AKUH Antimicrobial Guidelines (Protected Version) 2020

AKUH Antimicrobial
Guidelines
Seventh Edition - 2020
Preface to the Seventh Edition
Antimicrobial agents are some of the most widely, and often
injudiciously, used therapeutic drugs worldwide. Important
considerations when prescribing antimicrobial therapy include
obtaining an accurate diagnosis of infection; understanding
the difference between prophylactic, empiric and definitive
therapy; identifying opportunities to switch to narrow-spectrum,
cost-effective oral agents for the shortest duration necessary;
understanding drug characteristics that are peculiar to antimicrobial
agents (such as pharmacodynamics and efficacy at the site of
infection); accounting for host characteristics that influence
antimicrobial activity; and in turn, recognizing the adverse effects
of antimicrobial agents on the host. It is also important to understand
the importance of antimicrobial stewardship, to know when to
consult infectious disease specialists for guidance, and to be able
to identify situations when antimicrobial therapy is not needed. By
following these general principles, all practicing physicians should
be able to use antimicrobial agents in a responsible manner that
benefits both the individual patient and the community.
Antimicrobial therapy is a dynamic process. Results of cultures,

then sensitivities of organisms (unless mixed infections) are usually
available within 72 hours. Hence, critical re-evaluation of initial
therapy (“de-escalation”) is essential to provide a balance between
therapeutic efficacy, side effects, and the creation of antimicrobial
resistant organisms.
It gives me great pleasure to present to you the 7th edition of

“AKUH Antimicrobial Guidelines” prepared by “Antimicrobial
Stewardship Sub-Committee” (of the Pharmacy and Therapeutics
committee). The current edition is aimed at guiding physicians
who practice across different levels of healthcare acuity to select
appropriate empirical antibiotics for treatment of common
community & healthcare associated infections as well as for surgical
prophylaxis. Guidelines are considered supplementary strategy of
antimicrobial stewardship. I would like to thank all members that
contributed to this document and the general administration of
pharmaceutical care for its support.
We have reviewed updates to the guidelines published by various

i
authorities and incorporated any changes. We also sent the
relevant sections to all the service lines and have re-evaluated
our recommendations based on the suggestions provided. Our
antimicrobial formulary decisions are made annually after
thorough deliberations and consensus building with members of the
Infectious Disease, the Department of Pharmacy, and the Section of
Microbiology.
As always, I would like to thank the entire “Antimicrobial

Stewardship Committee” for their help in designing and reviewing
the guidelines. I would also like to especially point out the hard
work of Dr Nosheen Nasir, Dr. Joveria Farooqi, Dr. Falak Abro,
Kashif Hussain and Pharmacy team who spearheaded this project
and ensured that we were on schedule. I look forward to hearing
your thoughts and suggestions for future guidelines and anticipate
your cooperation in helping us streamline antimicrobial use at
AKUH.
Dr Asad Ali, Chair Antimicrobial Stewardship Sub-Committee
ii
Acknowledgement
We appreciate efforts of the Chairman and members of Pharmacy

and Therapeutic Committee to provide constant guidance, input and
finally approving the guidelines.
Members of Antimicrobial Stewardship Subcommittee
Dr Asad Ali,
Chair, Professor of Pediatric Infectious Diseases, Associate Dean
of Research
Dr Faisal Mahmood,
Associate Professor & Section Head Infectious Diseases (Adult),
Medicine
Dr Joveria Farooqi,
Assistant Professor, Microbiology, Pathology & Lab Medicine
Dr Mohammad Zeeshan,
Assistant Professor, Microbiology, Pathology & Lab Medicine
Dr Adnan Abdul Jabbar,

Associate Professor & Section Head Medical Oncology
Dr Kiren Habib,
Senior Instructor Infectious Disease (Adult), Medicine
Dr Nosheen Nasir,
Assistant Professor Infectious Disease (Adult), Medicine
Dr Farah Naz Qamar,

Associate Professor Pediatric Infectious Disease, Pediatrics and
Child Health
Dr Rizwan Haroon,
Assistant Professor, Surgery
Dr Madiha Ismail
Senior Instructor, Emergency Medicine
iii
Dr Falak Abro
Fellow II Infectious Disease, Pediatrics and Child Health
Dr Memoona Irshad
Fellow II Infectious Disease (Adult), Medicine
Asma Jesani,
Nurse, Infection Preventionist
Syed Shamim Raza,

Director, Pharmacy Services
Kashif Hussain,
Manager, Infectious Disease Pharmacist, Pharmacy Services
Gul Ambreen,
Senior Pharmacist (BCNSP), Pharmacy services
Mahreen Muzammil,
Clinical Pharmacist, Pharmacy Services
Samreen Sajjad,
Clinical Pharmacist, Pharmacy Services
Comments or Suggestions?
Please send us your feedback through email at:

drug.information@aku.edu
Or call us on 021-34861504, 021-34865337

Pager#8220
Pharmacy Services, AKUH
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Contents
l Preface
l Acknowledge
l Members of Antimicrobial Stewardship Subcommittee
Chapter 01: Mechanism of action of Antibiotics in AKUH........1
Chapter 02: Restricted and Controlled Antibiotics Policy......... 3
Chapter 03: Empiric Antibiotic Regimens...................................5
1. Skin and Soft Tissue / Bone / Joints Infections.................. 5

2. Central Nervous System Infection..................................... 7
3. Cardiovascular System Infections...................................... 8
4. Gastrointestinal Tract Infections.......................................11
5. Obstetrics /Gynecological Infections................................13
6. Genito-Urinary Tract Infection......................................... 14
7. Upper Respiratory Tract Infections...................................15
8. Lower Respiratory Tract Infections.................................. 16
9. Eye infections....................................................................17
10. Ear Infections....................................................................17
11. Empiric Antibiotic Regimens in the Emergency
Department........................................................................18
Chapter 04: Surgical Prophylaxis Guidelines........................... 22
1. Cardiovascular and Thoracic Surgery...............................24

2. Gastrointestinal surgery.................................................... 25
3. Gynecological and Obstetrics Surgery............................. 27
4. Head and Neck Surgery.................................................... 29
5. Orthopedic surgery........................................................... 30
6. Neurosurgery.................................................................... 31
7. Eye surgery....................................................................... 31
8. Urological Procedures...................................................... 32
9. Urologic Surgery (high risk patients only)....................... 33
10. Plastic Surgery.................................................................. 33
11. Vascular Surgery............................................................... 33
12. Odontogenic Infections.....................................................34
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Chapter 05: Treatment Guidelines and Protocols..................... 35
1. Febrile Neutropenia Guidelines........................................35

2. Clostridium Difficile Infection.........................................39
3. Malaria Treatment & Prophylaxis Guidelines.................. 39
4. Malaria Treatment Algorithm -1.......................................41
5. Malaria Treatment Algorithm -2.......................................42
6. Helicobacter pylori Treatment Guidelines........................44
7. COVID-19........................................................................ 45
8. Recommended Empirical Treatment for
CAP in Outpatient Setting................................................ 48
9. Recommended Empirical Treatment for CAP in the
Inpatient Setting................................................................50
10. Tuberculosis......................................................................52
11. Recommendations for Initial Therapy of Urinary
Tract Infections................................................................. 58
12. Primary Amebic Encephalitis (PAM) (Naegleria)............ 59
Chapter 06: Treatment for Miscellaneous Infections............... 61
1. Viral Infections................................................................. 61
2. Fungal Infections.............................................................. 63
3. Amphotericin B Administration Protocol......................... 67
4. Parasitic Infections............................................................69
Chapter 07: Antimicrobial Coverage & Sensitivity

(Antibiogram)............................................................................... 73
1. Akuh Inpatient. Percent Sensitive Jan-Dec 2019..............73

2. Akuh Outpatient. Precent Sensitive Jan-Dec 2019........... 74
3. Akuh / All Patients, Percent Sensitive January-
December 2019.................................................................76
Chapter 08: Drug Dosing, Pharmacokinetics and Safety......... 83
1. Adult Normal Doses and Antimicrobial drug Cost...........83

2. Safety of Antimicrobial in Pregnancy & Lactation...........88
3. Use of Vaccines in Pregnancy and/or lactation.................90
4. Dose Adjustments in Renal Failure Patients.....................93
5. Supplemental Doses for Antibiotics during Dialysis......101
6. CRRT Dosing Information (CVVH).............................. 103
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7. Hepatic Adjustment of Selected Antimicrobials.............104
8. Penetration of Antimicrobials in Cerebrospinal Fluid
(CSF)..............................................................................104
9. Intra-Ventricular Doses of Antimicrobials......................104
Chapter 09: Neonates and Pediatrics....................................... 105
1. Neonates (Sepsis)............................................................105
2. Meningitis....................................................................... 107
3. Miscellaneous................................................................. 108
4. Pediatric Empirical Therapy(CAP)................................ 109
5. Empiric Therapy CAP: Outpatient (Oral therapy)..........111
6. Empiric Therapy: (Inpatient): Complicated........... ...........112
7. Clostridium difficile infection........................................ 113
8. Typhoid Fever................................................................. 117
9. Neonates Antimicrobial Dosing (normal and renal
impaired) ........................................................................119
10. Pediatric Antimicrobial Dosing (normal and renal
impaired).........................................................................137
Chapter 10: Miscellaneous........................................................ 153
1. Guide for Antimicrobial Drug Dosing in Extremes

of Body weight................................................................153
2. Antibiotic Lock Therapy for Catheter-Related
Infection..........................................................................155
3. Administration protocol of Extended or Continuous
infusion of β-Lactam Antibiotics.................................... 158
Chapter 09: Drug Utilization Review and Use Criteria.........162
Chapter 10: Annexures.............................................................. 164
1. IV to PO Switch Guidelines...........................................164
2. Standardized Volume of Antibiotics in Pediatrics.......... 165
3. Recommended Labs for Patients on Long Term
Antibiotics......................................................................168
4. Antimicrobial Ophthalmic Agents..................................169
5. Topical Available at AKUH............................................171
6. AKUH Compounded Dermatological/Topical Agents... 175
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Chapter 01: Mechanism of action of
Antibiotics in AKUH
Aminoglycosides interfere with bacterial protein synthesis by
binding to 30S and 50S ribosomal subunits.
(Amikacin, Gentamicin, Tobramycin)
Beta-Lactams: Penicillins and cephalosporin’s inhibit bacterial

cell-wall synthesis by binding to one or more penicillin-binding
proteins which in turn inhibits the final transpeptidation step of
peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell-
wall biosynthesis.
Penicillins Cephalosporin’s Carbapenems

• Amoxicillin *Cefazolin *Meropenem
• Amoxicillin/Clavulanic acid *Cephalexin *Imipenem
• Ampicillin *Ceftriaxone *Ertapenem
• Cloxacillin *Cefixime
• Piperacillin-tazobactum *Cefpodoxime
• Benzyl penicillin *Cefotaxime
*Ceftazidime
Clindamycin binds to the 50S ribosomal subunit (reversibly),

preventing peptide-bond formation and inhibiting protein
synthesis.
Colistin is a polymixin antibiotic. Colistin is bactericidal in action.

It acts as a cationic detergent and interacts with phospholipids and
lipopolysaccharides and damages bacterial plasma membrane. This
damage alters the osmotic integrity of the cell membrane and causes
leak age of the intracellular components
Fluoroquinolones: Inhibits DNA-gyrase which does not allow the

uncoiling of supercoiled DNA and promote breakdown of
double-strand DNA. (Ciprofloxacin, Levofloxacin, Moxifloxacin)
Linezolid binds to a site on the 23S ribosomal RNA of the 50S

subunit, blocking formation of the 70S initiation complex thus
inhibiting translation.
1
Macrolides inhibit protein synthesis at the chain elongation step
and binds to the 50S ribosomal subunit.
Erythromycin, Azithromycin, Clarithromycin.
Metronidazole interacts with DNA causing a loss of helical DNA

structure and strand breakage, resulting in inhibition of protein
synthesis.
Tetracyclines inhibit protein synthesis by binding to the 30S and

possibly the 50S ribosomal subunits.
Doxycycline
Tigecycline binds at the same site on the ribosome as tetracycline’s,

however binds 5-fold more tightly. Also able to overcome the
ribosomal protection mechanism of tetracycline resistance.
Trimethoprim/sulfamethoxazole: Trimethoprim inhibits

dihydrofolic acid reduction to tetrahydrofolate, resulting in
sequential inhibition of the folic acid pathway. Sulfamethoxazole
interferes with bacterial folic acid synthesis and growth via
inhibition of dihydrofolic acid formation from PABA.
Vancomycin inhibits bacterial cell wall synthesis by blocking

glycopeptide polymerization through binding to the D-alanyl-D-
alanine portion of the cell wall precursor.
Fosfomycin The antibacterial effects of fosfomycin are related to

inhibition of bacterial cell-wall synthesis. Specifically, the drug
inactivates the enzyme pyruvyl transferase, which is responsible for
transformation of N-acetylglucosamine into N-acetyl-muraminic
acid; the latter is required for synthesis of the cell wall peptidoglycan
by bacteria. Fosfomycin is a bactericidal agent.
2
Chapter 02: Restricted and Controlled
Antibiotics Policy
Formulary restriction and controlled antibiotics is one of the pillars
of Antimicrobial Stewardship Program. The case for implementing
antimicrobial formulary restriction with preauthorization in a
hospital is well established. It has been shown to improve the quality
of antimicrobial prescribing, reducing rates of emerging resistance
and deliver a range of positive outcomes.
Antimicrobial Stewardship Program (ASP) protocol, can be

found on following link: https://one.aku.edu/PK/akuh/pharmacy/
Documents/Antibiotic%20Stewradship%20Progarmme%20-%20
Protocol.pdf
Restricted Antibiotic: Pre-authorization from ID pharmacist

(pager # 8220) ID physician is mandatory for restricted antibiotics.
However, in Iife threatening infections, 24 hour doses can be given,
afterwards approval is mandatory and drug will not be dispensed
from the pharmacy. The following drugs are considered in this
policy:
l Fosfomycin IV
l Tigecycline
l Linezolid IV/PO
l Co-trimoxazole IV
l ARV’S
l Caspofungin
l Remdesivir
l Tocilizumab
Controlled Antibiotics: Therapy can be started without pre-

authorization from I.D. but after 72 hours, for further continuation
an ID pharmacist/ ID physician/ medical microbiologist approval is
mandatory. The following antibiotic is considered in this policy:
l Colistin
3
Non-formulary antimicrobials:
l For certain rare infections need of arranging non-formulary

antimicrobials like Cefepime or other antimicrobial may arise.
l In such case primary team should seek prior approval from ID
physician/ ID Pharmacist before entering order.
l Once the approval is given, it is communicated to pharmacy
for the drug arrangement.
l The process of non-formulary drug arrangement shall
be followed as depicted in “Non Formulary Drug Request
Management” Policy
4
Chapter 03: Empiric Antibiotic Regimens
All treatments must be reviewed after 48 – 72 hours
Obtain appropriate cultures before starting antibiotics
Empiric antimicrobial therapy is directed against an anticipated and likely cause of infectious disease. It is used when
antimicrobials are given to a person before the specific bacterium or fungus causing an infection is known by considering
the facility antibiogram
Skin and Soft Tissue / Bone / Joints Infections
Antibiotic recommended
Indication Alternative
First line
5
Doxycycline 100mg q12h or
Acute recurrent boil/furunculosis Clindamycin PO 300-450mg q8h
Linezolid PO 600 mg q12h
Hidradenitis suppurativa Clindamycin PO 300-450mg q8h Linezolid PO 600mg q12h
Cellulitis (Purulent) Vancomycin IV 1g q12h Linezolid PO/IV 600mg q12h
(Non-purulent) Cefazolin IV 1-2g q8h Vancomycin IV 1g q12h
Ciprofloxacin IV 400 mg q12h+Clindamycin IV Ceftazidime IV 2g q8h
Acute Osteomyelitis
600mg q8h +Clindamycin 600mg IV q8h
Chronic Osteomyelitis Antibiotics based on cultures
Impetigo Cefazolin IV 1-2g q8h Clindamycin
Diabetic foot ulcer Ciprofloxacin PO 500mg q12h+Clindamycin PO 300- Piperacillin-tazobactam 4.5g q6-
Non-limb/life threatening 600mg q8h 8h+Vancomycin IV 1g q8-12h
Diabetic foot ulcer Piperacillin-tazobactam 4.5g q6-8h+Vancomycin IV 1g Imipenem IV 500mg q6h +
Limb/life threatening q8-12h Vancomycin IV 1g q8-12h
Necrotizing fasciitis / Gas gangrene Piperacillin-Tazobactam 4.5g q6-8h* + Clindamycin IV Imipenem 500mg q6h +
600mg q8h Clindamycin IV 600mg q8h
Add Vancomycin if suspected MRSA Add Vancomycin if suspected
MRSA
Pyomyositis Vancomycin IV 1g q12h Linezolid IV/PO 600 mg q12h
Septic arthritis Ceftriaxone IV 2g once daily Add Clindamycin or
Vancomycin if there is a
suspicion of MRSA
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Prosthetic joint, post op or infection Piperacillin-tazobactam 4.5g q6-8h+Vancomycin IV 1g Imipenem500mg q6h +
post intra-articular injection q12h Vancomycin IV 1g q12h
Septic bursitis Cefazolin IV 1g q8h Clindamycin IV 600mg q8h
Dog / cat / human / rat bite ** Amoxicillin-Clavulanate PO 1g q12h or 625 mg q8h Clindamycin Po 300 mg q6h +
Add **Doxycycline PO 100mg q12h Ciprofloxacin Po 500mg q12h
Infected Decubitus / venous / arterial Piperacillin-Tazobactam IV 4.5g q6-8h*
insufficiency ulcer with sepsis OR Imipenem IV 500mg q6h
Cefoperazone-Sulbactam IV 4g q12h
Vancomycin IV 1g q12h if
Phlebitis Cefazolin IV 1-2g q8h
already on a β-lactam antibiotic
*Reserve 4.5 g q6h dose for health care-associated infection, severe community-acquired infection, or patients with community-acquired infection at high risk of
adverse outcome and/or resistance
Central Nervous System Infection
Indication
First Line Alternative
Meningitis: Adults up to 50yrs Ceftriaxone IV 2g q12h + Vancomycin IV 1g q8-12h (Continue
-
(community acquired) vancomycin till cultures finalized)
Meropenem IV 2g
> 50 years +alcoholism/diabetes/ Ceftriaxone IV 2g q12h + Ampicillin IV 2g q4h + Vancomycin IV
q8h+ Vancomycin IV
impaired cellular immunity 1g q8-12h
1g q8-12h
Ventriculitis / meningitis post Vancomycin IV 1g q8-12h + Meropenem IV 2g q8h + -
neurosurgery Colistin IV 9MU load then as per CRCL
7
Brain abscess (community acquired) Ceftriaxone IV 2g once daily + Metronidazole IV 500 mg q8h
Herpes encephalitis Acyclovir IV 10 mg/kg q 8 hourly -
for 14 – 21 days
Cryptococcal meningitis (HIV +ve) Amphotericin B 0.7-1mg/kg/day + Fluconazole 800 mg x 2 weeks followed by Fluconazole
PO 800mg per day for minimum of 8 weeks, followed by 200 mg for > 1year (Fluconazole
as maintenance therapy in HIV on HAART is continued till CD4 COUNT is <100 and HIV
viral load is low or undetectable sustained for >3 months)
Cryptococcal meningitis (HIV –ve, Amphotericin B 0.7 mg/kg/day for 2-4 weeks weeks, followed by
immunocompromised) Fluconazole 400-800 mg for 8 weeks, then 200 mg for 6-12 months
HIV-ve immunocompetent Amphotericin B 0.7-1mg/kg/day for 4-6 weeks. Followed by Fluconazole 400-800 mg for 8
weeks then 200 mg for 6-12 months
Cardiovascular System Infections
Indication
First line Alternative
ID consult is recommended for Endocarditis
Native valve Endocarditis
Empiric while awaiting cultures Ceftriaxone IV 2g q24h + Vancomycin IV 1g12h Vancomycin IV 1g q12h +Gentamicin
1mg/kg q8h
Streptococcus species with Ceftriaxone IV 2g q24h for 4 weeks Penicillin G IV (12-18 million units per
penicillin MIC < 0.12 day q4h for 4wks)
• Viridans streptococci OR
8
• S. gallolyticus Vancomycin 1g q12h for 4 weeks
Streptococcus species with penicillin Pen G IV 24 million units per day q4h for 4 weeks Ceftriaxone IV 2g q24h for 4 weeks
MIC > 0.12 to < 0.5 + Gentamicin 1mg/kg q8h for 2 weeks +Gentamicin 1mg/kg q8h for 2 weeks
• Viridans streptococci OR
• gallolyticus Vancomycin 1g q12h for 4 weeks
Streptococcus species with Pen G IV 24 million units per day q4h for 4 weeks + Vancomycin 1g q12h for 4 weeks
penicillin MIC > 0.5 Gentamicin 1mg/kg q8h for 4 weeks
Viridans streptococci OR
S. gallolyticus
Ampicillin IV 12g per day q4h for 4 weeks
Granulicatella elegans
Granulicatella adjacens +Gentamicin 1mg/kg q8h for 4 weeks
Abiotrophia defectiva
Enterococcus species Ampicillin IV 12g per day q4h+Ceftriaxone IV 2g Ampicillin IV 12g per day q4h+
Synergy with gentamicin q12h for 6 weeks Gentamicin 1mg/kg q8h for 4-6 weeks
OR OR
Pen G IV 24 million units per day q4h + Gentamicin Vancomycin IV 1g q8-12h+Gentamicin
1mg/kg q8h for 4-6 weeks 1mg/kg q8h for 6 weeks(penicillin
resistant MIC >16µg/ml)
High Level gentamicin resistance Ampicillin IV 12g per day q4h+Ceftriaxone IV 2g
(MIC >500µg/ml) q12h for 6 weeks
OR
(If susceptible to Streptomycin MIC ≤ 1500 μg/ml)
9
Pen G IV 24 million units per day
q4h+Streptomycin 15mg/kg/day q12h IM for 4-6
weeks
MSSA aortic/mitral valve Cefazolin IV 2g q8h for 4-6weeks Cloxacillin IV 2g q4h for 4-6 weeks
OR
Vancomycin 1g q8-12h for 6 weeks
MSSA tricuspid valve Cefazolin IV 2g q8h for 4 weeks Cloxacillin IV 2g q4h for 6 weeks
OR
Vancomycin 1g q8-12h for 6 weeks
MRSA Endocarditis Vancomycin IV 1g q8-12h for 6 weeks -
Endocarditis due to HACEK Ceftriaxone IV 2g q24h for 4 weeks Ampicillin IV 2g q4h + Gentamicin 1mg/
kg q8h for 4 weeks
OR
Ciprofloxacin IV 400 mg q12h for 4 weeks
Prosthetic valve Endocarditis

ID and Surgery consult is recommended
Empiric while awaiting cultures Vancomycin IV 1g q8-12h + Gentamicin IV 1mg/kg -

q8h + Rifampin IV/PO 300mg q8h
MRSE or MRSA Vancomycin 1g q8-12h for 6 weeks + Rifampin 300 -
mg q8-12h for 6 week) +
10
Gentamicin IV 1mg/kg q8h for 2 weeks
MSSE or MSSA Cloxacillin IV 2g q4h for 6 weeks+ Rifampin IV/ Cefazolin IV 2g q8h for 6 weeks +
PO 300mg q8-12h for 6 weeks + Rifampin IV/PO 300mg q8-12h for 6
Gentamicin IV 1mg/kg q8h For 2 weeks weeks+ Gentamicin IV 1mg/kg q8h for 2
weeks
OR
Vancomycin IV 1g q8-12h for 6 weeks
Candida Amphotericin B IV 1mg/kg q24h Caspofungin IV 70mg load then 50 mg
q24h
Gastrointestinal Tract Infections
Indication
Neutropenic enterocolitis Piperacillin-Tazobactam IV 4.5g q6h Imipenem IV 500 mg q6h or Ertapenem
(typhlitis) IV 1g q24h
Diverticulitis/ Perirectal Ceftriaxone IV 2g q24h+ Metronidazole IV Piperacillin-Tazobactam IV 4.5g q6-8h*
abscess/ Peritonitis/Colorectal/ loading dose 1gm then 500mg q6h
Appendicitis/ (For appendicitis conservative management
Penetrating trauma abdomen 7-10days)
Patients with intestinal perforation should
receive antibiotics for 2-5 days, if no bowel
injury then one dose is adequate.
11
Intra-abdominal sepsis Piperacillin-TazobactamIV 4.5g q6-8h* Imipenem IV 500 mg q6h or Ertapenem IV
1g q24h or Doripenem IV 500mg q8h
Cholecystitis/ cholangitis Piperacillin-TazobactamIV 4.5g q8h Imipenem IV 500 mg q6h or Ertapenem
/biliary sepsis/ CBD IV 1g q24h
Obstruction
SBP (Spontaneous Bacterial Ceftriaxone IV 2g q24h Piperacillin-Tazobactam IV 4.5g q8h
Peritonitis)
(primary/mono-microbial)
Secondary Peritonitis Piperacillin-Tazobactam IV 4.5g q6-8h* Imipenem IV 500 mg q6h or Ertapenem
(polymicrobial) IV 1g q24h
(post- operative/ perforation)
Bacterial dysentery Azithromycin PO 500mg OR 1g single dose Ceftriaxone IV 2g q24h
OR
500mg q24h for 3 days
Amoebic dysentery Metronidazole PO 800mg q8h for 7-10 days -
Acute watery diarrhea (not No antibiotics Azithromycin (for severe diarrhea
cholera) with fever and toxicity)
Cholera Azithromycin PO 500 mg q24h for 3 days Doxycycline PO 300mg single dose
Amoebic liver abscess Metronidazole IV/PO 750/800 mg q8h -
(additional
Metronidazole/Diloxanide therapy
12
required for eradication)
Pyogenic liver abscess Ceftriaxone IV 2g q24h + Metronidazole IV Piperacillin-Tazobactam IV 4.5g q8h Add
750mg q8h Metronidazole ( if amoebic)
Enteric fever (Inpatient) Ceftriaxone IV 2g + Azithromycin IV 1g then Meropenem IV 1g q8h*
500 mg q24h *Unstable (impending perforation, shock)
Acute pancreatitis No Antibiotic Recommended
(Alcoholic/ without necrosis)
Pancreatic abscess/ Imipenem IV 500mg q6h -
Infected pseudocyst
Obstetrics /Gynecological Infections
Antibiotic Recommended
Indication
Endometritis/ Piperacillin-Tazobactam IV 4.5g q6-8* Imipenem OR Ertapenem OR Meropenem
septic pelvic phlebitis
(post-partum)
Also inform neonatal team if mother has endometritis

PID/ salpingitis/ tubo-ovarian Ceftriaxone IV 2g q24h + Metronidazole IV Amoxicillin-clavulanate IV 1.2g q8h +
Abscess 500mg q8h + Doxycycline PO 100mg q12h
Doxycycline PO 100 mg q12h
13
Septic abortion Piperacillin-Tazobactam IV 4.5g q6-8h*+ ImipenemIV 500mg q6h+ Doxycycline PO
Doxycycline PO 100mg q12h 100mg q12h
Candida vaginitis Clotrimazole vaginal pessaries Fluconazole 150mg single dose
Genito-Urinary Tract Infection
Antibiotics Recommended
Indication
Perinephric abscess Piperacillin-TazobactamIV 4.5g q6-8h* Imipenem or Meropenem or
Ertapenem
Asymptomatic bacteriuria Treat only in pregnancy /pre GU procedure
Prostatitis (without risk of STD) Ciprofloxacin PO500mg or IV 400 mg q12h Imipenem or Meropenem or
Ertapenem
Epididymo-orchitis/Prostatitis Ceftriaxone IM 250mg single dose + Amoxicillin-clavulanate PO 1g q12h
14
(risk of STD) Doxycycline PO 100mg q12h for 10 days
Gonorrhea/Non-gonococcal/post Azithromycin PO 1g single dose

gonococcal urethritis/cervicitis +Ceftriaxone IM 250mg single dose
Syphilis Penicillin G IV 4 million units q4h Ceftriaxone IV 2g q24h

UroSepsis: Imipenem IV 500mg q6h Piperacillin/Tazobactam IV 4.5g q6-
Life threatening sepsis 8h*
Upper Respiratory Tract Infections
Indication
Acute rhinosinusitis Usually symptomatic care. No antibiotics needed
(< 10 days)
Acute rhinosinusitis Amoxicillin-Clavulanate PO 875/125 Levofloxacin PO 750mg q24h or
(> 10 days, or facial pain) BID+500/125(ds) mg in between of Azithromycin 250-500mg q24h
875/125
Chronic bacterial sinusitis Amoxicillin-Clavulanate Clindamycin
(Symptoms > 3 months)
Nosocomial sinusitis (nasotracheal/ Piperacillin-Tazobactam IV 4.5g q6h +/- ImipenemIV 500 mg q6h+/- Vancomycin IV 1g
15
nasogastric intubation) Vancomycin IV 1g q12h q12h
Acute pharyngitis (bacterial) Amoxicillin Clarithromycin
(exudative or diffuse erythema or
petechiae)
Peritonsillar/ tonsillar abscess Amoxicillin-/Clavulanate Clindamycin
Vincent’s angina (anaerobes) Amoxicillin-Clavulanate Clindamycin
Parapharyngeal space infection Amoxicillin-Clavulanate Clindamycin
Jugular vein septic phlebitis Amoxicillin-Clavulanate Clindamycin
Perimandibular actinomycosis Penicillin G Or Amoxicillin-Clavulanate Clindamycin
Parotitis (adults) Cloxacillin Clindamycin
Diphtheria (Antitoxin+Antibiotics) Penicillin G 50000 Units/kg q12h Azithromycin:
Antitoxin is not available Max dose 4MIU For children: 10-12 mg/kg once daily (max. 500
mg/day). Treat for total of 14 days. For adults:
500 mg once daily. Treat for total of 14 days.
Lower Respiratory Tract Infections

Nosocomial Pneumonia (including Imipenem IV 500mg q6h or Meropenem IV
VAP) 1gq8h +
Vancomycin IV 1g q8-12h + Colistin IV
9MU load then as per CRCL
Aspiration Pneumonia (Community Piperacillin-Tazobactam IV 4.5g q6-8*
Acquired)
16
Aspiration pneumonia Piperacillin-TazobactamIV4.5gq6h + Imipenem IV 500mg q6h+ Vancomycin
(>3 days in hospital) Vancomycin IV 1g q12h IV 1g q12h
Lung abscess/Acute empyema Piperacillin-Tazobactam IV 4.5g q6- Imipenem IV 500mg q6h or
8h+Vancomycin IV Meropenem IV 1g q8h + Vancomycin
Chronic/subacute empyema Treat according to cultures -
Severe Acute bacterial exacerbation Piperacillin-Tazobactam IV 4.5g q6h Levofloxacin IV/PO 750mg q24h
of COPD
Cystic fibrosis/bronchiectasis Piperacillin-Tazobactam IV 4.5g q6h Imipenem IV 500mg q6h +inhaled
colistin 1-2MU q8-12h
Non CF/ bronchiectasis Piperacillin-Tazobactam IV 4.5g q6h
+inhaled tobramycin 300mg q12h
Eye infections
Indication
Orbital cellulitis Ceftriaxone IV 2g q24h + Clindamycin IV/PO
300-600 q8h
Dacryocystitis Amoxicillin-Clavulanate IV 1.2 g q8h or PO 500/125mg Clindamycin IV/PO 300-600 q8h
q8h
Endophthalmitis Vancomycin IV 1g q12h + Imipenem IV 500mg q6h along -
(hematogenous) with intravitreal antibiotics
(If suspicion of candida infection, systemic
and local antifungal agents may be needed)
17
Cavernous sinus Ceftriaxone IV 2g q24h +Vancomycin IV 1g q12h Imipenem IV 500mg q6h +
thrombosis Vancomycin IV 1g q12h
Toxoplasmosis Co-trimoxazole Clindamycin IV 600mg q8h or PO 300 mg
q6h + Primaquine 15mg-30mg base q24h
Ear Infections
Indication First line Alternative
Malignant otitis externa Ciprofloxacin IV 400mg q12h or PO 750 mg q12h Piperacillin-Tazobactam IV 4.5g q6h
Otitis media Amoxicillin/Clavulanate PO Cefpodoxime
Acute mastoiditis Amoxicillin/Clavulanate PO Ceftriaxone
Chronic mastoiditis
Based on cultures -
(Surgery often required)
Empiric Antibiotic Regimens in the Emergency Department
S# Indications First Line Second Line
1. Acute Bacterial Exacerbation of COPD Piperacillin/Tazobactam IV 4.5g q6h Levofloxacin IV/PO 750 mg q24h
2. Acute Sinusitis Amoxicillin -Clavulanate IV 1.2 g Levofloxacin IV/PO 750 mg q24h
q8h OR
Amoxicillin-Clavulanate PO 875/125
BID+500/125 mg in between of 875/125
3. Cystitis Nitrofurantoin 100mg q6h for 5days Fosfomycin PO 3g sachet one time
OR
Fosfomycin Calcium PO 500mg q6h or 1g q8h
for 5-7days
4. Aspiration Pneumonia (Community) Piperacillin-Tazobactam IV 4.5g q8h
18
5. Cellulitis, Erysipelas Cefazolin IV 1g-2g q8h Clindamycin IV 600mg q8h (if nosocomial
then vancomycin IV 1g q12h)
6. Cholecystitis/cholangitis/biliary Piperacillin-Tazobactam IV 4.5g q8h Imipenem 500 mg q6h or Ertapenem IV 1g
sepsis/CBD obst. q24h
7. Community Acq Pneumonia (severe/ Ceftriaxone IV 2g q24h Piperacillin-Tazobactum IV 4.5g q6-8h* +
ICU patient) +Azithromycin IV 500mg q24h Levofloxacin IV/PO 750mg q24h
or Ceftriaxone IV 2g q24h
+Levofloxacin IV/PO 750mg q24h
8. Community Acq Pneumonia Ceftriaxone IV 2g q24h + Levofloxacin IV/PO 750mg q24h
(In-hospital, non ICU) Clarithromycin PO 500mg q12h or
Azithromycin PO 500mg q24h
9. Community Acquired Pneumonia Cefpodoxime PO 200mg Levofloxacin PO 750mg q24h
(Sending Home) q12h+Clarithromycin PO 500mg
q12h or Azithromycin PO 500mg
q24h
10. Complicated UTI/Pyelonephritis Ertapenem IV 1g once daily OR Piperacillin-Tazobactam IV 4.5g q6-8h*
Meropenem IV 1g q8h or Doripenem
IV 500mg q8h
11. Diabetic foot ulcer (Limb/life Piperacillin-Tazobactam IV 4.5g q6- Imipenem IV 500mg q6h + Vancomycin IV 1g
threatening) 8h*+ Vancomycin IV 1g q8-12h q8-12h
12. Diabetic foot ulcer (Non-limb/life Ciprofloxacin PO 500mg Piperacillin-tazobactam 4.5g q8h+Vancomycin
threatening) q12h+Clindamycin PO 300-600mg IV 1g q12h
q8h
19
13. Diverticulitis/Perirectal Ceftriaxone IV 2g q24h+ Piperacillin-Tazobactam IV 4.5g q8h*
abscess/Peritonitis Metronidazole IV loading dose 1gm
then 500mg q6h
14. Dog/cat/human/rat bite** Amoxicillin-Clavulanate PO 500-125 Clindamycin Po 300 mg q6h + Ciprofloxacin
mg q8h Po 500mg q12h
Add ** Doxycycline PO 100mg q12h
15. Endocarditis Refer Empiric cardiovascular system
infections section
16. Enteric Fever Ceftriaxone IV 2g+Azithromycin IV ***Meropenem IV 1g q8h
1g then 500mg q24h ***Unstable (impending perforation, shock)
17. Epididymo-orchitis/Prostatitis(risk of Ceftriaxone IM 250mg single dose Amoxicillin-clavulanate PO 875/125 mg q12h
STD) + Doxycycline PO 100mg q12h for
10 days-
18. Febrile Neutropenia Refer Febrile neutropenia algorithm
19. Gastroenteritis (Cholera) Doxycycline 300 mg single dose Azithromycin 500 mg q24h for 3 days
20. Gonorrhea/Non-gonococcal/post Azithromycin PO 1g single dose
gonococcal urethritis/cervicitis +
Ceftriaxone IM 250mg single dose
21. Herpes Encephalitis Acyclovir IV 10 mg/kg q8h
22. Intra-abdominal sepsis Piperacillin-Tazobactam IV 4.5g Imipenem or Doripenem or Ertapenem
q6-8h
23. Pyogenic Liver abscess Ceftriaxone IV 2g q24h + Piperacillin-Tazobactam IV 4.5g q8h add
20
Metronidazole IV 750mg q8h Metronidazole ( if amoebic)
24. Malaria – Falciparum Refer Malaria Algorithm
25. Malaria – Vivax Refer Malaria Algorithm
26. Malaria-Falciparum complicated Refer Malaria Algorithm
27. Meningitis Adult (<50 years) Ceftriaxone IV 2g q12h +Vancomycin
IV 1g q8h
28. Meningitis Adult(>50years) with Ampicillin IV 2g q4h+ Ceftriaxone Meropenem IV 2g q8h +Vancomycin IV 1g
impaired cellular immunity IV 2g q12h+ Vancomycin IV 1g q8h q8h
29.. Necrotizing fasciitis Piperacillin-Tazobactam 4.5g q6-8h* Imipenem IV 500mg q6h + Clindamycin IV
+ Clindamycin IV 600mg q8h 600mg q8h
Add Vancomycin if suspected MRSA Add Vancomycin if suspected
MRSA
30. Severe Sepsis or Septic Shock Piperacillin-tazobactam IV 4.5 q6h Imipenem or Meropenem+Vancomycin
+Vancomycin
31. Spontaneous Bacterial Peritonitis (SBP) Ceftriaxone IV 2g q24h Piperacillin-Tazobactam IV 4.5g q8h
32. Secondary Peritonitis Piperacillin-Tazobactam IV 4.5g Imipenem IV 500 mg q6h or Ertapenem IV
(polymicrobial) q6-8h* 1g q24h
(post- operative/ perforation)
21
Chapter 04: Surgical Prophylaxis Guidelines
Important Note:
Prophylaxis should be targeted against most likely pathogens,

taking into consideration type of surgery and local epidemiology.
Timing of Antimicrobial Prophylaxis:

1. Administer correctly—goal is for adequate tissue
concentration at the time of risk
2. Administer within 30-60 minutes before the incision
3. For vancomycin and fluoroquinolones, the ideal timing is
to start the infusion 120 minutes prior to incision.
4. When a proximal tourniquet is required, however, the
entire antimicrobial dose should be administered before
the tourniquet is inflated.
5. Confirm with the surgeon at the Time-out or earlier since
occasionally antibiotics need to be delayed until after
culture
6. Prophylactic antibiotics should preferably be discontinued
24 hours after the end of surgery
7. In clean and clean-contaminated surgeries, discontinue
antibiotics after the surgical incision is closed unless the
patient has a documented or suspected infection, even if
a drain is in place.
Non-Antimicrobial methods of preventing infection:
Recent data suggest that attention to intraoperative temperature
control and supplemental oxygen administration along with
aggressive fluid resuscitation may reduce infection rates. Proper
glycemic control before operating is also known to reduce surgical
site infections.
Note: If the patient is already on antibiotic, there is no need to

initiate a new antibiotic for surgical prophylaxis. However, if the
dose time is due, there is a need to administer the due dose before
the procedure.
3 Adult Cefazolin IV dose would be 2g for patients weighing
<120 kg and 3g for patients weighing >120 kg.
3 Adult Clindamycin IV dose would be 600 mg for patients
weighing < 70kg and 900 mg for patients weighing > 70kg.
3 Adult Vancomycin IV dose would be 1g <80kg, 1.25g 80-99
kg and 1.5g 100-120kg patients
22
Recommended IntraOp Redosing Intervals for Commonly
Used Surgical Prophylaxis Antimicrobials for Adults with
Normal Renal Function
Antimicrobial Half-life Recommended

(IV) (hour) re-dosing interval
from initiation of
preoperative dose
(hour)
Cefazolin 2g 1.1-2.2 4
Ciprofloxacin 400mg 3-7 8-12
Clindamycin 600-900mg 2-4 6
Gentamicin 5mg/kg 2-3 No redosing
Ceftriaxone 2g 6-10 12
Metronidazole 500mg 6-8 8
Vancomycin 1-2g 4-8 12
Piperacillin-tazobactam 0.7-1.2 2
4.5g
Antimicrobial Children dose

(IV)
Cefazolin 30mg/kg
Ciprofloxacin 10-15mg/kg
Clindamycin 10mg/kg
Gentamicin 2.5mg/kg
Ceftriaxone 50-65mg/kg
Metronidazole 15mg/kg
Vancomycin 15mg/kg
Piperacillin-tazobactam 4.5g 100mg/kg of piperacillin
23
Cardiovascular and Thoracic Surgery
Indications First line Alternate
Coronary bypass; valve surgery Cefazolin IV 2 g then 1g q8 h x 48 Vancomycin/Clindamycin for 24-48 hrs.
(AVR/MVR) hours *Duration up to 72 hours for high rsk
Some recommend a 2nd dose at the surgeries only
time of removal from bypass.
Pace maker insertion,defibrillator Same as above
Implant
Peripheral vascular surgery, Cefazolin IV 2 g then 1g q8 h x 3 Vancomycin 15 mg/kg or Clindamycin +
Abdominal aorta, and legs or any doses gentamicin
procedure involving a prosthesis,
24
including coronary stents and
grafts for hemodialysis
Carotid or brachial artery None -
SD/TOF in paeds Cefazolin 30mg/kg preop 30 minutes Vancomycin 15mg/kg
before surgery then q8h for 48hrs
Lobectomy, pneumonectomy Cefazolin IV 2 g then 1 g q 8 Alternative Vancomycin 1 g IV pre- op over 60 min
hours x48 hours)1,
Gastrointestinal surgery
Gastric surgery (high risk Cefazolin <120kg 2g IV Clindamycin 600 mg IV +Gentamicin 1.7
only) Cefazolin >120kg 3g IV mg/kg
Biliary tract Cefazolin <120kg 2g IV Ciprofloxacin IV 400mg + Amikacin
ERCP Cefazolin >120kg 3g IV pre-op 15mg/kg
(Must send CS for open/radiologic OR
procedures) Ceftriaxone IV 2g
If prior biliary instrumentation/access:
Consider Piperacillin-Tazobactam 4.5g IV
Q8H
Colorectal (Elective 24h Coverage) If patient has history of prior antibiotic use,
25
Cefazolin <120kg 2g IV then start Piperacillin-Tazobactam IV 4.5
Cefazolin >120kg 3g IV gm q8h
+ Metronidazole 500mg IV
OR
Ceftriaxone IV 2g+Metronidazole IV 500mg
Appendectomy Clindamycin 600 IV + Amikacin
Cefazolin <120kg 2g IV 15 mg /kg
Cefazolin >120kg 3g IV
+Metronidazole IV 500mg
For uncomplicated appendix 24h coverage is
adequate.
Laparotomy, lysis of Clindamycin 600 IV + Amikacin
Adhesion (without GI tract surgery), Cefazolin <120kg 2g IV 15 mg /kg
splenectomy, etc. Cefazolin >120kg 3g IV
Without GI tract surgery
GI tract Spillage Ceftriaxone IV 2g +Metronidazole IV 500 mg

for 24h if source control and 3-5days if gross
contamination.
Splenectomy Ceftriaxone IV 2g q24h for 3 days

Inguinal Hernia repair/Mastectomy Cefazolin <120kg 2g IV
26
Total thyroidectomy No abx. recommended as it is a clean
procedure
Gynecological and Obstetrics Surgery
Vaginal/abdominal/radical/laparoscopic Clindamycin 900mg IV +Gentamicin
hysterectomy Cefazolin <120kg 2g IV 5mg/kg IV
Cefazolin >120kg 3g IV (single dose)
(single dose)
PPROM Ampicillin IV 2g q6h IV+ Erythromycin 250 Erythromycin alone in penicillin
mg PO q6h for 48 hours then Amoxicillin allergic patients
250 mg PO q8h + Erythromycin 250 mg PO
q8h for 5 days.
OR
27
Ampicillin IV 2g q6h for 48 hours
+Azithromycin 1g IV once then Amoxicillin
250mg q8h for 5 days
Caesarian section (high risk only)
Cefazolin <120 kg: 2g IV Clindamycin 900mg + Gentamicin
>120 kg: 3g IV 5mg/kg IV
(single dose) (single dose)
Uterine evacuation (suction D&C/D&E) Doxycycline 200 mg pre and post procedure Metronidazole 400 mg pre and post
procedure
(For patients with N. gonorrhea
and C. trachomatis, treat STD with
minimal delay in uterine evacuation)
GBS Benzyl penicillin IV 5MU after the onset of Penicillin allergic: Patients not at high
labor and 2.5 – 3 mu IV q4h until delivery risk for anaphylaxis Cefazolin 2gm IV
OR then 1g q8h until delivery.
Ampicillin 2gm IV then 1gm IV q4h till
delivery Patients at high risk for anaphylaxis
from beta-lactams: Clindamycin
900 mg IV q8h until delivery OR
Vancomycin 1g IV q12h until
delivery
Hysterosalpingography Doxycycline 200 mg pre-procedure Clindamycin 900 IV +
Amikacin 15 mg /kg stat, then QD
28
Colporrhaphy/Vaginal sling Cefazolin <120 kg: 2g IV
>120 kg: 3g IV
Cystocele and rectocele repair None -
Tubal ligation/Cystoscopy/endometrial None -
biopsy/hysteroscopy/IUD insertion/
laparoscopic and cervical tissue excision
procedures
Head and Neck Surgery
Clean None -
Clean with placement of Cefazolin <120kg 2g IV -
prosthesis Cefazolin >120kg 3g IV
Clean- contaminated Cefazolin <120kg 2g IV -

q 8h for 24 hour
+ Clindamycin 600 mg or Metronidazole 500 mg
q8h IV for 24 hour.
29
Rhinoplasty None
Tonsillectomy +/- adenoidectomy None
Major surgery with entry via oral Clindamycin 600-900 mg IV pre-op and q 8 hour Amoxicillin-Clavulanate IV 1.2 gm
cavity or pharynx for 48 hours q8hrly for 2-3 doses
Orthopedic surgery
Clean* None
*Not involving implantation of foreign material (laminectomy, knee, hand, and foot surgeries, also arthroscopies, carpel tunnel
release etc)
Other orthopedic surgeries Cefazolin 2 g IV at induction of anesthesia and 1g q
8 hour for 24 hour
Joint replacement Cefazolin 2 g IV pre-op (+/- second dose) Alternative: Vancomycin 1g IV or
Clindamycin 600 mg q 8 hour for 24 hours
30
Open reduction of fractures Ciprofloxacin IV 400mg q12h+Clindamycin IV Cefazolin 2 g IV (+/- 1g q 8 hour x3 doses)
/ internal fixation 600mg q8h for 24hours
Compound fracture Cefazolin 2 g IV then 1g q 8h x 5- 10 days or Vancomycin 1 g IV q 12 hour or Clindamycin
Amoxicillin-Clavulanate IV 1.2 g q8h (Start 600 mg q 8 hour for 5 to 10 days.
treatment immediately and continue for 5- 10 days)
Amputation of the leg Cefazolin IV 2 g Amoxicillin-Clavulanate IV 1.2 g
Traumatic wound Amoxicillin-clavulanate IV 1.2 g Cefazolin IV 2g
Neurosurgery
Elective craniotomy Cefazolin <120kg 2g IV Vancomycin IV 1 g
CSF fluid shunting/VP shunt Cefazolin <120kg 2g IV Vancomycin IV 1g
Spinal surgery/Laminectomy Cefazolin <120kg 2g IV If involving foreign material may use Cefazolin +
Cefazolin >120kg 3g IV Gentamicin
31
Eye surgery
First line Alternate
For elective procedures; Ciprofloxacin eye drops QID preop, Tobramycin 0.3% or Gentamicin 0.3% 2 drops instilled before the
For 1 day, then QID post op and tapered over 1 month procedure.
Vitrectomy No IV antibiotic Moxifloxacin eye drops should be applied for

four doses every 5 minutes
OR
Intracameral cefuroxime (1mg/0.1ml single dose)
Cataract Intracameral cefuroxime post-op
Urological Procedures
Simple catheterization, Urodynamics, None
Diagnostic cystoscopy ESWL
Difficult Catheterization/ Gentamicin IV 2-3mg/Kg (single dose)
Urethral dilatation /
Suprapubic catheterization
Cystoscopy+/- Biopsy
Stent removal
Prostate biopsy Ciprofloxacin IV 400mg q12h + Amikacin IV
15mg/kg q24h (For 3 days)
32
TURP/TURBT Amikacin IV 15 mg/kg (single dose) Cefazolin IV 2g OR Amoxicillin-
Clavulanate IV 1.2g OR Gentamicin IV
2-5mg/kg (single dose)
Retrograde Pyelography/ Amikacin IV 15 mg/kg (single dose) Cefazolin IV 2g OR Amoxicillin-
Ureteric stenting/ Clavulanate IV 1.2g OR Gentamicin IV
Ureteroscopy 2-5mg/kg (single dose)
Percutaneous nephrolithotomy(PCNL) Cefazolin IV 2g (single dose, can be given Amikacin IV 15mg/Kg +/-
24hours) Amoxicillin-Clavulanate IV 1.2g
Nephrectomy (Simple/Radical/ Donor/ Cefazolin IV 2g(single dose) Amoxicillin-Clavulanate IV 1.2g(single
Laparoscopic) dose)
Renal transplant low risk Ceftriaxone IV 2G (single dose) Piperacillin-tazobactam iv 4.5g(single
dose)
Renal transplant high risk Piperacillin-tazobactam IV 4.5g(single dose) Meropenem IV 1g (single dose)
Urologic Surgery (high risk patients only)

Indication Choice
Prostatectomy Infected urine Continue agent active in vitro or give single preoperative dose. Sterilization
of urine is must
Prostate biopsy and Dilatation of urethra None
Plastic Surgery
33
Indication Choice
Skin grafting/flaps Operating in oropharyngeal region Amoxicillin-Clavulanate IV 1.2g
Vascular Surgery
Including aneurysm repair, Cefazolin Vancomycin with or w/o
Thrombo-endarterectomy and vein Gentamicin, or Clindamycin if
bypass) patient has documented beta
lactam allergy
Odontogenic Infections
Antibiotic Adult Dose
500mg q8h Po
Amoxicillin
1000 mg q12h Po
500-125 mg q8h Po
Amoxicillin-clavulanate 875-125 mg q12h Po
1.2 g q8h IV
300 mg q8h Po
Clindamycin
600 mg q8h IV
Azithromycin 500 mg q24h Po
Ciprofloxacin 500 mg q12h Po
Metronidazole 400-800 mg q8h Po
Gentamycin 240 mg q24h IV/IM
1.2-2.4 MIU IM
Penicillin
Upto 24MIU /24hours IV
Metronidazole (Children)
• 1-3 years: 100mg three times daily for up to five days, review
after 2-3 days and discontinue if resolved
• 3-7 years: 200mg twice daily for up to five days, review after 2-3
days and discontinue if resolved
• 7-10 years: 200mg three times daily for up to five days, review
after 2-3 days and discontinue if resolved
• Over 10 years: 400mg three times daily for up to five days,
review after 2-3 days and discontinue if resolved
Amoxicillin (Children)
1 month–1 year, 125 mg every 8 hours, increased if necessary up to 30
mg/kg every 8 hours;
• 1–5 years, 250 mg every 8 hours, increased if necessary up to 30
mg/kg every 8 hours;
• 5–12 years, 500 mg every 8 hours, increased if necessary up to 30
mg/kg (max. 1 g) every 8 hours
• 12–18 years, 500 mg every 8 hours, in severe infection 1 g every
8 hours
Prevention and treatment of oral candidiasis Miconazole gel by
mouth, adult and child over 2 years, 2.5 mL 4 times daily after meals,
retain near oral lesions before swallowing (dental prosthesis should be
removed at night and brushed with gel).
Prevention and treatment of intestinal candidiasis, by mouth, adult and
child over 4 months, 5 mg/kg 4 times daily; max. 250 mg (10 mL) 4
times daily
Note; Treatment should be continued for at least 7 days after lesions have
healed or symptoms have cleared.
34
Chapter 05: Treatment Guidelines and
Protocols
Febrile Neutropenia Guidelines
Fever + ANC <500/mcl (or expected <500 within 24h) and unknown source
Indications for vancomycin Is the patient hemodynamically stable? NO

l Colonization with resistant gram +
(MRSA or PRSP)
l Catheter or soft tissue infection
l Blood culture positive for gram Empirical Parenteral
+ organism Therapy
l High risk for viridans group
YES
streptococcal infection Imipenem: 500mg q6h
or Meropenem 1g q8h or
YES Is vancomycin indicated? Piperacillin-tazobactam
4.5g q6h+ Amikacin
15mg/kg q24h
NO
Empirical Antifungal
Is Oral Therapy Acceptable
(MASCC* index >21) Therapy if persistent
fever after 4-7 days
Amphotericin IV 0.5-
Empirical Parenteral NO YES 1mg/kg q24h
therapy plus
vancomycin 15mg/
kg q12h ORAL THERAPY
Parenteral therapy Ciprofloxacin plus “RESCUE” REGIMEN
appropriate for amoxicillin-Clavulanate carbapenem +
neutropenic fever (consider inpatient for vancomycin + Amikacin
first 24h)
Defervescence
*Continue Rx till ANC
> 500 and afebrile for
≥ 24hr YES NO NO
*Change Rx as per
sensitivity
Galactomannan
Is Antifungal Therapy
YES Clinically Stable? NO Required?
Add antifungal if persistent YES

fever after 4-7 days
Indications for Antifungal

Add ANTIFUNGAL THERAPY Therapy
• Persistent fever 4-7 days
• New fever after defervescence
• New pulmonary infitrates while on broad
spectrum antibiotics
• Isolation of yeast from sterile site OR
mold from anywhere
A general approach to patients with fever and neutropenia without a clinically or

microbiologically documented infection. *MASCC: Multinational Association for
Supportive Care in Cancer Klatersky et al. JCO 18: 3038-51 (2000)
35
Fever and Neutropenia
Fever: A single oral temperature of greater than 38.3°C (101°F) or

38.0°C (100.4°F) or greater for over 1 hour.
Neutropenia: Absolute neutrophil count less than 500 /mcL or less
than 1,000 /mcL with predicted rapid decline.
Findings Evaluation and Modifications

Initial neutropenic Complete history and physical examination
fever with special attention to the mouth, skin,
catheter exit site, and perianal region.
Complete blood count and differential,
serum chemistry including liver function
tests, MP-ICT, at least two sets of blood
cultures, a urine culture, a chest radiograph
and potential sites of infection should be
sampled prior to instituting antibiotics.
Initiate empirical antibiotic therapy
promptly.
Persistent neutropenic Look for invasive fungal infection. Send
fever BDG/GM
(4–7 d) Add empirical antifungal therapy in patients
not receiving mold-active prophylaxis.
Consider MP x 3 to rule out malaria.
Recurrent neutropenic Signs of breakthrough sepsis (e.g.,
fever without a source hypotension, rigors, tachypnea, decline in
after initial response to urine
empirical antibiotics output) should prompt empirical
modification of antibacterial regimen.
Repeat blood cultures and a chest
radiograph.
Consider chest CT scan to evaluate for signs
of mold infection. If a nodule or
infiltrate is present, consider bronchoscopy
or percutaneous biopsy depending on
location.
Consider other laboratory tests and imaging
studies to investigate fever.
Persistent or recurrent Infections are diagnosed infrequently.
fever without a source Consider chronic disseminated candidiasis.
after ANC recovery
36
Antibiotic Regimens
The IDSA and the NCCN have published evidence-based guidelines

on antibiotic therapy for neutropenic patients with fever.
• The cornerstone of the management of fever in

neutropenic hosts is the prompt empirical administration
of a broad-spectrum β-lactam antibiotic with activity
against P. aeruginosa.
• The agents recommended are imipenem, and meropenem.
• Piperacillin/Tazobactam is an acceptable alternative but in
combination with aminoglycosides.
• The addition of an aminoglycoside otherwise, should be
limited to patients with hemodynamic instability.
• Empirical Vancomycin should be used for specific settings
during neutropenia, which include clinically apparent,
o central venous catheter-related infection,
o blood culture positive for a Gram-positive bacterium
prior to identification and susceptibility testing.
o known colonization with methicillin-resistant S.
aureus (MRSA) or penicillin-resistant Streptococcus
pneumoniae (PRSP).
• Hypotension or septic shock without an identified pathogen.
• Prior quinolone prophylaxis.
• Severe mucositis.
Empirical Vancomycin should be discontinued after 2 to 3 days if the
initial cultures are negative or show a pathogen such as methicillin-
susceptible S. aureus for which other antibiotics can be used.
Modification of the Antibiotic Regimen1

Daily evaluation of the patient is essential to search for new findings
(tachypnea, tachycardia, hypotension, new skin lesions, pain or
tenderness) that may suggest persistent or breakthrough infection.
Antibiotics need to be adjusted depending on positive culture.
Duration of Treatment
The standard recommendation is to continue antibiotics until
resolution of neutropenia. If the neutropenia persists, classic studies
showed that 7 days of treatment may not be enough, but 2 weeks
may be adequate. In contrast to the neutropenic period, empirical
antibiotics can be discontinued after resolution of neutropenia
in patients who are stable with fever without apparent source and
negative cultures. If a source of infection is identified, then antibiotic
therapy targeted to the specific pathogen(s) is advised.
37
Colony-Stimulating Factors (CSF)1
CSF may be considered in selected cases of profound neutropenia
(absolute neutrophil count less than 100 mcL), uncontrolled primary
disease, and in serious infections, such as pneumonia, hypotension,
multiorgan dysfunction, previous NF episode and invasive fungal
infection.
Risk Assessment (MASCC Index)

Multinational Association for Supportive Care in Cancer (MASCC)
index is the tool for the stratification of risk for complications
in febrile neutropenic patients which identified the following
independent factors;
1. Burden of illness: no or mild symptoms, +4; moderate

symptoms, +5
2. No hypotension, +5.
3. No chronic obstructive pulmonary disease, +4.
4. Solid tumor or no previous fungal infection, +4.
5. Outpatient status, +3.
6. Age < 60 years, +2.
A score of 26 or greater identified low-risk patients with a positive
predictive value of 91%, specificity of 68%, and sensitivity of 71%.
Outpatient Management of low-risk Febrile Neutropenic

Patients
In adults, Ciprofloxacin/Levofloxacin plus Amoxicillin/Clavulanate
is recommended with inpatient observation for 24 hours. In patients
allergic to Penicillin, the NCCN guidelines recommend substituting
Amoxicillin/Clavulanate with Clindamycin.
References
[1] Aapro MS. 2010 update of EORTC; EuJCa 47 (2011)8-32
• DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of
Oncology, Eighth Edition, 2008.
• Prevention and treatment of cancer-related infections. NCCN Guidelines
2008. World Wide Web URL: www.nccn.org.
• Hughes WT, Armstrong D, Bodey GP, et al. 2002 guidelines for the use
of antimicrobial agents in neutropenic patients with cancer. Clin Infect
Dis 2002; 34:730.
38
Clostridium Difficile Infection
Non severe Severe Fulminant
WBC <15000 cells/uL WBC >15000 Hypotension
No increase in Serum cells/uL or shock, Ileus,
creatinine S.cr > 50% megacolon
increase in baseline
First line
Vancomycin PO Vancomycin PO Vancomycin
125mg q6h for 125mg q6h for 500mg q6h via
10days 10days nasogastric tube +
Metronidazole
Alternative 500mg IV q8h
Metronidazole PO + Vancomycin
400mg q8h for 10 500mg q6h
days retention enema
particularly if
ileus is present
(in 100 ml normal
saline)
• Clinical Infectious Diseases, Volume 66, Issue 7, 1 April 2018,
Malaria Treatment & Prophylaxis Guidelines

In Pakistan, Chloroquine and Sulfadoxine- Pyrimethamine
resistance to P. falciparum is as high as 95% and 98% respectively.
Due to increasing emergence of drug resistance, the current emphasis
is to use combination antimalarial drugs for the treatment of P.
falciparum malaria. Plasmodium vivax resistance to Chloroquine is
also observed but is still not a major problem.
MP-ICT Interpretation:
− If only “Mixed” positive, implies infection with
plasmodium other than falciparum (P. vivax)
− If both “Mixed” and “falciparum” positive, then implies
either pure falciparum or falciparum plus vivax
infection
− If only “falciparum” positive may indicate treated
infection with falciparum or low parasitaemia with
falciparum or lab error (confirm with smear)
39
Treating uncomplicated P. falciparum malaria in special risk
groups:
Pregnancy:
In the second and third trimesters an artemisinin-based combination
therapy (ACT) i.e. artemether +lumefantrine. (In severe malaria
IV artesunate in all trimesters). The efficacy of the standard six-
dose artemether + lumefantrine regimen was inferior to 7 days of
artesunate monotherapy
Infants less than 5kg body weight

Treat infants weighing < 5 kg with uncomplicated P. falciparum
malaria with an ACT at the same mg/kg birth weight target dose as
for children weighing 5 kg.
Non-immune travelers
Treat travelers with uncomplicated P. falciparum malaria returning
to nonendemic settings with an ACT.
Uncomplicated hyperparasitaemia
People with P. falciparum hyperparasitaemia are at increased risk
of treatment failure, severe malaria and death so should be closely
monitored, in addition to receiving an ACT.
LACTATING WOMEN
The amounts of antimalarial drugs that enter breast milk consumed
by breastfeeding infants, relatively small.
References:
1. Guidelines for the treatment of malaria (3rd edition) World Health Organization,
2015
2. Treatment of malaria in the United States: a systematic review. JAMA
2007;297(20):2264-2277
40
Figure 1
Malaria Treatment Algorithm -1

MP: Trophozoites of P.vivax
MP-ICT: Mixed +ve only
Assess for the presence of any of the following
-Severe anemia -Severe thrombocytopenia -Acute renal failure -Cerebral malaria

-ARDS -Splenic rupture
No Yes
Chloroquine phosphate 250 mg (4 tabs loading, Treat as severe malaria

followed by 2 tabs at 6, 24 & 48hrs) (See Figure 3)
Check MP daily for 72 hours
In 48 hours, MP -ve for trophozoites No Consult ID
Yes
Complete course of Chloroquine
Second infection
(relapse)
Yes No
Primaquine 30 mg
daily for 14 days No Primaquine
After G6PD testing
41
Figure 2
Malaria Treatment Algorithm -2
MP: Trophozoites of P. falciparum
MPICT: Mixed & Falciparum +ve
Assess for the presence of any of the following
-Prostration -Impaired consciousness/coma -Respiratory distress -Multiple convulsions

- Circulatory shock -Pulmonary edema -ARDS -Abnormal bleeding -Jaundice -Severe anemia
- Acute renal failure -DIC -Acidosis -Hemoglobinuria -Parasitaemia >5%
No Yes
Co-Artemether 40/240mg* Treat as severe malaria

(2 tabs initially, followed by 2 tabs at 8, (See Figure 3)
24, 36, 48 & 60 hrs.)
Check MP daily for 72 hours
-Development of signs of severe malaria in the

presence of parasitaemia
-Increase in parasite count in 48 hours
-Less than 75% reduction in parasite count at
72 hours
-Any trophozoites after 72 hours with an Yes Consult ID
axillary temperature of ≥ 37.5 °C
No
Continue Co-Artemether to
complete the course
*Complete dose guide Co-Artemether - Treatment of uncomplicated falciparum

malaria:
• Adult and child over 12 years and body weight over 35 kg:
Initially 2 tablets (40/240mg) followed by 5 further doses of 2 tablets
each at 8, 24, 36, 48 and 60 hours (total 12 tablets over 60 hours);
• Body weight 25–34 kg, initially 1.5 tablets followed by 5 further doses of 1.5 tablets
each at 8, 24, 36, 48 and 60 hours (total 9 tablets over 60 hours)
• Body weight 15–24 kg, initially 1 tablet followed by 5 further doses of 1 tablet each
at 8, 24, 36, 48 and 60 hours (total 6 tablets over 60 hours);
• child body weight 5–14 kg, initially 1/2 tablet followed by 5 further doses of 1/2
tablet each at 8, 24, 36, 48 and 60 hours (total 3 tablets over 60 hours);
• Patient advice: Take tablets with food; repeat dose if vomiting occurs within 1 hour of
administration
42
Figure 3
MP: Trophozoites of P. falciparum or P.vivax
MPICT: Mixed & Falciparum +ve
Severe Malaria is defined by the presence of any of the following
-Prostration -Impaired consciousness/coma -Respiratory distress -Multiple convulsions

-Circulatory shock -Pulmonary edema -ARDS -Abnormal bleeding -Jaundice -Severe anemia
-Acute renal failure -DIC -Acidosis -Hemoglobinuria -Parasitemia >5%
Yes
-Support airway, breathing,

circulation -Admit in SCU/ICU
-Consider ID consult
Treat adults/children/pregnant women all trimesters/lactating women with IV

artesunate
Children <20 kg (3mg/kg at 0,12, 24, 48hrs) Children >20 kg and adults
2.4mg/kg at 0,12, 24 and 48hrs)
-Monitor blood glucose every 2-4 hourly Evaluate and monitor

Check daily MP’s for secondary bacterial
-Monitor EKG infections
-Development of signs of severe malaria in the

presence of parasitaemia
-Increase in parasite count in 48 hours -ID consult -
-Less than 75% reduction in parasite count Yes
at 72 hours
-Any trophozoites after 72 hours with an

axillary temperature of ≥ 37.5 °C
No
Continue therapy
Switch to oral therapy after 24 hrs if
improvement then complete 3 day
PO ACT regimen.
43
Helicobacter pylori Treatment Guidelines
Indications of Therapy
Treatment is highly recommended: Treatment is advised:
l Duodenal/gastric ulcer or complicated l Functional dyspepsia
peptic ulcer (active or inactive) l GERD (patients
l MALT lymphoma requiring long term acid
l Atrophic gastritis suppression)
l Recent resection of gastric cancer l NSAIDs use
1st line Treatment Options – Adults
Duration
Regimen
[days]
Clarithromycin triple+
PPI standard dose or double the standard dose
(Esomeprazole/Dexlansoprazole is once daily) + 14
Clarithromycin 500 mg q12h +Amoxicillin 1 g q12h
Clarithromycin-based concomitant+
PPI Standard dose q12h (Esomeprazole/Dexlansoprazole is
once daily)+Clarithromycin 500 mg 10–14
q12h+Amoxicillin 1g q12h+ Metronidazole 400 mg q12h
Bismuth quadruple
PPI Standard dose q12h (Esomeprazole/Dexlansoprazole
is once daily)+Bismuth subsalicylate 525 mg four times 10–14
daily+ Metronidazole
200 mg q6h or 400mg q8h + Tetracycline 500 mg q6h
Clarithromycin-based sequential+
PPI standard dose q12h (Esomeprazole/Dexlansoprazole is
once daily)+ Amoxicillin 1 g q12h for 5days followed by:
PPI+ Clarithromycin 500 mg q12h+Tinidazole 500mg q12h 10(total)
OR
Metronidazole 400mg q12h for 5days
Salvage therapy
Levofloxacin triple
PPI standard dose q12h 14
(Esomeprazole/Dexlansoprazole is QD)+,
Amoxicillin 1 g q12h+ levofloxacin 500 mg QD
+ In patients with risk factors for macrolide resistance, clarithromycin-based therapy
should be avoided
Note:
Standard doses of orally administered proton pump inhibitors include: Dexlansoprazole
30 mg daily, omeprazole 20 mg daily, esomeprazole 20 mg daily. Esomeprazole and
Dexlansoprazole has once a day dosing. Double dose of esomeprazole would be 40mg
once daily and Dexlansoprazole 60mg once daily
44
COVID-19
Classification Symptoms
Asymptomatic • SARS COV2 infection but
with no symptoms. Some
asymptomatic patients may
be pre-symptomatic if tested
early (e.g. as part of contact
tracing).
Non-Severe • Oxygen saturation > 94%
and respiratory rate < 25
breaths/minute.
Severe • Oxygen saturation <94% or
respiratory rate > 25 breaths/
minute.
• Oxygen saturation is
maintained by nasal cannulation
or simple facemask and there
is no need for non-invasive
ventilation (NIV), High Flow
Nasal Cannula (HFNC), or
mechanical ventilation (MV).
Critical • Respiratory compromise
severe enough to require NIV
(including CPAP or BiPAP),
HFNC or, MV.
Drugs Dose
Prophylactic
Anticoagulation***
a-LMWH (Enoxaparin) 40mg SC once daily
CrCl <30ml/min 30mg SC once
daily
b-Unfractionated Heparin 5000 units SC q12h
Therapeutic anticoagulation**
a-LMWH (Enoxaparin) Enoxaparin :1mg/kg SC q12h
CrCl <30ml/min 1mg/kg SC
once daily
b-Unfractionated Heparin 80 units/kg IV bolus then
continuous infusion at 18
units/kg/hour with 6 hourly
monitoring of APTT (As per
hospital protocol)
45
c-Rivaroxaban (As continuation
therapy on discharge when
diagnosis was presumptive for
1-3 months) CrCl >15ml/min 10mg once daily
If documented VTE follow Follow standard doses in

standard guidelines for duration. documented cases of VTE.
Remdesivir (Use only in severe 200mg IV on day 1
COVID and in those with
symptoms for 10 days or less) 100 mg IV once daily on days 2-5
• There is no benefit in using in Children dose: For weight 3.5

patients with critical COVID or kg to < 40kg 5mg /kg on day 1
those with symptoms for over 10 followed by 2. 5 mg/kg on days
days 2-5
*Patients who are responding to For weight >40kg same as adult

supportive care and steroids may dose.
not always require Remdesivir
ID approval is mandatory Use with caution in adult and

prior to maintenance doses (1st pediatric patients (>28 days old)
dose can be given without ID with eGFR less than 30 mL/
approval) min or in full-term neonates (≥7
days to ≤28 days old) with serum
creatinine greater than or equal to
1 mg/dl.
Contraindication: Don’t start in

patients with ALT >5 times ULN
Steroids (All patients with severe Methylprednisolone 20mg q12h
and critical COVID-19 OR any
patient requiring oxygen) Dexamethasone IV/PO 6mg once
daily
Duration : 7-10 days Hydrocortisone 50 mg q8h
For extremes of weight use weight

based dosing of steroids.
Tocilizumab (Reserved only in 400 mg for weight < 80kg
patients who have failed steroids
and continue to worsen despite
this)
46
ID approval is mandatory prior Weight based dosing of 4-8mg /kg
to administration (maximum 800mg) should be used
at extremes of age)
2nd dose is not recommended due

to increased risk of infection
Children dose: 2 years or older,

less than 30 kg 12 mg/kg
30 kg or greater 8 mg/kg
(Maximum 800mg).
Contraindications:
*Active TB
* Zoster
*Sepsis and positive blood culture
*Suspected GI perforation
*Multiple Sclerosis
*Allergy to Tocilizumab
*ALT > 5 times ULN or Bilirubin > 2
*ANC <2000 or platelets <50
*Pregnancy (relative contraindication)
**Documented presence of thromboembolic disease (such as

ultrasound Doppler or CT for pulmonary embolism), or strong
suspicion for thromboembolic disease when investigation cannot be
done. *** Don’t use in asymptomatic or non-severe patients.
47
Recommended Empirical Treatment for
CAP in Outpatient Setting
Patient characteristics Oral antibiotics regimens

No comorbidities or risk Choose one agent
factors for methicillin resistant Amoxicillin 1 gm q8h
staphylococcus aureus or Doxycycline 100mg q12h
Pseudomonas aeruginosaa Azithromycinb 500 day 1,
followed by 250 mg daily
Clarithromycinb 500mg q12h
Clarithromycin extended-
release 1000mg daily
Comorbidities ( chronic heart, Monotherapy with respiratory
lung, liver, or renal disease; fluoroquinolones:
diabetes mellitus; alcoholism; Levofloxacin 750mg daily
malignancy; asplenia) Moxifloxacin 400mg daily
Or
Beta-lactam plus macrolide OR

beta lactam plus doxycycline
Beta-lactam options:
Amoxicillin-clavulanate
500mg/125mg q8h
Amoxicillin-clavulanate
875mg/125mg q12h
Cefpodoxime 200mg q12h
Plus
Macrolide options:
Azithromycin 500mg day 1,
then 250mg daily
Clarithromycin 500 mg q12h
Or
Doxycycline 100 q12h
CAP: Community-acquired pneumonia a- Risk factors include prior

respiratory isolation of pathogen or hospitalization with receipt
of parenteral antibiotics within past 90days. b Use only if local
pneumococcal resistance is <25%.
Minimum therapy required for CAP should be for 5 days;
before discontinuing the therapy patient should be afebrile for
48–72h, and should have at least 1 sign of clinical stability.
Non severe pneumonia 5days
Severe Pneumonia 7days
48
Guideline Criteria for severe CAP
Patient must fulfill 1 major or>3 minor criteria
Major Criteria Minor Criteria
Respiratory failure requiring
Confusion or disorientation
mechanical ventilation
Septic shock requiring Hypotension requiring aggressive
vasopressors fluid resuscitation
Respiratory rate >30 breaths/
minute
PaO2/FiO2 ratio <250
Multilobular infiltrates
Uremia (BUN >20mg/dl)
Leucopenia (WBC count <4000
cells/mcL)
Thrombocytopenia (Platelet count
<100,000 cells/mcL)
49
Recommended Empirical Treatment for CAP in the Inpatient Setting
Pneumonia Add Pseudomonas aeruginosa

Standard Regimen Add MRSA Coverage
Classification Coverage
Non severe Monotherapy with a See below risk factors. See below risk factors
respiratory fluoroquinolone:
Levofloxacin 750mg daily Add vancomycin 15mg/kg IV with Antipseudomonal beta-lactams:
Moxifloxacin 400mg daily interval based on renal function Piperacillin-tazobactam 4.5g IV
q6h or Ceftazidime 2gm IV q8h
Or Or or Imipenem 500mg IV q6h or
Meropenem 1g IV q8h,
50
Beta-lactam plus macrolide Linezolid 600mg IV or PO q12h (ID
Beta-lactam options: approval is mandatory) .
Ceftriaxone 1g-2g IV daily,
Macrolide options:
Azithromycin 500mg IV or
Po daily
Clarithromycin Po 500mg
q12h
Severe Beta-lactam plus macrolide See below risk factors, See below risk factors
Or
Beta-lactam plus respiratory Add vancomycin 15mg/kg with Antipseudomonal beta-lactams:
fluoroquinolone interval based on renal function Piperacillin-tazobactam 4.5g IV
q6h or Ceftazidime 2g IV q8h
Beta-lactam options: Or or Imipenem 500mg IV q6h or
Ceftriaxone 1g-2g IV daily, Meropenem 1g IV q8h
Linezolid 600mg IV or PO q12h(ID
Macrolide options: approval is mandatory)
Azithromycin 500mg IV or PO
daily or Clarithromycin 500mg
PO q12h
51
Fluoroquinolone options:
Levofloxacin 750mg daily or
Moxifloxacin 400mg daily
Note: Obtain cultures or nasal PCR to confirm need for continued MRSA therapy or ability to deescalate. Obtain cultures to confirm need for continued
antipseudomonal therapy or ability to deescalate. CAP: community-acquired pneumonia; MRSA: methicillin –resistant Staphylococcus aureus;
Reference:
Diagnosis and Treatment of Adults with Community-acquired Pneumonia An Official Clinical Practice Guideline of the American Thoracic Society and Infectious
Diseases Society of America 2019
Risk Factors
MRSA Pseudomonas
Known colonization or prior Known colonization or prior
infection with MRSA infection with Pseudomonas
Gram positive cocci in clusters Gram negative bacilli seen on
on good quality sputum gram good quality sputum gram stain
stain
Receipt of IV antibiotics during Receipt of IV antibiotics during
a hospitalization in the prior 3 a hospitalization in the prior 3
months months.
Recent influenza like illness Structural lung abnormalities
(e.g. bronchiectasis)
Necrotizing or cavitary Frequent COPD exacerbations
pneumonia requiring frequent
glucocorticoid or antibiotic use.
Presence of empyema
Injection drug use
Tuberculosis
Classification by site
Pulmonary tuberculosis (PTB)

A case of TB involving the lung parenchyma
Bacteriological Confirmed TB
The presence of one acid fast bacillus (AFB+) in at least
one sputum sample
Extra pulmonary tuberculosis (EPTB)
A patient with one bacterial culture positive specimen
from an extra-pulmonary site or a patient with histological
and or clinical evidence consistent with active extra
pulmonary tuberculosis.
Patient Registration Groups
New Patient
• Never had treatment for TB, or has taken anti-TB drugs
for less than 1 month.
• New patients may have positive or negative bacteriology
and may have disease at any anatomical site.
52
Previously Treated
• Has received 1 month or more of anti-TB drugs in the
past.
• Previously treated patients may have positive or
negative bacteriology and may have disease at any
anatomical site.
• Previously treated patients may have relapsed, defaulted
or failed
Relapsed
Patient with positive AFB smear or culture or other newer
means of identifying M. tuberculosis who have previously
been declared cured or treatment completed (see below)
Defaulted
A patient who completed at least 1 month of treatment and
returns after at least 2 months’ interruption of treatment.
Failure
While on treatment, remains or becomes smear positive
again 5 or more months after starting treatment. There
may be cases that while smear-negative, remain culture-
positive at the end of treatment
Treatment outcomes
Cure Treatment completed

A patient whose sputum smear or A patient who completed
culture was positive at treatment but who does not
the beginning of the treatment have a negative sputum smear or
but who was smear- or culture result in the last
culture-negative in the last month month of treatment and on at least
of treatment and on at one previous occasion
least one previous occasion (i.e. testing not available or not
done)
Treatment failure
A patient whose sputum smear or culture is positive at 5 months or
later during treatment. Also included in this definition are patients
found to harbor a multidrug-resistant (MDR) strain at any point
of time during the treatment, whether they are smear-negative or
smear-positive
53
Duration of therapy: The optimal duration of therapy is 6-12
months depending upon site of infection.
Treatment regimens
New patient
2 months of RHEZ followed by 4 months of RH.
(6 months total)
Defaulted or relapsed patient

Send sputum/bronchial wash for AFB C/S and start ATT.
Consult ID or pulmonology for the ATT regimen required.
Doses
Normal Doses for Adults and Children
Drug Adults/children Daily dose Available as

Adults (max.) 5 mg/kg (300mg) Tab; 100 mg
Isoniazid
Children (max.) 10-15 mg/kg (300mg) Syp.: 50 mg/5ml
Adults (max.) 10 mg/kg (600mg) Tab; 300, 450 mg

Rifampin
Children (max.) 10-20 mg/kg (600mg) Syp.: 100 mg/5ml
Adults (max.) 20–30 mg/kg (2g) Tab; 500 mg

Pyrazinamide
Children (max.) 15-30 mg/kg (2 g) Syp.:250 mg/5ml
Adults (max.) 15–20 mg/kg (1.6 g) Tab; 400 mg

Ethambutol
Children (max.) 15-20 mg/kg (1.6 gm) Syp.100 mg/5ml
Fixed Dose Combinations (FDCs)
• FDCs have the advantage of improving patient

compliance. Always calculate dosage according to weight of
the patient. Use of separate drugs is advised in case of
weight-dosage discrepancy with FDCs.
• Any FDCs with Rifampicin must have a certificate of

bioavailability by a WHO recommended reference laboratory.
54
Patient Body Initial Phase Continuation Phase
Weight (Kg) 02 Months 04 Months
RHZE HR(DS/ SS)*
30-39 02 tablets 1.5/3
40-54 03 Tablets 2/4
>55 04 Tablets 2/4
(RHZE) R= 150 mg, H= 75mg, Z= 400mg, E= 275.

*HR Double strength (DS) H= 150mg, R= 300mg
*HR Single strength (SS) H=75mg, R=150mg
Managing Side effects
Drug(s) probably
Side-effects Management
responsible
Stop responsible
drug(s) and
Major
refer to clinician
urgently
Streptomycin,
Skin rash with or without
isoniazid, rifampicin, Stop anti-TB drugs
itching
pyrazinamide
Deafness (no wax on
Streptomycin Stop streptomycin
otoscopy)
Dizziness (vertigo and
Streptomycin Stop streptomycin
nystagmus)
Isoniazid,
Jaundice (other causes
pyrazinamide, Stop anti-TB drugs
excluded), hepatitis
rifampin
Confusion (suspect drug-
induced acute liver failure Most anti-TB drugs Stop anti-TB drugs
if there is jaundice)
Visual impairment (other
Ethambutol Stop ethambutol
causes excluded)
Decreased urine output Streptomycin Stop streptomycin
55
Continue anti-TB
Minor drugs, check
drug doses
Give drugs with small
meals or just
before bedtime, and
advise patient
to swallow pills
slowly with small
Pyrazinamide, sips of water. If
Anorexia, nausea,
rifampicin, symptoms persist
abdominal pain
isoniazid or worsen, or there is
protracted
vomiting or any sign
of bleeding,
consider the side-
effect to be major
and refer.
Aspirin or non-
steroidal anti-
Joint pains Pyrazinamide
inflammatory drug,
or paracetamol
Burning, numbness or
Pyridoxine 50–75 mg
tingling sensation in the Isoniazid
daily
hands or feet
Reassurance. Give
Drowsiness Isoniazid drugs before
bedtime
Reassurance. Patients
should be
told when starting
Orange/red urine Rifampicin
treatment that
this may happen and
is normal
Change from
Flu syndrome (fever, intermittent to once
Intermittent dosing
chills, malaise, headache, daily
of rifampin
bone pain) rifampin
administration
56
Monitoring Pulmonary TB
Treatment monitoring calendar for new patients

Month 1st 2nd 3rd 4th 5th 6th
Start X
End X X
If Next Step
At the end of the 2nd month Continue with the treatment as
patient is sputum smear-negative planned
(true for vast majority) until the end of regimen
Consider case treatment failure
Do drug susceptibility test
Re-register patient as treatment failure
Start retreatment regimen as treatment
At the start of the 5th month
failure
patient is sputum smear-positive
Obtain result of sensitivity test
Adapt treatment to susceptibility
of bacilli and continue with the
treatment
At the start of the 5th month Continue with the treatment as
patient is sputum smear-negative planned until the end of regimen
At the end of the 6th month
Patient is considered cured
patient is sputum smear-negative
Follow the same steps as at the
At the end of the 6th month
start of 5th month if sputum smear
patient is sputum smear-positive
-positive
FOR TREATMENT FAILURE Consult pulmonary or infectious

disease physician.
57
Recommendations for Initial Therapy of Urinary Tract Infections
Parenteral (Switch to oral when response as per
Parameter Oral
culture sensitivity)
Cystitis Nitrofurantoin 100mg q6h for
5days
Lower UTI’s known as cystitis, are OR
significantly more prevalent in women, the Fosfomycin trometamol 3g oral
syndrome involving dysuria, frequency, sachet 1dose
urgency, and occasionally suprapubic OR
tenderness in otherwise healthy non- Fosfomycin Calcium 500mg
pregnant women. q6h or 1g q8h for 5-7days
58
Complicated UTI/Pyelonephritis None Ertapenem 1g q24g
OR
Pregnant women, men, obstruction, Imipenem 500mg q6h
immunosuppression, renal failure, renal OR
transplantation, urinary retention from Doripenem 500mg q8h
neurologic disease, and individuals with OR
risk factors that predispose to persistent or Meropenem 1g q8h
relapsing infection (e.g., calculi, indwelling OR
catheters or other drainage devices). Piperacillin-tazobactam 4.5g q6-8h*
Duration=10-14days
It is characterized by flank pain, tenderness, Escalate or de-escalate as per culture sensitivity.
or both, and fever, often associated with
dysuria, urgency, and frequency
*Reserve 4.5 g q6h dose for health care-associated infection, severe community-acquired
infection, or patients with community-acquired infection at high risk of adverse outcome
and/or resistance
Asymptomatic bacteriuria • Women: Two consecutive voided
urine specimens with isolation of the same bacteria at ≥ 105 CFU/mL
• Men: A single, clean-catch, voided urine specimen with 1 bacteria
isolated 105 CFU/mL • A single catheterized urine specimen with 1
bacteria isolated ≥ 102 CFU/Ml
Treatment is required in:
• Pregnancy
• Urological procedures require mucosal breach
Primary Amebic Encephalitis (PAM) (Naegleria)

On arrival
Suspect Primary Amebic Encephalitis (PAM) in any patient
presenting with signs and symptoms consistent with Acute Bacterial
Meningitis (ABM). Factors which increase the likelihood of PAM
over ABM include being a male less than 40 years of age, complaints
of nausea and the presence of seizures.
Initial Management:
After maintaining the airway and an IV access, assess for any
contraindications to a lumbar puncture. If none present, send CSF
for DR and culture.
Antibiotic therapy (including steroids) for ABM should be started
as per protocol and not be delayed while waiting to perform the
lumbar puncture. If a lumbar puncture is not possible and suspicion
of PAM is high, anti-PAM therapy can also be started. In this case
consultation with Infectious Disease service is recommended.
Initial therapy for PAM includes the following:
• Amphotericin B 1.5 mg/kg/day every 12 hours for 3 days

followed by 1 mg/kg/day IV
• Azithromycin 10mg/kg once daily
• Fluconazole 800 mg every 24 hours
• Rifampin 600 mg once daily IV
• Miltefosine 150 mg per day (confirm availability from
pharmacy before ordering)
• Chlorpromazine 2g per day (confirm availability from
pharmacy before ordering)
59
Initial investigations
CSF finding suggestive of PAM include a low glucose, high white
cell count and elevated proteins with a negative gram stain. The
CSFDR is indistinguishable from bacterial meningitis. For patients
with the appropriate history and these findings on CSF:
• Please inform the microbiology laboratory to look for
Naegleria specifically
• Send CSF for Naegleria PCR
Further therapy
• If the CSF is negative for Naegleria or an alternate pathology
is found, the anti-PAM therapy can be discontinued
immediately.
• If the CSF is positive for Naegleria, anti-PAM therapy should
be continued and therapy for ABM can be held.
• In cases of confirmed PAM, Intrathecal amphotericin B 1.5
mg daily for 2 days followed by 1 mg daily every other day
for 8 days should also be started.
60
Chapter 06: Treatment for Miscellaneous
Infections
Viral Infections
Infection Therapy
Dengue Fever No antiviral recommended
Crimean-Congo Ribavirin 30mg/kg PO loading dose
Hemorrhagic (max 2.5g) then 15mg/kg
Fever (max 1g) q6h x 4 days then
7.5mg/kg x 6 days
CMV
Retinitis Ganciclovir 5mg/kg IV q12h x 14-21
days Or
Valganciclovir 900mg q12h
Colitis Ganciclovir 5mg/kg IV q12h x 3-6
weeks Or
Valganciclovir 900mg q12h
HSV
Bell’s palsy 1) Prednisolone 1mg/kg PO divided twice
daily x 5 days (max 60 mg per day) then
taper to 5mg BD over next 5 days (10 days
total)
2) Valacyclovir 500 mg BID x 5 days
Encephalitis Acyclovir 10mg/kg IV q8h for
14-21 days
Primary genital Acyclovir 400 mg PO TID x7-10 days
herpes OR
Valacyclovir 1g BID x 7-10 days
Genital herpes Acyclovir 800 mg PO TID x 2 days
episodic OR
recurrences Acyclovir 400 mg PO TID x 5 days
(Non-HIV) OR
Valacyclovir 500g BID x 3 days
OR
Valacyclovir 1g once daily for 5 days
Genital herpes Acyclovir 400 mg PO TID x 5-10
episodic days
recurrences OR
(HIV) Valacyclovir 1g BID x 5-10 days
Oro-labial (“Fever Acyclovir 400 mg PO TID x 5 days
Blisters”) OR
Valacyclovir 2g BID x 1 day
61
Varicella Zoster
Virus (VZV)
Chickenpox-Child No antiviral treatment
(2-12 years)
Chickenpox - Acyclovir 800 mg PO 5 times/day x
adolescent, young 5-7 days
adults OR
Valacyclovir 1g TID x 5 days
Chickenpox - Acyclovir 800 mg PO 5 times/day x
pneumonia or 3rd 5 days
trimester OR
Acyclovir 10mg/kg IV q8h for 5 days
Chickenpox - Acyclovir 10mg/kg IV q8h x 7 days
Immunocomp-
romised
host (any age)
Zoster - Normal Valacyclovir 1g TID x 7 days
Host OR
Acyclovir 800mg PO 5 times/day x
7-10 days
Add Prednisolone if patient >50 years at 30
mg PO BID days 1-7, 15 mg BID days 8-14
and 7.5 mg BID days 15-21
Zoster - Acyclovir 10-12 mg/kg (500 mg/m2)
Immunocompro- IV q8h x 7 days
mised Host or
disseminated
in normal host
62
Fungal Infections
Infection Therapy (doses for adults unless specified)
Aspergillosis
Allergic Itraconazole 200 mg q12h x16 weeks or longer or Voriconazole 400mg q12h for 2 doses then 200
Bronchopulmonary mg q12h for 16 weeks
Aspergillosis (ABPA) Treat asthma attacks with steroids
Amphotericin B* OR OR (for less severe
1 mg/kg/day Voriconazole disease or
Or 400 mg q12h on day 1 continuation therapy)
Liposomal amphotericin then Itraconazole
63
3-5mg/kg/day Weight ≥ 40kg: 200 mg 200 mg q8h for 3
Invasive aspergillosis
q12h days then
Also see Weight < 40kg: 100 mg 200 mg q12h
Amphotericin B q12h Take with fatty
administration meals and acidic
protocol liquids (cola drinks)
Candidiasis
Blood stream infection Caspofungin (requires ID Approval) OR Amphotericin B OR Liposomal amphotericin
Non-neutropenic OR Fluconazole 800 mg once then 400 mg q24h (in moderate to severe disease)
Amphotericin B* 0.5-1 mg/kg q24h
OR
Liposomal amphotericin 3-5mg/kg/day
Blood stream infection
Neutropenic
(If no exposure to azoles) Fluconazole 800 mg once then 400 mg q24h
Caspofungin therapy requires ID approval.

Fluconazole 400 mg q24h
Prophylaxis (during chemotherapy induction and duration of neutropenia as well as
SCT for duration of neutropenia)
Nystatin 500,000 units (5ml) swish and swallow q6h x 2 weeks
64
OR
Thrush Fluconazole 100-200 mg once daily x 2 weeks
OR
Itraconazole 200 mg q24h on empty stomach x 1 week
Esophageal Candidiasis Fluconazole 200-400 mg once daily x 2-3 weeks
Fluconazole 150 mg single dose
Clotrimazole Pessaries 200 mg x 3 nights or 100 mg x 6 nights
Clotrimazole Vaginal cream (1%) 5gm single dose – may be repeated if
Vaginitis-Sporadic required
Boric acid pessaries (compounded formulation) 600mg intravaginal once daily for 14 days
Vaginitis-Recurrent (≥4
Fluconazole 150mg every week for 6 months
episodes/year)
No treatment unless symptoms of UTI, high risk of dissemination or
Urinary undergoing urologic manipulation
65
Fluconazole 200mg q24h x7-10 days
Apply topical Clotrimazole, Miconazole or Ketoconazole. OR

Cutaneous
Use PO Ketoconazole 400 mg QD for 2 weeks
Dermatophytes
Terbinafine 250 mg q24h x 6-week fingernail and 12 weeks (toenail) OR
Itraconazole 200mg q24 hr. x 3 months OR
Onychomycosis
Itraconazole 200mg BID once a week/month x 2 months OR
Fluconazole 150-300 mg once weekly x 3-6 months
Topical antifungals
OR
Tinea corporis, cruris or Terbinafine 250 mg q24h x 2-4 weeks (5mg/kg/day x 4
pedis weeks for children)
OR
Fluconazole 150 mg once weekly x2-4 weeks
66
Tinea capitis Terbinafine 250 mg q24h x 4 weeks
OR
Itraconazole 5mg/kg/day x 4 weeks
Amphotericin B* 1.5 mg/kg q24h
Mucormycosis OR
Liposomal amphotericin 5-10mg/kg/day q24h
Amphotericin B Administration Protocol
S# Amphotericin B Description Comments
0.25-1.5 mg/kg IV Common side effects are fever, chills,
1. Normal dose Max. cumulative dose 2-3.6 gm hypokalemia, nephrotoxicity, headache and
weight loss.
Dose in renal Avoid concomitant use of nephrotoxic drugs
2. No adjustment required
failure
• 1 mg / 20 ml D5W over 20-30 • Test dose is not mandatory
minutes IV. • Pre-medication is not recommended by
• Monitor for fever +/- rigors, Antimicrobial Stewardship sub-committee
3. Test dose
67
chills, hypotension and anaphylaxis for * Should be given to only those patients
4 hrs post administration experiencing infusion related adverse drug
reaction after test dose.
• Recommended diluent: D5W 0.5-1 mg/ml is recommended for fluid
4. IV dilution • Concentration: 0.1-0.25 mg/ml restricted patients and should be
• Duration of infusion: 2-3 hours administered via central line.
Pharmacy will provide the pre-filled bag

5. Stability
with expiry label.
Adults: 250-500 ml NS 0.9% pre and post • Do not administer to patients with
administration of strict fluid or sodium restriction
Amphotericin B • This method helps to reduce the
6 Saline loading nephrotoxicity of the drug.
Children: Correct Fluid or serum sodium
level disturbances
• Avoid concomitant use of nephrotoxic drugs
68
Parasitic Infections
Protozoa – Intestinal
Entamoeba histolytica; amebiasis Alternative
-
Diloxanide furoate 500 mg q8h x 10 days
i)Asymptomatic cyst passer
ii)Mild diarrhea/dysentery, PO Rx Metronidazole PO 400mg-800 mg q8h+ -

possible Diloxanide furoate 500 mg q8h x 10 days
Metronidazole IV or PO 800 mg q8h x 7
days, followed by Metronidazole 400
69
iii)Severe or extra-intestinal disease, mg + Diloxanide furoate 500mg PO q8h x7 -
hepatic abscess days
OR
Metronidazole IV 750 mg q8h
Metronidazole PO 400mg-800 mg q8h x 5
Giardia lamblia; Giardiasis -
days
Blastocystis hominis No treatment required Metronidazole PO 800 mg q8h
Metronidazole PO 400mg-800 mg q8h x 10
Dientamoeba fragilis days
(30 mg/kg/day in children)
Protozoa – Extra intestinal
Malaria See Algorithm (see index)
Amebic meningoencephalitis
Naegleria fowleri See Index
Leishmaniasis
Amphotericin B 1 mg/kg/day IV for 21 Antimony (Meglumine
days antimonite or Stibogluconate) 20
Visceral – Kala Azar Miltefosine* 50 mg PO BID for 21 mg/kg in 2 divided doses IV/IM x
days (not in pregnancy)Confirm availability 28 days
from pharmacy
Warning: Avoid combining Amphotericin and Antimony compounds
70
Cutaneous (most resolve Fluconazole 200 mg QD PO for 6 Antimony intra-lesional
spontaneously) weeks
Pneumocystis jirovecii pneumonia (PCP)
Clindamycin 300-450 PO q6hrly
Not acutely ill (PO Rx possible) TMP/SMX-DS 2 tabs q8hrly x 21 days + Primaquine 15 mg base PO QD
(after G6PD) x 21 days
IV: TMP/SMX at 15mg/kg/day of TMP
component divided q6-8h with (confirm the
Acutely ill (PO Rx not possible,
availability from pharmacy before ordering)
PaO2 < 70 mmHg)
Prednisolone 40 mg BID x5 days, 40 mg QD
x 5 days and then 20 mg QD x11 days
Nematodes – Intestinal
Mebendazole 100 mg bid x 3
Ascariasis Albendazole 400 mg x 1 dose
days or 500 mg x 1 dose
Albendazole 400 x 1 dose, repeat in 2 Pyrantel pamoate 11mg/kg (max
Pinworm weeks or Mebendazole 100 mg x1 dose repeat 1 gm) x 1 dose (can repeat in 2
in 2 weeks weeks
Hookworm Albendazole 400 x 1 dose or Pyrantel pamoate 11mg/kg (max 1
Mebendazole 100 mg bid x 3 days gm) x 3 days
Ivermectin 200µg/kg/day PO for 2 days for
Strongyloides stercoralis asymptomatic or intestinal disease OR
Albendazole 400 mg bid x 7 days
71
Albendazole 400 mg q24h x 3 days Mebendazole 100 mg bid x 3
Whipworm days
Cestodes (Tapeworm)
Systemic (Echinococcus) Albendazole <60kg: 15 mg/kg/day q12h PAIR procedure recommended
>60kg: 400 mg q12h Use for 28 days*
Ectoparasites
Permethrin lotion 1%** apply to dry hair
Pediculosis (head lice) for 10 minutes. Then shampoo, repeat in
7-10days.
Permethrin 5% cream or lotion; apply on Benzyl benzoate lotion; apply and
entire skin from chin to toe, leave on 8-10 leave for 24 hours, may repeat after
Scabies hours, and repeat in 1 week. Note: safety not 2 days.
established less than 2 months of age.
* Give a 28-day cycle followed by a 14-day albendazole-free interval for a total of 3 cycles. Maximum dosage: 800 mg/day
**To Prepare 60ml of 1% lotion (12ml 5% lotion + 48 ml tap water)
72
Chapter 07: Antimicrobial Coverage & Sensitivity(Antibiogram)
AKUH INPATIENT. PERCENT SENSITIVE Jan-Dec 2019
Organism n AMK AMP ATM CAZ CFM CIP CRO CT CXM GEN IPM MEM SXT TZP TET TOB
Acinetobacter species 809 25 NT NT 9 NT 13 NT 94 NT 24 15 15 21 14 6 48
E.coli 2978 96 6 28 NT 17 24 21 13 70 88 88 28 68 NT NT
CR-E.coli 357 100
Enterobacter species 323 71 0 32 NT 15 43 25 0 55 64 64 50 53 NT NT
CR-Enterobacter spp 116 94
Klebsiella pneumoniae 1012 81 0 35 NT 25 43 34 21 72 77 77 44 70 NT NT
CR-K.pneumoniae 334 75
73
Pseudomonas aeruginosa 1087 88 NT 65 83 NT 79 NT NT 84 80 80 NT 83 NT NT
MDR P.aeruginosa 230 98
Proteus mirabilis 196 86 31 65 NT 42 37 55 NT NT 61 NT 98 31 95 NT NT
n CAZ LEV MINO MEM SXT
S.maltophilia 155 63* 93 94 NT 97
Burkholderia cepacia 97 87 28 50 71 94
n AMP CLR CLI ERY FD CIP LNZ TET SXT PEN OX VAN
Enterococcus species 1017 47 85 NT NT NT 7 100 35 NT NT NT 71
Staphylococcus aureus 1116 NT 96 73 43 73 37 100 61 58 0 32 100
Coagulase negative Staph. 1997 NT 63 62 19 NT 48 NT 68 44 0 21 100
AKUH OUTPATIENT. PRECENT SENSITIVE Jan-Dec 2019
Organism n AMK AMP ATM CAZ CEF CIP CRO CT CXM GEN IPM MEM SXT TZP TET TOB
Acinetobacter group 1873 53 NT NT 39 NT 33 NT NT 44 45 45 38 39 32 62
CR-Acinetobacter spp 1030 98
E.coli 18350 96 10 40 NT 27 31 31 22 67 94 94 31 82 NT NT
CR E.coli 1101 100
Enterobacter species 1153 76 0 45 NT 38 64 39 37 65 80 80 51 73 NT NT
CR Enterobacter spp 231 96
Klebsiella pneumoniae 4659 75 0 45 NT 41 51 46 36 67 82 82 45 72 NT NT
74
CR K.pneumoniae 839 92
Pseudomonas aeruginosa 4969 80 NT 58 78 NT 64 NT NT 73 81 81 NT 79 NT NT
MDR P.aeruginosa 826 98
Proteus mirabilis 921 83 31 69 NT 46 59 58 NT 40 62 NT 98 29 96 NT NT
n CAZ LEV MINOMEM SXT
S.maltophilia 356 47** 85 91 NT 92
Burkholderia cepacia 675 85 24 83 60 84
n AMP CLR CLI ERY FD CIP LNZ TET SXT PEN OX VAN
Enterococcus species 3801 75 77 NT NT NT 15 NT 28 NT NT NT 93
Staphylococcus aureus 5913 NT 100 76 44 91 45 NT 65 67 0 33 100
Coagulase negative Staph. 6491 NT 95 57 17 NT 45 NT 56 41 10 27 100
ABBREVIATIONS
AMK - Amikacin CLI - Clindamycin FLUC - Fluconazole OX – Oxacillin TOB - Tobramycin

AMP – Ampicillin CLR Chloramphenicol GEN – Gentamicin OFX-Ofloxacin VAN - Vancomycin
AMC- Amox/clav CRO - Ceftriaxone INH-Isoniazid PEN – Penicillin VOR-Voricomnazole
AMT-Amphotericin-B CXM – Cefuroxime IPM - Imipenem PZA-Pyrazinamide CR – Carbapenem-resistant
AZM-Azithromycin CT - Colistin LEV – Levofloxacin RIF-Rifampin MDR- Multidrug resistant
75
ATM – Aztreonam ERY – Erythromycin LNZ - Linezolid STR-Streptomycin n– Total isolates
CAZ - Ceftazidime ETHM-Ethambutol MEM - Meropenem SXT - Co-trimoxazole
CFM - Cefixime FEP-Cefepime MINO - Minocycline TET – Tetracycline
CIP - Ciprofloxacin FD - Fusidic acid NT - Not Tested TZP- Piper/Tazo
AKUH / ALL PATIENTS, PERCENT SENSITIVE. JANUARY-DECEMBER 2019
Organism n* AMP ATM AZM CAZ CFM CIP CLR CRO CXM ERY MEM/
IPM SXT TET
Aeromonas hydrophila 335 NT 92 NT 79 NT 84 NT 70 67 NT 81 52 NT
Campylobacter jejuni/ coli 371 NT NT NT NT NT 5 NT NT NT 95 NT NT 65
Salmonella Paratyphi A 470 99 NT NT NT 100 1 99 100 NT NT NT 99 NT
Salmonella Typhi 7706 15 NT 99.9 NT 26 1 15 26 NT NT 100 15 NT
Shigella species 170 24 NT NT NT 63 77 77 64 NT NT 100 14 NT
Vibrio cholerae 54 54 NT NT NT NT 85 100 NT NT NT NT 82 90
n * AMP AMC CIP CFM CLR CRO CXM ERY SXT TET PEN AZM
Haemophilus influenzae 549 90 92 63 NT 91 100 92 NT 25 84 NT NT
Moraxella catarrhalis 133 0 96 56 NT 89 100 NT 66 40 70 NT NT
76
Neisseria gonorrhoea 35 NT NT 3 100 NT 100 NT NT NT 40 9 100ǂ
n * CLI CLR ERY CXM LEV/
OFX PEN SXT TET VAN
Beta haemolytic strep. A 2859 60 82 60 NT 94 100 NT NT 100
Streptococcus pneumoniae 309 69 96 47 86 87 70 β 19 34 100
n * INH RIF STR ETHM LEV PZA
Mycobacterium tuberculosis 1340 76 82 81 81 80 89
n * AMC AMK CLA IPM CIP SXT MOX FEP
Nocardia species 65 9 92 20 22 14 96 40 28
n * FLU VOR AMT
Candida species 993 82 88
Fluconazole resistant 179 100
Candida spp
β=
Susceptibility data includes meningitic and non- meningitic isolates. Penicillin susceptibility suggests susceptibility to
amoxicillin and ampicillin for treatment of pneumonia cases, as well as to Penicillin G for treatment of meningitis
*CAZ checked against S. maltophilia AKU inpatients in 44% isolates only
** CAZ checked in S. maltophilia outpatients in 29% isolates only
ǂ Azithromycin tested on 27 of 35 isolates only
Note: Susceptibility profiles are derived from all specimen received by the Clinical Microbiology Laboratory. Antibiotic
susceptibilities of bacteria recovered from specific wards or populations may differ.
77
Aga Khan University Hospital
Clinical Laboratory
Microbiology
ANTIBIOTIC SUSCEPTIBILITY REPORT
Jan-Dec 2019
Telephone: 34930051 ext. 1608, 1682

Between 9:00 -5; 00 pm
During weekdays (Mon-Fri)
78
The following tables provide the antibiotic spectrum of selected antibiotics to some commonly encountered pathogens. When
deciding on an antibiotic, please also refer to the AKUH Antibiogram which provides the susceptibility patterns of pathogens
isolated at AKUH over the last 1 year.
Black boxes refer to the preferred agent. Empty Square denotes lack of data.
Gram Positives, β-Lactam drugs and quinolones
Pip-Tazo
Cefixime
Ceftazidime
Cefepime
Penicillin
Cloxacillin
Ertapenem
Cefazolin
Cefuroxime
Cefpodoxime
Ciprofloxacin
Levofloxacin
Imipenem /Meropenem
Cefoperazone-sulbactam
Ampicillin
Amox/Clav
Aztreonam
Cefotaxime/Ceftriaxone
Strept grp A,B,C,G + + + + + + + - + + + + + + + + ± +
S. pneumo + + + + + + + - - + + ± + ± + ± +
S. viridans ± ± ± ± + + + - + + + + - + ± + - +
Enterococcus (not VRE) ± - + + + + + - - - - - - - - - ± -
VRE - - - - - - - - - - - - - - - - ± -
79
MSSA - + - + + + + - + + + + - + ± + + +
MRSA - - - - - - - - - - - - - - - - - -
Coag negative staph - ± - ± ± ± ± - ± ± ± ± - ± ± ± ± ±
Listeria + - + + + + ± - - - - - - - - - + +
Chlamydia - - - - - - - - - - - - - - - - + +
Mycoplasma - - - - - - - - - - - - - - - - + +
Legionella - - - - - - - - - - - - - - - - + +
Bacteroides fragilis - - - + + + + - - - - + - - - - - -
Clostridium difficile - - - - - - - - - - - - - - - - - -
Clostridium (not difficile) + - + + + + + - + + + + + - ± +
Peptostreptococcus + - + + + + + - + + + + + + + + ± +
Gram Positives, Non β-lactam drugs
Tigecycline
Fusidic acid
Fosfomycin
Clindamycin
Vancomycin
TMP-SMX
Metronidazole
Erythromycin
Doxycycline
Nitrofurantoin
Clarithromycin
Teicoplanin
Linezolid
Chloramphenicol
Azithromycin
Polymyxin-E
Amikacin/Gentamicin
Strept grp A,B,C,G - + + ± ± ± ± + + + ± - - - + -
S. pneumo - + + + + + + + + + ± + - - + -
Enterococcus (not VRE) + - - - - - + + + + - + + - + -
VRE + - - - - - + - ± ± - + + - + -
MSSA ± + ± + + ± + + + + + + - + -
80
MRSA ± ± ± ± ± ± + + + + + + - + -
Coag negative staph - ± ± ± ± ± + + + + + + - + -
Listeria Syn + + + + + + + + + - - + -
Chlamydia - + - + + + + + - - - - - - - -
Mycoplasma - + - + + + + + - - - - - - - -
Legionella - - + + + + + - - - - - - - -
Bacteroides fragilis - + + - - - ± + - - - - - + - -
Clostridium difficile - - - - - - - - + + - - - - + - -
Clostridium (not difficile) - + ± + + + + + + + - - + + -
Peptostreptococcus - + + ± + ± + + + + + - - + + -
*Syn = Synergy with Beta Lactams
Gram negatives
β-lactam drugs and Quinolones
Pip/Tazo
Ertapenem
Penicillin
Cloxacillin
Ampicillin
Amox/Clav
Imipenem /
Meropenem
Aztreonam
Cefazolin
Cefuroxime
Cefotaxime/
Ceftriaxone
Cefoperazone-
sulbactam
Ceftazidime
Cefepime
Cefixime
Cefpodoxime
Ciprofloxacin
Levofloxacin
N. gonorrhoeae - - - - + + + - + ± + ± + + + - -
81
N. meningitidis + - + + + + + + - + + ± + ± - -
E.coli - - ± + + + + + + + + + + + + + + +
Klebsiella - - - + + + + + - + + + + + + + + +
Enterobacter - - - - + + + + - ± + + + + + + + +
ESBL + GNR - - - + + + + - - - - + - - - - + +
Salmonella - - + + + + + + + + + + + +
Shigella - - + + + + + + + + + + + + + +
Acinetobacter - - - - + + - - - - - + ± ± - - ± ±
Pseudomonas aeruginosa - - - - + + - + - - - ± + + - - + ±
B. cepacia - - - - + - - - - - - + ± - - - -
S. maltophilia - - - - ± - - - - - - - ± - - - - -
Gram negatives, Non β-lactam drugs
Amikacin
Chloramphenicol
Clindamycin
Erythromycin
Azithromycin
Clarithromycin
Doxycycline
Tigecycline
Vancomycin
Teicoplanin
Fusidic acid
TMP-SMX
Nitrofurantoin
Fosfomycin
Metronidazole
Linezolid
Polymyxin-E
N. gonorrhea - + - ± ± ± ± + - - + ± + + - - -
N. meningitidis - + - + + + - - + + - - -
E.coli + + - - - - + + - - - + + + - - +
82
Klebsiella + ± - - - - + + - - - + + + - - +
Enterobacter + - - - - - + + - - - + + + - - +
ESBL + GNR + ± - - - - + + - - - + + + - - +
Salmonella + - - + - ± + - - - + - - - -
Shigella - + - - + - ± + - - - + - - - -
Acinetobacter ± - - - - - - ± - - - - - - - - +
Pseudomonas aeruginosa + - - - - - - - - - - - - - - - +
B. cepacia - + - - - - - ± - - - - - - - - -
S. maltophilia - + - - - - - + - - - + - - - - ±
Chapter 08: Drug Dosing, Pharmacokinetics and Safety
Adult Normal Doses and Antimicrobial drug Cost
(Rs/
(Rs/day)
Drug Dose Range Strength day) Common Adverse Effects
Parenteral
Oral
300-750mg q8hrs IV 500 mg IV
Acyclovir 800 mg q5times a day 200, 400, 800 200-280 3398- 6797 Dryness, Scaling, Nephrotoxicity
PO Tablet
200 mg tab Abdominal pain, Nausea, Vomiting,
Albendazole 400 mg stat 27-28 -
200 mg/5ml Susp. Headache
Nephrotoxicity, Ototoxicity, Tinnitus,
Amikacin 750-1000mg q24hrs 50mg 250 mg, 500 mg - 500-680
83
Drug fever.
Ampicillin 1-2g q6hrs 250 mg, 500 mg - 380-760 Rashes, Nausea, Vomiting, Diarrhea.
Amphotericin B Chills, Fever, Headache, Rash,
25-75mg q24hrs 1232-2464
Amphotericin B 50 mg/vial - Nephrotoxicity,
3 to 5 mg/kg/day 14000-28000
(liposomal) Weight loss, Hypokalemia.
600mg, 1.2 gm (IV) -
1.2g q8hrs IV 375mg, 625mg, 76-86 Diarrhea, Abdominal discomfort,
Amox/Clav 375-625 mg TID (PO) 1 gm (tablet) 77 735-780 Rashes,
Or 1 gm q12hrly 156.25mg/5 ml, 149/bot Urticaria.
312.50mg/5 ml (Susp.) 230/bot
500mg/vl
Abdominal pain, Diarrhea, Nausea
Azithromycin 250-500 mg q24h 200mg/5ml 165/bot 200/-
and vomiting, Headache
250mg,500mg cap 32-60
Cefotaxime 1-2g q8hrs 250 mg, 1000 mg vials - 807-1614 Rash, Pruritis, Colitis.
Diarrhea, abdominal pain, nausea,
100 mg tab 65-131
Cefpodoxime 200-400 mg per day - vomiting, skin eruptions, eosinophilia,
40 mg/5 ml syrup 180/bot
dermal mycosis and urticaria.
Diarrhea, Neuromuscular excitability,
Ceftazidime 1-2g q8hrs 1000 mg vial - 896-1792
Steven-Johnson Syndrome.
Ceftriaxone 1-2g q24hrs 1000 mg vial - 409-818 Headache, leucopoenia.
Aplastic anemia, Bone marrow
1000 mg IV
84
Chloramphenicol 0.5-1 g q6hrs 20-40 140 suppression,
250 mg cap.
Gray baby Syndrome.
200-400mg q12hrs IV 200 mg IV, 400mg IV
Ciprofloxacin 33-60 174-348 Restlessness, Rash
250 – 500 mg q12hrs PO 250mg, 500 mg tab.
,250 mg, 500 mgTab, 88-175 Headache, Rash, Diarrhea, Abnormal
Clarithromycin 250-500mg q12hrs -
125mg/5 ml Susp. 385/bot taste, Heartburn.
600mg q8hrs IV 600 mg IV Diarrhea, Rash, Colitis, anemia,
Clindamycin 92-131 757
300-450 mg q8hrs PO 150mg, 300 mg cap. hepatotoxicity.
Diarrhea, Abdominal pain, Allergic
Cloxacillin 250-500mg q6hrs 250 mg IV 100-200
- reactions.
Colistin 9 MIU Loading Neurotoxicity, nephrotoxicity,
1 MU/vial - 16000
(Polymyxin E) 5MIU q12h respiratory failure.
Discoloration of teeth in children,
Doxycycline 200mg q24hrs 100 mg cap. 16 -
Esophagitis, Diarrhea.
Abdominal pain, Cramping, Nausea
250 mg, 500 mg tab 73 - 145
Erythromycin 0.5-1g q6hrs - Vomiting, Oral candidiasis, Phlebitis
200 mg/5 ml Susp. 97/ bot
at Inj. Site, Cholestatic jaundice.
Swelling/edema, headache, altered
mental status, rash, diarrhea, nausea,
Ertapenem 1gm QD 1000 mg - 3950 vomiting, constipation, increased PLT
count, raised hepatic enzymes, local
vein complication
100 mg IV
Headache, Rash, Abdominal pain,
Fluconazole 100-200mg q24hrs 50mg, 150 mg, 318-805 1120-2240
85
Dizziness.
200 mg Cap.
1g IV
12-24g/day IV 33 1776-3552 Large sodium load(IV)14.4mEq/gm
Fosfomycin 500mg cap
1.5g/day 150 ,Diarrhea.
3g/sachet
Skin rash, Pruritus, Nausea,
Fusidic Acid 500mg q8hrs 250 mg tab. 834 -
Thrombophlebitis.
Neurotoxicity, Ototoxicity,
Gentamicin 160-320mg q24hrs 80 mg IV - 76 – 153
Nephrotoxicity, edema.
Erythema multiform, Stevens-
Johnson syndrome, Toxic epidermal
necrolysis, Agranulocytosis,
Imipenem 500 mg q6hrly 500 mg IV - 4200
Leukopenia (rare), Neutropenia,
Seizure, Most commonly in patients
with CNS disorders
2 Nausea, Vomiting, Loss of appetite,
100 mg tablet,
Isoniazid 300mg q24hrs 250/bot Weakness, Peripheral Neuropathy,
50 mg/5ml Susp.
Jaundice.
500 mg IV,
500mg q24hrs 108 Seizures, hypersensitivity reaction,
Levofloxacin 250 mg, 500 mg, 370
750mg q24hrs 45 diarrhea
750mg tab.
86
Reversible myelosuppression, lactic
600 mg tab
Linezolid 600 mg q12h 200 1340 acidosis, peripheral
600 mg/infusion
or optic neuropathy
Meropenem 1-2g q8h 500 mg, 1000 mg IV - 7350 -14700 See Imipenem
500 mg IV,
500mg q6hrs IV 6.5-13
Metronidazole 200 mg, 400 mg tab. 540 Dizziness, Headache, metallic taste.
1.2-2.4g/day 49/bot
200mg/5 ml Susp.
Convulsions, Hemolytic Anemia,
3-4 million unit
Penicillin G 1 Million Units - 420-462 Positive Coomb's
q4-6hrs
Reaction, Interstitial nephritis
Piperacillin/ 4.5 gm 2665-3540 Diarrhea, Hypertension, Insomnia,
4.5g q6-8hrs -
Tazobactam 2.25gm 429/vial Headache, Rash, Rhinitis.
100-200mg Load 13200
Tigecycline 50mg IV - Nausea & vomiting, acute pancreatitis
50-100mg q12h 6600-13200
Hypotension accompanied by
Vancomycin 1g q12hrs 500 mg - 4132 flushing, Erythematous rash
on face and upper body
Prices quoted are prone to change with the change in brands or price revision by the manufacturer.
87
Safety of Antimicrobial in Pregnancy & Lactation
Pregnancy Lactation
S# Antibiotics
Category Status
1. Acyclovir B Compatible
2. Amantadine C Unsafe
3. Amikacin D Compatible
4. Amoxicillin B Compatible
5. Amoxicillin/Clavulanic acid B Compatible
6. Amphotericin B B Unsafe
7. Ampicillin B Caution advised
8. Ampicillin/Sulbactam B Caution advised
9. Azithromycin B Caution advised
10. Cefazolin B Compatible
11. Cefixime B Unknown
12. Cefotaxime B Compatible
13. Cefpodoxime B Caution advised
14. Ceftazidime B Compatible
15. Ceftriaxone B Compatible
16. Cephalexin B Safe
17. Ciprofloxacin C Compatible
18. Clarithromycin C Caution advised
19. Clindamycin B Compatible
20. Cloxacillin B Compatible
21. Colistin C Caution advised
22. Cycloserine C Compatible
23. Doxycycline D Unsafe
24. Erythromycin B Compatible
25. Ethambutol C Compatible
26. Ethionamide C Caution advised
27. Fosfomycin B Unknown
28. Fluconazole D Compatible
29. Fusidic Acid C Unknown
C (topical/
30. Gentamicin ophth) Compatible
D injection
31. Imipenem/Cilastatin C Caution advised
32. Isoniazid C Compatible
33. Itraconazole C Unsafe
34. Kanamycin D Compatible
35. Ketoconazole C Compatible
36. Levofloxacin C Unsafe
37. Linezolid C Caution advised
38. Meropenem B Unknown
88
B (unsafe in 1st
39. Metronidazole Unsafe
trimester)
40. Minocycline D Unsafe
41. Oxytetracycline D Unsafe
42. Penicillin G B Compatible
43. Penicillin G Benzathine B Caution advised
44. Piperacillin/Tazobactam B Compatible
45. Polymyxin B Unknown Caution advised
46. Pyrazinamide C Caution advised
47. Ribavirin X Unsafe
48. Rifampicin C Compatible
49. Streptomycin D Compatible
50. Sulfadoxine/Pyrimethamine C (D at term) Unsafe
51. Tigecycline D Unknown
B ophth
52. Tobramycin Caution advised
D injection
53. Valacyclovir B Compatible
54. Vancomycin C Caution advised
55. Voriconazole D Unknown
Lactation status definition:

Caution advised: Enters in breast milk in significant quantities
Unknown: FDA Pregnancy Category not defined.
Definition of Pregnancy Categories (FDA)
l Category A: Controlled studies in women have failed to

demonstrate a risk of the fetus
l Category B: Animal studies have shown no risk but no

controlled human studies have been performed,
OR animal studies have shown an adverse effect
that has not been confirmed in human studies.
l Category C: Animal studies have revealed adverse effects and

there are no controlled studies in women OR
studies in women and animals are not available.
Benefit must exceed risk
l Category D: There is evidence of fetal adverse effects but the

benefit may outweigh the risks.
l Category X: There is strong evidence of fetal abnormalities in

humans; Risk outweighs the benefit.
89
Use of Vaccines in Pregnancy and/or lactation
S# Vaccines Type Lactation General Recom- Comments (Pregnancy)
Status mendation for use
in Pregnancy
01 BCG Live attenuated Safe Contraindicated Avoid during pregnancy
Recommended A single dose of Tdap during every pregnancy,
02 Tdap Toxoid & antigen Safe preferably during the early part of gestational weeks
27 through 36.
Should be used if
03 Td Toxoids Safe other-wise indicated Indicated in 2nd and 3rd trimester
(Tdap pre-ferred).
04 Hepatitis B Recombinant Safe Recommended in Indicated in Hepatitis B carriers
90
some circumstances.
05 H. influenza Conjugate Safe Base decision on Not routinely indicated but can be given in certain
type b risk vs. benefit. indications other than primary immunization
06 Polio Vaccine Inactivated Safe May be used if Indicated in women at high risk needing immediate
needed. protection
07 MMR Live attenuated Safe Contraindicated Avoid during pregnancy
Avoid during pregnancy. Women exposed to
08 Varicella Live attenuated Safe Contraindicated chickenpox either in first 20 weeks or near gestation
should receive Varicella Ig**
Safety of pneumococcal polysaccharide vaccine
Inadequate data for during the first trimester of pregnancy has not been
09 Pneumococcal Polysaccharide Safe specific evaluated, although no adverse consequences have
recommendation. been reported among newborns whose mothers were
inadvertently vaccinated during pregnancy.
10 Pneumococcal Conjugate Safe No recommendation. Insufficient to inform vaccine-associated risks in
pregnancy
There has been no observed increase in maternal or
11 Hepatitis A Inactivated Safe Base decision on infant adverse events after hepatitis A vaccination or
risk vs. benefit. IG administration in pregnancy. Give hepatitis Ig **
(0.1 mL/kg). within 1st week of exposure
12 Influenza Inactivated Safe Recommended Influenza vaccination can be administered at any time
91
Vaccine during pregnancy, before and during the influenza season.
13 Meningococcal Polysaccharide Safe May be used if Pregnancy should not preclude vaccination with
(ACWY) otherwise indicated. MenACWY or MPSV4
14 Tetanus Toxoid Tetanus toxoid Safe Should be used if
otherwise indicated Indicated in 2nd and 3rd trimester
(Tdap preferred).
Not recommended for use in pregnant women. If
Human a woman is found to be pregnant after initiating the
15 Papillomavirus Inactivated Safe Not recommended. vaccination series, the remainder of the 3-dose series
should be delayed until completion of pregnancy.
(HPV) Pregnancy testing is not needed before vaccination. If a
vaccine dose has been administered during pregnancy,
no intervention is needed
Can be given as post exposure prophylaxis. If the
16 Rabies Inactivated Safe May be used if risk of exposure to rabies is substantial, pre-expo-
otherwise sure prophylaxis also might be indicated during
indicated. pregnancy.
17 Measles Live attenuated Safe Contraindicated Avoid during pregnancy
Live vaccines like Ty21a are contraindicated in
18 Typhoid Conjugate UnSafe Inadequate data. pregnancy. Vi polysaccharide vaccine should be
given to pregnant women only if clearly needed
If travel is unavoidable, and the risks for YFV
exposure are felt to outweigh the vaccination risks, a
Contrain- May be used if pregnant woman should be vaccinated. If the risks for
19 Yellow Fever Live dicated benefit outweighs vaccination are felt to outweigh the risks for YFV ex-
92
risk. posure, pregnant women should be issued a medical
waiver to fulfill health regulations
• All Live Vaccines are considered contraindicated during pregnancy ** Immunoglobulin (Immunoglobulins are usually
• Pregnancy / Conception should be avoided 1 month after MMR, considered safe)
Varicella and Yellow fever vaccination ! Center of Disease Control
Dose Adjustments in Renal Failure Patients
For the following drugs, there is NO need for the adjustment of

dosage in patients with renal impairment:
Amphotericin B, Itraconazole, Azithromycin, Ceftriaxone,
Chloramphenicol, Clindamycin, Doxycycline, Fusidic acid,
Metronidazole, Cloxacillin, Linezolid, Moxifloxacin, Rifampin,
Albendazole, Mebendazole, Pyrantal Pamoate and Isoniazid
Formula for creatinine clearance calculation:
Different methods recommended for obese (20% over IBW or BMI
>30) and non-obese patients
Adult- non obese
CrCl = (140 – Age) x IBW (Kg) (multiply answer by 0.85 for females)
72 x Serum Creatinine
IBW is
• Men: 50 kg plus 2.3kg/inch over 60 inches in height
• Women: 45 kg plus 2.3 kg/inch over 60 inches in height
Adult obese patient
Men: (137-age) x (0.285 x wt in Kg) + (12.1 x ht in m2)
Women: (146-age) x (0.287 x wt in Kg) + (9.74 x ht in m2)

Note:
Adjusted doses mentioned are for mild to moderate susceptible
infections. For severe infections with moderately susceptible infection, a
higher dose may be required. (1 inch=2.54 cm)
93
Dose
adjustment
Antimicrobials Adjustment as per creatinine clearance (CrCl ml/min)
method
(see footnote)
Carbapenems CrCl >50-90 CrCl 10-50 CrCl <10
25-50ml/min:1-2 gm Q12h
Meropenem D&I 1-2 gm Q8h 0.5-1gm Q24h
10-25ml/min:0.5-1gm Q12h
Ertapenem D 1 gm Q24h 0.5 gm Q24h (<30ml/min) 0.5 gm Q24h
30-50ml/min:250mg Q8h
Doripenem D&I 500mg Q8h No data
10-30ml/min:250mg Q12h
Cephalosporin’s
94
Normal dose > 60 ml/min
Cefixime D 300 mg Q24h (21-40ml/min) 200mg Q24h (<20ml/min)
(>50-90 400mg po q24h)
Cefpodoxime I 200mg Q12h 200mg Q12h 200mg Q24h
Cefotaxime I 2 gm Q8h 2g Q12h 2g Q24h
Ceftazidime I 2g Q8h 2g q12-24h 2 g Q24-48h
Cefazolin I 1-2 gm Q8hrly 1-2g Q12hrly 1-2g Q24h
Fluoroquinolones CrCl >50-90 CrCl 10-50 CrCl <10
<20: 750mg *1 then 500mg
Levofloxacin D&I 750mg Q24h 20-49ml/min: 750mg q48h
Q48h
Ofloxacin D&I 200-400 mg Q12h 200-400mg Q24h 200mg Q24h
Ciprofloxacin PO D 500-750 mg PO Q12h 250 – 500mg Q12h 500 mg Q24h
Ciprofloxacin IV D 400 mg Q12h 400mg Q24h 400mg Q24h
Macrolides CrCl >50-90 CrCl 10-50 CrCl <10
Clarithromycin I 500 mg Q12h 500mg Q12-24h 500mg Q24h
Erythromycin D 250-500 Q6h 100% 50- 75%
Penicillin’s CrCl >50-90 CrCl 10-50 CrCl <10
30-50:1-2g Q6-8h,
Ampicillin I 1-2gm Q4-6h 1-2g Q12h
10-30: 1-2gm Q8-12h
Amoxicillin I 500mg Q8h 500mgQ8-12h 500mg Q24h
Amoxicillin/ PO Q12h
PO 500/125 mg Q8h PO 250-500mg amoxQ24h
Clavulanate(po) D&I Crcl 10-30 1.2g then
IV 1.2g Q8h IV 1.2g1 then 600 mg Q24h
95
Amox/Clavulanate (IV) 600mg Q 12h (IV)
Penicillin G D&I 0.5-4 million U Q4h 0.5-4 million U Q8h 0.5-4 million U Q12h
20-40 ml/min: 2.25 Q6h
Piperacillin/Tazobactam >40 ml/min
D&I <20 ml/min 2.25gm Q8h
Non Pseudomonas 4.5gm Q8h
2.25 g Q8h
20-40ml/min:
Piperacillin/Tazobactam 3.375 gm Q6h
D&I >40ml/min: 4.5 gm q6h 2.25gm Q6h
Anti-Pseudomonas dose <20ml/min
2.25 gm q6h
Antifungal CrCl >50-90 CrCl 10-50 CrCl <10
Amphotericin 0.5-1mg/kg Q24h Q24h Q24h
Fluconazole D 200-400mg Q24h 50% 50%
No reference Better to avoid
Terbinafine - 250mg Q24h
(avoid use) (avoid use)
PO 400mg Q12h for 2doses 100% 100%
then 200mg Q12h
Voriconazole
IV 6mg/kg Q12h for 2doses, Discontinue IV use oral Discontinue IV use oral
then 4mg/kg Q12h
Antivirals CrCl >50-90 CrCl 10-50 CrCl <10
Acyclovir(IV) D&I 10mg/kg Q8h Q12h 5-6.25mg/kg Q24h
Adefovir I 10mg Q24h 10 mg Q48-72h 10mg Q72h
96
Amantadine I 100mg Q12h Q24-48h weekly
Entecavir D 0.5 mg Q24h 0.15-0.25 mg Q24h 0.05mg Q24h
(25-49ml/min: 2.5mg/kg q24h
Ganciclovir (IV) (70-90ml/min: 5mg/kg Q12h)
D&I 10-24ml/min: 1.25mg/kg 1.25mg/kg 3 times/week
Induction 50-69ml/min: 2.5mg/kg Q12h)
q24h)
25-49ml/min 1.25mg/kg
Q24h 0.625 mg/kg 3times
Ganciclovir maintenance D&I 2.5-5 mg/kg Q24h
10-24ml/min 0.625mg/kg per week
Q24h
31-60 ml/min
30mg Q12h or 75 mg Q24h (no recommendation
Oseltamivir I >60 CrCl ml/min : 75 mg bid
10-30ml/min unless HD)
30mg Q24h
Ribavirin - Use with caution in Cr Cl < 50 ml/min
30-49 ml/min 300 mg Q48h
Tenofovir - 300 mg Q24h 10-29ml/min: 300 mg Q72- No data
q96H
Valacyclovir D&I 1gm Q8h 0.5gm-1gm Q12h 0.5gm Q24h
Anti-TB DRUGS D&I CrCl >50-90 CrCl 10-50 CrCl <10
97
30-50ml/min 15-25mg/kg
Q24-36h 15mg/kg Q48h
Ethambutol I 15-25mg/kg Q24h
10-30ml/min 15-25mg/kg
Q36-48h
Ethionamide D 500mg Q12h 100% 50% Q12h
Isoniazid - 300mg Q24h 100% 100%
21-50ml/minQ24h
Pyrazinamide I 25mg/kg Q24h 25mg/kg Q48h
10-20ml/min Q48h
Rifampicin - 600mg Q24h Same dose Same dose
Miscellaneous
>90 ml/min :183.33mg Q12h
LD=9 MU
(5.5MU Q12h) or 6mg/kg/day
(300mg)
50-89 ml/min:150 mg Q12h 10-29ml/min:83.33mg Q12h <10ml/min:66.66mg
Colistin (Polymyxin-E) (Maintenance
(4.5MU Q12h) or 5mg/kg/ (2.5MU Q12h) Q12h(2MU Q12h) or
dose in base dose after 12
day q12h Or 2.7 mg/kg/day 2.2 mg/kg/day
hrs. of LD
30-49 ml/min: 133.33mg Q12h
(4MU Q12h) or 4.4 mg/kg/day
CrCl >50-90 CrCl 10-50 CrCl <10

7.5mg/kg Q6h (500mg Q6h)
Metronidazole I 100% Q12h
98
Max.dose 4g/day
LD:100-200mg
Tigecycline - Same dose Same dose
50-100mg Q12h
Crcl 30-40 8-16g per day
>40 (Normal dose 12-24g/day Q8-12h 1-2g q12h (2g post
Fosfomycin IV D&I
Q8-12h) Crcl 10-30: 6-12g per day dialysis)
Q8-12h
Trimethoprim-
Note: normal prophylaxis Note: normal prophylaxis
Sulfamethoxazole D Normal prophylaxis dose
dose can be given. dose can be given.
(Prophylaxis)
30-50 Crcl: 5-20mg/kg/day
Trimethoprim – Not recommended
5-20mg/kg/day divided q6 – divided Q6-12h
Sulfamethoxazole D&I but if used 5-10mg/
q12h 10-29 Crcl: 5-10mg/kg/ day
(Treatment) kg Q24h
Q12h
Vancomycin D&I 1 gmQ8-12h 1 gm Q24h (follow AUC0-24
Anthelmintic drugs Dose adjustment not required
Dose 24hr (mg/kg)
Aminoglycosides
CrCl >80 CrCl 60-80 CrCl 40-60 CrCl 30-40
Amikacin, Streptomycin - 15 12 7.5 4
99
Gentamicin, Tobramycin - 5.1 4 3.5 2.5
Dose
Dose 72 hrly (mg/kg) and AD*
48 hrly (mg/kg)
CrCl 20-30 CrCl 10-20 CrCl <10
Amikacin, Streptomycin - 7.5 4 3
Gentamicin, Tobramycin - 4 3 2
Imipenem/Cilastatin
Total daily dose 2g/day Total daily dose 3g/day Total daily dose 4g/day
CrCl ≥60 to <90 mL/minute: 500 mg CrCl ≥60 to <90 mL/minute: 750 mg every
Crcl >40-50 Dose=500 mg q8h
every 6 hours 8 hours
Crcl >20-40 Dose=250 mg q6h
Crcl 5-20 Dose=250 mg q12h
After dialysis supplement 500 mg CrCl less than 15 mL/min: Do not initiate CrCl less than 15 mL/min: Do not initiate
100
therapy unless hemodialysis will begin therapy unless hemodialysis will begin
within 48 hours within 48 hours
Footnote:
Dose adjustment method:
D = dose adjustment
I = Interval adjustment
D&I = both interval and dose can be
adjusted * AD: After Dialysis
Supplemental Doses for Antibiotics during Dialysis
Supplement Doses (Pediatrics) Supplemental doses (adults)
Antimicrobials
Peritoneal Dialysis Hemodialysis
Ampicillin Dose for CrCl < 10ml/min 500-2000 mg AD*
Amoxicillin/ Oral = 375-625mg
Dose for CrCl < 10ml/min
Clavulanate IV= 600 mg -1.2 gm AD*
Amikacin Follow levels 3.25mg/kg AD
Acyclovir Dose for CrCl < 10ml/min Dose for CrCl < 10ml/min AD*
Cefazolin Dose for CrCl < 10ml/min 1-2 gm AD*
Cefixime Dose for CrCl < 10ml/min
(dose AD on dialysis days)
101
Ceftazidime Dose for CrCl < 10ml/min 1-2 gm AD*
Cefotaxime Dose for CrCl < 10ml/min 1 gm AD*
Ciprofloxacin ½ of the normal renal function dose AD* Give adjusted dose AD
0.5 gm q24h (+150 mg AD if given within 6 hr prior
Ertapenem Dose for CrCl < 10ml/min
to HD)
Gentamicin 3-4 mg/L/day is removed (see footnote) (1.7-2.0mg/kg q48h (+extra 0.85-1.0mg/kg AD)
Fosfomycin Dose for CrCl < 10ml/min 2g AD*(IV)
Dose for CrCl < 10ml/min, adjust to 50% of
Isoniazid 300 mg administer AD on dialysis days)
normal dose/day for CAPD
Itraconazole (PO) - 100-200 mg AD*
Dose for CrCl < 20 ml/min
Levofloxacin Dose for CrCl < 20 ml/min
(750mg X 1 then 500mg q48h)
Meropenem Dose for CrCl < 10ml/min Give adjusted dose AD*
Imipenem 250-500 mg AD*
Metronidazole Dose for CrCl < 10ml/min 500 mg q12h (give one of the dialysis day doses AD)
Oseltamivir None (30mg after each dialysis; no drug on non-HD days)
(non pseudomonas dose:2.25gm q12h plus extra
Piperacillin/ 0.75gm AD
Tazobactam Anti-Pseudomonas dose: 2.25gm q8h plus extra
0.75g AD
Colistin - 2 MU(66.66mg) AD
102
Pyrazinamide None Administer AD on dialysis days
Vancomycin As per levels As per levels
AD* After dialysis
Footnote:
1. Usual method for CAPD is 2 L replaced qid (8L/day): give 8Lx 20mg lost per L = 160 mg supplement every day
2. Drugs which are not mentioned in the table should be given as their routine adjusted dose preferably after dialysis. Supplemental doses are not
required in this case.
CRRT Dosing Information (CVVH)
Drug Dosing
Acyclovir 5-10mg/kg q24h
Load 10mg/kg, then 7.5mg/kg q24h (follow
Amikacin
serum trough levels)
Amphotericin B 0.5-1mg/kg q24h
Ampicillin Load 2gm then 1-2gm q8-12h
INH and Rifampin 100 %,
ATT dosing
PZA and Ethambutol three times a week
Cefazolin Load 2gm then 1-2g q12h
Cefotaxime 2gm q12-24h
Ceftazidime Load 2gm then 1-2g q12h
Ciprofloxacin 200-400mg q12h
Colistin Load 9MU then 6MU q12h
Fluconazole Load 400-800mg then 200-400mg q24h
Levofloxacin Load 750mg then 500mg q48h
Meropenem 1-2g q12h
Oseltamivir 75-150mg q12h
Piperacillin/ (non pseudomonas dose: 2.25g q6h
Tazobactam Anti-Pseudomonas dose: 3.375g q6h)
Trimethoprim- 5mg/kg q8h
sulfamethoxazole For prophylaxis no Change
Vancomycin Load 20-35mg/kg (max 3gm) 7.5-10mg/kg q12h
400 mg q12h × 2 doses then 200 mg q12h(Avoid
Voriconazole
IV use)
Antimicrobials that do not require dosing adjustment during

CRRT:
Amphotericin, Azithromycin, Caspofungin, Ceftriaxone, Clindamycin,
Doxycycline, Fosfomycin, Linezolid, Metronidazole, Rifampin,
Tigecycline, Voriconazole.
103
Hepatic Adjustment of Selected Antimicrobials
Following drugs require hepatic dose adjustment, consult Drug and
Poison Information Centre for dosing details:
Antibacterial Antifungal Antiviral
Ceftriaxone Rifampicin
Chloramphenicol Tigecycline Itraconazole
Tinidazole Voriconazole
Clindamycin Pyrazinamide\ Caspofungin Anti-retroviral
Fusidic acid Fluconazole
Isoniazid
Metronidazole
Penetration of Antimicrobial in Cerebrospinal Fluid (CSF)
Sub-Therapeutic
Therapeutic Therapeutic Concentration in
Concentration in CSF Concentration in CSF CSF with
without inflammation with inflammation or without
inflammation
Chloramphenicol Acyclovir Amikacin
Isoniazid Ampicillin Amphotericin B
Metronidazole Cefotaxime Cefazolin
Rifampicin Ciprofloxacin1 Clindamycin
Sulfonamides antibiotic Ceftazidime Gentamicin
Ceftriaxone Itraconazole
Imipenem2 Colistin
Meropenem Streptomycin
Penicillin G high doses3
Vancomycin
Note:
1
Concentration not good for streptococci
2
Avoid for meningitis therapy due to seizure potential
3
Does not apply to penicillin resistant S. pneumoniae
Intra-Ventricular Doses of Antimicrobials

Drug Daily Dose
Amikacin 5-10 mg
Amphotericin B 0.3-1.5 mg
Ampicillin l0-50 mg
Colistin 10 mg
Gentamicin 25-100 mg
Vancomycin 5 mg
104
Chapter 09: Neonates and Pediatrics
Neonates
Sepsis
Early signs include: Late signs Lab Parameters
Reluctant to feed Tachypnea, grunting Hematolgoy: CBC
(Platelets<150*10E9/L),
Lethargic Tachycardia/bradycardia/arrhythmias Total leukocyte counts (>20000 or
<5000*10E9/L), ANC count <7500/mL or
Seizures/irritability/lethargy >14 500/mL
Poor neonatal reflex
Apnea Biochemistry: Raised CRP, RBS(high/
105
Hyper/hypoglycemia low), CSF DR and Urine DR (suggestive
Diarrhea, and abdominal distention. of infection)
Vomiting
Delayed capillary refill Microbiology: Blood culture, CSF
Temperature instability culture, urine culture, tracheal aspirate or
Oliguria from any other source of infection
Temperature instability Radiology: Chest X-ray, Ultrasound head,

MRI/CT brain if needed
Empiric treatment
Presumed neonatal sepsis (inborn) Presumed neonatal sepsis (out born or admitted through ER)
Ampicillin+ Aminoglycoside (Gentamicin/ Cefotaxime + aminoglycoside
Amikacin) (Gentamicin/Amikacin)
Ampicillin: 25 to 50 mg/kg/dose IV q12 hourly
(<7days), 8hourly(≥7days)
Gentamicin: 4-5mg/kg/dose IV once a day
Amikacin: 15mg/kg IV once a day
Presumed Hospital acquired neonatal sepsis (first
Presumed Hospital acquired neonatal sepsis(Alternative)
line)
Meropenem+ Vancomycin Meropenem+ Vancomycin +Colistin
106
Meropenem: 20mg/kg/dose IV 12hourly (<14 days), Take ID onboard.
8 hourly (>14days) Colistin:2.5-5mg/kg/day of Colistin base in 2 divided doses.
Vancomycin: 10 mg/kg/dose IV 12hours (<14 days),
8 hourly (>14days)
*ID consult is mandatory after 72 hours of therapy
For complete dosing refer Neonates Antimicrobial Dosing section

Meningitis
Meningitis: Treatment
-Perform a Lumbar Puncture in sick babies First line: Cefotaxime (with or without Ampicillin) +Aminoglycoside
and also consider it if: For Suspected MDR (Nosocomial): Meropenem + Vancomycin (For colistin
-CRP>20 take ID on-board)
-Positive Blood Cultures Meropenem: 40mg/kg/dose IV q12hourly (<14 days), q 8 hourly (≥14days).
-Non responders to antibiotics Vancomycin: 10 mg/kg/dose IV q12hours (<14 days), q8 hourly (≥14days)
-Neurological symptoms. Ampicillin 200-300mg/kg/day IV q8h (<7days),300mg/kg/day q6h (≥7days)
-A Lumbar Puncture is contraindicated if Cefotaxime 100-150mg/kg/day q8-12h(<7days), 150-200mg/kg/day q6-8h(≥-
the baby is unstable clinically or if there is 7days)
coagulopathy/Low platelets. Gentamicin 5mg/kg IV q24h
107
Miscellaneous
Pre-Nec/Necrotizing Enterocolitis (NEC) Septic arthritis/ Osteomyelitis Suspected Fungal Infection
Empiric treatment: Empiric treatment Empiric treatment:
Ampicillin+ gentamicin+ Cefazolin + gentamicin First choice is

Metronidazole /clindamycin. Amphotericin B: 1-1.5mg/
For MSSA: Cloxacillin, cefazolin, kg OD
OR: cephalexin, and clindamycin.
Alternative:
Vancomycin instead of ampicillin for For MRSA: Vancomycin and linezolid are Fluconazole: 12mg/kg Loading
suspected MRSA or ampicillin-resistant used. (Clindamycin if susceptible) dose
enterococcus. Maintenance: 6mg/kg/dose OD
108
Duration: 4-6weeks, with initial 2-3 weeks (IV or Oral)
Alternative: intravenous antibiotics followed by 3-4
Meropenem+ Vancomycin in case of weeks oral therapy with ESR/CRP to monitor
complications. treatment response. Duration: 14-21 days after
documented clearance in blood
Duration: 10-14 days + Surgical Management (2 negative culture 24 hour
apart), urine and CSF culture.
For complete dosing refer Neonates Antimicrobial Dosing section
Pediatric Empirical Therapy
Community Acquired Pneumonia (CAP)
Mild Pneumonia Moderate- Severe Pneumonia Severe Pneumonia
(Outpatient Treatment) (Inpatient Treatment) (ICU Treatment)
-Age > 3 months and -Age <3months and fever, (any of the below Criteria for Respiratory Distress
-fever, cough, sore throat with cough, sore throat signs or symptoms) -Altered mental status
-Absence of: -Need for mechanical
- Apnea
-Retractions OR ventilator support with
-Grunting artificial airway -Dyspnea
-Nasal flaring -Age > 3 months -New or increased -Grunting
-Apnea CPAP or BiPap support -Nasal flaring
-Pulse oximetry < 92% in -Apnea, inadequate
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-Presence of any of the below -Pulse oximetry < 92% percent
room air signs or symptoms ventilation, severe
on room air
-Non-toxic appearance respiratory distress
-Ability to tolerate oral - Persistent Fever -Hypoxemia despite -Retractions (i.e., suprasternal,
medications and fluids -Moderate-severe dyspnea significant intercostal, or subcostal)
-Adequate observation/ -Retractions O2 defined as: -Tachypnea, Respiratory rate,
follow-up care -Grunting O2 Saturation < 92% on
40% high flow nasal breaths per minute*
-Nasal flaring
cannula or 50% face - 0 to 2 months: > 60
-Apnea
mask -3 to 12 months: > 50
-Pulse oximetry < 92% in room Cannot transition from
air 100% non-rebreathe ->1 to 5 years: > 40
mask -> 5 years: > 30
-Alteration in mental status Systemic signs of
-Moderate to large Para inadequate perfusion
pneumonic effusion (change in mental
-Concern for inadequate status, hemodynamic
outpatient --care/observation/ instability)
follow-up -Para pneumonic
-Dehydration, vomiting, or effusion requiring
inability to take oral medication emergent drainage
--Failure of initial outpatient Clinical concern for
treatment* impending respiratory
* Treatment failure is defined as failure
> 48 hours of preferred first line
110
therapy in a patient that tolerated
the regimen with increasing
respiratory distress or worsening
fever curve.
Empiric Therapy: Outpatient (Oral therapy)
Presumed Bacteria CAP Presumed Atypical pneumonia Presumed Influenza pneumonia
First line: First line: Oseltamivir: (oral)
Amoxicillin 45mg/kg/day q8h. Azithromycin 10 mg/kg on <3 months: 12 mg q12hr
day 1, followed by 5 mg/kg >3months weight based dosing
once daily on days 2–5); <15 kg: 30 mg q12hr
15-23 kg: 45 mg q12hr
Alternative: 24-40 kg: 60 mg q12hr
Amoxicillin-clavulanate Alternative: >40kg: 75mg q12hr
Clarithromycin: 15 mg/kg/day q12h
40 mg/kg/day 8h
or
For children allergic to amoxicillin
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Erythromycin: 40 mg/kg/day 6h
(oral)
Cephalexin 75–100 mg/kg/day q8h
Cefpodoxime 10mg/kg/day q12h
Levofloxacin < 5Yr (10mg/kg q12h
> 5Yr (10mg/kg q24h
Duration: 5-7 days Duration: 5-7 days Duration: 5 days
Antibiotics are routinely not required for children aged < 5 year until bacterial co-infection is suspected. For Children aged > 5year,
with clinical, laboratory and radiological findings consistent with either pneumococcal or atypical CAP, a macrolide can be added.
Empiric Therapy: (Inpatient): Complicated CAP
Presumed Bacteria CAP Presumed Atypical pneumonia Presumed Influenza pneumonia
First line: First line: Oseltamivir (oral)
Ceftriaxone: IV 75mg/kg q24h Azithromycin oral/IV (10 mg/kg on day 1, <3 months: 12 mg q12hr
+ followed by 5mg/kg/day >3months weight based dosing
*Vancomycin IV 45-60mg/kg/day q8h once daily on days 2–5) <15 kg: 30 mg q12hr
15-23 kg: 45 mg q12hr
Alternative: Alternative: Oral 23-40 kg: 60 mg q12hr
If Beta lactam allergy: Clarithromycin: 15 mg/kg/day 12h >40kg: 75mg q12hr
Levofloxacin: IV or
< 5Yr (10mg/kg q12h) Erythromycin: 40 mg/kg/day q6h
> 5Yr (10mg/kg q24h)
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If vancomycin allergy:
Linezolid: (IV/oral)
<12yrs -10mg/kg/dose q8h
>12yrs-600mg q12h
Duration: 10-14 days Duration: 10-14 days Duration: 5 days
Vancomycin goal trough: 10-15 mcg/mL
*Consider if infection suspected due to community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) in

cases of Necrotizing pneumonia, Sepsis, Concurrent skin infection due to MRSA, and/or Previous MRSA colonization.
Clostridium difficile infection
Non severe Initial episode Severe Fulminant
WBC <15000 cells/uL WBC >15000 cells/uL Hypotension or shock, ileus,
No increase in Serum creatinine S.cr > 1.5 X pre-disease baseline megacolon
Metronidazole 10mg/kg/dose PO q8h for Vancomycin 10mg/kg/dose PO q6h daily Vancomycin 10 mg/kg/dose
10 days. (max 500mg per dose) (max 125mg/dose) for 10 days (maximum 500mg per dose) for
10 days (PO or PR) +
Metronidazole 10mg/kg/dose
If no response to metronidazole in 5 days (max 500 mg per dose) IV for
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change to vancomycin 10mg/kg/dose PO 10 days
q6h (max 125 mg/dose) for 10 days
IV Metronidazole is suboptimal for C. difficile treatment compared to PO metronidazole.

For recurrent C. difficile consult Pediatrics Infectious disease
l Cohen, SH, et al. Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare
Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infect Control Hosp
Epidemiol 2010; 31:431-455.
l Schutze, GE, et al. Clostridium difficile infection in infants and children. Pediatrics 2013; 131:196-200.
l Clinical Infectious Diseases, Volume 66, Issue 7, 1 April 2018,
Febrile Neutropenia
Perform a rapid comprehensive assessment
Establish intravenous access, collect base line labs and blood cultures
Stable Patient Patient with suspected: Septic Patient: Toxic look,
Gram+ve infection eg: altered conscious state,
CVAD** or High dose hemodynamic instability,
Administer antibiotics cytarabine poor pulses, skin purpura
within 60min. and petechiae.
Piperacillin/tazobactam Administer antibiotics -Critically unwell.
100mg/kg/dose (max within 60 min. Piperacillin/
4g) IV 8h tazobactam 100mg/kg/ Administer antibiotics +
dose (max 4g) IV 8h and fluid bolus Piperacillin/
Vancomycin 15mg/kg q6-8h tazobactam 100mg/kg
If remains stable perform (max 4g) IV 8h plus
other investigations like Admit Aminoglycoside plus
CXR, urine analysis, Vancomycin 15mg/kg q6-8h
Respiratory virus PCR
If remains stable perform
other investigations like Admit
CXR, urine analysis,
Assess CBC results Respiratory virus PCR Once stable perform
other investigations like
Positive Blood Culture CXR, urine analysis,
Neutropenic Patients Respiratory virus PCR
-High risk patients Repeat Blood Culture
(Appendix 1) (48-72hrs)
Stop aminoglycoside and
Continue antibiotics as vancomycin at 48 hrs.
Consider Discharge appropriate for organism if negative culture and
(Oncologist decision only): stable. Piperacillin/
-Neutrophils are >0.5 and tazobactam continue for
High Risk Disease total 5-7 days.
Patient remain stable (Appendix 1)
Assess at 48-72 hours
If afebrile for at least
Negative Blood culture 24 hrs at completion of
Afebrile for more than 24 5-7 days of antibiotics,
hours and completed 3 then stop antibiotics and
days of IV abx discharge
Low Risk Disease
(Appendix 2)
Yes No
Continue antibiotic, reassess and

Assess at 48-72 hours repeat blood cultures and review
at 96 hours. No need for empiric
antibiotic change if stable
Afebrile? Pip-taz
Low risk of bacterial disease? continue, Afebrile for 24 hours on day 4?
(Appendix 2) repeat blood
culture, Yes No
reassess
after 72 hours. Continue antibiotics if remains febrile,
Yes No No need reassess, repeat blood, urine and send
for empiric fungal cultures, viral PCR, CXR, CT
antibiotic chest and ultrasound abdomen. Add
change if stable antifungal IV Amphotericin 1mg/kg
Stop IV antibiotic and and no positive q24h. If clinical deterioration or fever
consider oral antibiotics cultures. persists, change antibiotic to meropenem
and add vancomycin. Consult infection
for 5-7 days. diseases team.
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Empiric Antifungal Therapy is recommended for:
High risk Patients for Invasive fungal disease (IFD):
-Acute myeloid leukemia (AML).
-Relapsed acute leukemia.
-Patients receiving highly myelo-suppressive chemotherapy for other
malignancies.
-High dose steroids
-Allogeneic HSCT recipients with persistent fever spikes.
-And with prolonged (≥ 96 hours) broad-spectrum antibiotic therapy
and expected prolonged neutropenia (>10 days). All others should be
categorized as low risk IFD (appendix2).
-Updated clinical practice guidelines of febrile neutropenia 2017

recommends CT lung and ultrasound abdomen for evaluation of invasive
fungal disease in patients with >96 hours prolonged febrile neutropenia
rather than using fungal biomarkers (BDG and GM) due to poor positive
predictive values.
-It is recommended to initiate Caspofungin or Amphotericin B for

empirical antifungal therapy.
115
Appendix 1 Appendix 2
HIGH RISK LOW RISK PATIENTS LOW RISK OF BACTERIAL INFECTIONS
-AML -Age more than 12 months. -Clinically well
-ALL: -Not on intensive chemotherapy -No evidence of significant source of infection
-Infant ALL (<1Yr) drugs. (eg: pneumonia, soft tissue infection, and severe
-Induction -No social or economic mucositis).
-Delayed intensification conditions that compromise -No positive blood cultures or significant raised
-ANC= <0.1 x 109/L patient’s care of treatment. CRP >100mg/l or rising
-Down syndrome -No other medical conditions -Evidence of recovering marrow function
-HLH patient requiring hospitalization.
-Severe Aplastic anemia -Evidence of recovering marrow
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-Lymphoma: Induction therapy function.
-Neuroblastoma -ANC= 0.1-0.5 x 109/L
-Bone marrow transplant -Duration of neutropenia less
-Hemodynamic instability than 7 days.
-Focal infections (pneumonia, soft
tissue infection, abdomen pain,
perianal tenderness and severe
mucositis).
-Re-induction therapy for any relapse
-Duration of neutropenia more than
7 days.
Typhoid Fever
Optimal Therapy Alternate Effective therapy
Susceptibility Antibiotic Daily dose Duration Antibiotic Daily dose Days

(mg/kg/ day) (mg/kg/day)
Uncomplicated Typhoid Fever
Multidrug resistant Ceftriaxone 60-75 7-14 Azithromycin 8-10 7
strains (Isolates fully OR Cefixime 15-20 7-14
resistant to amoxicillin,
trimethoprim-
117
sulfamethoxazole and
chloramphenicol)
Extensively drug Azithromycin 20 7 -10 Meropenem 60 10-14
resistant (XDR)
(isolates fully resistant
to amoxicillin,
trimethoprim-
sulfamethoxazole,
chloramphenicol,
fluoroquinolones and
cephalosporin)
*Complicated Typhoid Fever
Multidrug resistant Ceftriaxone 60-75 10-14 Azithromycin 20 10-14
strains (Isolates fully
resistant to amoxicillin,
trimthoprim-
sulfamethoxazole and
chloramphenicol)
Extensively drug Meropenem 60 10-14 Azithromycin 20 7-10
resistant (XDR) Additional treatment OR
with Meropenem 60 10-14
(isolates fully resistant Dxamethasone (3 mg/
to amoxicillin, kg for the initial dose,
118
trimethoprim- followed by 1 mg/kg
sulfamethoxazole, every 6
chloramphenicol, hours for 48 hours*)
for patients with shock,
fluoroquinolones and
stupor, obtundation or
cephalosporin) coma.
*Note: Dexamethasone
initial dose would be
max 60mg for >20kg
and subsequent doses
10mg q6h for >10kg.
ANTIBACTERIAL DRUGS
Neonates Antimicrobial Dosing
(normal and renal impaired)
Estimated GFR (mL/min/1.73 m2 ) =kL / Pcr
where k = proportionality constant; L = height (cm); Pcr = plasma creatinine (mg/dL)
k=0.33
NORMAL VALUES OF GLOMERULAR FILTRATION RATE
119
Age GFR (MEAN)ml/ Range(ml/min/1.73m2)
min/1.73m2
Neonates <34 week gestational age
2-8 days 11 11-15
4-28 days 20 15-28
Neonates >34 week gestational age
2-8 days 39 17-60
4-28 days 47 26-68
AMINOGLYCOSIDES
Follow institutional guide line for Aminoglycoside dosing; http://intranet/pharmacy/pdf/PHA-HW-CPG-005.pdf
BETA LACTAMS
CARBAPENEMS
By intravenous infusion ( express in term of imipenem)
Imipenem with Dose Post menstrual Post natal days Interval (hours)
cilastatin age(pma)
Meningitis :25 mg/ >32 weeks 0-1 week Q12h
kg/dose
1-4 week Q8h
120
If meningitis ruled 32-34 weeks 0-1 week Q12h
out:20 mg/kg/dose
1-4 week Q8h
If meningitis ruled >34 weeks 0-1 week Q12h
out: :25 mg/kg/dose
1-4 week Q8h
By intravenous injection or by intravenous infusion
Indication PMA Post natal days Dose Interval (hours)

Meropenem Meningitis/ 32-37week 0-1 week 20mg/kg/dose Q8h
disseminated
infection 1-4 week 30mg/kg/dose Q8h
If meningitis 32-34weeks 0-1week 13mg/kg/dose Q8h
ruled out:
1-4 week 20mg/kg/dose Q8h
>34weeks 0-4week 20mg/kg/dose Q8h
Intra-abdominal/ <32 weeks 0-2 week 20mg/kg/dose Q12h
121
non-cns infections <32 weeks >2week 20mg/kg/dose Q8h
>32 weeks <2weeks 20mg/kg/dose Q8h
>32 weeks >2week 30mg/kg/dose Q8h
meningitis <32 weeks <2weeks 40mg/kg/dose Q12h
<32 weeks >2week 40mg/kg/dose Q8h
>32 weeks 40mg/kg/dose Q8h
RENAL ADJUSTMENT;
Based on the doses of 20-40 mg//kg/dose
Creatinine clearance dose interval
50mL/minute No adjustment
30to50mL/min 20-40 mg/kg/dose Q12h
10to29mL/min 10-20 mg/ kg /dose Q12h
<10mL/min 10-20 mg/ kg /dose Q24h
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CEPHALOSPRINS
Cefpodoxime By mouth
Child > 15 days 4 mg/kg twice daily
By mouth
Neonate under 7 days 25 mg/kg (max. 125 mg)
twice daily
Cephalexin
Neonate 7–21 days 25 mg/kg (max. 125 mg) 3
times daily
Neonate 21–28 days 25 mg/kg (max. 125 mg) 4
times daily
Cefazolin By intravenous injection
Dose Pma Post natal days Interval (hours)
25 mg/kg/dose ≤29weeks 0-28 days Q12h
>28 Q8h
25mg/kg/dose 30-36weeks 0-14 days Q12h
>14 Q8h
25 mg/kg/dose 37-44weeks 0-7days Q12h
>7 Q8h
25mg/kg/dose ≥45 ALL Q6h
123
By intravenous injection
Ceftazidime
>28 Q8h
30 mg/kg/dose 30-36weeks 0-14 days Q12h
>14 Q8h
>7 Q8h
30 mg/kg/dose ≥45 ALL Q8h
In meningitis 0-7 days 100-150mg/kg/day q8-12h
8 days or older 150-200mg/kg/day q6-8h
Cefotaxime Sepsis
50 mg/kg/dose <29 weeks Younger than 7 Q12h
days
50 mg/kg/dose <32 weeks 7 days or older Q8h
50 mg/kg/dose 32 weeks or more 7 days or older Q6h
RENAL ADJUSTMENT;
124
are based on doses of 100 to 200 mg/kg/day divided every 8 hours
Creatinine clearance Dose Interval
30to50mL/min 30-70 mg/kg/dose Q8h-q12h
10to29mL/min 30-70mg/kg/dose Q12h
<10mL/min 30-70mg/kg/dose Q24h
Ceftriaxone By intravenous infusion
SEPSIS: 50 mg/kg once daily for 7 days

MENINGITIS: 100 mg/kg loading dose, 80 mg/kg Q24h
PENICILLINS
Amoxicillin By mouth
Neonate 7–28 days 30 mg/kg (max. 62.5 mg) 3 times daily; dose doubled in severe infection
Neonate under 7 days 30 mg/kg every 12 hours; community acquired pneumonia, or salmonellosis
Neonate 7–28 days 30 mg/kg every 8 hours; community acquired pneumonia, or salmonellosis
Ampicillin By intravenous injection
125
>28 Q8h
50 mg/kg/dose 30-36weeks 0-14 days Q12h
>14 Q8h

>7 Q8h
50 mg/kg/dose ≥45 ALL Q6h
Group B Streptococcal meningitis,Empiric therapy:
≤7 days: 200-300 mg/kg/day divided Q8h

≥ 8 days: 300mg/kg/day divided Q6h
RENAL ADJUSTMENT; Based on doses of 100 to 200 mg/kg/day divided every
6 hours
30to50mL/min 30-50 mg/kg/dose Q6h
10to29mL/min 30-50 mg/kg/dose Q8h-Q12h
<10mL/min 30-50 mg/kg/dose Q12h
126
Cloxacillin 25-50 mg/kg IV Q4-Q6H
Penicillin G By slow intravenous injection or infusion
Bacteremia: 25,000-50,000 units/kg/dose IV
Meningitis: 75,000-1,00,000 units/kg/dose IV
Pma Post natal days Interval (hours)
≤29weeks 0-28 days Q12h
>28 Q8h
30-36weeks 0-14 days Q12h
>14 Q8h
37-44weeks 0-7days Q12h
>7 Q8h
≥45 ALL Q6h
Group B Streptococcal meningitis:

≤7 days: 250,000-450,000 units/kg/day IV divided Q8H
127
≥ 8 days: 450,000-500,000 units/kg/day IV divided Q6H
Piperacillin- By intravenous infusion
tazobactam 50-100 mg/kg/dose IV(piperacillin component)
>28 Q8h
>14 Q8h
128
>7 Q8h
≥45 ALL Q8h
RENAL ADJUSTMENT;
>50 mL/min No adjustment
50-30 mL/min 35-50mg piperacillin/kg/dose Q6H
<30 mL/min 35-50mg piperacillin/kg/dose Q8H

FLOUROQUINILONES
Ciprofloxacin By mouth or by intravenous infusion

Preterm neonates (32 to 37 weeks): 10 - 15 mg/kg/dose every 12 hours
Term neonates (>37 weeks): 10 - 15 mg/kg/dose every 12 hours
LINCOSAMIDES
Clindamycin By mouth or by intravenous infusion

5-7.5 mg/kg/dose (Both IV/Oral)
129
>28 Q8h
>14 Q8h
>7 Q8h
≥45 ALL Q8h

MACROLIDES
Clarithromycin By mouth
Neonate 7.5 mg/kg twice daily
Erythromycin By mouth or by intravenous infusion
Pneumonitis/Conjunctivitis: 12.5 mg/kg every 6 hours for 14 days
Pro-kinetic: 10mg/kg/dose Q6H for 2 days followed by 4 mg/kg/dose Q6H for 5 days
OTHERS
Fusidic acid By mouth
Neonate 15 mg/kg 3 times daily
130
Colistin By intravenous infusion
(Dose expressed in term of colistin base)
Loading dose: 5 mg/kg
Maintenance dose: 2.5-5 mg/kg/day divided every12 hours
RENAL ADJUSTMENT;
Creatinine Dose Interval
50-79ml/min 2.5-3.8 mg/kg/day Q12H
30-49 mL/min 2.5 mg/kg/day QD
10-29 mL/min 1.5 mg/kg/day Q36H

Linezolid By mouth or by intravenous infusion
Neonate under 7 days 10 mg/kg every 12 hours
Neonate over 7 days 10 mg/kg every 8 hours
Metronidazole By mouth or by intravenous infusion
Neonate 7.5 mg/kg every 12 hours
Pma (weeks) Post natal days Interval (hours)

≤29 0-28 48
>28 24
131
30-36 0-14 24
>14 12
37-44 0-7 24
> PMA 7 12
>45 ALL 8
By mouth or by intravenous infusion
Rifampin Pma (weeks) Post natal days Dose Interval (hours)
32-38 weeks 0-28 5 mg/kg/dose Q12H
38 week or more 0-7 5 mg/kg/dose Q12H
8-28 10 mg/kg/dose Q12H

Persistent Staphylococcal infection:
Oral: 10-20 mg/kg/dose Q24h
132
IV: 5-10 mg/kg/dose every 12 hours
TMP-SMX By mouth / IV
(Dose expressed in term of Trimethoprim)
Neonate initially 3 mg/kg as a single dose then 2–3 mg/kg twice daily
Vancomycin By intravenous infusion
Meningitis: 15mg/kg/dose IV
Bacteremia: 10mg/kg/dose IV
Pma(Weeks) Post natal (days) Interval (hours)
≤29 0-14 18
>14 12
30-36 0-14 12
>14 8
37-44 0-7 12
> PMA 7 8
>45 ALL 6
133
ANTIFUNGAL
Amphotericin B 1 mg/kg once daily, increased if necessary to 1.5 mg/kg daily;
Test dose: 0.1 mg/kg IV
Dose Duration
1-1.5mg/ kg Q24h For candidemia without
metastasis is 2weeks. Take
ID on board
1-1.5mg/ kg Q24h For CNS infections Take ID
on board
RENAL ADJUSTMENT:
If serum Cr raised 0.4 mg/ Hold dose for 2-5 days Then give doses
dl from baseline during Q48hrly
therapy
Fluconazole By mouth or by intravenous infusion

Loading dose: 12 -25mg/kg (invasive candidiasis)
Maintenance dose: 6 -12mg/kg with the following dosing intervals
Pma weeks Post natal age Dosing interval
(hours)
134
≤29 0-14 48
>14 24
30 and older 0-7 48
>7 24
For prophylaxis (birth weight <1500 g) 3-6mg/kg twice weekly
No data for renal dose adjustment in neonates
Voriconazole IV/PO:12-20mg/kg/day Q8-12h; maximum 24mg/kg/day.

No renal adjustment
Itraconazole By mouth:
2.5 to 5 mg/kg/dose every 12 hours for treatment; for relapse prevention, once daily dose may be
considered.
No renal dose adjustment.
ANTI VIRAL
Acyclovir By intravenous
Pma weeks Dose Interval
<30 weeks 20 mg/kg/dose Q12h
30 to less than 36 20 mg/kg/dose Q8h
135
weeks
36 to 41 weeks 20 mg/kg/dose Q8h
RENAL ADJUSTMENT:
S.Cr Dose Interval
0.8-1.1 mg/ dl usual dose Q12h
1.2-1.5mg/dl usual dose Q24h
1.5 mg/dl or urine Decrease dose by Q24h
output less than 1 ml/ 50%
kg/hr.
Oseltamivir By mouth
Pre-term neonate (24–37 weeks gestation) 1 mg/kg/dose BID
38-40 weeks : 1.5mg/kg/dose BID , >40 weeks :3mg/kg/dose BID
Reference:
• Pediatric Formulary Committee. Bnf for Children 2019-2020.

• The Harriet Lane Hand Book 21st Edition
• Uptodate 2020
• Neofax IBM 2020
136
Pediatric Antimicrobial Dosing (normal and renal impaired)
Pediatric Antimicrobial Dosing (normal and renal impaired)

Estimated GFR from plasma creatinine:
Estimated GFR (mL/min/1.73 m2 ) kL / Pcr
where k = proportionality constant; L = height (cm); Pcr = plasma creatinine (mg/dL)
PROPORTIONALITY CONSTANT FOR CALCULATING GLOMERULAR FILTRATION RATE
Age K values
Low birth weight during first year of life 0.33
Term AGA (Appropriate for gestational 0.45
137
age) during first year of life
Children and adolescent girls 0.55
Adolescent boys 0.70
NORMAL VALUES OF GLOMERULAR FILTRATION RATE
Age GFR (Mean) (mL/min/1.73 m2) Range (mL/min/1.73 m2)
30–90 days 58 30-86
1–6 month 77 39-114
6–12 month 103 49-157
12–19 month 127 62-191
2 yr–adult 127 89-165
ANTIBACTERIAL
DOSE
DRUGS
AMINOGLYCOSIDES (IV)
Amikacin 15-20mg/kg/day(once daily)
Renal Dose Adjustment:
Take trough level after 24 hours, and hold dose until trough level is available. Adjust dosage interval
according to serum levels (<1mcg/ml). Target peak 56-64ug/ml
CrCl ml/min >80 60-80 40-60 30-40 20-30 10-20 0-10

Dose mg/kg 15 (q24h) 12 (q24h) 7.5 (q24h) 4 (q24h) 7.5 4 3
(q48h) (q48h) (q72h and
138
after HD)
Gentamicin 5-7mg/kg/day once daily
30-70ml/min: 3-5mg/kg
10-30ml/min: 2-3mg/kg
<10ml/min 2mg/kg
Take trough level after 24hours, and hold next dose until trough level is available. Adjust dosage
interval according to serum levels - aim to keep trough <1mg/L and peak 5-10mg/L.
CARBAPENEMS (IV)
Imipenem 75-100mg/kg/day (divided q6h-8h) max.2-4gm/day. Not recommended in children with CNS infections
due to risk of seizures
Not recommended in pediatric patients weighing<30kg with renal impairment (no data)
30-70ml/min: >4 weeks of life: Give 80-100% of dose every 8 hours
20-30ml/min: >4 weeks of life: Give 80-100% of dose every 12 hours
<20ml/min: Avoid use (or 50% of dose q12h)
Meropenem 60mg/kg/day divided q8h; meningitis 120 mg/kg/day divided q8h; max 6gm/day
139
Based on the doses of 20-40 mg//kg/dose
>50mL/minute No adjustment
26to50mL/min 20 to 40 mg/kg/dose Q12h
10to25 mL/min 10-20 mg/ kg /dose Q12h
<10mL/min 10-20 mg/ kg /dose Q24h
(Same dose in PD)
Dose adjustment in HD:
Give 50% of dose every 24 hours, administered after dialysis session
Dose adjustment in CVVH: 20-40mg/kg/dose every 12 hours,
CEPHALOSPRINS (PO)
Cefixime 8mg/kg/day q12-24 (enteric 16-20mg/kg/day q12h)
Renal Dose Adjustment
≤10 to 20 mL/min Reduce dose by 50 %
Anuric Reduce dose by 50 %
HD &PD Not significantly removed
Cefpodoxime 10mg/kg/day q12h
140
>30 mL/min No adjustment
<30 mL/min Administer every 24 hour
HD Three times weekly after dialysis sessions
Cephalexin 25-100mg/kg/day divided q6h-8h
30-50 mL/min 100% dose administer q8h
10-29 mL/min 100% dose administer q12 h
<10 mL/min 100% dose administer q24 h
HD & PD Every 24 hours after dialysis
CEPHALOSPORINS (IV)
Cefazolin 50-100mg/kg/day q 6-8h, max 6gm/day
11-34 ml/min 50% dose administer q12h
<10 ml/min 50% dose administer q24h
Cefotaxime 100-200mg/kg/day q6-8h, meningitis dose 300 mg/kg/day q6h
20-50 mL/min No dosage adjustment required - give normal dose
141
5-20 mL/min No dosage adjustment required - give normal dose q12h
<5 mL/min 50% of the normal dose q24hours
Dose adjustment in HD: 50% of the normal dose q24h, supplement post-dialysis.
Dose adjustment in CVVH: Normal dose q12h
Dose adjustment in PD: 50% of the normal dose q24h
Ceftazidime 100-150mg/kg/day q8h, Cystic fibrosis and meningitis:150-200mg/kg/day q6-8hr

30-50 mL/min normal dose q12 hours
15-30 mL/min normal dose q24 hours
5-15 mL/min 50% of normal dose q24 hours
50% of the normal dose q24 hours, supplemental dose after dialysis
Dose adjustment in CVVH:
Give 50-100% of normal dose every 12 hours
Dose adjustment in PD: 50% of the normal dose q24 hours
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Ceftriaxone 50-100mg/kg/day q12-24h; For meningitis 50mg/kg q12h
Not required
PENICILLINS
Amoxicillin (PO) 30 -100mg/kg/day q8h-12h

GFR 10-29 mL/min/1.73m2: 20mg/kg/dose q12h
GFR <10 mL/min/1.73m2: 20mg/kg/dose q24h
Dose adjustment in HD:20 mg/kg every 24 hours; give after dialysis
Dose adjustment in PD: 20mg/kg/ dose Q24H
Ampicillin 200mg/kg/day q6h: meningitis dose 300mg/kg/day q6h
20-50 mL/min No dose adjustment
10-20 mL/min Same dose q8h
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<10 mL/min Same dose every 12 hours
Dose adjustment in HD: 35 to 50 mg/kg/dose every 12 hours
Dose adjustment in PD: 35 to 50 mg/kg/dose every 12 hours
Dose adjustment in CRRT: 35 to 50 mg/kg/dose every 6 hours
Cloxacillin If <20 kg: 50-100mg/kg/day q6h PO, otherwise dose as adult PO…IV dose 200-300 mg/kg/day
q4-6h(max 2g/dose)
Penicillin G 100,000-300,000units/kg/day IV q4-6h (max 12-20MU/day)
Renal dose adjustment: Crcl <10 mL/min: A full loading dose should be given, followed by 50% of the
usual dose every 8 hours
Piperacillin/ 300mg/kg/day divided q6-8h
tazobactam
40-80 mL/min > 12years: decrease frequency q8h
< 12 years: old –no dose adjustment required
20-39 mL/min >1 month old: decrease frequency q8h
<20 mL/min >1 month old: decrease frequency to q12h
HD/PD: 50 to 75 mg piperacillin/kg/dose every 12 hours
Dose adjustment in CRRT: 35 to 50 mg piperacillin/kg/dose every 8 hours
FLOUROQUINILONES
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Ciprofloxacin (PO) 20-40mg/kg/day q12h max 1.5gm/day PO
(IV)
20-30mg/kg/day q12h max 1.2gm/day IV
30-50 mL/min No dosage adjustment required – give normal dose
10-30 mL/min Give 50% of the normal dose every 12 hours
<10 mL/min Give 50% of the normal dose every 12 -24 hour
Dose adjustment in HD: 50% of normal dose q12h
Dose adjustment in CRRT: Give 75%-100% of the dose every 12 hours

Levofloxacin IV/PO Age (6months -5years) 16-20mg/kg q24h(max 750mg per dose) ///>5years 8-10 mg/kg q24h
(max 750mg per dose)
10-30 mL/min 5 to 10 mg/kg/dose every 24 hours
<10 mL/min 5 to 10 mg/kg/dose every 48 hours
Dose adjustment in HD: 5 to 10 mg/kg/dose every 48 hours; (no supplemental dose)
Dose adjustment in PD: 5 to 10 mg/kg/dose every 48 hours
Dose adjustment in CRRT: 10 mg/kg/dose every 24 hours
Clindamycin (IV) 20-40mg/kg/day q8h PO (max 1.8 g/day)
(PO)
20-30mg/kg/day q8h IV
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Renal Dose Adjustment: No dose Adjustment
MACROLIDES
Azithromycin 5-10mg/kg once daily PO (max dose 500mg)
10mg/kg once daily IV (max dose 500mg)
Clarithromycin 15mg/kg/day q12h (max 1gm/day PO)

30-50 mL/min No dose adjustment is required
<30 mL/min Give 50% of normal dose
Dose adjustment in CVVH: No dosage adjustment required
Dose adjustment in HD: Give after HD session is completed: 4 mg/kg/dose once daily
PD:4mg/kg once daily
TERACYCLINES
Doxycycline 2-4mg/kg/day q12h ( max.200mg/day )
(age >8years)
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MISCELLANEOUS
Colistin 2.5-5mg/kg/day divided 12h. (Dose expressed in term of colistin base)
Renal dose adjustment:(Based on adult)
50-89ml/min 5mg/kg/day q12h

30-49ml/min 4.4 mg/kg/day q12h
10-29ml/min 2.7mg/kg/day q12h
<10ml/min 2.2 mg/kg/day q12h
Give dose of GFR<10ml/min. Give supplemental dose after dialysis
6-7mg/kg/day q12h
Linezolid up to 12yrs 30mg/kg/day divided q8h IV/PO (Max dose 1.2 g/day)
Renal Dose Adjustment: No dose adjustment is required
12 years or older 15mg/kg/dose q12h IV/PO (Max dose 1.2g/day)
Co-trimoxazole 2months -12years 6-12mg/kg/day divided q6h-q12h IV/PO (Based on trimethoprim)
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For PCP 15-20mg/kg/day divided q6h-q8h IV/PO (Based on trimethoprim)
Renal Dose Adjustment: CrCl 15-30 ml/min: 50% of standard dose.
CrCl <15 ml/min: Not recommended but if used 5-10mg/kg q24h
Dose in CRRT:5mg/kg q8h
Metronidazole 30-40mg/kg/day q6-8h IV/PO

Renal Dose Adjustment: No dose adjustment is required
Nitrofurantoin 5-7mg/kg/day q6h PO

Tigecycline <8 years (from 36days): loading: 1.5 to 3 mg /kg once, maintenance dose:
1-2 mg /kg /dose q12h
> 8years :1.2 mg/kg IV q12h (max 50 mg q12h)
Fosfomycin Premature infants: 100mg/kg/day q12h

1-12 years: 200-400 mg/kg/day q8h (max single dose 8g) Loading dose not more than 8g.
(Max dose 24g/day)
PO:100-200 mg/kg/day (Max 1.5g/day)
>40 ml/min Normal dose
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30-40ml/min 60% of normal dose q8h
10-30ml/min 1/3rd of normal dose q12h (supplemental dose after dialysis)
ANTIMYCOBACTERIAL
Ethambutol 15-25mg/kg once daily (max 1.6 g/day)
Isoniazid 10-15mg/kg/day once daily( max 300mg/day)
Pyrazinamide 30-40mg/kg/day once daily(max 2g/day))
Rifampin 10-20mg/kg/day q24hrs ( max 600mg) PO/IV
Streptomycin 20-40mg/kg/day once daily (max dose 1gm IM)
ANTIFUNGALS
Amphotericin B 0.5 mg - 1 mg /kg (once daily), max. 1.5mg /kg/ day
Renal dose adjustment: No dose adjustment
Fluconazole Loading dose:6-12mg/kg (max. 800 mg /day). Maintenance dose:3-12mg/kg Q24h

<50ml/min: 50% of the normal dose
50% of the normal dose daily, give post dialysis
149
Dose adjustment in CVVH: No dosage adjustment
Itraconazole 5-10mg/kg/day q12h PO
Renal dose Adjustment: Not required
Terbinafine <20 kg: 62.5mg/day, PO
for 20-40kg: 125mg/day, PO
for >40kg: 250mg/day (adult dose) PO
Voriconazole Loading dose:6-9mg/kg q12h for 2 doses IV/PO (max 400 mg per dose) then 4-8mg/kg q12h IV/PO
(max 200 mg per dose)
Renal dose adjustment:
<50ml/min: No dose adjustment is required in PO, however IV use is contraindicated.
Caspofungin 70mg/m2(1st dose) then 50mg/m2

Renal dose Adjustment: Not required
ANTI VIRALS
Acyclovir Varicella (>2years weight <40kg: Dose 20mg/kg IV q6h), >40 kg 800mg Q6h for 5 days PO
150
>3months-12years in encephalitis IV: 20mg/kg Q8h
>12 years 10mg/kg Q8h
25-50ml/min: Q12h
0-25ml/min Every 24 hours
0-10ml/min 50% Q24 hours
HD/PD 5 mg/kg/dose Q24 hours
CVVH 10 mg/kg/dose Q12h
Oseltamivir <9months 6mg/kg/day/day divided Q12h
9 months to < 1year 7mg/kg/day Q12h
Oseltamivir >1yrs <15kg: 30mg Q12h
>15-23kg: 45mg Q12h
>23-40kg 60mg Q12h
>40kg 75mg Q12h (adult dose)
Prophylaxis
3-8 months 3mg/kg Q24h
≥9months 3.5mg/kg Q24h
≤15 kg: Oral: 30 mg Q24h
>15 kg to 23 kg: Oral: 45 mg Q24h
151
>23 kg to 40 kg: Oral: 60 mg Q24h
>40 kg: Oral: 75 mg Q24h
31-60ml/min/1.73m2: Treatment:50 % of normal dose q12h
Prophylaxis: 50% of normal dose q24h
11-30 Treatment:50% of normal dose q24h
Prophylaxis:50% of normal dose q48 hrs.
<10/HD: Treatment: Give after each dialysis session (≤15 kg=7.5mg,
16-23kg=10mg,24-40kg=15mg,>40kg=30mg)
Prophylaxis:50% of the normal dose (31-60 ml/min q24h, 10-30ml/min q48h)
Dose adjustment in PD:
Treatment: give 50% of the normal dose as a single dose once a week, after dialysate exchange
Prophylaxis: give 50% of the normal dose as a single stat dose. A second dose may be given after one
week
Treatment: give 100% of the normal dose every 24 hours Prophylaxis: give 100% of the normal dose
every 48 hours
Valacyclovir (herpes 20mg/kg/dose Q8h. (max 3gm per day)

or varicella)
152
Reference:
• Pediatric Formulary Committee. Bnf for Children 2019-2020
• UpToDate 2020
• The Harriet Lane Hand Book 21st Edition
• Micromedex IBM 2020
• Sanford 20
Chapter 10: Miscellaneous
Guide for Antimicrobial Drug Dosing in Extremes of
Body Weight
Due to variable alterations in the volume of distribution, clearance and
elimination half‐life in obesity dosing adjustments can be complex. In
obese patients, the glomerular filtration rate (GFR) may be increased
relative to a “normal” patient, so in theory drug clearance may be
increased. Calculation of creatinine clearance using the Cockcroft
& Gault equation in obese patients should use lean body weight (or
maximum body weight).
Common measures of weight used

Total Body Weight (TBW) / Weight (Kg)
Actual Body Weight (ABW)
Body Mass Index (BMI) Weight (kg) / (Height (m))2
(m=height in inches x 0.025)
m2=m x m
Ideal body weight (IBW) 45.5 kg + 2.3 x no. of inches over 5
ft (female)
50 kg + 2.3 x no. of inches over 5 ft
(male)
Maximum body weight IBW x 1.2 or (IBW +20%)
(MBW)
Lean Body Weight (LBW) Males = (9270 x Weight[kg]) / [6680
+(216 x BMI)]
Females = (9270 x Weight[kg]) /
[8780+(244 x BMI)]
Adjusted Body Weight IBW + (0.4 x (actual body weight –
(ADbw) IBW))
The World Health Organization (WHO) and NICE have both defined
weight categories based on a person’s BMI as follows
Underweight: <18.5Kg/m2
¨ Healthy weight: 18.5-24.9 Kg/m2
¨ Overweight: 25-29.9 Kg/m2
¨ Obesity: 30 Kg/m2 or more
Obese Class I and II (obese) BMI 30-40 kg/m2
Obese Class III (morbidly obese) BMI ≥ 40 kg/m2
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Drug Dosing in obese patients Additional comments
Acyclovir Dose based on ADbw
Amphotericin Dose on ABW
Benzyl penicillin Dose at upper limit of the normal dosing.
Ceftriaxone and other cephalosporin’s Dose at upper limit of the normal dosing.
Ciprofloxacin 400 mg q8h IV
750 mg q12h PO
Clindamycin For life threating infections doses upto Use ABW
4.8g IV daily in divided doses.
PO 600-900 mg q8h
154
Co-trimoxazole Doses of 20mg/kg/day of TMP have been Consider ADbw when using high doses
used. (>8mg/kg/day)
Fluconazole Based on TBW (12 mg/kg load and 6mg/ Take renal and hepatic function into account.
kg maintenance)
Levofloxacin Normal dosing (little information
available)
Meropenem/Imipenem Use normal doses. In critically ill patients Consider extended infusion
use upper end of doses.
Metronidazole/oseltamivir Normal doses
Piperacillin-tazobactam 6.75g over 4 hours every 8 hourly Consider administration by extended or
considered depending on renal function. continuous infusion, after an initial
Max 18 g per day. bolus dose
Rifampin/Voriconazole Use IBW Rifampin: Use up to 1200mg/day in divided
For voriconazole ADbw can also be used doses.
Vancomycin Use ABW Adjust doses by AUC0-24 mg*h/l (400-600)
Amikacin and gentamicin Dose based on ADbw Take renal function into account.
Antibiotic Lock Therapy (ALT) for Catheter-Related Infection

For patients with surgically implanted catheters and peripherally inserted central venous catheters, the most common infecting
155
microorganisms are coagulase-negative staphylococci, enteric gram-negative bacilli, Staphylococcus aureus, and Pseudomonas
aeruginosa. For patients with catheter-related bloodstream infections involving long-term catheters with no signs of exit site or
tunnel infection and for whom catheter salvage is the goal, antibiotic lock therapy is indicated. Antibiotic lock therapy should be used
concurrently with systemic antimicrobial therapy, 7- to 14-day regimen is generally recommended. For catheter-related bloodstream
infections due to Staphylococcus aureus and Candida species, catheter removal is recommended instead of antibiotic lock therapy
and catheter retention.
Dwell times for an antibiotic lock solution should not exceed 48 hours, preferably reinstallation should take place every 12-24
hours
METHOD OF USE
Antibiotic lock therapy involves administering a high concentration of an antibiotic through the infected line and allowing it to reside
in the line between infusions. Use of the line may continue while treating the infection. Antibiotic lock solutions contain the desired
antimicrobial concentration and heparin or normal saline in sufficient volume to fill the catheter lumen.
Hemodialysis (HD) and Non (HD) ALT Preparations
Antibiotic Solution Heparin Heparin Storage and
Final concentration in concentration concentration Stability
Normal saline (units/ml) in (units/ml) in at room
(For HD and non HD) HD non HD temperature
Ampicillin 10mg/ml 5000 units/ml Use NS 24 hours
Piperacillin-tazobactam
100 units/ml Use NS 12 hours
10mg/ml
Cloxacillin 100mg/ml 1000 units/ml Use NS 24 hours
2500-5000
Cefazolin 5-10mg/ml 10 units/ml 24 hours
units/ml
Ceftazidime 0.5-2mg/ml 100 units/ml 100 units/ml 24 hours
Ceftriaxone 83mg/ml No heparin Use NS 12 hours
Ciprofloxacin 0.2mg/ml 5000 units/ml Use NS 24 hours
Incompatible
Gentamicin 1mg/ml Use NS 24 hours
(use NS)
Vancomycin 2.5-5mg/ml 2500 units/ml 100 units/ml 24 hours
Linezolid 2mg/ml 100 units/ml 10 units/ml 8 hours
100-1000
Colistin 0.1-0.8mg/ml Use NS No data
units/ml
Note:
l Pharmacy will dispense 3ml antibiotic lock solution in syringe,
with auxiliary labels of “Not for IV use” and “High Alert”
l For double lumen lock, if more than 3ml is required then
Pharmacy will send two syringes of 3ml.
l Normal saline can be used instead of heparin for lock solutions.
(If patient has a history of Heparin induced thrombocytopenia
or lack of data).
l Implanted vascular access (Port-A-Cath) have a lumen of 5ml
capacity.
Pharmacy Preparation Instructions HD ALT (Some examples are
given below)
Antibiotic solution final Preparation Instructions
concentration
Vancomycin 2.5 mg/mL + 1. Dilute 500 mg of vancomycin with
heparin 2500 units/mL 10 mL of NS (50 mg/mL)
2. Remove 1 mL and further dilute
with 9 mL of sodium chloride resulting
in a vancomycin concentration of 5
mg/mL – Label as “solution A”
3. Draw up 1.5 mL of 5,000 units/mL
heparin into a syringe and mix with 1.5
mL of solution A (vancomycin 7.5mg)
for 3 mL of final solution
156
Gentamicin 1mg/ml 1-Remove 1 ml from ampule of
80mg/2ml i.e. 40 mg.
2-Dilute 1 ml (40mg) with 19ml
NS resulting in a gentamicin
concentration of 2mg/ml.-Label as
“solution A”
3- Draw up 1.5 ml NS into a syringe
and mix with 1.5 mL of solution A
(gentamicin 3mg) for 3 ml of final
solution.
Pharmacy Preparation Instructions Non-HD ALT (Some examples
are given below)
Vancomycin 2.5 mg/mL + 1. Dilute 500 mg of vancomycin with

heparin 100 units/mL 10 mL of NS (50 mg/mL)
in a vancomycin concentration of 5
mg/mL – Label as “solution A”
3. Draw 2 mL of 5,000 units/mL
(10000 units) heparin and mix with
48 ml NS resulting in a heparin
concentration of 200 units/ml-Label as
“solution B”
4-Draw up 1.5 ml solution A
(vancomycin 7.5mg) and mix with 1.5
ml of solution “B”(heparin 300units)
for 3 mL of final solution.
Cefazolin 5mg/ml+ Heparin 1. Dilute 500 mg of cefazolin with 10
10 units/ml mL of NS (50 mg/mL)
in a cefazolin concentration of 10 mg/
mL – Label as “solution A”
3. Draw 2 mL of 5,000 units/mL
(10000 units) heparin and mix with
498 ml NS resulting in a heparin
concentration of 20 units/ml-Label as
“solution B”
4-Draw up 1.5 ml solution A (cefazolin
15mg) and mix with 1.5 ml of solution
“B”(heparin 30 units) for 3 mL of final
solution.
157
Administration Instructions:
l Prior to installation of antibiotic lock, withdraw contents from

catheter lumen
l Flush catheter with normal saline
l Pharmacy will dispense 3ml antibiotic lock solution in syringe,
l Instill antibiotic lock solution to fill catheter lumen as per
volume capacity.
l Label the catheter: “DO NOT USE- Antibiotic Lock”
l Allow lock solution to dwell for a period specified. Usual
duration 12-24 hours.
l After dwell time is complete, aspirate antibiotic lock solution
from catheter lumen
l Flush catheter with normal saline before using line to
administer medication
References:
l Anthony TU, Rubin LG. Stability of antibiotics used for

antibiotic-lock treatment of infections of implantable venous
devices (ports). Antimicrob Agents Chemother. Aug
1999;43(8):2074-2076
l Rijnders BJ, Van Wijngaerden E, Vandecasteele SJ, Stas M,
Peetermans WE. Treatment of long-term intravascular
catheter-related bacteraemia with antibiotic lock: randomized,
placebo-controlled trial. J Antimicrob Chemother. Jan
2005;55(1):90-94
l Robinson JL, Tawfik G, Saxinger L, Stang L, Etches W, Lee
B. Stability of heparin and physical compatibility of heparin/
antibiotic solutions in concentrations appropriate for antibiotic
lock therapy. J Antimicrob Chemother. Nov 2005;56(5):951-
953.
l Mermel LA, Allon M, Bouza E, et al. Clinical practice
guidelines for the diagnosis and management of intravascular
catheter-related infection: 2009 Update by the Infectious
Diseases Society of America. Clin Infect Dis. 2009;49(1):1–45
l Centers for Disease Control and Prevention (CDC) Vital Signs.
Making Health Care Safer: Reducing Bloodstream Infections.
Atlanta, GA: Centers for Disease Control and Prevention;
2011. [Accessed May 10, 2014]
158
Administration protocol of Extended or Continuous infusion
of β-Lactam Antibiotics
It is well established that β-lactam antibiotics exhibit time dependent

killing. The degree of antimicrobial killing co-relates well with
the amount of free drug remaining above the minimum inhibitory
concentration (MIC) for a given amount of time over the dosing interval.
Pharmacokinetics-Pharmacodynamics (PK- PD) studies shown that

extended infusion or continuous infusion allows maintaining steady state
concentrations and maximizes the percent of time above an organism’s
MIC over a 24-hour period and result in more cure rates. Cephalosporin’s
and penicillin’s require T>MIC (>50%) to exhibit bactericidal activity.
For Carbapenems T>MIC required for bactericidal activity is 40%.
Intermittent infusion Infusion lasts for 30-60 minutes

Extended infusion Infusion lasts for 3-4 hours
Continuous infusion Continuous infusion at a fixed rate.
Summary of Antimicrobial Pharmacodynamic Parameters:

Antibiotics Pharmacodynamic Goal of Parameter
characteristics Regimen correlating
with in vivo
efficacy
Aminoglycosides
Concentration Maximization
Fluoroquinolones
dependent of C MAX / MIC
Metronidazole
killing concentrations
Colistin
Penicillins Maximization
Time dependent
Cephalosporin of exposure T>MIC
killing
Aztreonam time
Maximization
Time dependent
Vancomycin of exposure
killing + AUC/MIC
Clindamycin time (serum
prolonged T>MIC
Macrolide levels can fall
persistent effect
below MIC)
159
Carbapenems are more unstable at room temperature compared to cephalosporin and penicillin’s, therefore the extended infusion of
Carbapenems over 3-4 hours is sufficient to get required pharmacodynamics properties
Recommendations
The target population for the utilization of extended infusion/continuous infusion of β-lactams consists of patients with normal
renal function and severe infections with following organisms:
• Carbapenemase-producing enterobacteriaceae
• MDR-Acinetobacter species
• MDR-Pseudomonas species
Dosing recommendations for Extended /Continuous infusion of β-lactams
Antibiotic Intermittent Dose of Extended infusion with Dose of Continuous infusion
160
name infusion (Normal renal function(Over 3-4 hours) with renal function (at a fixed rate)
dose and interval)
Ceftazidime 2 g q8h CRCL: >50ml/min 2g loading over 30 minutes, then
2g over 4 hours q8h 6g over 24hours.
CRCL: 30-50 ml/min CRCL: 30-50ml/min
2g load then 4g over
2g over 4 hours q12h
24hours.
CRCL: 10-30ml/min 2g over 4hours q24h CRCL: 10-30ml/min 2g load then 2g over
24hours
Piperacillin- 4.5g q6-8h 4.5g over 30 minutes then after4 hours start 4.5g loading over 30 minutes then after 4
Tazobactam CRCL:40 ml/min: hours start
4.5g q6h-q8h over 4hrs 13.5g-18g over 24 hours
CRCL: 20-40 ml/min CRCL: 20-50ml/min
2.25-3.375g q6h over 4 hours. 4.5g load over 30 minutes then 9g-13.5g over
CRCL: <20 ml/min 24 hours
2.25-3.375g q12h over 4 hours CRCL: <20ml/min
Use renal adjusted dose with Intermittent
infusion.
Meropenem 1 g-2g q8h 2g q8h over 3hours Not applicable
CRCL 30-49 ml/min
1g-2g q12h over 3hours
161
CRCL 10-29ml/min
1g q12h over 3 hours
Imipenem 500 mg-1g q6h-q8h 500 mg-1g q6-q8h over 3 hours Not applicable
Not studied in renal compromised patients.
Vancomycin 1g q8h-12h Loading dose 20-35 mg/kg (max 3g) over 60-
180 minutes then 30mg/kg over 24 hours.
(targeting levels of 20-25 mg/L)
No data in renal impairment.
References
• Lodise TP, Lomaestro BM and Drusano JL. Application of Antimicrobial Pharmacodynamic Concepts into Clinical Practice: Focus on beta lactam Antibiotics:
Insights from the society of infectious diseases Pharmacists. Pharmacotherapy 2006;26(9):1320-1332.
• Lorente L, Lorenzo L, Martin MM, Jiminez A, Mora ML, Meropenem by continuous versus intermittent infusion in ventilator associated pneumonia due to gram
negative bacilli. Ann of pharmacotherapy 2006; 40:219-23
• Lorente L, Martin MM, Jiminez A, Iribarren JL, Jiminez JJ, Mora ML. Clinical cure of ventilator associated pneumonia treated with piperacillin/tazobactam
administered by continuous or intermittent infusion. Int J Antimicrobial agents 2009;33(5):464-8
• Lodise Jr TP, Lomaestro B, Drusano GL. Piperacillin/tazobactam for Pseudomonas aeruginosa infection: clinical implications of an extended –infusion dosing
strategy. CID 2007; 44:357-63.
• CID (2013)57(2):324-325
162
Chapter 09: Drug Utilization Review and
Use Criteria
Checklist for rational antibiotic use:
• Indication of starting the antibiotic documented
• Appropriate cultures sent BEFORE starting the therapy
• Baseline lab tests (Cr, CBC etc.) are done
• Dose is appropriate based on infection type, severity and
adjusted if required (Renal or Hepatic)
• After 72hrs evaluate for continued need of antibiotic and
discontinue or deescalate if possible
• Appropriate lab tests (Cr, CBC etc.) are repeated
periodically
• Length of therapy is as short as possible
Vancomycin dosing information:
Vancomycin 2020 Guidelines Features

• AUC/MIC of 400-600 mg×h/La recommended
• Trough >15mg/l causes increased risk of nephrotoxicity
based on elevated AUC.
• Addresses vancomycin use for serious infections caused

by MRSA (bacteremia, endocarditis, bone/joint infections,
pneumonia, necrotizing fasciitis, febrile neutropenia, sepsis
with unknown source), except SSTIs, UTIs, surgical.
prophylaxis and meningitis.
• For meningitis/CNS infections trough based monitoring 15-
20mg/l is recommended.
• The guidelines also do not apply to non-MRSA pathogens
such as methicillin-susceptible S. aureus, coagulase-
negative Staphylococcus, and Streptococcus due to a lack of
data on appropriate pharmacodynamic targets.
• Clear link with increased exposureb leading to nephrotoxicity
• LD: 20-35 mg/kg based on ABW, with a maximum of 3 g
dose (Maintenance of 15-20mg/kg/dose based on ABW q8-
12h). LD can be given at rate of 1g/hour.
163
• Obesity—LD: 20-25 mg/kg based on ABW, with a 3 g dose cap
• Pediatrics—60-80 mg/kg/day in divided doses every 6 h
older than 3 months.
• 60-70mg/kg/day in divided doses q6-8h for children aged 12
years and older.
• Neonates (up to 3 months)—10-20 mg/kg every 8-48 hours
depending on postmenstrual age, weight, and S.Cr
• Continuous infusion can be used; targeting levels of 20-25
mg/L
• Hemodialysis—target pre-dialysis concentrations of 15-20
mg/Lc Hybrid hemodialysis recommendations—LD, with
maintenance dose of 10-15 mg/kg after dialysis, CRRT
dosing recommendations—LD, with empiric maintenance
dose of 7.5-10 mg/kg every 12 h
• Check random levels after 4 hours post-HD to allow time for
fluid redistribution. When <15mg/l re-dose.
• An increase in SCr of ≥0.3 mg/dL over a 48-hour period may
be considered as an indicator of vancomycin-associated AKI
a- Assumed MIC of 1 for staph infections. b Higher troughs, more

aggressive dosing, and higher AUCs. c Limited to no data on AUC
monitoring in hemodialysis.
ABW, actual body weight; AUC, area under the curve; CRRT,
continuous renal replacement therapy; LD, loading dose; MIC,
minimum inhibitory concentration; MRSA, methicillin-resistant
Staphylococcus aureus; SCr, serum creatinine; SSTI, skin and soft
tissue infection; UTI, urinary tract infection
Reference:
Rybak MJ, Le J, Lodise TP, et al. Therapeutic monitoring of vancomycin for serious
methicillin-resistant Staphylococcus aureus infections: a revised consensus guideline and
review by the American Society of Health-System Pharmacists, the Infectious Diseases
Society of America, the Pediatric Infectious Diseases Society, and the Society of Infectious
Diseases Pharmacists. Am J Health Syst Pharm. 2020;77(11):835-864.
For complicated patients dosing consult ID pharmacist
164
Chapter 10: Annexures
IV to PO Switch Guidelines
Introduction
IV to oral switch is the prompt conversion of IV antibiotic therapy
to oral. Patients may be considered candidates for switching from
IV to oral therapy once the patient has shown clinical improvement
and is medically stable.
Rationale
The majority of patients with a severe infection who are adequately
absorbing oral medication and initially require IV therapy can be
safely switched to oral therapy within 48 hours. There are a number
of advantages to support the prompt switch from IV to oral therapy
these are as follows:
• Reduction in the likelihood of hospital acquired bacteremia
and infected IV lines.
• Saves both medical and nursing time
• Reduces discomfort for patients and enables improved
mobility and the possibility of earlier hospital discharge.
• Potential to significantly reduce treatment costs.
• Patient is more likely to receive antibiotics at the correct time.
• Potential reduction in the risk of adverse effects; errors in
preparation are significantly higher with parenteral drugs,
compared to oral formulation.
Considerations for the early switch to oral therapy:(review at
48 hours)
*Functioning gastrointestinal tract
*Clinically stable (Afebrile for at least 24 hours, WBC
normalizing)
Exclusion Criteria:
* Patients with an unreliable response to oral medication (i.e.
continuous NG suction, short bowel syndrome, motility
disorder of the GI system, unresponsive to previous oral
therapy).
* Patients with Grade III or IV mucositis
* Patients whose disease state does not support oral therapy
(i.e. meningitis, endocarditis).
*Septic shock
165
Deep seated infections High risk infections requiring
that may require an initial prolonged IV therapy
2 weeks of IV therapy
• Osteomyelitis, Septic • Staphylococcus aureus bacteremia
arthritis (N.B. high-dose • Severe necrotizing soft tissue infections
oral Clindamycin may be • Severe infections during chemotherapy
appropriate once patient related neutropenia
is stable) • Infected implants/prosthesis
• Empyema • Meningitis/encephalitis
• Cavitating pneumonia • Intracranial abscesses
• Mediastinitis
• Endocarditis
• Exacerbation of cystic fibrosis/
bronchiectasis
• Inadequately drained abscesses or
empyema
What medications are eligible for IV to PO conversion?
Ciprofloxacin, Clindamycin, Fluconazole, Levofloxacin,
Linezolid, Metronidazole, Trimethoprim/sulfamethoxazole,
Voriconazole
Drug IV DOSE Equivalent PO dose
Ciprofloxacin 400 mg q12h 500 mg q12h
Clindamycin 600-900 mg q8h 300-450 mg q8h
Fluconazole 200 mg q24h 200 mg q24h
Levofloxacin 750 mg q24h 750 mg q24h
Linezolid 600 mg q12h 600 mg q12h
Metronidazole 500 mg q8h 400 mg q8h
Trimethoprim/
8-20 mg/kg/day q6-8h 8-20 mg/kg/day q6-8h
sulfamethoxazole
Voriconazole 200 mg q12h 200 mg q12h
References
1. Mertz D, Koller M, Haller P, et al. Outcomes of early switching from

intravenous to oral antibiotics on medical wards. J Antimicrob Chemother.
2009;64(1):188-199.
2. Guidance for intravenous antibiotic ‘switch’ therapy. 2004. North West Antibiotic
Pharmacists Network Advisory Group.
3. Centers for Medicare & Medicaid Services. Pre-decisional surveyor worksheet:
assessing hospital compliance with the condition of participation for Infection Control.
Pilot draft. Published May 18, 2012.
4. McLaughlin C Et al. Pharmacy-implemented guidelines on switching from intravenous
to oral antibiotics: an intervention study. Q J Med 2005; 98:745:752
166
Standardized Volume of Antibiotics in Pediatrics
Volume
Weight Piperacillin/
Penicillin Ampicillin Cloxacillin Cefazolin Cefotaxime Ceftriaxone Ceftazidime used
in Kg Tazobactam
(ml)
3-5 - - - - - - - - -
5-7 3lac 200 200 150 250 400 250 500 10
8-10 4lac 300 300 200 350 650 350 1000 15
11-15 6lac 400 400 300 500 850 500 1500 20
16-20 10lac 500 500 500 1000 1000 750 2000 25
21-25 10lac 800 800 500 1000 1500 1000 2500 30
167167
26-30 20lac 1000 1000 750 1000 2000 1000 3000 35
25000-
Dose 12.5-50 6.25-25 17-33 15-50 50-75 30-50 50-100
100,000
range mg/kg mg/kg mg/kg mg/kg mg/kg mg/kg mg/kg
units/kg
Max
Conc. 10lac 130 70 40
30 mg/ml 50 mg/ml 120 mg/ml 200 mg/ml
For units/ml mg/ml mg/ml mg/ml
infusion
Vancomycin
Weight in Kg Meropenem
Dose (mg) Max Vol Min Vol.
3-5 40 10 5
5-7 65 15 7
8-10 100 20 10
11-15 150 30 15
Non-
16-20 200 40 20
kg/dose
kg/dose
21-25 250 50 25
26-30 300 60 30
MeningiticDose40mg/
MeningiticDose20mg/
Dose range mg/kg Dose range 10-15 mg/kg
168168
Max Conc. For Conc. For 10 mg/ml
50 mg/ml 5 mg/ml
infusion infusion Fluid restriction
Drugs Normal concentration Max Conc. (fluid restricted)

Acyclovir < or equal to 7mg/ml 10 mg/ml
Amphotericin B 0.1 mg/ml 1 mg/ml (but via central line)
Colistin 30000 units/ml 60000 units/ml
Ceftriaxone 10-30 mg/ml 40 mg/ml
Recommended Labs for Patients on Long Term Antibiotics
Acyclovir – CBC and Creatinine Weekly

Aminoglycosides (Gentamicin, Tobramycin, Amikacin etc.)
− Creatinine twice per week,
− Aminoglycoside Peak and Trough twice per week until
dose stable then may monitor Aminoglycoside trough level
when clinically indicated (e.g. with change in Creatinine),
− CBC Weekly
− If the patient is likely to receive > 5 days of therapy, an
audiology test should be performed at baseline and every 2
weeks thereafter while on therapy.
Amphotericin B – Magnesium, Creatinine and Potassium
twice a week and CBC Weekly
Fluconazole - CBC and Creatinine weekly, LFTs Monthly
Itraconazole - LFT’s Monthly
Linezolid – CBC with platelets Weekly, if patient on this drug
for longer than 2 weeks
Penicillins, Cephalosporin, Carbapenems – Comprehensive
Metabolic Profile (CMP) and CBC every two weeks, with
additional monitoring for the two antibiotics listed below:
Rifampin – Liver Function Tests (LFT’s) Monthly
Trimethoprim/sulfamethoxazole (Co-Trimoxazole)
(Septran) - Basic Metabolic Profile (BMP) and CBC
Weekly,Potassium
Vancomycin – Creatinine, Complete Blood Count (CBC) and
Vancomycin Trough levels weekly for AUC calculation.
Voriconazole – LFT’s monthly
The above list includes the minimum labs required for proper
monitoring of a patient on prolonged courses of antibiotics and
is based, in part, on published recommendations by the Infectious
Disease Society of America. Additional labs may be requested at the
discretion of the provider. Additional (less common) antimicrobials
may also require monitoring.
169169
Antimicrobial Ophthalmic Agents
Antibiotics
S# Trade Name Generic Cost Rs Indication Dose
1. Ciloxan e/d Ciprofloxacin 0.3% 216 Bacterial eye infection 1-2 drops QID
Bacterial eye infection (broad
2. Vigamox e/d Moxifloxacin 0.5% 463 1 drop 3 times a day for 7 days
spectrum)
Conjunctivitis, Trachoma,
3. Santachlor e/d & oint Chloramphenicol 0.5 % 55 2-3 drops QID
Blepharitis, Keratitis
Conjunctivitis, Trachoma,
4. Neo-Phenicol oint Chloramphenicol 1 % 15 Up to q3 hr. & PRN
170170
Blepharitis, Keratitis
1-2 drops q 2-4 hr. x 2 days
5. Exocin e/d Ofloxacin 0.3% 99.79 Bacterial eye infection
then qid x total 10 days
Conjunctivitis, Blepharitis,
6.. Genticyn e/d Gentamicin 0.3% 20 1-3 drops Q 3-4 hr.
corneal ulcer
7.. Polyfax ointment Polymyxin B+ Bacitracin 21 Bacterial Conjunctivitis 2 or more times a day
8.. Tobrex e/d & oint. Tobramycin 0.3% 223& 186 Bacterial eye infection q1-4 hr.
1 cm ribbon 5 times a day, 4
9.. Santovir ointment Acyclovir 3% 185 Herpes simplex Keratitis
hours apart
Steroid + Antibiotic
Betamethasone 0.1% Inflammatory conditions 1-2 drops 1-2 hr.
1. Betnesol N e/d & oint 33 & 15
Neomycin 0.5% where infection is suspected Oint.; 2-3 times a day
Post-surgery infection, chronic
One drop q2 hr. x 24-48 hours
Dexamethasone 0.1% + anterior uveitis, corneal injury
2. Dexoflox e/d 100 then 1-2 drop
Ofloxacin 0.3% from chemical, radiation or
4-6 times a day
thermal burns
1 drop q2 hr. for 1-2 days
Moxifloxacin 5mg, Inflammatory conditions along
3. Deximox 200 followed by q4-6
dexamethasone 1mg with severe eye infection
Hr. or as prescribed.
Neomycin + Polymyxin
4. Maxitrol e/d 130 Infected ocular inflammation 1-2 drops q 4-6 hr.
+ Dexamethasone
171171
Tobramycin 0.3% 335 &
5. Tobradex e/d, oint Infected ocular inflammation 1-2 drops q 4-6 hr.
Dexamethasone 0.1% 335
Steroid +/- Antibiotic +/- Adrenergic agonist
Prednisolone 0.2%
Blepharitis, bacterial
1. Blephapred e/d & oint Sulphacetamide 10% 57 & 104 1-2 drops q 3-4 hr.
conjunctivitis
Phenylephrine 0.12%
AKUH Compounded Ophthalmic agents
S# Drug E/D Strength Indication Expiry
1. Amikacin 33 mg/ml & 66 mg/ml Corneal ulcers caused by p..aeruginosa 7 days
2. Amphotericin 0.5% ,0.3%, 0.2%,1% Ocular fungal infection 7 days
3. Ceftazidime 5% Gram –ve endopthalmitis 05 days
4. Cefazolin 33 mg/ml & 50 mg/ml Bacterial endophthalmitis 4 weeks
5. Chlorhexidine 0.02% Acanthamoeba Keratitis 30 days
6. Fluconazole 1,2% Fungal endophthalmitis 30 days
7. Voriconazole 1% Fungal endophthalmitis 30 days
8. Ketoconazole 2% Keratomycosis 14 days
172172
9. Vancomycin 50mg/ml Bacterial endophthalmitis 7 days
10 Gentamicin 13.6mg/ml Corneal ulcers 3 months
Topical Available at AKUH

Antibiotics / Antiseptic
Dalacin-T (L) Moderate to severe acne
1. Clindamycin Apply 2-3 times a day
vulgaris
Apply sparingly to whole affected
2. Skin A Isotretinoin 0.05% Acne
area once or twice a day
3. Fucidin C, O Fusidic acid Bacterial skin infection Apply 2-3 times a day
Apply in layer 3-5mm thick, change
Wounds, burns, leg ulcer
4. Quench C Silver sulfadiazine 1% dressing every alternate day for
(infected), pressure sores
ulcers and daily for burns
5. Polyfax O Polymyxin B, Bacitracin Skin infections Apply 2 or more times a day
Neomycin 0.5%, Bacitracin 250U,
Prophylaxis in burns, cuts,
6. Cicatrin powder Cysteine 0.2%, Glycine 1%, Apply 3 times a day
ulcers, scratches
Threonine 0.1%
7. Genticyn C Gentamicin Aminoglycoside antibacterial Apply 2-3 times a day
Topical anti-bacterial agent
8. Mupir C Mupirocin active against MRSA Apply 2 times a day
colonization
173173
Antimicrobials +/- Steroids
Betamethasone 0.1 %,neomycin Eczema, infantile, vulval
9. Betnovate-N C Apply sparingly 2 or 3 times a daily
0.5% pruritus, otitis externa
Skin Infection due to Apply 2-3 times daily. Rub the cream
10. Daktarin C Miconazole Nitrate dermatophytes, yeasts and into the skin with your finger until it
other fungi has fully penetrated
Dermatophytes and yeast Apply 2-3 times daily, Apply thin
11. Hydrozole C Hydrocortisone, Clotrimazole
infection layer rub gently.
Fluocinolone Acetonide,
12. Synalar-N C Eczema and dermatitis Apply 2-3 times daily
Neomycin sulphate
Fusicort Fusidic acid 20 mg, Inflammatory dermatoses where
13. Apply 3-4 times daily.
C Betamethasone 1mg bacterial infection is present
Nerisone - C Difluocortilone0.1%, Anti-inflammatory +
14. Apply 2-3 times daily
C chlorquinaldol antibacterial
Fucidin - H Fusidic acid 20 gm, Inflammatory dermatoses where
15. Apply2-3 times daily
C hydrocortisone10 mg bacterial infection is suspected
Canesten (C)
16. Clotrimazole 1% Candida infection Apply 2-3 times daily
Clotrim (L)
Clobetasol propionate 0.5%, Apply once or twice weekly, max
17. Dermovate NN Psoriasis, intractable eczema,
neomycin sulphate 0.1%, nystatin 40 gms
174174
. O inflammatory dermatoses
100,000 units/1gm /week, max duration 4 weeks
Antiseptic, topical: apply to
Candidiasis, mucosal abrasions, minor cuts, and surface
18. Gentian Violet L Gentian Violet Antiseptic, topical, Surgical injuries of the skin Candidiasis,
skin marker mucosal: apply to mucosal surface
2 to 3 times daily for several days
Tinea infections, cutaneous
19. Conaz C Ketoconazole Apply once or twice daily
candidiasis, seborrhea
Athlete's foot, jock itch, and
20. Lamisil C Terbinafine Apply once or twice daily
ringworm
Triamcinolone, Gramicidin, Bacterial/fungal infection with
21. Kenacomb O Apply 2-3 times a day
Neomycin, Nystatin inflammation
22. Travacort C Isoconazole, diflucortolone Dermatomycosis Apply 2 times a day
Antivirals
Zovirax C Herpes zoster and simplex
23. Acyclovir 5% Apply 4-6 times a day
Lovir C infection
Pediculicide/Scabicide
24. Lotrix C Scabies Apply once, repeat after 14 days
For Pediculosis Capitis (Head
lice): Shampoo hair, towel and
dry, apply 1% lotion rinse to scalp,
leave on 10 minutes, rinse; repeat
Lotrix 5% L
175 175
application if live lice present 7
For Head lice use days after initial treatment.
1% lotion((Take Permethrin For Scabies: Apply a generous
Scabies & Lice Infestation
25. 12ml of 5% lotion amount from neck to feet (clean,
and make up the dry and cool skin), leave on for
volume with tap minimum of 8 hours, wash with
water upto 60ml) soap/water, repeat application if
living mites present 14 days after
initial treatment(Not more than one
bottle 60ml should be used during a
single application)
Adult: Apply for 24 hours & wash
26. S.P. Lotion Benzyl Benzoate Scabies, Pediculosis Use diluted solution in children
Infants: (1:3 in water)
C cream O ointment G gel L Lotion V/C Vaginal cream
AKUH Compounded Dermatological/Topical Agents

Compounding Indications Expiry
S#
Antibiotic/Antifungals/Antiseptics
1. Whitfield ointment Fungal infections 1 year
2. Bismuth Iodoform paste (sterile) used for packing cavities after oral and otorhinological surgery 6 months
176176
3. Eusol ½ strength solution Skin disinfectant, for wound dressing 14 days
4. Acetic acid solution 1%, 3%, 5% Bactericidal for wound care 1 year
5. Metronidazole gel 0.75% Acne Rosacea 28 days
6. Potassium permanganate sol 1:5000 Disinfectant, deodorants, in bromhidrosis 7 days
7. Silver nitrate sticks Burns, wounds & treatment of warts 3 months

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AKUH Antimicrobial

Antimicrobial therapy is a dynamic process. Results of cultures,

It gives me great pleasure to present to you the 7th edition of

We have reviewed updates to the guidelines published by various

As always, I would like to thank the entire “Antimicrobial

Dr Asad Ali, Chair Antimicrobial Stewardship Sub-Committee

We appreciate efforts of the Chairman and members of Pharmacy

Members of Antimicrobial Stewardship Subcommittee

Dr Adnan Abdul Jabbar,

Dr Farah Naz Qamar,

Syed Shamim Raza,

Please send us your feedback through email at:

Or call us on 021-34861504, 021-34865337

Chapter 01: Mechanism of action of Antibiotics in AKUH........1

Chapter 02: Restricted and Controlled Antibiotics Policy......... 3

Chapter 03: Empiric Antibiotic Regimens...................................5

1. Skin and Soft Tissue / Bone / Joints Infections.................. 5

Chapter 04: Surgical Prophylaxis Guidelines........................... 22

1. Cardiovascular and Thoracic Surgery...............................24

1. Febrile Neutropenia Guidelines........................................35

Chapter 06: Treatment for Miscellaneous Infections............... 61

Chapter 07: Antimicrobial Coverage & Sensitivity

1. Akuh Inpatient. Percent Sensitive Jan-Dec 2019..............73

Chapter 08: Drug Dosing, Pharmacokinetics and Safety......... 83

1. Adult Normal Doses and Antimicrobial drug Cost...........83

Chapter 09: Neonates and Pediatrics....................................... 105

Chapter 10: Miscellaneous........................................................ 153

1. Guide for Antimicrobial Drug Dosing in Extremes

Chapter 09: Drug Utilization Review and Use Criteria.........162

Chapter 10: Annexures.............................................................. 164

Beta-Lactams: Penicillins and cephalosporin’s inhibit bacterial

Penicillins Cephalosporin’s Carbapenems

Clindamycin binds to the 50S ribosomal subunit (reversibly),

Colistin is a polymixin antibiotic. Colistin is bactericidal in action.

Fluoroquinolones: Inhibits DNA-gyrase which does not allow the

Linezolid binds to a site on the 23S ribosomal RNA of the 50S

Metronidazole interacts with DNA causing a loss of helical DNA

Tetracyclines inhibit protein synthesis by binding to the 30S and

Tigecycline binds at the same site on the ribosome as tetracycline’s,

Trimethoprim/sulfamethoxazole: Trimethoprim inhibits

Vancomycin inhibits bacterial cell wall synthesis by blocking

Fosfomycin The antibacterial effects of fosfomycin are related to

Antimicrobial Stewardship Program (ASP) protocol, can be

Restricted Antibiotic: Pre-authorization from ID pharmacist

Controlled Antibiotics: Therapy can be started without pre-

l For certain rare infections need of arranging non-formulary

Prosthetic valve Endocarditis

Empiric while awaiting cultures Vancomycin IV 1g q8-12h + Gentamicin IV 1mg/kg -

Also inform neonatal team if mother has endometritis

Gonorrhea/Non-gonococcal/post Azithromycin PO 1g single dose

Syphilis Penicillin G IV 4 million units q4h Ceftriaxone IV 2g q24h

Lower Respiratory Tract Infections

Prophylaxis should be targeted against most likely pathogens,

Timing of Antimicrobial Prophylaxis:

Note: If the patient is already on antibiotic, there is no need to

Antimicrobial Half-life Recommended

Antimicrobial Children dose

GI tract Spillage Ceftriaxone IV 2g +Metronidazole IV 500 mg

Splenectomy Ceftriaxone IV 2g q24h for 3 days