Editors:

Dr. B N Harish
Dr. Sujatha Sistla
Dr. Jharna Mandal
Dr. Kadhiravan T
Dr. Vishnu Bhat
Dr. Sriram Krishnamurthy
Dr. Narayanan P
Dr. Biswajit Dubashi
Dr. Krishnan Balasubramaniam
Dr. Srinivas Rajagopalan
Dr. DG Shewade
Dr. Dinoop KP
Acknowledgements:
Dr. S.C.Parija
Department of Microbiology
JIPMER - Pondicherry
2014
Third edition June 2014
Handbook of
Antimicrobial Use
at JIPMER
Front Cover inside
Contents
Page
GI and intra Abdominal Infectons. ............................ 5-8
CVS Infectons .......................................................... 9-10
Skin and sof tssue Infectons .................................... 11
Bone and joint Infectons. .......................................... 12
Respiratory Infectons ............................................ 14-16
Genitourinary Infectons............................................. 17
CNS Infectons ....................................................... 18-19
Ocular Infectons ................................................... 20-21
Dental Infectons ........................................................ 22
Empiric antbiotc therapy for ICU .............................. 23
Treatment of Patents with
Fever and Neutropenia ............................................... 28
For management in NICU ........................................... 31
Changes made in the handbook- an entire section which deals with empiric antibi-
otic therapy in febrile neutropenia and one section dedicated to empiric therapy
in the ICU,NICU. Certain new class of antibiotics have been included so that the
pressure on certain groups of antibiotics are minimized like the carbapenems.
OBJECTIVES OF
THE HANDBOOK
The appropriate use of antimicrobials is an essential part of patient
safety and deserves careful attention and guidance. Antimicrobial
resistance is an evolutionary phenomenon and the selection of re-
sistant pathogens is signifcantly associated with antimicrobial use.
Antimicrobial resistance results in increased morbidity, mortality,
and costs of health care. Prevention of the emergence of resistance
and the dissemination of resistant microorganisms will reduce these
adverse effects and their attendant costs. We therefore urge everyone
to restrict our use of antimicrobial agents. In this revised edition, we
have added a few sections on the empiric treatment of febrile neu-
tropenia and in the intensive care units. We hope that this second
edition of the Handbook of Antimicrobial Use at JIPMERwould
address some of the pending issues of the last edition. We are very
grateful to all our colleagues who gave their valuable suggestions in
making of this edition of the handbook. There are bound to be errors
and we would welcome all feedback so that future editions can be
corrected. We hope that this handbook would act as a basic refer-
ence to the clinicians in prescribing antibiotics and help streamline
the management of common infections encountered in the hospital.
5
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Empiric antibiotic therapy for ICU
Patient risk stratifcation
Patient type I
Community acquired
infection (CAI)
Patient type II
Healthcare associated
infection/Nosocomial
infection
Patient type III
Healthcare associated
infection/Nosocomial
infection
Patient coming to the ICU
with CAI
No contact with healthcare
system
No prior antibiotic treatment
No procedures done
Patient young (<65 years)
with no or few co-morbid
conditions
Contact with health care
system (e.g. Recent hospital
admission, nursing home,
dialysis without invasive
procedure within last 90
days)
Recent antibiotic therapy-
within last 90 days
Minimum procedures done
Patient old (>65 years) with
few co-morbidities
Long hospitalization and/ or
invasive procedures within
last 90 days
Recent & multiple antibiotic
therapies- with in last 90
days
Patient old (>65 years) within
multiple co-morbidities
Major invasive procedures
done Structural lung disease,
AIDS, Neutropenia other
severe immunodefciency
Please send appropriate sample for culture and sensitivity and de-escalate
wherever possible as per the sensitivity report.
24
Blood
Stream
Infections
Patient type I Patient type II Patient type III
Before
Culture
reports are
available
Inj. Amoxycillin-
clavulanate
plus
Inj. Amikacin
Or
Ceftriaxone
plus
Inj. Amikacin
Inj. Amoxycillin-
clavulanate plus
Inj. Amikacin
Or
Cefoperazone-
Sulbactam plus
amikacin
Cefoperazone-
Sulbactam plus
amikacin
Or
Piperacillin-
Tazobactam plus
amikacin
After
culture
reports are
available
If non-ESBL/
MSSA then
treat as per the
susceptibility
report
ESBL positive:
Continue the same
as above MRSA:
Vancomycin
(Linezolid
only when
vancomycin is
contraindicated)
Isolation of
Candida:
Fluconazole
ESBL positive:
Continue the same
as above MRSA:
Vancomycin
(Linezolid only
when vancomycin
is contraindicated)
Isolation of Candida:
Fluconazole
Escalation If ESBL positive
or MRSA
positive then
treat as type II
If patient does not
respond then treat
as in type III
Only when all others
are found resistant-
Cefepime- tazobactam
Or
Carbapenem
(Imipenem- cilastatin,
Meropenem) If a
carbapenemase
producer :
Colistin Antifungal-
(Voriconazole/
Amphotericin B)
De-
escalation
If non-ESBL/
MSSA then
treat per the
susceptibility
report
If non-ESBL/
MSSA then
treat as type I
or treat per the
susceptibility
report
If non-ESBL/
MSSA /non-
carbapenemase
producer then treat as
type I or treat as per
the susceptibility
report
25
Pneumonia Patient Type I Patient type II Patient type III
Before
culture
reports are
available
Inj Amoxycillin-
clavulanate
plus inj
Azithromycin
Or
Inj ceftriaxone
plus Inj
Azithromycin
Cefoperazone-
sulbactam (add
Inj.metronidazole
if aspiration
suspected)plus
inj azithromycin
Cefoperazone-
sulbactam
Or
Piperacillin
tazobactam (add
Inj.metronidazole
if aspiration
suspected)
Consider adding
vancomycin only
if strong clinical
indication of MRSA
After culture
reports
available
If non-ESBL/
MSSA
then treat per
the
susceptibility
report
ESBL positive:
Continue
the same as
above MRSA:
Vancomycin
(Linezolid
only when
vancomycin is
contraindicated)
Isolation of
Candida:
Fluconazole
ESBL positive:
Continue the same
as above MRSA:
Vancomycin
(Linezolid only
when vancomycin
is contraindicated)
Isolation of Candida:
Fluconazole
Escalation If ESBL positive
or MRSA
positive
then treat as
type II
If patient does
not
respond then
treat
as in type III
Only when all
others are found
resistant: Cefepime-
tazobactam
Or
Carbapenem
(Imipenem-cilastatin
,Meropenem) If a
carbapenemase
producer :
Colistin Antifungal-
(Voriconazole/
Amphotericin B)
De-escalation If non-ESBL/
MSSA then
treat per the
susceptibility
report
If non-ESBL/
MSSA then
treat as type I
or treat per the
susceptibility
report
If non-ESBL/MSSA/
non-carbapenemase
producer then treat
as type I or treat as
per the susceptibility
report
26
UTI Patient type I Patient type II Patient type III
Before culture
reports available
Amikacin
Or
Ceftriaxone
Amikacin
Or
Cefoperazone-
sulbactam
Amikacin
Or
Cefoperazone-
sulbactam
After culture
reports
available
Non-ESBL /
MSSA:
continue the same
as above
ESBL positive:
Continue
the same as
above MRSA:
Vancomycin
(Linezolid
only when
vancomycin is
contraindicated)
Isolation of
Candida:
Fluconazole
ESBL positive:
Continue the same
as above MRSA:
Vancomycin
(Linezolid only
when vancomycin
is contraindicated)
Isolation of
Candida:
Fluconazole
Escalate If ESBL positive or
MRSA positive
then treat as
type II
If patient does not
respond then treat
as in type III
Only when
all others are
found resistant-
Cefepime-
tazobactam
Or
Carbapenem
(Imipenem-cilastatin
,Meropenem) If a
carbapenemase
producer :
Colistin Antifungal-
(Voriconazole/
Amphotericin B)
De-escalate If non-ESBL/
MSSA then
treat per the
susceptibility
report
If non-ESBL/
MSSA then
treat as type I
or treat per the
susceptibility
report
If non-ESBL /
MSSA / non-
carbapenemase
producer then
treat as type I or
treat as per the
susceptibility report
Please send appropriate sample for culture and sensitivity and de-escalate wher-
ever possible as per the sensitivity report.
27
Complicated
Intra-
abdominal
infections
Patient type I Patient type II Patient type III
Before
Culture
reports
available
Inj. Amoxycillin-
clavulanate
plus Inj.
Amikacin plus
metronidazole
Or
Ceftriaxone
plus Inj.
Amikacin plus
metronidazole
Inj. Amoxycillin-
clavulanate plus
Inj. Amikacin plus
metronidazole
Or
Cefoperazone-
sulbactam plus
metronidazole/
Cefoperazone-
sulbactam plus
metronidazole
Or
Piperacillin-
tazobactam plus
metronidazole
After
culture
reports are
available
If non-ESBL/
MSSA then
treat per the
susceptibility
report
ESBL positive:
Continue
the same as
above MRSA:
Vancomycin
(Linezolid
only when
vancomycin is
contraindicated)
Isolation of
Candida:
Fluconazole
ESBL positive:
Continue the same
as above MRSA:
Vancomycin
(Linezolid only
when vancomycin
is contraindicated)
Isolation of Candida:
Fluconazole
Escalation If ESBL
positive or
MRSA positive
then treat as
type II
If patient does
not respond then
treat as in type III
Only when all others
are found resistant-
Cefepime-tazobactam
Or
Carbapenem
(Imipenem-cilastatin,
Meropenem): If a
carbapenemase
producer :
Colistin Antifungal-
(Voriconazole/
Amphotericin B)
De-escalation If non-ESBL/
MSSA then
treat per the
susceptibility
report
If non-ESBL/
MSSA then
treat as type I
or treat per the
susceptibility
report
If non-ESBL/MSSA/
non-carbapenemase
producer then treat
as type I or treat as
per the susceptibility
report
NOTE: It may be noted that the following antibiotics can be prescribed only by the HOD or Professor or Additional professor:
Cefepime Cefepime-tazobactam Vancomycin
Piperacillin-tazobactam Meropenem Linezolid
28
Treatment of Patients with
Fever And Neutropenia
Principles
Empirical antbiotc therapy should be administered promptly to all neutropenic patents at the onset of fever
or any other new signs and symptoms of infecton
Antbiotcs chosen should:
Provide adequate coverage of Pseudomonas aeruginosa
Be based on local antimicrobial susceptibility patterns of frequently identifed bacterial
Pathogens
Low risk High risk
Solid organ malignancy with no organ All haematological malignancies, solid organ
dysfunction malignancies with organ dysfunction
Age<60 years Age>60 years
No comorbid illness Presence of comorbid illness
Initial empirical antibiotic therapy :
Low-risk patients should receive initial oral antibiotics: Levofoxacin plus amoxicillin-clavulanate in
combination is recommended.
High-risk patients require hospitalization for IV empirical antibiotic therapy; monotherapy with an
antipseudomonal -lactam agent, such as cefepime, a carbapenem (meropenem or imipenem-
cilastatin), or piperacillin-tazobactam, is recommended. Other antimicrobials (aminoglycosides,
fuoroquinolones, and/or vancomycin) may be added to the initial regimen for management of
complications (eg, hypotension and pneumonia) or if antimicrobial resistance is suspected or
proven.
First line: Ceftazidime +amikacin Or cefepime+ amikacin
Second line : Piperacillin-tazobactam + amikacin Or Cefepime-tazobactam + amikacin
Or Meropenem.
Vancomycin (or other agents active against aerobic gram positive cocci) is not recommended as
a standard part of the initial antibiotic regimen for fever and neutropenia . These agents should be
considered for specifc clinical indications, including suspected catheter-related infection, skin or
soft-tissue infection, pneumonia, or hemodynamic instability.
Vancomycin plus 1 or 2 antbiotcs, if criteria for use of Vancomycin is met: As above + Vancomycin.
29
Modifcations of initial antibiotic therapy:
Modifcations to initial empirical therapy may be considered for patients at risk for infection with
the following antibiotic-resistant organisms, particularly - if the patients condition is unstable or
if the patient has positive blood culture [methicillin-resistant Staphylococcus aureus (MRSA),
vancomycin-resistant enterococcus (VRE), extended-spectrum b-lactamase (ESBL)producing
gram-negative bacteria, and carbapenemase-producing organisms, including Klebsiella
pneumoniae carbapenemase (KPC)].
Modifcations to the initial antibiotic regimen should be guided by clinical and microbiologic data and
should be treated with antibiotics appropriate for the site and for the susceptibilities of any isolated
organisms.
Escalation: Patients who remain hemodynamically unstable after initial doses with standard agents
for neutropenic fever should have their antimicrobial regimen.
De-escalaton: Low-risk patients who have initiated oral antibiotics in the hospital may have their
treatment approach simplifed if they are clinically stable.
Empirical antifungal coverage should be considered in high-risk patients who have persistent fever
after 47 days of a broad-spectrum antibacterial regimen and no identifed fever source.
First line: amphotericin B for Candida spp, voriconazole for Aspergillus spp
Second line: Caspofungin for Candida spp
Please send appropriate sample for culture and sensitivity and de-escalate wher-
ever possible as per the sensitivity report.
30
Therapy Duration
A. Patient becomes afebrile in 3 days 1. Patient afebrile by day 3.
Etologic agent identfed - adjust therapy to most
appropriate drugs.
No etologic agent identfed :
Patent at low risk initally, and on oral antbiotcs
with no subsequent complicatons - contnue use
of the same drugs
Patent at low risk initally and therapy with
i.v.drugs begun with no subsequent complicatons
change to oral ciprofoxacin + amoxicillin
clavulanate afer 48 hours.
Patent at high risk initally with no subsequent
complicaton contnue use of same i.v.drugs
ANC 500cells /mm
3
for 2 consecutve days,
no defnite site of infecton, and no positve
cultures - stop antbiotc therapy when the
patent is afebrile for 48 h.
ANC < 500 cells /mm
3
Patent initally at low risk , and no
subsequent complicatons -stop therapy
when patent is afebrile for 5-7 days
Patent initally at risk and no subsequent
complicatons - contnue same antbiotcs
B. Persistent fever throughout the frst 3 days 2. Persistent fever on day 3.
Reassess therapy on day 3
If no clinical worsening , contnue use ot the same
antbiotcs.
Stop Vancomycin ( if part of inital regimen) if
cultures negatve
If there progressive disease, change antbiotcs
( Imipenem 0.5gm i.v.Q6H / Meropenem
1gmi.v.Q8H).
If patent febrile afer 72-96 hours, consider
adding Amphotericin B, with and without a change
in antbiotc regimen.
Additonal indicatons for Amphotericin B /
Voriconazole: Pleural rub, pulmonary infltrates
suggestve of invasive aspergillosis, paranasal
sinusits.
ANC 500cells /mm
3
- stop antbiotcs 4-5
days afer ANC 2 500cells /mm
3
.-
ANC < 500 cells /mm
3
- reassess and contnue
antbiotcs for 2 more weeks; reassess and
consider stopping therapy if no disease site
found
Others
Hand hygiene, maximal sterile barrier precautions, and cutaneous antisepsis with chlorhexidine
during CVC insertion are recommended for all CVC insertions.
Please send appropriate sample for culture and sensitivity and de-escalate
wherever possible as per the sensitivity report.
31
For Management in the NICU
S.no. Clinical situation Antibiotics and dose
1 Babies born to mothers with PROM of > 18
hrs, or foul smelling liquor or evidence of
chorioamnionitis
Cefotaxime 100mg/kg/day BD and
gentamicin 5mg/kg/day OD
2 Babies who re admitted in the nursery
from birth with suspected sepsis/persistent
respiratory distress >6 hrs with initial septic
screen positive
Cefotaxime 100mg/kg/day BD and
gentamicin 5mg/kg/day OD
3 Babies who are shifted fro the mothers
side with suspicion of late onset sepsis and
meningitis
Cefotaxime200mg/kg/day BD and
gentamicin 5mg/kg/day OD
4 Babies with clinical suspicion of necrotizing
enterocolitis
Cefaperazone+sulbactam 150mg/
day BD ,gentamicin 5mg/kg/day
OD and metronidazole 7.5 mg/kg/
dose Q8H
5 Preterm babies born through meconium
stained liquor with respiratory distress and
clinical suspicion of Listeria infection
Ampicillin 100mg/kg/day- 150mg/
kg/ day BD and gentamicin 5mg/k/
day OD
Duration of Therapy
1.
Started for risk factors,sepsis screen
negative,baby well
48-72 hours, till blood culture
reported sterile
2.
Sepsis screen positive, baby improves with
frst line antibiotics, blood culture sterile 7 days
3. Blood culture positive
10-14 days, based on organism and
sensitivity
4.
Strong clinical suspicion of meningitis,CSF
biochemical values suggestive, CSF and
blood culture sterile 10-14 days based on clinical course
Second line antibiotic used empirically if clinical situation not improving/worsening and/or if repeat
septic screen is positive after at least 48 hours of the frst line antibioticcefaperazone+sulbactam
150mg/kg/day BD and amikacin 15mg/kg/day OD
32
Seven steps of handwashing
Back Cover inside
Notes
33
Rub palms together.
Interlock ngers and rub the back
of ngers of both hands
Rub thumb in a rotating manner
followed by the area between index
nger and thumb for both hands.
Rub both wrists in a rotating
manner. Rinse and dry
thoroughly
Rub the back of both hands.
Rub ngertips on palm for both
hands.
Seven steps of handwashing
Interlace ngers and rub hands
together.
Back Cover
Published by
Department of Microbiology,
JIPMER
34
Handbook of
Antimicrobial Use
at JIPMER
For internal use only Valid till June 2015
POCKET GUIDE
Front Cover