization by the intramuscular route may take a week or more to produce
detectable immune response, multiple sites (e. g., 8 or 4 sites) intradermal
immunization may be considered to accelerate the response.
Rabies vaccine is the inactivated rabies virus in chick embryo ceil culture.
Its potency is equal to or more than 2.5 IU. The immunization schedule
must be followed exactly, even if considerable time has elapsed since
exposure. The vaccine should be stored at 0 to 4 C. It should not be used
after the expiry date. The vaccine should be used immediately after
reconstitution. Intravas-cular administration may cause anaphyl actic shock
Human rabies immune globulin neutralizes the virus before its invasion of the
29
nervous system. I t should not be administered i n the same syringe, or into the
same anatomical site as vaccine, or more than 7 days after the initiation of
vaccine. Because Human rabies immune globulin may partially suppress active
production of antibody, no more than the recommended dose should be given.
Amoxycillin is a 4-hydroxy analogue of ampicillin and is better absorbed from
the "ut especially after food. Diarrhoea is less frequent with amoxycillin than
with ampicillin. Amoxycillin is preferred because of its greater bioavailability
and fewer side efects.
Clavulanic acid is a beta-Iactam compound which has little intrinsic
antibacterial acitivity but is important because it binds competitively to beta
lactarases. Thereby competitively penicillin protects it against bacteria which
owe their resistance to production of beta-Iactamase, i.e., clavulanic acid acts
as a "suicide" inhibitor. Combination of amoxycillin and c1avulanic acid is
known as co-amoxiclav.
In case ofsnake bite (treatment within the hospital)
Drug of choice
Polyvalent
antiserum
plus
tetanus
5-20 vials should be dil uted ( 1 0 ml each) and then added to
500 ml of intravenous fluid and infused slowly over a period
of about 4 hours
250-500 units deep intramuscularly or tetanus toxoid (primary
immunoglobulin immunization) intramuscularly depending on the
immunization status of the victim
Tetanus toxoid should be given at the same time but at a separate site.
Any antibiotic (preferable penicillin) may be prescribed if there is any sign of infection.
BREAST ABSCESSIASTITIS
In case oflactating woman
Mastitis is usually due to Staphylococcus aureus. There is no
contraindication of breast feeding, rather continuing breast feeding
helps response to antibiotic therapy.
Drug of choice
Flucloxacillin
or
Cloxacillin
or
Cefradine
30
500 mg orally 6 hourly
Cloxacillin is narrow spectrum penicillin that resists degradation by gastric
acid and is absorbed from the gut. Food markedly interferes with
absorption.
Cefradine is a frst-generation cephalosphorin antibiotic. It is available in oral
and parenteral preparation.
In case ofnonlactating woman
It is usually due to anaerobes and/or Staphylococcus aureus.
Drug of choice
Flucloxacillin
or
Cloxacillin
or
Cefradine
plus
Metronidazole
500 mg intravenously or deep intramuscularly 6 hourly.
I ntravenous administration should be done in 5 min
7.5 mg/kg intravenously 6 hourly
Flucloxacillin is better absorbed and gives higher concentration than does
cloxacillin. It may cause cholestatic jaundice, particularly when used for more
than 2 weeks or to patients >55 years.
Metronidazole is one of the azoles and is bacteriostatic. In anaerobic
microrganisms metronidazole is converted into an active form by reduction
of its nitro group. This binds to DNA and prevents nucleic acid formation.
Pretreatment aerobic culture is required. Surgical drainage for abscess may be
done.
BRONCHI ECTASIS
Drug of choice
Ampicillin
or
Amoxycillin
or
Co-trimoxazole
500 mg orally 6 hourly for 1 4 days
1 DS tablet twice daily orally for 1 4 days
31
ANTIBIOTIC GUIDELI NE
In case ofpseudomonas aeroginossa
Drug of choice
Ciprofloxacin
or
Cefotaxime
In chronic case
Drug of choice
Amoxyci l l i n
or
Polymyxi n B
Or
500 mg orally 1 2 hourly for 1 4 days
1 9 intravenously 8 hourly for 1 4 days
500 mg orally 8 hourly for 4 weeks
1 -2 mega units inhaled twice daily
Amoxycillin 500 mg orally 8 hourly for 1 4 days
followed by
Co-trimoxazole 1 OS tablet orally twice daily for 1 4 days
followed by
Tetracycline 500 mg orally 6 hourly for 1 4 days
BRONCHITIS
In case ofacute attack (viral cause)
Acute bronchitis is almost always caused by viruses (influenza
viruses, adenoviruses).
Drug of choice
No antibiotic
In case ofacute attack (bacterial cause)
Bacterial infection is much less common in bronchitis than we used
to think. In the immunocompetent host, acute bronchitis, even when
bacterial in etiology, is self-limiting condition. Antibiotic therapy is
not required.
32
Very rarely, an infection caused by a fungus can cause acute
bronchitis. If severe, secondary bacterial infection may be assumed,
usually due to Streptococcus pneumoniae or Haemophilus injuenzae
Drug of choice
Amoxycillin
or
Erythromycin
or
Tetracycline
500 mg orally 8 hourly for 7 days
500 mg orally 8 hourl y for 7 days
Dose of amoxicillin should be reduced in severe renal impairment. If the
patient is a smoker, then cut down on the number of cigarette smoke, or stop
smoking altogether. This will help the bronchial tree heal faster.
Erythromycin is an efective alterative choice for penicillin-allergic patients.
In case acute exacerbation ofchronic form
Viruses are often implicated, at least initially. Secondary infections by
bacteria such as Streptococcus pneumoniae, Moraxella catarrhalis and
Haemophilus injuenzae may be involved when sputum becomes
purulent and increases in volume. Although most clinicians treat patients
in this setting with antibiotics, most studies comparing antibiotics with
placebo have shown little diference in the rate of resolution of
symptoms. If antibiotics are prescribed, these should be based on the
culture and sensitivity results and should be given for 7-10 days.
Amoxycillin may be considered initially for empiric antibiotic therapy.
CHANCROID
Chancroid ulcer is due to the Ducrey bacillus, Haemophilus ducreyi.
Antibiotic therapy eliminates H. ducreyi and lesions heal in 1-2
weeks.
Drug of choice
Co-trimoxazole
or
Cefixime
1 OS tablet twice daily orally for 7 days
400 mg orally as a single dose
Co-trimoxazole is a sulfonamide-trimethoprim combination (5: I). Each drug
is well absorbed from the gut and is mainly excreted by the kidney. The dose
of co-trimoxazole should be reduced when renal function is impaired.
33
ANTI BIOTI C GUI DELI NE
Cefxime is a third-generation cephalosphorin antibiotic and is stable to
hydrolysis by many beta-Iactamases. Cefixime is better absorbd from oral
suspension than from tablet. Absorption is fairly slow. The most frequent
adverse efects are gastrointestinal disturbances especially diarrhea. It should
b discontinued if diarrhea is severe.
CELLULITIS
Cellulitis is usually due to Streptococcus pyogenes, but Staphylo
coccus au reus is often also involved. When cellulitis is associated
with an open wound, there is usually an exudate that can be obtained
for culture. In the setting of cellulitis with unbroken skin, a needle
aspiration from the advancing edge can sometimes yield a psitive
diagnosis. Blood cultures are also of diagnostic value.
Ludwig's angina is a severe form of cellulitis which usually arise
from the lower second or third molar. It involves the sublingual and
submandibular spaces bilaterally and it readily spreads into the lateral
pharyngeal and pterygoid spaces and can extend up to mediastinum.
Pathogens involves are mainly Fusiorm (bacilli and spiral form),
Staphylococcus, Streptococcus, Bacterides, E. coli and Pseudomonas.
In diabetics and debilitated patients, consider Staphylococcus aureus,
Enterobactericeae and anaerobes.
Drug of choice
Co-amoxiclav
or
Flucloxacillin
375/ 62 5 mg orally half an hour before meal 8 hourly for 7 days
plus phenoxymethyl 2 50 -50mg 6 hourly half an hour before meal for 7 days
penicillin
or
Gatifloxacin
or
Ceftriaxone
400 mg once daily orally for 7 days
2 9 intravenously daily i n single or divided doses
Ceftriaxone is a third-generation cephalosphorin antibiotic. It is highly
protein-bund and is able to displace bilirubin fom albumin binding sites,
causing hyperbilirubinemia.
Gatifloxacin is a fluoroquinolone antibacterial with actions and uses similar to
those of ciprofloxacin. Gatifloxacin may have the potential to prolong the QT
interval and should be avoided in patients with existing QT prolongation.
34
Caution should be exercised when gatifloxacin i s used with drugs such
astemizole, terfenadine, cisapride, erythromycin, pentamidine, phenothiazines
or tricyclic antidepressants.
The
.
dose of gatifloxacin should be reduced in patient with renal im
p
airment.
ImtIal dose of 40 mg should be followed by maintenance dose of 20
daily in those with a creatinine clearance less than 4 mllmin.

CEREBRAL ABSCESS
Bacteria may enter the cerebral substance through penetating injury,
by direct spread from paranasal sinuses or the middle ear or by
hematogenous spread from septicemia. Antimicrobial therapy is
indicated once the diagnosis is made. Surgical treatment by burhole
aspiration or excision may be necessary.
Drug of choice
Ceftriaxone
plus
Gentamicin
plus
Metronidazole
followed by
Cefixime
or
1 9 intramuscularly or intravenously
80 mg intravenously 8 hourly for 1 5 days
200 mg orally twice daily for 6 weeks
Crystalline penicilline 10 lac unit intravenously 6 hourly for 1 5 days
plus
Gentamicin
plus
Metronidazole
followed by
Amoxycillin
or
Co-amoxiclav
500 mg orally 8 hourly for 6 weeks
37 5/ 62 5 mg orally after meal 8 hourly for 6 weeks
35
CHOLECYSTITIS (ACUTE)
The pathogenesis of acute choleystitis is unclear, but the initial
inflammation is possibly chemically induced. At the time of surgcy
approximately 50% of cultures of the gall bladder contents are sterile.
Infection occurs eventually and in elderly patients or those with
diabetes mellitus a severe infection with gas-forming organism can
cause emphysematous cholecystitis.
Drug of choice
Gentamicin
or
Ceftriaxone
plus
Metronidazole
80 mg intravenously 8 hourly
1 9 intravenously 12 hourly depending on the body weight
and severity of infection
500 mg intravenously 8 hourly ( 1 5 mg/kg in children)
Gentamicin is an aminoglycoside antibiotic and has adverse efects like
ototoxicity and nephrotoxicity. This drug should not generally be mixed with
other drugs in syringes or infusion solutions nor given through the same
intavenous line. When gentamicin is given with a beta-lac tam administration
should generally be at separate sites.
CHOLERA
Cholera is caused by Vibrio cholerae serotype 01. A new classical
toxigenic strain, serotype 0139, established itself in Bangladesh in
. 1992 and started a new pandemic.
Antibiotic treatment in adult reduces the duration of excretion of
Vibrio and the total volume of fluid needed for replacement.
Drug of choice
Tetracycline
or
Doxycycline
or
Erthromycin
or
Ciprofloxacin
40 mg/kg/day orally for 3 days
300 mg (6 mg/kg i n children) single dose orally
1 9 single dose orally
There is no risk of staining teeth with such short courses of tetracyclines in
case of children.
36
CONJUNCTIVITIS
In case ofviral conjunctivitis (pink eye)
Viral conjunctivitis is usually unilateral and highly contagious. It is
usually self-limited, but there i s evidence that treatment with a topical
antibiotic shortens its course and prevent bacterial superinfection.
Children are generally kept out of the school for up to 2 weeks after
the onset of infection. Topical antiviral drugs are not administered.
The use of topical corticosteroid therapy is controversial. Onset of
ocular pain and photophobia in an adult suggests associated keratitis
(rare). If there is no improvement in 7 to 10 days, the patient should
be referred to an ophthalmologist.
In case ofbacterial conjunctivitis
Acute bacterial conjunctivitis in the adult is most often due to
staphylococci and/or streptococci. Haemophilus inJluenzae is more
common in children.
Treatment consists of a broad-spectrum topical antibiotic
administered 4 times daily. This empirical approach is highly
effective, and adverse consequences are infrequent.
Drug of choice
Chloramphenicol
or
Ciprofloxacin (0.3%)
or
Ofloxacin (0.3%)
or
Tobramycin (0.3%)
1 -2 drops 4 times daily for 7-1 0 days
1 -2 drops 4 times daily for 7-10 days
Tobramycin is an aminoglycoside antibiotic with actions and uses similar to
those of gentamicin.
Though highly efective and topical chloramphenicol (0.5 %) has been
associated with a rare but devastating aplastic anemia. The topical
ciprofloxacin (0.3 %) and ofloxacin (0.3%) are also highly effective but should
be reserved for severe infections. Bacitracin (50 units/g) and erythromycin
(0.5%). which are effective against Gram-positive bacteria. are available only
in the form of ointments that are dificult to install and cause blurred vision.
Oral antibiotics alone may be insufcient to treat bacterial conjunctivitis in
adults. If the disorder does not improve in one week. the patient should be
referred to an ophthalmologist.
37
In case of conjunctivitis in the newbor
It is due to Chlamydia trachomatis or Neisseria gonorrhoeae. The
best form of prophylaxis is 2.5% aqueous povidone-iodine solution.
In case of conjunctivitis (Chlamydia trachomatis)
Drug of choice
Tetracycline
or
Erythromycin
Ointment twice daily i n the eye for 2 weeks
2 5 mg!kg orally twice daily for 2 weeks
Investigate and treat parents for genital infection.
In case of conjunctivitis (Neisseria gonorrhoeae)
Drug of choice
Ceftriaxone
or
Gentamicin!
bacitracin
2 5-50 mg!kg intramuscularly as a single dose
Should be given topically
Investigations and treatment of parents needed for genital infection.
CORNEAL ULCER
In case of bacterial cause
Bacterial infection is a common sight threatening condition of corea
(keratitis), if untreated often leads to progessive tissue destruction
with perforation. Common causes are trauma, contact lens wear and
infection from ocular adnexa. Common organism is Staphyllococcus
aureus. Staph epidermis, Strep pneumoniae, Pseudomonous
aeruginosa etc.
In case of fungal cause
Fungal keratitis is common among agriculture workers. Candida
albicans (yeast) and Fusarium solani (filamentous), Aspergillous spp.
are common pathogens.
Topical drops of natamycin 5% for filamentary fungal keratitis and
amphotericin B 0.15% solution is recommended for Aspergillous Spp.
and yeast keratitis.
38
ANTI BIOTIC GUIDELINE
CYSTITIS (ACUTE UNCOMPLICATED)
This includes patients with asymptomatic bacteriuria. It is usually
caused by Escherichia coli (90%), Staphylococcus saprophyticus
(5%), or other Enterobactericeae (5%). Mixed infections are rare. In
view of the high prevalence of resistance to ampicillin and co
trimoxazole, an oral frst generation cephalosprin (e. g. cephalexin),
or a quinolone (ciprofoxacin, ofoxacin etc) is recommended the
empiric agents of choice. However, some advocate the use of co
trimoxazole for uncomplicated UTI since these antibiotics frequently.
achieve concentrations in urine in excess of the MICs of resistant
strains. This may explain why an uncomplicated UTI may apparently
respond to an antibiotic even when the pathogen is judged resistant by
laboratory tests.
Drug of choice
Amoxycil l i n
or
2 50 mg 8 hourly orally for 3 days ( 50 mg/ kg/day i n children)
Co-trimoxazole 1 DS tablet 1 2 hourly for 3 days
or
Ciprofloxacin 2 50 mg orally 1 2 hourly for 3 days
Single dose therapy is no longer favored. In pregnancy, consider a 7-day
regimen of amoxycillin, co-trimoxazole (not in 3rd trimester) or cephalexin.
Quinolones should be avoided during pregnancy. A 3-day regimen achieves
the best results in patients with uncomplicated UI. Tis is considered as
efective, costs less, and causes fewer side effects than 7-day regimens. One
day regimens are associated with higher recurrence rates.
DYSENTERY (BACI LLARY)
Bacillary dysenter (shigellosis) is an enteric infection caused by the
Shigella spp. S. dysenter, S. fexneri, S. boydii, or S. sonnei. Disease
severity varies from mild S. sonnei infections that may escape
detection to more severe S. flexneri infections, while those due to S.
dysenteriae may be fulminating and cause death within 48 hours.
Shigella gastroenteritis is essentially self-limiting and antibiotics are
probably only indicated for severely ill patients, those with dysentery,
and the very young or old.
39
Drug of choice
Ciprofloxacin
pius
Vitamin A (in case of chi ldren)
ECZEMA (INFECTED)
Drug of choice
Combination of gentamicin
and hydrocortisone
or
Combination of neomycin
and betamethasone
500 mg orally 1 2 hourly for 5-7 days
A single oral dose of 200,000 I U
Apply thrice daily for up t o 2 weeks
Apply thrice daily for up to 2 weeks
Use of drug after removal of crusts ensure better access of drug. Topical
neomycin is preferred as it is not ordinarily used for systemic infection and
therefore, development of drug resistance is less likely. Absorption of
neomycin may cause serious injury to eight cranial nerve.
Hydrocortisone or betamethasone is used to suppress inflammation.
ENTERIC FEVER
Enteric fever is caused by Salmonella tphi and paratphi.
In case of uncomplicated enteric fever
Drug of choice
Co-trimoxazole
or
P-floxaci l l i n
or
Ciprofloxacin
or
Ceftriaxone
or
Azithromycin
DS 1 tablet orally 1 2 hourly for 1 4 days
400 mg 1 2 hourly for 1 0- 1 4 days
500-750 mg orally 1 2 hourly for 1 0-1 4 days
60 mg/kg/day (maximal dose- 4 g) intravenously for 7
days
500 mg orally once daily for 7 days
Carrier state should be treated for 4 weeks
40
ANTI BI OTI C GUI DELI NE
I n case of severe case of enteric fever with delirium, obtundation,
stupor coma, shock
Drug of choice
Ofloxacin 15 mg/kg/day by intravenous infusion (O.2% solution) over
30 min for 1 0- 1 4 days
plus
Dexamethasone 3 mg/kg by slow intravenous infusion followed by 1 mg/kg
every 6 hourly for eight additional doses
The mortality rate was reduced from over 50 % to 10 % in Indonesian adults and
children who were given dexamethasone at an initial dose of 3 mgkg by slow
intravenous infusion over a period of 30 minutes, followed by I mg of
dexamethasone per kg given at the same rate every 6 hours for 8 additional doses.
Hydrocortisone at a lower dose is not efective.
There ae fe data on the treatment of pregnant women with typhoid.
The beta-Iactam antibiotics are considered safe. In addition, there
have been several case reports of the successful use of fluoroquino
lones. Although these drugs have generally been avoided because of
concer about safety, the general consensus is that they are also safe
FEBRILE NEUTROPENIA
Patients of febrile neutropeni a are treated at the Ward.
Drug of choice
Ceftazidime
or
Aminoglycoside
1 00 mg/kg/day ( 1 .5 g/m
2
/dose, maximum dose of 2 g)
intravenously 8 hourly for 7 days
8 mg/m
2
/dose ever y 8 hourly
No intramuscular injection
If any of the following conditions are present, add vancomycin 400
mg/m
2
/dose every 8 hourly infused over I hour. First dose stat
a) recent history of receiving intensive chemotherapy that
produces substantial mucosal damage (defined as confluent
fibrinous mucositis, ulceration, pain, superficial ulceration,
necrosis, hemorrhage).
41
ANTIBIOTIC GUI DEL I NE
b) evidence of sepsis. including shock. hyptension. rigors.
septic emboli. unexplained respiratory distress or
hypxemia. or por peripheral perfusion
c) proven or suspected meningitis (including eNS shunt infection)
If any of the following conditions are present. substitute
imipnemlmeropnem for ceftazidime/cetriaxone:
a) severe abdominal pain or radiographic findings suggesting
typhlitis
b) severe abdominal pain with evidence of sepsis. including
shock. hypotension. rigors. septic emboli. unexplained
respiratory distress or hypoxemia or poor peripheral perfusion
Afer 2 days
careful reassessment of the patient via physical examination and
review of culture results. If culture report is positive. then antibiotic
should b changed accordingly. If culture is negative. then continue
cefazidime/cefriaxone for minimum 7 days and reevaluate criteria
for using vancomycin andlor imipenemlmeropenem.
If the patient does not respond after 7 days of using antibiotics
Begin ampotericin B empirically at 1 mg/kg/day (maximum dose of
50 mg) along with antibiotics.
If afebrile. then discontinue intravenous antibiotic therapy and change
to suitable oral antibiotic.
GENITAL HERPES
Infection is caused by herpes simplex type 1 or type 2.
III case of frst episode
Drug of choice
Acyclovir
or
Famciclovir
or
Valacyclovir
42
400 mg orally 8 hourly for 7 -1 0 days
250 mg orally 8 hourly for 7-1 0 days
1 g orally 1 2 hourly for 7 1 0 days
ANTIBIOTIC GUI DEL I NE
Topical acyclovir provides no benefit in the episodic treatment of genital
herpes and is not recommended.
III case of recurrence
Drug of choice
Acyclovir
or
Famciclovir
or
Valacyclovir
1 g orally 1 2 hourly for 1 0 days
In case of prophylaxis
Drug of choice
Acyclovir
or
Famciclovir
or
Valacyclovir
GIARDIASIS
400 mg orally 1 2 hourly
250 mg orally 1 2 hourly
0 .5-1 g orally daily
Giardiasis is caused by a fagellate protozoan Giardia intestinalis
(also known as G. lamblia).
Drug of choice
Metronidazole
or
Tinidazole
or
Secnidazole
2 g orally as a single dose
or
400 mg orally twice daily ( 1 5 mg /g/day i n 3 divided doses
children) for 7-1 0 days
2 g (30 mgg in children) single dose orally
Paromomycin can be used during pregnancy. but when disease is mild. delay
of treatment till after delivery is recommended. Drug resistance and relapses
may occur with any drug.
43
ANTI BIOTIC GUI DELI NE
GINGIVITIS
The vast majority of cases of gingivitis are caused by the collection of
highly infected debris on the tooth surface in the ledge formed by the
gingival margin. The microorganisms present in the debris are
Streptococcus, Actinomyces, Veillonella, Treponema, Fusobacterium.,
.
nucleatum, Prevotella intermedia. Among gingivitis, acute ulcerative
.
type is a purely infectous type where the causative microorganisms
are mainly Treponema and Fusobacterium nucleatum.
Drug of choice
Metronidazole 200-400 mg orally 8 hourly for 5-7 days
plus
Tetracycline 250 mg orally 6 hourly for 5-7 days
or
Doxycycline 200 mg orally stat and 1 00 mg daily for 5-7 days
or
Amoxycillin 250-500 mg orally 8 hourly for 5-7 days
PYOGENIC LIVER ABSCESS
Drug of choice
Ciprofloxacin 500 mg orally 1 2 hourly for 1 0-1 4 days
plus
Gentamicin 80 mg intravenously 8 hourly for 1 0- 1 4 days
plus
Metronidazole 200-400 mg orally thrice daily for 1 0-1 4 days
MASTOIDITIS
In case of acute mastoiditis
Acute mastoiditis is due to S. pneumoniae, S. pyogens, S. aureus, H
injluenzae and P aeruginosa. An urgent specialist opinion i s
advisable, as surgery may be necessary.
Drug of choice
Cefotaxime
or
Ceftriaxone
44
1 -2 9 intravenously 4-8 hourly (depends on severity)
2 9 intravenously daily i n single or divided doses on adult. The
dose may be modified in case of children according to the age
ANTIBIOTI C GUI DELI NE
In case of chronic mastoiditis
Treatment will be surgical intervention with antibiotics.
Drug of choice
Ceftriaxone
or
Ciprofloxacin
MENINGITIS
500 mg intravenously 1 2 hourly for 1 0 days
500 mg intravenously 1 2 hourly for 1 0 days
In case of bacterial meningitis
S. Pneumoniae is the Commonest cause of meningitis in adult (almost
50% of all cases).
N. meningitides accounts for 25% of all cases. The presence of
petechial or purpuric skin lesions can provide an important clue.
Enteric gram-negative bacilli are increasingly common causes of
meningitis in individuals with chronic and debilitating diseases such
as diabetes mellitus, cirrhosis of liver, alcoholism or those with UTI
or craniotomy.
Group B Streptococcus or S. agalactiae in patient> 50 years of age.
N L. monocytogenes in neonate, pregnant women & > 60 years of
age. N H. infuenzae is another important cause in our country
although its incidence is declining in western world due to
vaccination.
S. aureus & coagulase negative staphylococci are important causes in
invasive neurosurgical procedures.
Treatment : Bacterial meningitis is a medical emergency. Treatment
should be started within 60 minutes of patient's arrival.
Empirical treatment should be started in suspected cases of
bacterial meningitis before doing CSF study. S. Pneumoniae and
N. meningitides are the commonest organisms in adult. Due to
emergence of penicillin and ceplosporin resi stant S.
45
pneumoniae, empirical therapy of community acquired bacterial
meningitis in children and adult should include a third
generation cephalosporin (e.g. ceftriaxone or cefotaxime) and
vancomycin.
Antibiotics used in empirical therapy of bacterial meningitis and focal
eNS infections
Indication
Pre-term infants to infants <1 month
Infants 1 -3 months
Immunocompetent children > 3 months
and adult < 55 years
Adult > 55 years and adults of any age
wh Alcoholism or other debitlitating
disease Hospital-acquired meningitis,
post-traumatic or postneurosurgery
meningitis, cases patients with impaired
immunity neu1ropenic
Antibiotics
Ampicillin + cefotaxime
Ampicillin + cefotaxime or ceftriaxone
Cefotaxime or ceftriaxone + vancomycin
Ampicillin + cefotaxime or ceftriaxone +
vancomycin
Ampicillin + Ceftazidime +vancomycin
Antimicrobial agent Child 1 month) Adult
AmpiCillin 200 mglkg/d, q 4h 12 9 mid , q 4h
Cefotaxime 200 mglkg/d, q 6h 12 9 mid , q 4h
Ceftriaxone 100 mglkg/d, q12 h 4 grd, q 12h
Ceftazidime 150 mglkg/d, q 8h 6 grd, q 8h
Gentamicin 7,5 mg/kg/d, q 8h 7,5 mg/kg/d, q 8h
Vancomycin 60 mg/kgld, 16h 2g,d, q 12h
46
NEONATAL SEPSIS
Drug of choice
Ampici ll i n
plus
Gentamicin
100 mglkg body weight/day
If the patient's condition is not improved, then-
Drug of choice
Ceftazidime
plus
Amikacin
100 mglkg/day intravenously every 8 hourly for 7 days
OTITIS EXTERNA
Most are due to so-called "swimmer's ear" and the pathogens
involved are usually Pseudomonas aeruginosa, Poteus mirabilis or
other gram negative bacteria. Treatment of otitis extema vaies
according to the disease condition, In all cases meticulous cleaning of
the ear if necessary by micro suction is essential for effective
treatment and prevention of further recurrence.
Drug of choice
Gentamicin or ciprofloxacin
with hydrocortisone ear drop
In case of otomycosis
Drug of choice
Topical antifungal cream with
Steroid e,g, Econazole nitrate 1%
Triamcinolone acetonide
2-4 drops topically 6-8 hourly
Apply on a cotton bud twice daily
for 10-14 days
47
In case offurunculosis
Drug of choice
Flucloxacin 250-500 mg daily 6 hourly for 7-1 0 days
In case of otitis externa with cellulitis of the auricle or periauricular structure
Systemic antibiotics are necessary along with ear drop and ear wick
(eg. Pope wick)
Drug of choice
Gentamicin or ciprofloxacin
with hydrocortisone ear drop
plus
Co-amoxiclav
Or
Ciprofloxacin
2-4 drops 6 - 8 hourly
375/625 mg orally 8 hourly for 7-1 0 day
500 mg twice daily for 7-1 0 days
In case of malignant otitis externa
Drug of choice
Ciprofloxacin 500-750 mg twice daily for prolonged
period (up to 6-8 weeks) if there i s
radiological evidence of osteomyelitis
Surgical debridement may necessary if medical therapy is unsuccessfl.
Certain general skin conditions may cause otitis extema e.g. psoriasis,
seborrhoeic dermatitis and eczema. Treatment of any underlying
eczema in the canal, e.g. with 1 % hydrocortisone cream introduced on
a cotton bud is important when the inflammation has settled.
OTITIS MEDIA (ACUTE SUPPURATIVE)
Otitis media is usually caused by Streptococcus pneul11oniae,
Haemophilus injluenZQe and Moraxella catarrhalis. Occasional
pathogens include Streptococcus pyogenes and Staphylococcus auleus.
48
Drug of choice
Co-amoxiclav
or
Ciprofloxacin
or
Ceftriaxone
375 mg or 625 mg 8 hourly for 7 days
500 mg twice daily for 7-1 0 days
1 9 invervenously once daily

Dose should be reduced in patient with severe renal impairment.
ORAL THRUSH (CANDIDIASIS)
Oral thrush is caused by the yeast Candida albicans. It is a normal
mouth commensal but it may proliferate to cause thrush.
Drug of choice
Nystatin
Wash with 5-10 ml of suspension ( 1 00,000 units/ml) thrice daily
or
for minimum 14 days
Fluconazole
1 00 mg orally daily for 7-1 4 days
or
Itraconazole
200 mg (oral solution) orally once daily.
PEPTIC ULCER (DUE TO HELICOBACTER PYLORI)
All patients with peptic ulceration who are also infected with H
pylori should receive antibiotic therapy. Effective treatment regimens
include a proton pump inhibitor plus at least two antibiotics.
Drug of choice
Omeprazole
plus
Amoxyci llin
plus
Metronidazole
20 mg orally twice daily for 7-14 days
1 9 orally 12 hourly for 7-1 4 days
400 mg orally twice daily for 7-14 days
49
or
Drug of choice
Lansoprazole
plus
Amoxycillin
plus
Clarithromycin
1 g orally 12 hourly for 14 days
Lansoprazole is a proton pump inhibitor with actions and uses similar to those
of omeprazole. Glossitis assoiated with black t
?
ngue or
. .
stomattls may
develop. Antacids and sucralfate may reduce the blOavailabthty of lansopra
zole. Treatment with lansoprazole may cause false-negatIve results H the urea
breath test for H pylori.
Clarithromycin is a macrolide derived from erythromycin. It should not be
used during pregnancy if possible. Dose should be reduced H patIents With
renallhepatic impairment.
PERICORONITIS
Incomplete eruption of a wisdom tooth produces a large stagnation area under
the gum flap. It can easily become infected, causing acute pericoronitis. It is
caused by various microorganisms (both .aerobic and anaerobic) like
Staphylococcus, Streptococcus, Fusobacterium and Bacteroids.
Drug of choice
Amoxicillin 250-500 mg orally 8 hourly for 7 days
or
Cefradine 250-500 mg orally 6-8 hourly for 7 days
plus
Metronidazole 200-400 mg orally thrice daily for 5-7 days
PERIODONTAL ABSCESS
Periodrlal abscess may occur as d sequele of chronic periodontitis.
It is caused by Fusobacterium nucleatum, Prevotella intermedia and
EikpnlUa corrodens.
Drug of choice
A
!
oxyciliin
or
Cefradine
plus
Metronidazole
50
500 mg o
r
ally 8 hourly for 5-7 days
200-400 m
g
orally thrice daily for 5-7 days
SPONTANEOUS BACTERIAL PERITONITIS
Drug of choice
Ceftriaxone
or
Cefotaxime
or
Ceftipime
1 g intravenously 12 hourly
1 g intravenously 8-12 hourly (depends on severity)
1 g i ntravenously 12 hourly
Till the patient improves then switch over to
Ciprofloxacin 500 mg orally 12 hourly for 14 days
For prophylaxis of spontaneous bacterial peritonitis, tablet noroxacin 400
mg 1-2 times daily for indefnite period
PHARYNGITIS
The commonest causes are viral.
Drug of choice
No antibiotic.
The most important bacterial cause is Streptococcus pyogenes. Other
bacterial causes of pharyngitis inClude Cornebacterium haemoly-ticum,
chlamydia pneumoniae, Cornebacterium diphtheriae, Neisseria
gonorrhoeae, group C beta-haemolytica Streptococci and anaerobic bacteria.
Penicillin is the only agent conclusively shown to prevent rheumatic
fever. The expense of the new macrolides and the cephalosporins do
not warrant their use as frst line agents.
Drug of choice
Benzathine 600,000 unit as Single intramuscular dose 30 kg body weight)
benzylpenicillin 1200,000 unit as single intramuscular dose (>30 kg body weight)
or
Phenoxyme
thylpenicillin
or
Erthromycin
or
Clarithromycin
250-500 mg (50 mg/kg/day i n children) orally 6 hourly for 10 days
250-500 mg orally 8 hourly for 10 days (i n case of penicillin
allergic patient)
500 mg by mouth 12 hourly for 1\days (in case of hypersensitivity)
51
Benzathine benzylpenicillin is given by deep intramuscular injection, it forms
a depot from which it is slowly released and hydrolyzed to penicillin.
Depending on the dose, benzylpenicillin is usually detectable in plasma for up
to 4 weeks.
PNEUMONIA
In case ofcommunity acquired less-severe pneumonia (below the
age of60 years)
Drg of choice
Benzylpenicillin
or
Ampicillin
or
Clarithromycin
or
Co-amoxiclav
1. 2 9 intravenously 6 hourly for 14 days
500 mg intravenously 6 hourly for 14 days
375 / 625 mg orally after meal 8 hourly. Duration of treatment
depends on the clinical condition
In case ofcommunity acquired severe pneumonia (below the age of
60 years and presence ofco-existing lung disease)
Drg of choice
Co-amoxiclav
plus
Clarithromycin
D!
Cefuroxime
plus
Clarithromycin
Df
Ciprofloxacin
plus
Vancomycin
52
1 .5 9 intravenously 8 hourly for 1 4 days
In case ofcommunit acquired severe pneumonia (age above 60
years or pre-existing lung disease)
Drg of choice
Cefotaxime
plus
Clarithromycin
500 mg intravenously 1 2 hourly for 14 days
In case ofhospital acquired less-severe pneumonia
Drg of choice
Cefuroxime
or
Cefotaxime
or
Co-amoxiclav
or
Ciprofloxacin
or
Clindamycin
1 . 5 9 intravenously 8 hourly for 1 4 days
In case ofhospital acquired severe pneumonia
Drg of choice
Cefuroxi me
pl us
Gentamicin
1
Cefotaxime
plus
Gentamicin
1
I mi penem
plus
Gentamicin
1.5 9 intravenously 8 hourly for 1 4 days
1 9 intravenously 8 hourly for 14 days
53
ANTI BI OTIC GUI DELI NE
In case of lung abscess/suppurative pneumonia/aspiration
pneumonia
Drug of choice
Benzylpenicillin
plus
Metronidazole
plus
Gentamicin
1.2 9 intravenously 6 hourly for 4-6 weeks
200 mg intravenously 8 hourly for 4-6 weeks
In case of mycoplasma pneumonae
Drug of choice
Ery1hromycin
or
Tetracycline
or
Doxycycli ne
or
Ciprofloxacin
500 mg orally 6 hourly for 2-3 weeks
1 00 mg orally 12 hourly for 2-3 weeks
In case of empyma thoracis
Drug of choice
Benzylpenicillin
plus
Metronidazole
or
Cl i ndamycin
54
1.2 9 intravenously 6 hourly for 4-6 weeks
PROSTATITIS
In acute case
Drug of choice
Ciprofloxacin
or
Co-trimoxazole
500 mg 1 2 hourly for 2-4 weeks
1 double strength tablet 1 2 hourly for 2-4 weeks
Urine culture is necessary in the initial work up. and 1 0- 1 4 days after
completion of treatment.
In chronic case
Drug of choice
Ciprofloxacin
or
Co-trimoxazole
500 mg 12 hourly for 4 weeks
1 DS tablet 1 2 hourly for 4 weeks
If there is no response after 4 weeks. the same antibiotic should be given for
12 weeks.
PYELONEPHRITIS (ACUTE)
This is caused by the same range of pathogens as uncomplicated cystitis.
except that Staphylococcus saprophyticus is a rare cause of pyelonephritis.
In case of mild-to-moderate i l lness
Drug of choice
Ciprofloxacin 250 mg orally 1 2 hourly for 1 4 days
Change the antibiotic that depends on culture and sensitivity
In case of acute severe il lness and possible urosepsis
Drug of choice
Ceftriaxone
or
Imepenum
1 9 intravenously 12 hourly for ! days
1 9 intravenously 12 hourly for 7 days
55
SEPSIS I N NEUROPATHIC FOOT I N DIABETES MELLITUS
Antibiotic should be used for general cover or specific if organism is
known.
For general cover regimen
Drug of choice
Cefuroxime
plus
Flucloxaci l l i n
plus
Metronidazole
SI NUSITIS
1 . 5 g intravenously for 1 0- 1 4 days
or
400-800 mg orally for 1 0- 1 4 days
Sinusitis is caused by Haemophilus injuenzae, Streptococcus
pneumoniae and Moraxella catarrhalis. Anaerobes play a signifcant role
in adult sinusitis especially if persistent - so-called "chronic sinusitis".
ANTIBI OTIC GUI DELI NE
SYPHI LIS
Syphilis is a sexually transmitted disease caused by the spirochaete
Treponema pallidum.
In case ofearly congenital syphilis
Drug of choice
Benzylpenicillin 50,000 U/kg intravenously 1 2 hourly for 1 0- 1 4 days
or
Procaine
benzylpenicillin
or
Benzathine
benzylpenicillin
50,000 U/kg intramuscularly once daily for 1 0 days for
symptomatic infant or those with neurosyphilis
50,000 U/kg intramuscularly as a single injection for
asymptomatic infant without neurosyphi l i s
Benzylpenicillin or proaine benzylpenicillin is preferred to benzathine benzylpnicillin
for infants with congenital syphylis. The pharmacokinetics of benzathine penicillin
appear to be altered in late pregnancy (only 40% achieved adequate serum concentration
for days).
In case ofprimary or secondary syphilis
Drug of choice
Benzathine 2.4 mi l l i on U intramuscularly once per week for 1 4 days
benzylpenicillin
or
Doxycycli ne 1 00 mg oral l y 12 hourly for 1 4 days
If the patient responds poorly to frst choice of therapy, consider
or
treatment which includes anaerobes in its spectrum of activity.
Drug of choice
Co-amoxiclav
or
Ciprofloxacin
or
Levofloxacin
375/625 mg orally after meal 8 hourly for 1 0- 1 4 days
500 mg 1 2 hourly ( 1 25 mg 1 2 hourly i n children < 2 years,
and 250 mg i n children 2-1 2 years) for 1 0- 1 4 days
500 mg once daily for 1 0- 1 4 days.
Topical decongestant for 5 days
56
Tetracycline 500 mg orally 6 hourly for 1 4 days
If a patient is allergic to penicillin, then doxycycline/tetracycline is administered.
In case oflatent or tertiary syphilis
Drug of choice
Tetracycline
or
Doxycycline
or
Benzathine
benzylpenicillin
200 mg orally 12 hourly for 14 days, for penicillin-allergic patient
2.4 million unit intramuscularly weekly for 3 successive weeks
57
ANTI BIOTIC GUI DELI NE
In case ofneurosyphilis
The disease is very diffcult to treat. Follow sequential serum and
CSF titres
Drug of choice
Benzyl penicillin
or
Procaine
benzylpenicillin
2.4 million U intravenously 4 hourly for 1 4 days
2.4 million U intramuscularly once \aily for 1 4-21 days
Benzathine benzylpenicillin is not recommended due to its poor penetration to
the CSF.
TONSILLITIS
The most common and important bacterial cause is Streptococcus
pyogenes.
Penicillin is the only agent conclusively shown to prevent rheumatic
fever. The expense of the new macrolides and the cephalosporins do
not warrant their use as frst line agents.
Drug of choice
Co-amoxiclav
or
Er1hromycin
or
Cefalaxin
375 / 625 mg orally after meal 8 hourly for 1 0 days
250-500 mg orally 8 hourly for 1 0 days
1 -2 g daily orally i n 2-3 divided doses
For the penicillin-allergic patient, erythromycin may be used.
Cefalexin is a frst-generation cephalosporin antibiotic. If it is taken with food,
absorption may be delayed, but the total amount absorbed is not appreciably
altered. Doses may need to be reduced in severe renal impairment.
TUBERCULOSIS
In case ofcategor-I tuberculosis
[new smear-positive, new smear-negative pulmonar tuberculosis
with extensive parenchymal involvement or severe forms of
58
extrapulmonary tuberculosis (e. g. meningeal, miliar, pericardial,
peritoneal, massive unilateral bilateral pl eural efusion, spinal,
intestinal, genitourinar and multi-organ tuberculosis)]
Drug of choice
Patient weight (kg) Dosage
30-37
55-70
4 tablets
>70
4 tablets
2 tablets (4Fixed-dose combination) daily for first
2 months followed by
2 tablets (2Fixed-dose combination) thrice-weekly
for another 4 months
3 tablets (4Fixed-dose combination) daily for first 2 months
followed by
3 tablets (2Fixed-dose combination) thrice-weekly for another
4 months
4 tablets (4Fixed-dose combination) daily for fi rst 2 months
followed by
(2Fixed-dose combination) thrice-weekly for another 4 months
followed by
(2Fixed-dose combination) thrice-weekly for another 4 months
4Fixed-dose combination contains 150 mg of rifampicin 75 mg of isoniazid
400 mg of pyrazinamide 275 mg of ethambutol
2Fixed-dose combination contains 150 mg of rifampicin 75 mg of isoniazid
In case ofcategory-II tuberculosis
(previously treated for more than I month with sputum smear-positive
pulmonar tuberculosis with relapse/treatment after interruption!
treatment failure).
59
Drug of choice
Patient
weight (kg)
30-37
38-54
55-70
>70
Dosage
2 tablets (4Fixed-dose combination) daily for first 3 months plus
Streptomycin injection 500 mg daily for first 2 months followed by
2 tablets (2Fixed-dose combination) 2 tablets of ethumbutol
(400 mg) thrice-weekly for another 5 months
Streptomycin injection 750 mg daily for first 2 months followed by
3 tablets (2Fixed-dose combination) + 3 tablets of ethumbutol
Streptomycin injection 1 000 mg daily for first 2 months followed by
Streptomycin injection 1 000 mg daily for first 2 months fol lowed by
The dose of streptomycin should not exceed 750 mg daily after the age of 50
years
In case of categor-Ill tuberculosis
[new smear-negative pulmonar tuberculosis (other than categor l),
less severe form of extrapulmonar tuberculosis (e. g. , lymph node,
pleural efusion {unilateral}, bone {excluding spine}, peripheral
joint, skin tuberculosis))
60
Drug of choice
Patient
wei
g
ht (kg)
30-37
38-54
55-70
>70
Dosage
followed by
4 months
3 tablets (3Fixed-dose combination) daily for 2 first months
followed by
4 months
followed by
4 months
followed by
4 months
3Fixed-dose combination contains 1 50 mg of rifampicin 75 mg of isoniazid
400 mg of pyrazinamide
2Fixed-dose combination contains ISO mg of rifampicin 75 mg of isoniazid
In case of tuberculosis with pregnancy
Most antitubercular drugs are safe in pregnancy with the exception of
streptomycin, which is ototoxic to the fetus.
In case of tuberculosis with lactation
A women with tuberculosis which is breast-feeding should receive a
full course of antitubercular drugs. Regular and full course
chemotherapy is the best way to prevent transmission of tuberculi
bacilli to her baby. The mother and baby should stay together and
breast-feeding should be continued.
61
In case oftubercuLosis woman taking oraL contraceptive
A women taking oral contraceptive and antitubercular drugs has
increased risk of pregnancy. Rifampicin reduces the eficacy of
estrogen. So, a higher dose of estrogen with rifampicin or another
form of contraception can be used.
URETHRITIS (ACUTE, FOR MALES)
In case ofgonococcaL or chLamydiaL infection
Drug of choice
Azithromycin 1 g orally as a single dose
Gastrointestinal adverse efects are usually mild and less frequent than with
erythromycin. Absorption frm the capsule formulation, but not the tablet
formulation, is reduced by food. Capsule formulation should be given at least
an hour before, or 2 hour after, meal. Concurrent administration of antacids
containing aluminium or magnesium salts can reduce the rate, but not the
extent of absorption of azithromycin.
URINARY TRACT I NFECTIONS
Initial management will be the use of an antibiotic that depends on
culture and sensitivity and general condition of patient.
Drug of choice
Co-trimoxazole
or
Ciprofloxacin
or
Nitrofurantoin
1 DS tablet twice daily orally for 1 0- 1 4 days
1 00 mg 6 hourly for 7-1 4 days
In case ofrecurrent infection
Continuous prophylactic antibiotic therapy should be considered in
women with more than 3 UTI' s/year.
62
Drug of choice
Nitrofurantoin 1 00 mg orally after dinner for 2-3 months
or
Ciprofloxacin
or
Ofloxacin
or
250 mg orally at bed time for 2-3 months
200 mg at bed time for 2-3 months
Co-trimoxazole 480 mg orally at bed time for 2-3 months
Duration of treatment varies according to age and clinical condition of patient.
Prevention ofcatheter-associated UTI
Administration of antimicrobials is not of value in preventing
colonisation/i nfection in patients with indwelling catheters. Furthermore,
this has been shown to promote the selection of resistance.
VAGI NAL CANDIDIASIS
In case ofnon-pregnant woman
Drug of choice
Clotrimazole
or
Fluconazole
500 mg vaginal tab once
or
two 1 00 mg vaginal tab nocte for 3 nights
or
vaginal ( 1 %) cream nocte for 6 nights
1 50 mg orally as a Single dose
Clotrimazole is an imidazole antifungal agent. Intravaginal preparation may
damage latex contraceptives and additional contraceptive measures are
therefore necessary during local administration.
Fluconazole is a triazole antifungal agent. Concentration of fluconazole in
breast milk, joint fluid, saliva, sputum, vaginal fluids and peritoneal fluids are
simi lar to those achieved in plasma.
.
63
In case ofpregnant woman
Drug of choice
Clotrimazole 500 mg vaginal tab for 7 days
or
or
Miconazole
two 1 00 mg vaginal tab nocte for 7 nights
or
vaginal ( 1 %) cream nocte for 7 nights
5 g of intravaginal cream (2%) to be inserted into the vagina once
daily for 1 0- 1 4 days or twice daily for 7 days
Clotrimazole is not contraindicated in pregnancy but one should be cautious
about its use as there may be systemic absorption.
Miconazole is an imidazole antifungal agent. Intavaginal preparation may
damage latex contraceptives and additional contaceptive measures are
therefore necessary during local administation.
VAGI NAL TRICHOMONIASIS
Drug of choice
Metronidazole
or
Tinidazole
or
Secnidazole
2 g as a single oral dose or 400 mg 1 2 hourly for 7 days
2 g single dose for both partners
Metonidazole has been used extensively in pregnancy for the treatment of
trichomoniasis. The teratogenic efect appears to be minimal and if present.
greatest during the first trimester. when the drug should not be used. If therapy
cannot be avoided. then it can probably be used safely in the last two timesters
of pregnancy. The sexual partner(s) should also be treated to prevent
reinfection.
VAGINOSIS (BACTERIAL)
Drug of choice
Clindamycin
or
Metronidazole
64
One applicatorful intravaginally at night for 7 days
One applicator/ul intravaginally once daily for 5 days
WOUNDS (INFECTED)
Treat according to the clinical condition and the results of culture and
sensitivity tests from representative specimens. It is important to
distinguish between superficial wound colonization and true
infection. as antimicrobial therapy is generally not indicated for
colonization.
The need for tetanus prophylaxis should be evaluated in the case of
traumatic wounds.
Drug of choice
Gentamicin
or
Fusidic acid
or
Mupirocin
or
Combination
of Bacitracin
and Neomycin
Apply the cream locally 2-3 times daily
Apply the cream/ointment locally 2-3 times daily
Apply the cream/ointment locally 2-3 times daily
Apply the cream locally 2-3 times daily Fusidic acid is
a steroid antimicrobial agent which is used almost
exclusively against -lactamase-producing
staphylococci.
Fusidic acid is a steroid antimicrobial agent which is used almost exclusively
against -lactarse-producing staphyloocci.
65
GUI DELI NE FOR USE OF ANTIBIOTICS I N RENAL FAI LURE
USE OF ANTIBIOTICS I N LIVER DISEASE
Drugs
Creatinine level
Dosage recommendation
(mmolll)
Drugs Comment
Acyclovir
1 50-350 I ncrease dosing interval (IV)
>500 I ncrease dosing interal (oral)
Azithromycin
Avoid; jaundice reported
Ami noglycosides 1 50-300 I ncrease dosing interal; avoid if possible
Amoxicillin >500 I ncrease dosing interval
Ceftriaxone
Reduce dose and monitor plasma cncentration if associated
renal impairment
Azathioprine >500 Decrease dose/ increase dosing interval
Chloramphenicol
Avoid- increased risk of bone marrow depression
Benzylpenicillin >500 Halve the dose Ciprofloxacin
Hepatitis with necrosis may ocur
Ceftazidine >1 50-300 Increase dosing interval
Cefuroxime >500 I ncrease dosing interval
Clarithromycin
H'patic dysfunction including jaundice reported
Cefalexin >500 I ncrease dosing interal
Ceftriaxone >500 No adjustment if hepatic function is normal
Co-amoxiclav
Cholestatic jaundice reported, monor liver function in liver
disease
Chloramphenicol >700 Avoid
Co-trimoxazole Avoid in severe liver disease
Chloroquine
1 50-300 Maximum 75 mg/day
300-500 Maximum 50 mg/day
Doxycycline Use with caution
Ciprofloxacin 150-30 Halve the dose
Erythromycin
May cause idiosyncratic hepatotoxicity
Cisplatin 150-300 I ncrease dosing interval
Co-trimoxazole >500 Maximum 960 mg/day
Flucloxacillin Cholestatic jaundice
Cyclophosphamide 30-500 Decrease dose Fluconazole
Monitor liver function, discontinue if liver function impaired
Cyclosporine Decrease dose if GFR falls
Doxycycline 1 50-300 I ncrease dosing interval
Fusidic acid
Impair bi liary excretion; increased risk of hepatotoxicity; avoid
or reduce dose
Ethumbutol 150-300 I ncrease dosing interval
Fluconazole 1 50-300 I ncrease dosing interval
Griseofulvin Avoid i n sevElle liver disease
I soniazid >500 Maximum 200 mg/day
Ketoconazole 1 50-300 Unchanged
Isoniazid
Avoid if possible; idiosyncratic hepatotoxicity more common;
monitor liver function regularly
Methotrexate 300-500 I ncrease dosing interval
Itraconazole
Half-life prolonged; dose reduction may be necessary
Nalidixic acid 30-500 Avoid
Ketoconaiole Avoid
Neomycin 150-300 Avoid
Nitrofurantoin 1 50-300 Avoid
Mefloquine
Avoid for prophylaxis in severe liver disease
Sulfadiazine >500 Avoid
Metronidazole Reduce the dose in severe liver disease
Sulfasalazine >500 Ensure increase fluid intake
Tetracycline 150-300 Avoid
Norfloxacin
Hepatitis with necrosis; use in spontaneous bacterial peritonitis
Vancomycin 1 50-300 Avoid Ofloxacin Reduce dose
Vincristine 1 50-300 Unchanged
Rifampicin Avoid i n liver disease
66
67
ANTI BI OTICS I N PREGNANCY
Drugs Trimester Comment
Drugs Trimester
Comment
Acyclovir
Use only when potential benefit outweighs risk
Griseofulvin
Avoid (fetotoxicity and teratogenicity in animals);
effective contraception required during and for at
least 1 month after administration
Amikacin 2, 3
Auditory or vestibular nere damage
Amphotericin B
Not known to be harmful but use only if adequate
alternatives are not available
Use only i n life-threatening situations (toxicity at
Itraconazole
high doses i n ani mal studies); ensure effective
contraception during treatment and until the next
Azithromycin
menstrual period
Ceftriaxone
Not known to be harmful Ketoconazole
Teratogenic i n ani mal studies; packs carry a
warning to avoid in pregnancy
Chloramphenicol
Neonatal ' Grey syndrome'
Avoid- arthropathy in ani mal studies; safer
Ciprofloxacin 1 , 2, 3
alternatives available
Mebendazole Toxicity in animal studies
Mefloquine 1 Teratogenic in animal studies
Clarithromycin
Metronidazole Avoid high-dose regimen
Clindamycin
Not known to be harmful Nalidixic acid 1 , 2, 3
Avoid- arthropathy i n ani mal studi es; safer
No evidence of teratogenicity
but avoid unless
Co-amoxiclav
essential
Nitrofurantoin 3 May produce neonatal hemolysis if use at term
1
Theoretical teratogenic risk (trimethoprim a folate
antagonist)
Norfloxacin 1 , 2, 3
Co-trimoxazole 3 Neonatal hemolysis and methemoglobinemia; fear
of increased ri sk of kernicterus in
neonates
appears to be unfounded
Ofloxacin 1 , 2, 3
1
Effects on skeletal development i n animal studies Pentamidine Avoid unless essential
Doxycycl ine
3
Dental discoloration; maternal hepatotoxicity with
large parenteral doses
Primaquine 3 Neonatal hemolysis and methemoglobinemia
Erythromycin
Not known to be harmful
Theoretical teratogenic risk (trimethoprim a folate
Pyrimethamine 1 antagonist); adequate folate supplements should
Ethionamide
1 May be teratogenic
be given to mother
1
Possible teratogenic
risk (trimethoprim a folate
antagonist)
Fansidar
3 Neonatal hemolysis and methemoglobinemia; fear
of increased
risk of kernicterus in
neonates
appears to be unfounded
Qui ni ne 1
Teratogenic at high doses; but i n malaria benefit of
treatment outweighs risk
Streptomycin 2, 3 Auditory or vesti bular nerve damage
Fluconazole
Avoid- multiple congenital abnormalities reported
with long-term high doses
Flucytosine
Teratogenic i n animal studies;
use only when
potential benefit outweighs risk
Gentamicin 2, 3
Auditory or vestibular nerve damage
1
Effects on skeletal development i n animal studies
Tetracyclines
Dental discoloration; maternal hepatotoxicity with
3
large parenteral doses
Zidovudine
Limited information available; use only if clearly
indicated
68
69
DRUGS PRESENT I N BREAST MI LK
Drugs Comment
Aciclovir
Si gnificant amount is found i n milk after systemic
administration
Azithromycin
Prescribe with caution; no harmful effect i s known; use
only if there is no alternative
Use alternative, if possible; may cause bone marrow
Chloramphenicol depression; concentration i n milk i s insufficient to cause
Grey baby syndrome
Chloroquine
Amount too small to be harmful; inadequate for reliable
protection against malaria
Ciprofloxacin High concentration i n milk; avoid
Clarithromycin Avoid; excreted in milk
Co-trimoxazole
Smal l risk of kernicterus i n jaundiced infant and of
hemolysis in G6PD-deficient infant
Doxycycline Avoid; if necessary discontinue breast feeding
Fluconazole Avoid; present in milk
Gentamicin Avoid
I nterferon Avoid; no information available
Isotretinoin Avoid
Itraconazole Smal l amount found i n milk; not harmful
Metronidazole Significant amount in milk; do not take single large dose
Ofloxacin Avoid
Penicillamine Trace amount in milk; use with caution
Rifampicin Amount to small to be harmful
Tetracycline Avoid; deformity and dental decolorization in infant
Tretinoin Avoid
MANAGEMENT OF ANAPHYLACTIC SHOCK
Management consists of stopping the offending drug, treating the
acute reaction, and making a determination concering futures use of
the drug. A detailed medical history, knowledge of the signs and
symptoms which often include rashes, angio-edema, serum sickness
syndrome, anaphylaxis and asthma are helpful.
Management of acute reaction includes :
I . secure the airway- give 1 00% oxygen. Intubate i f respiratory
obstruction imminent
2. remove the cause; raising the foot end may help restore the
circulation
3. give adrenaline intramuscularly (0.5 m of 1: 1 000); repeat every
5 mins, if needed as guided by blood pressure, pulse, respiratory
function
4. secure intravenous access
5. chlorpheniramine 1 0 mg intravenously and hydrocortisone 200
mg intravenously
6. intravenous infusion (0.9% saline, eg., 500 m over 1 5 minutes;
up to 2 I may be needed). Titrate against blood pressure
7. if wheeze, nebulize salmeterol, 20 min interval. Intubate if
necessary for ventilatory support
8. if still hypotensive admission to ICU and an intravenous infusion
of adrenaline may be needed 2 aminophylline and nebulized
salbutamol; get expert help
Further management:
Admit to ward; monitor ECG
Continue chiorpheniramine 4 mg orally 8 hourly if itching
Skin-prick tests showing specific IgE help identify which
allergens to avoid
70
71
ANTIBIOTIC PROPHYLAXIS I N SURGERY
Fundamental principles of Surgical Prophylaxis
The antibiotic must be in the tissue before the bacteria are

introduced i . e. antibiotic must be given intravenously shortly
before surgery to ensure high blood / tissue levels. Prophylaxis
failure may be due to antibiotics given too late or more often,
given too early. The half-life of the particular antibiotic is
therefore important.
There is no data to support more than a single dose. Further
doses generally constitute treatment. Note the waste of
resources, the increased risk of complications ad the fact that
mUltiple doses are not associated with increased efficiency (not
to be continued after 72 hours if not otherwise indicated).
The chosen antibiotics must be active against the most common
expected pathogens.
High risk patients, e. g. patients with jaundice or diabetes, or
patients who undergo any procedures to insert prosthetic
devices, generally warrant antibiotic prophylaxis.
For all practical purpose suitable antibiotic to be prescribed on the basis of
bacteriological culture and sensitivity whenever possible ( e. g. , blood, pus,
bile, ets for culture and sensitivity).
For which type of operations?
Antibiotic prophylaxis is generally indicated for patients undergoing
the following types of operations:
All clean-contaminated procedures; these include penetration of
the gastrointestinal tract (especially colo-rectal), whether by
penetrating trauma or related to a pathological organ event (e. g.
ruptured appendix, perforated colonic diverticulum) prior to the
development of clinical peritoniti s.
Clean operations with foreign body implant (e. g. vascular,
cardiac and orthopaedic operations), and those without foreign
body implants especially hernia repair, breast surgery, median
sterotomy, vascular surgery involving the aorta and the lower
extremities, and craniotomy.
72
The use of antibiotics i n operations classified as contaminated or
dirtylinfected should be considered as therapeutic and is clearly not
prophylactic i. e. treatment should be given for a longer duration.
Operations for acute cholecystitis, empyema of the gallbladder,
ascending cholangitis or liver abscess require antibiotic treatment
rather than prophylaxis. The same applies to operations for a
perforated appendix with evidence of local or generalized peritonitis
and/or intra-abdominal abscess, and penetrating abdominal trauma
where signifcant gastrointestinal leakage with peritoneal soiling is
identifed at the time of the operation.
Timing of antibiotic prophylaxis
Current recommendations are that the parenteral antibiotics used in
prophylaxis should be given in sufficient dosage (according to weight
of the patient) within 30 minutes preceding incision. This results in
near maximum drug levels in the wound and the surrounding tissues
during the operation. This can be facilitated by administer the
antibiotic in the operating room when the intravenous lines are
inserted shortly before operative incision. A single preoperative dose
of antibiotic has the same effcacy as multiple doses and the current
recommendation is to administer a second dose only if the operation
lasts for longer than 2 - 3 hours. With the oral preoperative antibiotic
preparation commonly used before elective colonic resection, the
chosen agents should be given during the 24 hours before the
operation in order to attain significant intraluminal (local) and serum
(systemic) levels.
Route of administration of prophylactic antibiotics
Intravenous administration of the prophylactic antibiotic is preferred
for most patients undergoing an operative procedure. Oral antibiotics
currently play a major role only in the preparation of patients before
elective colon surgery.
Antibiotic prophylaxis for common surgical operations
73
1. Cardiovascular surger
Antibiotic prophylaxis in cardiovascular surgery has proven
beneficial only in the following procedures:
Reconstruction of the abdominal aorta
Procedures on the leg which involve a groin incision
Any vascular procedure with insertion of a prosthesis I foreign
body
Lower extremity amputation for ischaemia
Cardiac surgery
In case of prosthetic valve insertion. coronar arter bypass graft.
other open heart surger and pacemaker implant
Drug of choice
Ceftriaxone
plus
Gentamicin
1 9 intravenously daily for 5-7 days
80 mg intravenously 8 hourly for 5-7 days
Ceftriaxone should be started 24 hours before operation. Gentamicin should be
gi ven after operation
In case of superfcial infection following cardiovascular surger
Drug of choice
Flucloxacillin 500 mg orally 6 hourly for 1 0-1 5 days
In case of aortic resection
Drug of choice
Ceftriaxone
plus
Gentamicin
plus
Metronidazole
74
1 9 intravenously daily for 5-7 days
500 mg intravenously 8 hourly for 3 days. After 3 days oral
preparation of the drug should be admi nistered
2. Orthopaedic surgery
In case of arthroplasty ofjoints. andor joint replacement
Any 3rd generation cephalosporins I - 2 g pre-operatively. If the
operation is longer than 3 hours, give a second dose or for up to 48
hours after the procedure.
In case of open reduction of fracture. laminectomy. spinal fusion,
lower limb amputation
Any 3rd generation cephalosporin I - 2 g IV pre-operatively.
Compound (open) fractures are considered contaminated. so
antibiotics are essentially therapeutic in such situations.
3. Gastroduodenal surger
Antibiotics are indicated in high risk patients only, i. e. patients with
bleeding ulcer, obstructive duodenal ulcer, gastric ulcer, low gastric
acidity, decreased or motility, malignancy or morbid obesity.
a. 1 st generation cephalosporins e.g. cefazolin I g IV pre-operatively.
b. For beta-Iactam allergy, gentamicin 1 20 mg plus clindamicin
600 mg IV preoperatively.
4. Biliar tract surger
Most studies show that achieving adequate drainage will prevent
post-procedural cholangitis or sepsis and there is no further benefit
from prophylactic antibiotics. With inadequate drainage, antibiotics
may be of value. The American Society for GI Endoscopy
recommends prophylaxis for known or suspected biliary obstruction.
The value of prophylaxis for ERCP is controversial.
Note that cephalosporins are not active against the enterococci, yet'
are clinically effective as prophylaxis in biliary surgery. With
cholangitis, treat as infection, not prophylaxis. High risk patients
include those >70 years of age, acute cholecystitis, non-functioning
gall-bladder, obstructive jaundice or common duct stones.
a. 1 st generation cephalosporins e. g. cefazolin 2 g pre-operatively
as a single dose
OR
b. cefoxitin 2 g pre-operatively as a single dose.
75
5. Inguinal heria repair
Available data is limited, routine use is not recommended. For a mesh
implant, give prophylaxis e.g. I st generation cephalosporin as a single
dose.
6. Appendicectomy
Drug of choice
Ceftriaxone
or
Metronidazole
2 9 intravenously preoperatively and 2 more doses.
If perforated, continued for 3-5 days
500 mg intravenously pre-operatively or use
metronidazole i n the form of suppository
Metronidazole should be given for patients with beta-lactam allergy
7. Penetrating abdominal trauma
Any antibiotic cover can be considered as treatment and not as
prophylaxis.
Drug of choice
Gentamicin
pi us
Ceftriaxone
or
Cefuroxime
2 9 intravenously on admission and then 1 9 twice daily for
3-5 days
8. Urological surger
Cystoscopy
Drug of choice
Gentamicin
or
Ceftriaxone
76
80 mg intravenously prior to anesthesia
1 9 intravenously prior to anesthesia
Prostatectomy
Drug of choice
Ceftriaxone 1 9 intravenously stat and daily for 3 days or till the catheter
i s removed
or
Ciprofloxacin 500 mg intravenously stat and then 500 mg of tablet given
orally for 3-5 days
Transrectal prostate biopsy
Drug of choice
Ceftriaxone
followed by
1 9 intravenously pre-operatively (1 5 minutes prior to operation)
Cefalexine
plus
Metronidazole 400 mg orally thrice daily for 5 days.
Kidney transplantation
In case of donar
Drug of choice
Ceftriaxone
supplemented by
Amoxycil l i n
plus Clavulanic
acid
1 9 intravenously pre-operatively ( 1 5 minutes prior to
operation) stat and then for 3 days
250 mg of amoxycillin plus 1 25 mg of
Clavulanic acid orally after meal 8 hourly.
In case ofrecipient
Drug of choice
Ceftriaxone 1 9 intravenously pre-operatively ( 1 5 minutes prior to operation)
stat and then for 3 days
77
9. Head and neck surger
Major head, neck and oral surgery
Drug of choice
Ceftriaxone
or
1 9 intravenously pre-operatively ( 1 5 minutes prior to operation)
Gentamicin plus 80 mg of gentamicin and 600 mg of clindamycin
Clindamycin intramuscularly as single dose
or
Cefradine 1 9 intravenously as single dose
10. Obstetrics & Gynecology
Cesarean section
Drg of choice
Ceftriaxone 1 9 intravenously pre-operatively (1 5 minutes prior to operation)
plus
Metronidazole 500 mg intravenously pre-opeatively (within 60 minutes prior
to operation)
Maintenance dose: Ceftriaxone 1 9 intravenously ti l l the patient is
nothing by mouth followed by oral dose of cephalosporin 500 mg
6 hourly up to 5-7 days of operation
Hysterectomy (abdominal and vaginal)
Drg of choice
Ceftriaxone
plus
Metonidazole
50mg intavensly pre-opratively
(witin 6 minutes prior to operation)
Maintenance dose: Ceftriaxone 1 9 intravenously till the patient is
nothi ng by mouth followed by oral dose of cephalosporin 500 mg
6 hourly up to 5-7 days of operation.
78
10
. Maillofacial surger
Cleft lip/palate surgery, condylectomy, segmental resection of
maxilla/mandible, postexcisional bone grafting, malignancy, jaw
fracture.
Drg of choice
Ceitriaxone
or
Cefradine
and next 2-4 days
79
ANTIBIOTIC PROPHYLAXIS FOR NONSURGICAL CONDITIONS
Bacterial endocarditis
Prevention of infective endocarditis in persons with certain
underlying cardiac conditions is important since this infection
continues to cause serious morbidity and mortality despite advances
in diagnosis and teatment.
Procedures for which Endocarditis Prophylaxis is necessary, include:
Dental procedures known to cause mucosal or gingival bleeding
e. g. extractions, dental implant placement and reimplantation of
avulsed teeth, root canal instrumentation or surgery, professional
cleaning
Tonsillectomy and/or adenoidectomy
Surgical conditions that involve penetration of intestinal or
respiratory mucosa
Bronchoscopy with a rigid bronchoscope
Sclerotherapy for oesophageal varices
Biliary tract surgery
Cystoscopy
Urethral dilatation
Urethral catheterisation, if infection is present
Prostatic surgery
Incision and drainage of infected tissue
Prophylactic regimens
In case of tooth extraction or minor oral surgery
Streptococcus viridans is the most common cause of endocarditis
following dental, oral , respiratory tract, or oesophageal procedures.
Drug of choice
Amoxicillin 50 mg orally 8 hourly for 5-7 days
or
Any cephalosporin For 5-7 days
plus
Metronidazole 400 mg three times daily for 5-7 days
80
Genitourinary and gastrointestinal procedures
The relevant organisms are usually enterococci, and rarely Gram
negative bacilli.
Ampicillin 2 g intravenously (50 mg/kg in children) PLUS
gentamicin 1 . 5 mg/kg intravenously ( 1 . 5 mg/kg in children) 30
minutes before the procedure followed by one dose of
amoxycillin 1 g orally (25 mg/kg in children) 6 hours after the
initial dose
or
one dose of ampicillin 1 g intravenously (25 mg/kg in children)
8 hours after the initial dose.
If allergic to ampicillin/penicillin or unable to take oral medication:
Vancomycin I g intravenously (20 mg/kg in children) PLUS
gentamicin 1 . 5 mg/kg intravenously (2 mg/kg in children) 30
minutes before the procedure, as single dose only.
Contacts of invasive Haemophilus infuenza type b and
meningococcal infections
The purpose of chemoprophylaxis in contacts is to eradicate
nasopharyngeal colonization by Neisseria meningitidis or
Haemophilus influenzae type b and thus reduce both the risk of
disease in contacts and the transmission to nonimmune susceptible
people.
Meningococcus contacts
Household contacts, day-care contacts, and only health-care
workers with direct exposure to oral secretions (e. g. mouth-to
mouth resuscitation) of patients with invasive meningococcal
infection, require prophylaxis. The index case also requires an
agent to eradicate nasopharyngeal carriage, prior to discharge
from hospital (unless treated with ceftriaxone or cefotaxime) since
therapy with penicillin may not eliminate nasopharyngeal carriage
of the organism.
81
The recommended chemoprophylactic agents include:
Rifampicin
for 4 doses
or
Ceftriaxone
or
Ciprofloxacin
20 mglkg (to a maximum of 600 mg) given 1 2 hourly orally
250 mg (in adults) or 1 25 mg (in children) intramuscularly
as a single dose
500 mg orally as a single dose in adults and older children
Contact with chicken pox
Acyclovir orally 20 mg/kg/day for 5 days
Contact with measles
Hyperimmune gamma globulin 1 . 5 g/m2 single dose (if not available,
then polyvalent globulin)
Pertussis
Erythromycin may be given to household contacts in doses of 50
mg/kg/day in 4 divided doses for 14 days.
Rheumatic fever
In case of rhehmatic fever without carditis
Chemoprophylaxis is usually started after the first episode of rheumatic
fever and continued for 5 years, or up to the age of 22 years, which ever
is the longer. The aim is to maintain antibiotic levels suficient to
prevent pharngeal infection with Streptococcus pyogenes.
Drug of choice
Benzathine
benzylpenicillin
or
1 .2 million IU deep intramuscularly every 3-weekly
(600,000 IU for
children less than 30 kg body weight)
Phenoxymethylpenicil l i n 250 mg orally 1 2 hourly (1 25 mg orally 1 2 hourly in
children less than 5 years)
or
Erythromycin
82
250 mg orally 12 hourly ( 1 0 mg/kglday if less than 40 kg)
I n case of sensitivity to penicillin
In case of rhehmatic fever with carditis but no residual valvular lesion
Chemoprophylaxis is usually started after the first epi sode of
rheumatic fever and continued for 1 0 years, or up to the age of 30
years, which ever is the longer.
Drug of choice
Benzathine
or
1 .2 million U intramuscularly every 3-weekly (600,000
U for children less than 30 kg body weight)
Phenoxymethylpenicillin 250 mg orally 1 2 hourly ( 1 25 mg orally 1 2 hourly in
or
Erythromycin
250 mg orally 1 2 hourly ( 1 0 mg/kglday if less than 40
kg) In case of sensitivity to penicillin
In case of rhehmatic fever with carditis and residual valvular lesion
Chemoprophylaxis is usually started after the first epi sode of
rheumatic fever and continued for lifelong.
Drug of choice
Benzathine
benzylpenicillin
or
1 . 2 million U intramuscularly every 3-weekly (600,000 U
for children less than 30 kg body weight)
Phenoxymethylpenicillin 250 mg orally 1 2 hourly ( 1 25 mg orally 1 2 hourly in
or
Erythromycin
250 mg orally 12 hourly (10 mglkg/day if less than 40 kg)
In case of sensitivity to penicillin
83
ANTIMICROBIAL AGENTS ASSOCIATED WITH PHOTOSENSITIVITY
The fol lowing drugs are known to cause photosensitivity in
some individuals:
Azithromycin, ciprofloxacin, dapsone, doxycycline, erythromycin.
flucytosine, gancic\ovir, griseofulvin, interferons, levofloxacin,
lomeflozacin, norfloxacin, ofloxacin, pefloxacin, pyrazinamide,
saquinavir, sparfloxacin, sulfonamides, tetracyclines, tretinions,
trovafoxacin, trimethoprim
84
HOSPITAL I NFECTION CONTROL
An infection within the hospital, you can take the help of infection
control team. To whom you have to contact:
Dr. Sharmin Ahmed
Associate Professor
Department of Microbiology and Immunology
Telephone 4424
441 8
85
^
Susceptibil ity of some bacteria to certain antibiotics
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Strep (group A) 1 0 2 0 2 2 0 0 2 2R 2 R 2R 0 R 2 R
Strep pneumoniae 1 0 1 0 2 2 2 0 2 2R R 2R 2R R R 2 R
Enterococcus faecalis R R 1 2 R R R R 2 0 R R R 0 R 2 R
N meningitides 1 0 2 0 2 0 2 0 2 0 0 R 2 R R R R
Listeria monocytogenes 0 0 1 0 R R R R 2 R R 0 0 0 2 0 R
H influenzae R R 1 R 0 2 1 R 1 0 2 R R 2R 0 2 0 R R
Ecoli R R 2R 2 2 1 R 2R R 2 R R R R 1 R 1 R* R R
Klebsiella species R R R 2R 2 1 R 2R 2R 2 R R R R 1 R 1 R* R R
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Posteus species R R 1 R 2R 2 1 R 2R R 2 R R R R 1 R 1 R* R R
Pseudomonas aeruginosa R R R 1 R R R R 1 R 2 R R R R R 1 R* R R
Bacteroides frogilis R R R R R R R R 2 R 2 0 2R R R R 1
Other Bacteroides species 2 R R R R R R R 2 R 2 0 2R R R R 1
Clostridium difficule 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 1
1= susceptible, first choice. 2 = 2nd choice, R = Resistance likely. = Usually inappropriate. R' = resistance is rare in most areas.
N . This table is a guide only, and different populations will exhibit their own (changing) patterns of resistance.
. In practice, the best thing is ofen to talk to a microbiologist
Classifcation of medically important bacteria
Characteristics Genus Representative Diseases
I. Rigid, thick-walled cells
A. Free-living (extracellular bacteria)
1 . Gram-positive
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Streptococcus Pneumonia, pharyngitis, cellulites
b. Spore-forming rods
( 1 ) Aerobic Bacillus
(2) Anaerobic
c. Non-spore-formi ng rods
(1 ) Nonfilamentous
(2) Filamentous
2. Gram-negative
a. Cocci
b. Rods
( 1 ) Facultative
(a) Straight
(i) Respi ratory organisms
(ii) Zoonotic organisms
Staphylococcus
Anthrax
Clostridium
Corynebacterium
Listeria
Actinomyces
Nocardia
Neisseria
Haemophilus
Bordetella
Legionella
Brucella
Francisella
Yersinia
Abscess of skin and other organs
Tetanus, gas gangrene, botulism
Diphtheria
Meningitis
ActinomYCOSis
Nocardiosis
Gonorrhea, meningitis
Meningitis
Whooping cough
Pneumonia
Brucellosis
Tularemioa
Plagus
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I NDEX
A
Abdominal trauma 76
Abscess
alveolar 27
breast 30
cerebral 35
liver (pyogenic) 44
periodontal 50
Acne vulgaris 26
Acyclovir 42, 43
Alveolar osteitis 27
Ami kacin 47
Amoebiasis 28
Amoxyci l l i n 27, 31 , 32, 33,
39, 44, 49, 50
Ampicillin 31 , 46, 47, 52
Amputation
lower l i mb 75
Antibiotic
liver disease 67
pregnancy 68
renal fai l ure 66
Antimicrobial therapy 1
Antiserum 30
Aortic resection 74
Appendicectomy 76
Azelaic acid 26
Azithromycin 26, 40, 62
B
Bacitracin 38, 65
Bacterial endocarditis 80
Benzylpenicillin 35,52,54, 57,58
Benzathine 51 , 57
Procaine 57, 58
Benzoyl peroxide 27
Betamethasone 40
Biopsy
trans rectal prostate 77
Bronchiectasis 31
Bronchitis 32
c
Cefalaxin 58
Cefixime 33, 35
Cefotaxime 32, 44, 46, 51 , 53
Cefradine 27, 30, 31 , 50
Ceftazi di me 41 , 46, 47
Cefti pi me 51
Cefuroxime 52, 53, 56
Cel l ul itis 34
Cesarean section 78
Ceftriaxone 34, 35, 36, 38,
40, 44, 45, 46, 49, 51 , 55
Chicken pox 82
Chancroid 33
Chloramphenicol 37
Chol ecystitis
acute 36
Cholera 36
89
Ci profloxacin 28, 32, 36, 37,
39, 40, 44, 45, 47, 48, 49, 51 ,
52, 53, 54, 55, 56, 62, 63
Clarithromycin 50, 51 , 52, 53
Cl eft lip 79
Cl i ndamycin 53, 54, 64
Clotrimazole 63, 64
Cloxacillin 30, 31
Co-amoxiclav 29, 34, 35, 49,
52, 53, 56, 58
Conjunctivitis 37
Co-trimoxazole 31 , 32, 33,
39, 40, 55, 62, 63
Cystitis
acute uncomplicated 39
Cystoscopy 76
o
Dexamethasone 41
Doxycycline 27, 36, 44, 54, 57
Drugs i n
breast mi l k 70
Dysentery
amoebic 28
bacillary 39
E
Econazole 47
Eczema (i nfected) 40
Endocarditis
bacterial 80
Enteric fever 40
Erythromycin 26, 27, 33, 36,
38, 51 , 54, 58 .
Ethambutol 59
90
F
Famciciovir 42, 43
Fever
enteric 40
rheumatic 82
Febrile neutropenia 41
Fl ucloxacil li n 27, 30, 31 , 34,
48, 56
Fl uconazole 49, 63
Fracture
open reduction 75
Fusidic acid 65
G
Gatifloxacin 34
Gentamicin 28, 35, 36, 40,
44, 46, 47, 48, 53, 54, 65
Giardiasis 43
Gi ngivitis 44
H
Helicobacter pylori 49
Herpes genital 42
Hydrocortisone 40, 47, 48
Hysterectomy 78
I mepenum 53, 55
Infection
uri nary tract 62
I nguinal hernia repair 76
I soni azid 59, 60, 61
Itraconazole 49
J
Joi nts
L
arthroplasty 75
replacement 75
Lansoprazole 50
Levofloxacin 56
Liver abscess (pyogenic) 44
M
Mastitis 30
Mastoiditis 44
Measles 82
Meningitis 45
Meni ngococcus contact 81
Metronidazole 27, 28, 31 , 35,
36, 43, 44, 49, 50, 54, 56, 64
Miconazole 64
Mupirocin 65
N
Neomycin 40, 65
Nitrofurantoin 62, 63
Nystatin 49
o
Ofloxacin 37, 41 , 63
Omeprazole 49
Oral thrush (candidiasis) 49
Otitis
externa 47
media (acute suppurative) 48
p
Pacemaker implant 74
Peptic ulcer 49
Pericoronitis 50
Peritonitis 51
Pertussis 82
P-floxaci llin 40
Pharyngitis 51
Phenoxymethyl penicillin 34, 51
Photosensitivity 84
Polymyxin B 32
Pneumoni a 52
Prostate biopsy
trans rectal 77
Prostatectomy 77
Prostatitis 55
Prosthetic valve i nseri on 74
Pyelonephritis (acute) 55
Pyrazi nami de 59, 60, 61
91
R
Rabies
i mmune gl obul i n 29
vaccine 29
Rheumatic fever 82
Rifampicin 59, 60, 61 T
Tetanus i mmunogi obul i n 30
Tetracycline 32, 33, 36, 38,
44, 54, 57
Tinidazole 28, 43, 64
Tobramycin 37
Tonsillitis 58
Tooth extraction 80
Transplantation
Kidney 77
Treti noi n 26
Triamcinolone 47
Tuberculosis 58
s
Secnidazole 28, 43, 64
Sepsis
bil iary 28
neonatal 47
neuropathi c foot in
Surgery
bi l i ary tract 75
cardi ovascul ar 74
gastroduodenal 75
open heart 74
orhopaedic 75
urological 76
Syphilis 57
u
Ulcer
corneal 38
Urethritis (acute, for males) 62
Urinary tract i nfection 62
v
Vaccine
rabies 29
Vagi nal
candidiasis 63
trichomoniasis 64
Vaginosis (bacterial) 64
Valacyclovir 42, 43
Vancomycin 46,52
Vitamin A 40
diabetes mell itus 56
W
Shock
anaphylactic 71
Sinusitis 56
Streptomycin 60
Wounds
bite 29
i nfected 65

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