the northern way of caring

Antimicrobial Stewardship Program

Empiric Treatment Guidelines for Common Infections in Adults
August 2020, 4th Edition
Note: All doses contained in this document should be adjusted for renal function
(refer to the Antimicrobial Stewardship Program Adult Dosing Guidelines Pocket-card [10-110-6004])

CNS Infections
Clinical Key Points
• When culture susceptibilities available change to PATHOGEN-DIRECTED therapy
• Consider dexamethasone 10 mg IV q6h x 4 days; 1st dose before or with 1st dose of antibiotics
• Draw blood cultures prior to 1st dose of antibiotics
Indication Typical Pathogen(s) Empiric Treatment
Bacterial Meningitis (Duration of therapy) (in order of preference)
Age 18 to 50 years S. pneumoniae (10 to 14 days) Ceftriaxone 2 g IV q12h + Vanco 25
N. meningitidis (7 days) mg/kg IV load, then 15 mg/kg IV q8 to
H. influenzae (7 to 10 days) 12h (target trough = 15 to 20)
If severe cephalosporin allergy Vanco as above + Meropenem 2 g IV
(anaphylaxis) q8h
Bacterial meningitis S. pneumoniae (10 to 14 days) Ceftriaxone + Vanco (both as above)
N. meningitidis (7 days) + Ampicillin 2 g IV q4h
Age greater than L. monocytogenes (21 days)
50 years, pregnant, Enterobacteriaceae (21 days)
immunocompromised,
If severe penicillin and/or Vanco as above + Meropenem 2 g IV
diabetes, renal failure
cephalosporin allergy (anaphylaxis) q8h + SMX-TMP 5 mg/kg (TMP) IV
q6h
Health care-Associated As above (10 to 14 days) 1. Vanco as above + Ceftazidime**
and or Head Trauma P. aeruginosa (10 to 14 days) 2 g IV q8h
Other gram negative bacilli or
(e.g. Post-neurosurgery, (10 to 14 days) 2. Vanco + Meropenem (both as
shunt, drain, intrathecal S. epidermidis, S. aureus above)
pump placement, skull (10 to 14 days)
fracture or penetrating Fracture: H. flu, Grp A strep
trauma) (10 to 14 days)
Suspected Viral Herpes Simplex Virus 1 & 2 Acyclovir 10 to 15 mg/kg (obese pts
encephalitis (14 to 21 days) BMI 30 or higher use adjusted body
Varicella Zoster Virus (10 to 14 days) wt [AdjBW])
If VZV suspected use 15 mg/kg
For Sepsis: Adult Sepsis Order Set: 10-111-5102
For Febrile Neutropenia: Adult Febrile Neutropenia Order Set: 10-111-5100

Abbreviations
Vanco = Vancomycin; SMX-TMP = Sulfamethoxazole-Trimethoprim;
Cipro = Ciprofloxacin; Pip-Tazo = Piperacillin-Tazobactam,
Amoxi-Clav = Amoxicillin-Clavulanate; Azithro = Azithromycin
Gent = Gentamicin; Tobra = Tobramycin;
Metro = Metronidazole, Clinda = Clindamycin IBW = ideal body weight
AdjBW = IBW + 0.4(total body wt - IBW)
 Community-acquired Pneumonia (CAP) refer to order set: 10-111-5094
Clinical Key Points
• Avoid using same class of antibiotics if used within previous 3 MONTHS
• When culture susceptibilities available change to PATHOGEN-DIRECTED therapy
• Broader empiric regimens used when certain CO-MORBIDITIES present: Heart, lung, liver disease;
diabetes; alcoholism; malignancies; asplenia; immunosuppression
• Consider IV è PO step down if afebrile x 24 to 48 hr, GI tract functioning, hemodynamically stable and
clinical improvement while on IV treatment
Typical Empiric Treatment
Indication
Pathogen(s) (in order of preference)
CAP Outpatient S. pneumoniae 1. Amoxicillin 1 g PO TID x 1 day then 500 mg PO TID x 4 to
(previously M. pneumoniae 6 days or
healthy) C. pneumoniae 2. Doxycycline 100 mg PO BID x 5 to 7 days
CURB-65: score
0 to 1
CAP Outpatient As above 1. Amoxi-Clav 875 mg PO BID + Doxycycline 100 mg PO BID
(comorbidities H. influenzae x 5 to 7 days or
present - see M. catarrhalis 2. Amoxi-Clav as above x 5 to 7 days + Azithromycin€ 500 mg
above) Legionella spp. PO daily x 3 days
CURB-65: score Enterobacteriaceae
0 to 1 S. aureus (IVDU)
€
Consider If severe penicillin
Cefuroxime 500 mg PO BID + Azithro or Doxycycline as above)
baseline ECG to (anaphylaxis) x 5 to 7 days
assess QTc allergy
CAP Inpatient As above 1. Ampicillin 1 g IV q6h + Doxycycline**
Mild/Moderate 100 mg PO BID or
CURB-65: score 2. Ceftriaxone 2 g IV q24h + Doxycycline**
2 100 mg PO BID
[**alt = Azithro€ 500 mg PO/IV daily x 3 days]
€
Consider Step down to PO for total duration of 7 days
baseline ECG to
assess QTc
CAP Inpatient As Above 1. Ceftriaxone 2 g IV q24h x 7 days + Azithro€ 500 mg IV/PO
Severe (ICU) daily x 3 days or
CURB-65: score 2. If recent macrolide use: Ceftriaxone 2 g IV q24h +
3 to 5 Moxifloxacin€ 400 mg IV/PO q 24h x 7 days
€
Consider MRSA/ Isolation of MRSA or Pseudo from resp tract within past year or
baseline ECG to Pseudomonas risk hospital admit and IV abx exposure in previous 3 months
assess QTc CONSULT Pharmacist or ID specialist

Abbreviations
Vanco = Vancomycin; SMX-TMP = Sulfamethoxazole-Trimethoprim;
Cipro = Ciprofloxacin; Pip-Tazo = Piperacillin-Tazobactam,
Amoxi-Clav = Amoxicillin-Clavulanate; Azithro = Azithromycin
Gent = Gentamicin; Tobra = Tobramycin;
Metro = Metronidazole, Clinda = Clindamycin IBW = ideal body weight
AdjBW = IBW + 0.4(total body wt - IBW)
 Hospital-acquired (HAP) &
Ventilator-associated pneumonia (VAP)
Clinical Key Points
• *RISK FACTORS for multi-drug resistant microbes: prior IV antibiotics within 90 days, recent antibiotic
use within 30 days; prolonged hospital stay (5 days or more), septic shock, ARDS or acute renal
replacement therapy prior to VAP onset
• When culture susceptibilities available change to PATHOGEN-DIRECTED therapy
• Consider DISCONTINUE empiric therapy if lower resp. tract cultures negative at 48 to 72hr and clinical
improvement
• Consider IV è PO step down (see criteria under Community-acquired Pneumonia)
Empiric Treatment
Indication Typical Pathogen(s)
(in order of preference)
Infection See community-acquired Refer to empiric treatment for CAP inpatient
occurring pneumonia section
72 hours or
less since
admission
HAP S. Enterobacter 1. Ceftriaxone 2 g IV q24h x 7 days
(infection pneumoniae spp. 2. amoxi-clav 875 mg PO BID x 7 days
occurring H. influenzae Proteus spp. 3. €moxifloxacin 400 mg PO daily x 7 days
greater than S.aureus Serratia
72 hrs after E. Coli marcescens
admission) K.
No risk factors pneumoniae
(listed above*)
for MDR MRSA suspected or known Add Vancomycin 25 mg/kg IV load, then 15 mg/kg IV q8
microbes history to 12h x 14 days (min.) for confirmed MRSA
€
Consider See above RISK FACTORS*
baseline ECG
to assess QTc
HAP - Risk As above 1. Pip-Tazo 4.5 g IV q6h +/- Vancomycin as above x 7 days#
factors* P. aeruginosa or
for MDR K. pneumoniae (ESBL) 2. Meropenem 1 g IV q8h +/- Vancomycin as above x 7
microbes Acinetobacter spp. days
including
(ESBL suspected or known history)
MRSA

HAP in ICU As above 1. Pip-Tazo 4.5 g IV q6h + (Cipro 400 mg IV q8h x 7

or days# or gent/tobra see order set 10-111-5336)
VAP If severe penicillin 1. Meropenem 1 g IV q8h + (Cipro as above x 7 days# or
Infection (anaphylaxis) allergy gent/tobra see order set 10-111-5336)
occurring If culture positive for SMX-TMP 2 DS tab PO/via tube TID x 14 days
greater than stenotrophomonas
48 hrs after maltophilia
intubation MRSA suspected or known Add Vancomycin 25 mg/kg IV load, then 15 mg/kg IV q8
history to 12h x 14 days (min.) for confirmed MRSA
#
Treat x 14 See above RISK FACTORS*
days (min.) if
confirmed
P. aeruginosa
 Aspiration Pneumonia
Clinical Key Points
• Routine addition of anaerobic coverage for suspected aspiration pneumonia is not recommended unless
lung abscess or empyema is suspected
• **NO ROLE for prophylactic antibiotics post aspiration – REASSESS patient 24 to 48 hrs after, if CXR
abnormality PLUS above risk factors, consider antibiotics
• RISK FACTORS for anaerobes poor oral hygiene, severe periodontal disease or putrid sputum
$

Typical Empiric Treatment

Indication
Pathogen(s) (in order of preference)
Community S. pneumonia No risk of anaerobes
Acquired or H. Influenza 1. Ceftriaxone 2 g IV daily x 7 days
Nursing Home Enterobacteriaceae (after 72 hrs of IV reassess for PO step down)
S. aureus Risk of Anaerobes$
Strep spp. 1. Amoxi-Clav 875 mg PO BID x 7 days
Oral anaerobes$ 2. Ceftriaxone 2 g IV daily + metronidazole 500 mg PO BID x 7 days
Hospital acquired Polymicrobial: Mild/moderate with no recent antibiotic use: As for community
S. pneumonia acquired above
#
(if recent H. Influenza Severe (ICU) or recent antibiotic use:
ventilator support Enterobacteriaceae 1. Pip-Tazo 4.5 g IV q6h
and or multiple S. aureus x 7 days or
antibiotics Oral anaerobes 2. Meropenem 1g IV q8h
previously) P.aeruginosa# x 7 days
M. catarrhalis
Aspiration Sterile No antibiotics recommended**
Pneumonitis
(aspiration of
gastric contents)
Dental Infections
Clinical Key Points
• Prolonged use of chlorhexidine is NOT recommended as it may result in selection of resistant oral microbes
• Assess for IV è PO step down after 24 to 48 hr of IV treatment
Typical Empiric Treatment
Indication
Pathogen(s) (in order of preference)
Endodontic/ 1. Incision and Drainage
periodontal 2. Pen V 600 mg PO QID +/- metronidazole 500 mg PO BID x 7 days
abscess
Penicillin allergy (anaphylaxis):
• Clindamycin 300 mg PO QID x 7 days
Facial space 1. Incision and Drainage
Polymicrobial
infection
(normal oral flora) 2. Pen G 2 million units IV q4 to 6h + metro 500 mg IV q12h x
10 days (consider oral step down after 24 to 48 hr)
e.g. aerobic
3. Outpatient: Ceftriaxone 2 g IV q24h + metro 500 mg PO BID x
(gram positive
and negative) and 10 days (consider oral step down after 24 to 48 hr)
anaerobic bacteria Severe (septic):
• Pip/Tazo 3.375 g IV q6h x 10 days (consider oral step down after
24 to 48 hr)
Penicillin allergy (anaphylaxis):
• Meropenem 1 g IV q8h x 10 days (consider oral step down after
24 to 48 hr)
 Intra-abdominal Infection
Clinical Key Points
• When culture susceptibilities available change to PATHOGEN-DIRECTED therapy
• DISCONTINUE antibiotics at day 4 to 7 if adequate SOURCE CONTROL achieved and good clinical
response
• If inadequate clinical response at day 4 to 7, consider DIAGNOSTIC INTERVENTIONS
• Antibiotics should be discontinued within 24 HOURS in the following:
-- Acute appendicitis WITHOUT perforation, abscess or peritonitis
-- Bowel injury due to penetrating or blunt trauma repaired WITHIN 12HR
Empiric Treatment
Indication Typical Pathogen(s)
(in order of preference)
Community-acquired Strep sp. 1. Cefazolin** 2 g IV q8h + Metronidazole
(Mild/moderate) Enterobacteriaceae (E. Coli, 500 mg PO/IV q12h
-Diverticulitis,
- Klebsiella sp., Proteus sp, Serratia [**alt. Ceftriaxone 2g IV q24h] or
cholecystitis, sp.) 2. Cipro 500 mg PO BID or 400 mg IV
appendicitis & other Anaerobes (B. Fragilis, Clostridium q12h + Metronidazole as above
infections sp., fusobacterium sp. Lactobacillus OUTPATIENT
sp., peptostreptococcus sp.) 1. Amoxi-Clav 875 mg PO BID x 7 days
2. SMX-TMP 1 DS tab PO BID + Metro po
as above x 7 days or
Community-acquired As above 1. Piperacillin-Tazobactam 3.375 g IV q6h
(Severe) or
-Perforated
- or 2. Cipro 500 mg PO BID or 400 mg IV
abscessed biliary tract q12h + Metronidazole as above or
-physiologic
- 3. Meropenem 1g IV q8h
disturbance,
advanced age or
immunocompromised
Healthcare As above 1. Pip-Tazo 3.375 g IV q6h or
associated, Acinetobacter 2. Meropenem 1g IV q8h
complicated or MDR gram neg bacilli
recurrent If MRSA suspected or known history Add Vancomycin 25 mg/kg IV load, then
15 mg/kg IV q8 to 12h

Abbreviations
Vanco = Vancomycin; SMX-TMP = Sulfamethoxazole-Trimethoprim;
Cipro = Ciprofloxacin; Pip-Tazo = Piperacillin-Tazobactam,
Amoxi-Clav = Amoxicillin-Clavulanate; Azithro = Azithromycin
Gent = Gentamicin; Tobra = Tobramycin;
Metro = Metronidazole, Clinda = Clindamycin IBW = ideal body weight
AdjBW = IBW + 0.4(total body wt - IBW)
 Clostridium difficile Infection (CDI) refer to order set: 10-111-5354
Clinical Key Points
• DISCONTINUE current antibiotics if possible
• DISCONTINUE anti-peristaltics, laxatives, pro-motility agents, anti-inflammatories (NSAIDs)
• If present, REASSESS need for Proton Pump Inhibitor or Histamine-2 Receptor Antagonist
CDI Severity Empiric Treatment
1st episode non-severe 1. Metronidazole 500 mg PO/NG TID x 10 to 14 days.
(WBC less than 15 and SrCr less than or equal (If no improvement by day 4 or intolerant to PO
to 1.5 x baseline) metro, change to option 2) or
2. Vancomycin 125 mg PO/NG QID x 10 to 14 days
Severe (WBC greater than 15, or acute kidney Vancomycin 125 mg PO/NG QID x 10 to 14 days
injury (SrCr greater than 1.5 x baseline), or
hypoalbuminemia))
1st Recurrence/relapse 1. Vancomycin 125 mg PO/NG QID x 10 to 14 days
(use if initial episode treated with metro)
Consider ID consult 2. Vancomycin taper regimen - see below for dosing
(use if initial episode treated with vanco)
Recurrence/relapse (2nd or more) Vancomycin 125 mg PO/NG QID x 14 days then taper
over 4 weeks
CONSULT INFECTIOUS DISEASE e.g. 125 mg BID x 7 days, 125 mg daily x 7 days, 125
mg q2 days x 7 days, 125 mg q3d x 7 days
Fulminant (toxic megacolon, perforation, Vancomycin 500 mg PO/NG QID x 10 to 14 days +
ileus, sepsis/hypotension or shock shock or metronidazole 500 mg IV q8h x 10 to 14 days
peritonitis) (if ileus or unable to take via PO/NG give vanco 500 mg in
Consider consults: ID, Gen Surgery, ICU 100 mL NS retention enema QID rectally R/A daily)

Abbreviations
Vanco = Vancomycin; SMX-TMP = Sulfamethoxazole-Trimethoprim;
Cipro = Ciprofloxacin; Pip-Tazo = Piperacillin-Tazobactam,
Amoxi-Clav = Amoxicillin-Clavulanate; Azithro = Azithromycin
Gent = Gentamicin; Tobra = Tobramycin;
Metro = Metronidazole, Clinda = Clindamycin IBW = ideal body weight
AdjBW = IBW + 0.4(total body wt - IBW)
 Urinary Tract Infections (UTI) in Non-pregnant Adults
Clinical Key Points
• Malodorous/cloudy urine alone is NOT a sign/symptom of UTI and is NOT an indication for urine
cultures
• Positive urine cultures in asymptomatic patients should NOT be treated EXCEPT in pregnancy or prior
to urologic/gynecologic surgery
• Delirium or change in behaviour REQUIRES clinical assessment to RULE OUT dehydration, adverse
effect of new medication, trauma, hypoxia, hypoglycemia or other infection (do not assume UTI)
• Urine cultures should ALWAYS be collected mid-stream or by in/out catheter
• Risk factors for ESBL**: frequent hospitalizations, residence in care facility, advanced age, male
gender, frequent and or recent (within 30 day) antibiotic use, and recurrent UTIs
Symptoms:
• New onset or worsening urgency, dysuria, incontinence, fever, rigors, altered mental status, malaise,
flank pain, costovertebral angle tenderness, acute hematuria, and/or pelvic discomfort.
Empiric Treatment
Indication Typical Pathogen(s)
(in order of preference)
Uncomplicated cystitis Enterobacteriaceae 1. Nitrofurantoin (MacroBID®) 100 mg PO BID x
(premenopausal female (predominently E. coli) 5 days [ONLY USE if CrCl 40 mL/min or greater]
with no urological Enterococcus sp. or
abnormalities or 2. SMX-TMP 1 DS tab po BID x 3 days or
co-morbidities) 3. trimethoprim 100 mg PO BID x 3 days
Complicated cystitis As above 1. SMX-TMP as above x 10 days or
(all males, females 65 yrs (higher risk for resistant 2. Amoxi-Clav 875 mg PO BID x 10 days or
and older or with urologic organisms) 3. Nitrofurantoin as above x 10 days (if use in males
abnormalities or co- CrCl must be greater than 60 mL/min; rule out
morbidities) prostatitis)
4. Cefixime 400 mg PO daily x 10 days or
5. Cipro 500 mg PO BID x 7 days
Mild pyelonephritis As above 1. Cefixime 400 mg PO daily x 10 to 14 days or
(outpatient) 2. Cipro 500 mg PO BID x 7 days
Moderate pyelonephritis As above 1. Cefotaxime 2 g IV q8h x 10 to 14 days
(inpatient) (step down to oral when stable) or
Obtain blood cultures 2. Cipro 500 mg po BID x 7 days
x2 prior to 1st dose
Urosepsis/severe As above; refer to 1. Pip-Tazo 3.375 g IV q6h
pyelonephritis (Blood Sepsis order set (step down to oral when stable)
cultures x 2 as above) 10-111-5102
ESBL **suspected/ 1. Meropenem 1 g IV q8h
known (all severities) (step down to oral cipro if culture sensitive or
fosfomycin 3 g PO q3 days x 3 doses)
ESBL outpatient 1. Fosfomycin 3 g PO q3 days x 3 doses
treatment 2. Ertapenem 1 g IV q24h x 10 to 14 days (consult
pharmacist or ID physician)

Abbreviations
Vanco = Vancomycin; SMX-TMP = Sulfamethoxazole-Trimethoprim;
Cipro = Ciprofloxacin; Pip-Tazo = Piperacillin-Tazobactam,
Amoxi-Clav = Amoxicillin-Clavulanate; Azithro = Azithromycin
Gent = Gentamicin; Tobra = Tobramycin;
Metro = Metronidazole, Clinda = Clindamycin IBW = ideal body weight
AdjBW = IBW + 0.4(total body wt - IBW)
 Catheter-associated UTI (CA-UTI)
Diagnosis: Presence of SIGNS/SYMPTOMS (see below) plus positive urinalysis and GROWTH of 1 or
more bacterial species in a single catheter urine specimen or midstream void within 48 hr of catheter removal.
Clinical Key Points
• DO NOT collect urine culture in absence of symptoms
• DO NOT treat a positive culture in absence of symptoms
• DISCONTINUE catheter as soon as appropriate
• When culture susceptibilities available change to PATHOGEN-DIRECTED therapy
Symptoms:
• New onset: fever, rigors, malaise, lethargy, altered mental status with NO OTHER CAUSE, flank pain,
CVA tenderness, acute hematuria or pelvic discomfort
• If catheter recently removed (48 hrs) è dysuria, urgency or frequency, suprapubic pain/tenderness (in
addition to above symptoms)
• Spinal cord injury patients è increased spasticity, sense of unease or autonomic dysreflexia
Catheter Replacement
• Assess continued need for catheter – remove if possible
• If catheter still indicated and has been in place for greater than 2 weeks, replace and repeat urine culture
prior to starting antibiotics
Culture and Sampling
• Obtain urine sample for analysis and culture from new catheter prior to antimicrobial therapy
• If catheter removed, collect sample voided mid-stream
Typical Pathogen(s)
Short-term catheter: E.Coli, Klebsiella, Serratia, Citrobacter, Enterobacter, enterococcus, coag. neg staph
Long-term catheter: As above (often polymicrobial), pseudomonas, proteus, morganella, providencia
Empiric Treatment
(treat for 7 days if prompt response; 10 to 14 days if delayed response)
Mild/Moderate:
Cefixime 400 mg po daily or Amoxicillin-Clavulanate 875 mg po BID or Ciprofloxacin 500 mg po BID
Severe (febrile/systemically unwell):
1. Ampicillin 1 to 2 g IV q6h + (Ceftazidime 2g IV q8h or Gentamicin/Tobramycin 5 to 7 mg/kg (IBW) IV
q24h)
2. Piperacillin-Tazobactam 3.375 g IV q6h +/- Gentamicin/Tobramycin 5 to 7 mg/kg (IBW) IV q24h
(septic)

ESBL suspected/known (any severity)

1. Meropenem 1 g IV q8h (step down to cipro if culture sensitive or fosfomycin 3 g PO q2 to 3 days x 3
doses
2. Outpatient: Ertapenem 1 g IV daily x 10 to 14 days (consult pharmacist or ID physician)

Abbreviations
Vanco = Vancomycin; SMX-TMP = Sulfamethoxazole-Trimethoprim;
Cipro = Ciprofloxacin; Pip-Tazo = Piperacillin-Tazobactam,
Amoxi-Clav = Amoxicillin-Clavulanate; Azithro = Azithromycin
Gent = Gentamicin; Tobra = Tobramycin;
Metro = Metronidazole, Clinda = Clindamycin IBW = ideal body weight
AdjBW = IBW + 0.4(total body wt - IBW)
 Skin and Soft Tissue Infections (Cellulitis and Diabetic Foot)
Clinical Key Points
• Avoid using same class of antibiotics if used within previous 3 MONTHS
• Superficial skin swabs NOT recommended
• Cellulitis usually PROGRESSES 24 to 48 hr after initiation of treatment BEFORE it improves
• ELEVATE above the heart, whenever possible
• STEP DOWN to PO when resolution of systemic symptoms or no further progression
Typical Empiric Treatment
Indication
Pathogen(s) (in order of preference)
Non- Mild/Moderate 1. Amoxicillin 0.5 to 1 g PO TID x 5 to 7 days or
purulent 2. Cephalexin 0.5 to 1 g PO QID x 5 to 7 days
Cellulitis Severe Outpatient Cefazolin 2 g IV q24h PLUS probenecid 1 g PO daily x 72
Strep hrs then reassess for oral step down x 7 to 10 days total
Grp A, B, C, Suspected necrotizing 1. Vanco 25 mg/kg IV load, then 15 mg/kg IV q8 to 12h + Pip-
G fasciitis Tazo 4.5 g IV q6h - Consult surgeon ASAP
Purulent S. aureus Mild I&D
Cellulitis or Moderate 1. I&D and send for culture
Abscess 2. TMP/SMX 1 to 2 tab po BID or doxycycline 100 mg po
BID
Once cultures back refine therapy: if MSSA = Cloxacillin 0.5
to 1 g po QID or cephalexin 0.5 to 1 g po QID x 5 to 10 days
Severe 1. I&D and send for culture
2. Vanco 25 mg/kg IV load, then 15 mg/kg IV q8 to 12h
Once cultures back refine therapy: if MSSA = Cloxacillin 2g
IV q6h or cefazolin 2g IV q8h x 5 to 10 days
Step down to oral therapy once stable
Diabetic foot infections: Mild: local infection with erythema greater than 0.5 cm and less than or equal to
2 cm around ulcer; Moderate: local infection with erythema greater than 2 cm or deeper infection with NO
systemic symptoms; Severe: as moderate PLUS signs of systemic infection
Diabetic foot ulcer (no sign of infection) Wound care only – no antibiotics required
Diabetic foot infection S. aureus 1. Cloxacillin or Cephalexin 0.5 to 1 g PO QID x 1 to 2 wks or
(Mild) Strep sp 2. Amoxi-Clav 875 mg PO BID (if recent antibiotic use) x 1 to
*** Try to treat as 2 wks
outpatient***
Diabetic foot infection As above 1. Amoxi-Clav 875 mg PO BID x 2 to 3 wks or
(moderate) Enterobacteriaceae 2. Moxifloxacin 400 mg PO daily x 2 to 3 wks (If beta-lactam
Screen for Anaerobes allergic)
osteomyelitis
Treat as outpatient if
possible
Diabetic foot infection As above 1. Ceftriaxone 2 g IV q24h + metro 500 mg PO BID x 4 days
(Severe) then reassess or
Screen for 2. Pip-Tazo 3.375 g IV q6h x 4 days then reassess or
osteomyelitis 3. Meropenem 1g IV q8h x 4 days then reassess
Outpatient 4. Ertapenem 1 g IV q24h x 4 days then reassess for oral
treatment step down therapy
ID consult needed
MRSA suspected or 1. Add Doxycycline 100 mg PO BID or
known (all severities) 2. Add SMX-TMP 2 DS tabs PO BID or
3. Add Vancomycin 25 mg/kg IV load, then 15mg/kg IV
q8 to 12h (for moderate/severe) x 4 days then reassess
for oral step down therapy