Sandbox ID Systemic

# Babesiosis
- 1. Mild/moderate disease
- Preferred regimen: Atovaquone 750 mg PO bid AND Azithromycin 600 mg PO qd for 7-10 days
- 2. Severe disease:
- Preferred regimen: Clindamycin 600 mg PO tid AND Quinine 650 mg PO tid for 710 days
- Preferred regimen: Clindamycin 1.2 g IV q12h
- Note (1): For overwhelming infection in asplenic patients and immunocompromised patients, treat for 6 or more weeks.
- Note (2): Consider transfusion if 10% parasitemia.

# Bartonella
- Bartonella
- 1. Bartonella quintana
- 1.1 Acute or chronic infections without endocarditis
- Preferred regimen: Doxycycline 200 mg PO qd or 100 mg bid for 4 weeks AND Gentamicin 3 mg/kg IV qd for the first 2 weeks
- 1.2 Endocarditis
- Preferred regimen: Gentamicin 3 mg/kg/day IV q8h for 14 days AND Ceftriaxone 2 g IV q24h for 6 weeks  Doxycycline 100 mg PO bid for 6 weeks
- 2. Bartonella elizabethae
- 2.1 Endocarditis
- Preferred regimen: Gentamicin 3 mg/kg/day IV q8h for 14 days AND  Ceftriaxone 2 g IV q24h for 6 weeks  Doxycycline 100 mg PO bid for 6 weeks
- 3. Bartonella bacilliformis
- 3.1 Oroya fever
- Preferred regimen: Ciprofloxacin 500 mg PO bid for 14 days
- Note: If severe disease, add Ceftriaxone 1 g IV qd for 14 days
- 3.2 Verruga peruana
- Preferred regimen: Azithromycin 500 mg PO qd for 7 days
- Alternative regimen (1): Rifampin 600 mg PO qd for 14-21 days
- Alternative regimen (2): Ciprofloxacin 500 mg bid for 7-10 days
- 4. Bartonella henselae
- 4.1 Cat scratch disease
- No treatment recommended for typical cat scratch disease, consider treatment if there is an extensive lymphadenopathy
- 4.1.1 If extensive lymphadenopathy
- Preferred regimen (1) (pediatrics): Azithromycin 500 mg PO on day 1 THEN 250 mg PO qd on days 2 to 5
- Preferred regimen (2) (adults): Azithromycin 1 g PO at day 1 THEN 500 mg PO for 4 days
- 4.2 Endocarditis
- Preferred regimen: Gentamicin 3 mg/kg/day IV q8h for 14 days AND  Ceftriaxone 2 g/day IV for 6weeks  Doxycycline 100 mg PO bid for 6 weeks
- 4.3 Retinitis
- Preferred regimen: Doxycycline 100 mg bid AND  Rifampin 300 mg bid PO for 4-6 weeks
- 4.4 Bacillary angiomatosis
- Preferred regimen (1): Erythromycin 500 mg PO qid for 2 months at least
- Preferred regimen (2): Doxycycline 100 mg PO bid for 2 months at least
- 4.5 Bacillary Pelliosis
- Preferred regimen (1): Erythromycin 500 mg PO qid  for 4 months at least
- Preferred regimen (2): Doxycycline 100 mg PO bid for 4 months at least

# Botulism
- Botulism
- 1.Foodborne botulism
- 1.1 Adult
- Preferred regimen: Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.5 mL/min; incremental infusion rate if tolerated (every 30 minutes): double the rate; maximum infusion rate: 2 mL/min
- 1.2 Children
- 1.2.1 Children < 1 year
- Preferred regimen: Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.01  mL/kg/min; incremental infusion rate if tolerated (every 30 minutes): 0.01  mL/kg/min ; maximum infusion rate: 0.03  mL/kg/min (10% of adult dose regardless of body weight)
- 1.2.1 Children  1-17 years
- Preferred regimen: Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.01  mL/kg/min; incremental infusion rate if tolerated (every 30 minutes): 0.01  mL/kg/min ; maximum infusion rate: 0.03  mL/kg/min (20  100% of adult dose)
- Note:Physicians may try to remove contaminated food still in the gut by inducing vomiting or by using enemas.  A patient with severe botulism may require a ventilator as well as intensive medical and nursing care for several months.
- 2. Infant botulism
- Preferred regimen:  BabyBIG, Botulism Immune Globulin Intravenous (Human) (BIG-IV) is  for the treatment of patients below one year of age.The recommended total dosage  is 1mL/kg (50mg/kg), given as a single IV infusion as soon as the clinical diagnosis of infant botulism is made
- Note: infant with botulism must receive supportive care during their recovery. This includes ensuring proper nutrition,keeping the airway clear,watching for respiratory failure and if it develops,ventilator  may be needed.
- 3. Wound botulism
- 3.1 Adult
- Preferred regimen (adult): Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.5 mL/min; incremental infusion rate if tolerated (every 30 minutes): double the rate; maximum infusion rate: 2 mL/min
- 3.2 Children
- 3.2.1 Children < 1 year
- Preferred regimen: Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.01  mL/kg/min; incremental infusion rate if tolerated (every 30 minutes): 0.01  mL/kg/min ; maximum infusion rate: 0.03  mL/kg/min (10% of adult dose regardless of body weight)
- 3.2.2 Children  1-17 years
- Preferred regimen: Heptavalent botulism antitoxin IV starting infusion rate (first 30 minutes): 0.01  mL/kg/min; incremental infusion rate if tolerated (every 30 minutes): 0.01  mL/kg/min ; maximum infusion rate: 0.03  mL/kg/min (20  100% of adult dose)
- Note (1): Physicians may try to remove contaminated food still in the gut by inducing vomiting or by using enemas.  A patient with severe botulism may require a ventilator as well as intensive medical and nursing care for several months.
- Note (2): For wound botulism, antibiotics are used in addition to appropriate debridement.
- Note (3): Antibiotic therapy is recommended for wound botulism after antitoxin has been administered.  Penicillin G 3 MU IV q4h in adults is frequently used. Metronidazole 500 mg IV q8h may be used as an alternative for penicillin-allergic patients.

# Boutonneuese fever
- Boutonneuese fever
- 1. Adult
- Preferred regimen (1): Doxycycline 200 mg PO bid for 1 day
- Preferred regimen (2): Doxycycline 200 mg  or 100 mg PO bid for 2-5 days
- Alternative regimen (1): Josamycin 1g q8h for 7 days
- Alternative regimen (2):Ciprofloxacin
- 2. Children
- Preferred regimen (Children <100 lbs): Doxycycline 2.2 mg/kg PO bid
- Preferred regimen (Children >100lbs): Doxycycline 200 mg PO bid in one day and 200 mg bid/qid or 100 mg bid for 2-5 days
- Alternative regimen (Children <8 years) (1): Josamycin 2.2mg/kg q12h for 5 days
- Alternative regimen (Children <8 years) (2): Clarithromycin 15 mg/ kg in bid for 7 days AND Azithromycin 10 mg/kg/day qd for 3 days

# Diphtheria
- Diphtheria treatment  
- Preferred Regimen (1): Erythromycin 40 mg/kg/day; maximum, 2 gm/day) PO for 14 days
- Preferred Regimen (2): Procaine penicillin G  3MU/day (for  weight 10 kg ) IM q24h for 14 days
- Note: Since 1997, diphtheria antitoxin has been available only from CDC, through an Investigational New Drug (IND) protocol.

# Fever of unknown origin
- Fever of unknown origin (FUO)
- Management should generally be withheld until the etiology of the fever has been ascertained, so that treatment can be directed against a specific pathology.
- Specific clinical considerations
- 1.Neutropenic fever
- Exception may be made for neutropenic patients in which delayed treatment could lead to serious complications.
- After samples for cultures are obtained, patients with febrile neutropenia should be aggressively treated with broad-spectrum antibiotics covering Pseudomonas
- 2.HIV/AIDS individuals
- HIV/AIDS individuals with pyrexia and hypoxia should be placed on empiric therapy for Pneumocystis jirovecii.
- 3.Giant cell arteritis
- Empiric corticosteroids may be considered in patients with suspected giant cell arteritis to prevent vascular complications.
- Giant cell arteritis should be suspected in a patient over the age of 50 with the following symptoms:
- Newly onset headaches
- Abrupt onset of blurry vision
- Symptoms of polymyalgia rheumatica
- Jaw claudication
- Unexplained anemia
- Elevated ESR and/or CRP

# Lymphangitis
- 1.Lymphangitis treatment
- Preferred regimen: Dicloxacillin
- Preferred regimen: Cephalexin 500 mg PO qid for 1 week
- 2. Patient with lymphangitis and if Community-Associated Methicillin-Resistant Staphylococcus Aureus (CA-MRSA) suspected:
- Trimethoprim-sulfamethoxazole PO bid  AND  vancomycin 1 g IV every 12 hr
- 3.Patient with lymphangitis allergic to penicillin:
- Clindamycin 300 mg PO qid for 7 days OR Erythromycin 500 mg PO qid for 7 days OR Levofloxacin 500 mg PO daily OR Moxifloxacin 400 mg PO daily for 7 days.

# Neutropenic fever, prophylaxis
- Neutropenic fever, prophylaxis
- 1.Low risk (standard chemotherapy regimen for soild tumor, anticipated neutropenia < 7 days)
- Antibacterial agent: none
- Antifungal agent: none
- Antiviral agent: none unless prior HSV episode
- 2. Intermediate risk (autologous HSCT, lymphoma, multiple myeloma, CLL, Purine analog therapy , anticipated neutropenia 7-10 days)
- 2.1 Antibacterial agent: consider fluroquinolone prophylaxis
- 2.2 Antifungal agent: consider fluconozole during neutropenia and for anticipated mucositis
- 2.3 Antiviral agent:
- 2.3.1 HSV prophylaxis
- Preferred regimen (1): Acyclovir 400-800 mg PO bid
- Preferred regimen (2): Famciclovir 250 mg PO bid
- Preferred regimen (3): Valacyclovir 500 mg PO bid-tid
- 2.3.2 VZV prophylaxis
- Preferred regimen (1): Acyclovir 800 mg PO bid (in allogeneic HSCT)
- Preferred regimen (2): Famciclovir 250 mg PO bid
- Preferred regimen (3): Valacyclovir 500 mg PO bid-tid
- 3.High risk (acute leukemia, Alemutuzumab therapy, in allogenic HSCT including cord blood, GVHD treated with high dose steriods, anticipated neutropenia > 10 days)
- 3.1 Antibacterial agent: Levofloxacin 500-750 mg PO/IV q24h
- 3.2 Antifungal agent:
- 3.2.1 ALL
- Preferred regimen:  Fluconazole in adult with normal renal function 400 mg IV/ PO daily
- Alternative regimen:  Amphotericin B
- 3.2.2 MDS or AML
- Preferred regimen: Posaconazole EC 300 mg bid on day 1 and then 300 mg IV q day after or IV 300 mg q day after
- Alternative regimen: Voriconazole   6mg/kg IV q 12 h X 2 doses then 4 mg/kg q 12 h  until resolution of neutropenia
- Alternative regimen: Fluconazole in adult with normal renal function 400mg IV/PO q24h
- Alternative regimen: Amphotericin B until resolution of neutropenia
- 3.2.3 Autologous HSCT with mucositis
- Preferred regimen: Fluconazole 400mg IV/PO q24h (in adult with normal renal function) OR Micafungin 50-100mg/ d IV until resolution of neutropenia
- 3.2.4 Allogenic HSCT
- Preferred regimen: Fluconazole 400mg IV/PO q24h (in adult with normal renal function) OR Micafungin 50-100mg/ d IV until resolution of neutropenia
- Alternative regimen (1): Itraconazole
- Alternative regimen (2): Voriconazole 6mg/kg IV q 12 h X 2 doses then 4 mg/kg q 12 h
- Alternative regimen (3): Posaconazole  EC 300 mg bid on day 1 and then 300 mg IV q day after or IV 300 mg q day after
- Alternative regimen (4): Amphotericin B continue during neutropenia and for at least 75 days after transplant
- 3.2.5 Significant GVHD
- Preferred regimen: Posaconazole  EC 300 mg bid on day 1 and then 300 mg IV q day after or IV 300 mg q day after
- Alternative regimen (1): Voriconazole6mg/kg IV q 12 h X 2 doses then 4 mg/kg q 12 h
- Alternative regimen (2): Echinocandin
- Alternative regimen (3): Amphotericin B until resolution of Significant GVHD
- 3.3 Antiviral agent:
- 3.3.1 Acute Leukemia
- HSV prophylaxis
- Preferred regimen (1): Acyclovir 400-800 mg PO bid
- Preferred regimen (2): Famciclovir 250 mg PO bid
- Preferred regimen (3): Valacyclovir 500 mg PO bid-tid
- Proteasome inhibitors
- VZV prophylaxis
- Preferred regimen (1): Acyclovir 800 mg PO bid (in allogeneic HSCT)
- Preferred regimen (2): Famciclovir 250 mg PO bid
- Preferred regimen (3): Valacyclovir 500 mg PO bid-tid
- Alemutuzumab Therapy, allogenic HSCT ,GVDH requiring  steriod treatment
- HSV prophylaxis
- Preferred regimen (1): Acyclovir 400-800 mg PO bid
- Preferred regimen (2): Famciclovir 250 mg PO bid
- Preferred regimen (3): Valacyclovir 500 mg PO bid-tid
- VZV prophylaxis
- Preferred regimen (1): Acyclovir 800 mg PO bid (in allogeneic HSCT)
- Preferred regimen (2): Famciclovir 250 mg PO bid
- Preferred regimen (3): Valacyclovir 500 mg PO bid-tid
- Anti CMV prophylaxis
- Allogenic stem cell transplant (surveillance period: 1-6 months after transplant, GVDH requiring therapy)
- Preferred regimen: Valganciclovir900 mg daily PO OR Ganciclovir5 mg / kg IV q 12 h for 2 weeks followed by 5-6mg / kg daily for at least an additional 2-4 weeks and resolution of all symptoms
- Alternative regimen: Foscarnet 60 mg / kg IV q 8-12 h for 7 d followed by 90-120mg / kg daily until day 100 after HSCTOR Cidofovir IV
- Alemtuzumab therapy (suveillance period: for a minimum of 2 months after alemtuzumab)
- Preferred regimen: Valganciclovir 900 mg daily PO OR Ganciclovir5 mg / kg IV q 12 h for 2 weeks followed by 5-6mg / kg daily for at least an additional 2-4 weeks and resolution of all symptoms
- Alternative regimen: Foscarnet 60 mg / kg IV q 8-12 h for 7 d followed by 90-120mg / kg daily until day 100 after HSCT OR Cidofovir IV
- Anti Pneumocystis prophylaxis
- Duration of prophylaxis:
- Allogenic stem cell recipients: for at least 6 months and while receving immunosuppresive therapy
- Acute lymphocytic leukemia: throughout anti-leukemic therapy
- Alemtuzumab therapy: for a minimum of 2 months after Alemtuzumab and until CD4 count > 200 cells/mcL
- Preferred regimen: TMP/SMZ
- Alternative regimen (if TMP-SMZ intolerant): Atovaquone OR Dapsone OR Pentamidine aersolized or IV
- HBV prophylaxis
- Allogenic stem cell transplant, Anti CD20 or Anti CD52 monoclonal antibodies
- Therapy considerations
- ID consult to determine possible antiviral prophylaxis, consider delayed transplant if active infection
- Antiviral therapy
- Preferred regimen (1): Entecavir0.5 mg PO q24h ( nucleoside- treatment- naive with compensated liver disease) or 1 mg PO 24 h ( lamivudine - refractory or known Lamivudine or telbivudine resistance mutation or decompensated liver disease
- Preferred regimen (2): Tenofovir300 mg PO q 24 h
- Preferred regimen (3): Lamivudine 100mg PO q 24 h
- Preferred regimen (4): Adefovir 10mg PO q 24 h
- Preferred regimen (5): Telbivudine60 mg PO q 24 h
- Surveillance
- At least 6-12 months following conclusion of treatment
- Prophylaxis in HIV
- Chemotherapy, targeted therapies
- Therapy considerations
- ID consult to adjust dosing and regimen for concurrent treatment
- Antiviral therapy
- Preferred regimen: antiretroviral therapy
- Surveillance
- Monthly during therapy then as clinically indicated

# Neutropenic fever, treatment

# Salmonella bacteremia
- 1. Salmonella bacteremia treatment
- Preferred regimen: Ciprofloxacin 400 mg IV q12h AND Ceftriaxone 1 to 2 g IV q12-24h
- 2.When the salmonellae are known to be susceptible
- Preferred regimen: Ampicillin 1 to 2 g IV  q4-6h
- Preferred regimen: Trimethoprim-sulfamethoxazole 8 mg/kg/day PO

# Clostridial toxic shock syndrome
- Clostridium sordelli toxic shock syndrome 
- Preferred regimen (1): Ampicillin 250-500 mg IV/IM  q4-8h
- Preferred regimen (2): Amoxicillin-clavulanate 250-500 mg PO bid/tid
- Preferred regimen (3): Piperacillin-tazobactam 4.5 g IV q8h
- Preferred regimen (4): Ticarcillin 3.1 g IV q8h
- Preferred regimen (5): Clindamycin 600 to 900 mg IV q8h
- Preferred regimen (6): Vancomycin 15 to 20 mg/kg IV q8-12h, not to exceed 2 g per dose
- Preferred regimen (7): Imipenem 500 mg IV q6h
- Preferred regimen (8): Linezolid 600 mg IV/PO q12h
- Preferred regimen (9): Metronidazole 30 mg/kg/24 hr PO/IV q6h  (maximum dose: 4 g/24 hr)
- Note (1): Clostridium sordellii is a cause of toxic shock syndrome (CSTS) associated with gynecologic procedures, childbirth, and abortion (including spontaneous, surgical, and medical abortion). Gastrointestinal and vaginal colonization of Clostridium sordellii can occur in healthy individuals.
- Note (2): Treatment of Clostridium sordellii toxic shock syndrome consists of antibiotic therapy, surgical debridement, and aggressive resuscitation

# Staphylococcal toxic shock syndrome
- Staphylococcal toxic shock syndrome 
- 1. Methicillin sensitive Staphylococcus aureus
- Preferred regimen (1): Cloxacillin  250-500 mg PO qid (maximum dose: 4 g/24 hr)
- Preferred regimen (2): Nafcillin  4-12 g/24 hr IV q4-6hr (maximum dose: 12 g/24 hr)
- Preferred regimen (3): Cefazolin 0.5-2g IV/IM q8h (maximum dose: 12 g/24 hr), AND Clindamycin 150-600 mg IV/IM/PO q6-8h (maximum dose: 5 g/24 hr IV/IM or 2 g/24 hr PO)
- Alternative regimen (1): Clarithromycin 250-500 mg PO q12h (maximum dose: 1 g/24 hr) AND Clindamycin 150-600 mg  IV/IM/PO q6-8h (maximum dose: 5 g/24 hr IV/IM or 2 g/24 hr PO)
- Alternative regimen (1): Rifampicin, AND Linezolid 600 mg  IV/PO q12hr
- Alternative regimen (2): Daptomycin
- Alternative regimen (3): Tigecycline 100 mg IV loading dose followed by 50 mg q12h
- 2. Methicillin resistant Staphylococcus  aureus
- Preferred regimen: Clindamycin 150-600 mg q6-8h IV/IM/PO (max dose: 5 g/24 hr IV or IM or 2 g/24 hr PO)
- Preferred regimen: Linezolid 600 mg IV/PO q12h AND (Vancomycin 15 to 20 mg/kg IV q8-12h, not to exceed 2 g per dose or Teicoplanin)
- Alternative regimen (1): Rifampicin AND Linezolid 600 mg IV/PO q12h
- Alternative regimen (2): Daptomycin
- Alternative regimen (3): Tigecycline 100 mg loading dose followed by 50 mg IV q12h
- 3. Glycopeptide resistant or intermediate Staphylococcus aureus
- Preferred regimen: Linezolid 600 mg IV/PO q12h AND Clindamycin 150-600 mg IM/IV/PO q6-8h (maximum dose: 5 g/24 hr IV/IM or 2 g/24 hr PO) (if sensitive)
- Alternative regimen: Daptomycin OR Tigecycline 100 mg loading dose followed by 50 mg  IV q12h

# Streptococcal toxic shock syndrome
- Streptococcal toxic shock syndrome 
- 1. Group A streptococcus
- Preferred regimen: Penicillin G, 24 MU IV q46h AND Clindamycin 600900 mg q8h IV, (maximum dose: 5 g/24 hr IV/IM or 2 g/24 hr PO)
- Alternative regimen (1): (Macrolide Azithromycin 500 mg PO day 1 followed by 250 mg for 4 days
- Alternative regimen (2): Fluoroquinolone Oxacillin 2-12 g/24 hr divided q4-6h IV (maximum dose: 12 g/24 hr)), AND Clindamycin 150-600 mg q6-8h IV, IM, or PO (max dose: 5 g/24 hr IV/IM or 2 g/24 hr PO)
- Alternative regimen (3): Linezolid 600 mg IV/PO q12h
- Alternative regimen (4): Daptomycin OR Tigecycline 100 mg loading dose followed by 50 mg q12h IV
- Note: Macrolide and Fluoroquinolone resistance increasing
- 2. Macrolide, lincosamide, and streptogramin B (MLS) resistant group A streptococcus
- Preferred regimen: Penicillin G 2-24 MU/24h IV/IM  q4-6h  AND (Vancomycin 15 to 20 mg/kg IV q8-12h, not to exceed 2 g/dose OR Teicoplanin)
- Alternative regimen (1): Vancomycin 15 to 20 mg/kg IV q8-12h, not to exceed 2 g/dose OR Teicoplanin
- Alternative regimen (2): Linezolid 600 mg IV/PO q12h
- Alternative regimen (3): Daptomycin
- Alternative regimen (4): Tigecycline 100 mg IV loading dose followed by 50 mg q12h
- Alternative regimen (5): Teicoplanin
- Note: Macrolide resistance associated with Clindamycin resistance

# Typhus, louse-borne
- Louse born typhus, Rickettsia prowazekii (epidemic typhus, sylvatic typhus and  BrillZinsser typhus 
- Pathogen-directed antimicrobial therapy
- In adults
- Preferred regimen (1): Doxycycline 200 mg PO for 5 days or 2-3 days after defervescence
- Preferred regimen (2): Doxycycline 100-200 mg PO single dose in outbreak situation
- Alternative regimen: Chloramphenicol 60 to 75 mg/kg/day PO in four divided doses
- In childern
- Preferred regimen (1): Doxycycline 100-200 mg PO single dose
- In pregnant women
- Preferred regimen: Doxycycline 100-200 mg PO single dose

# Typhus, murine
- Murine typhus,Rickettsia typhi (flea-borne infection) 
- Pathogen-directed antimicrobial therapy
- 1. Adults
- Preferred regimen : Doxycycline 100 mg PO bid continued for 3 days after the symptoms have resolved, Doxycycline 100-200 mg, PO single dose
- Alternative regimen (1): Oxacillin 2-12 g/24 hr  IV q4-6h IV (maximum dose: 12 g/24)
- Alternative regimen (2): Chloramphenicol 60 to 75 mg/kg/day PO in qid
- 2. Childern
- Preferred regimen: Doxycycline 100-200 mg, PO for 3-7 days
- Alternative regimen: Chloramphenicol 50-75 mg/kg/24 hr IV/PO q 6-8 hr
- 3. Pregnant women
- Preferred regimen: Doxycycline 100-200 mg, PO single dose ( late trimester)
- Alternative regimen (1): Erythromycin Base: 333 mg PO tid or estolate/stearate/ base: 250-500 mg PO qid
- Alternative regimen (2): Chloramphenicol 50 mg/kg/24 hr IV/PO  q6h (maximum dose: 4 g/24 hr) (early trimester: first and second trimesters)

# Typhus, scrub
- Scrub typhus,  Orientia tsutsugamushi (previously called Rickettsia tsutsugamushi- mite-borne infectious disease) 
- Pathogen-directed antimicrobial therapy
- Preferred regimen (1): Doxycycline 100 mg PO/IV q12h for 3 days
- Preferred regimen (2): Chloramphenicol 500 mg PO/IV q6h
- Alternative regimen: Azithromycin 500 mg PO day 1 followed by 250 mg for 4 days

# Anaplasmosis
- Human granulocytic anaplasmosis, suspected or symptomatic 
- Preferred regimen: Doxycycline 100 mg PO bid (or IV for those patients unable to take an oral medication) for 10 days
- Alternative regimen: Rifampin 300 mg PO bid for 710 days (For patients with mild illness due to HGA who are not optimally suited for doxycycline treatment because of a history of drug allergy, pregnancy, or age <8 years)
- Pediatric regimen:
- Children  8 years of age
- Preferred regimen: Doxycycline 4 mg/kg/day PO bid (Maximum, 100 mg/dose) (or IV for children unable to take an oral medication) for 10 days
- Children < 8 years of age
- Preferred regimen: Rifampin 10 mg/kg bid (Maximum, 300 mg/dose) for 4-5 days
- Note (1): If the patient has concomitant Lyme disease, then Amoxicillin 50 mg/kg/day in 3 divided doses (maximum of 500 mg per dose) OR Cefuroxime axetil 30 mg/kg per day in 2 divided doses (maximum of 500 mg per dose) should be initiated at the conclusion of the course of Doxycycline to complete a 14-day total course of antibiotic therapy
- Note (2): Rifampin is not effective therapy for Lyme disease, patients coinfected with B. burgdorferi should also be treated with Amoxicillin OR Cefuroxime axetil

# Brucellosis
- 1. Uncomplicated brucellosis in adults 
- Preferred regimen (1): (Streptomycin 1 g IM q24h for the first 2-3 weeks of therapy OR Gentamicin 5 mg/kg/day IV/IM for 7-10 days) AND Doxycycline 100 mg PO bid for six weeks
- Preferred regimen (2): (Streptomycin 1 g IM q24h for the first 2-3 weeks of therapy OR Gentamicin 5 mg/kg/day IV/IM for 7-10 days) AND Tetracycline 500 mg PO qid  for at least six weeks
- Alternative regimen (1): Doxycycline 200 mg/day PO for 6 weeks AND Rifampicin 600900 mg/day PO for six weeks
- Alternative regimen (2): Fluoroquinolones
- Note (1): Quinolones should always be used in combination with other drugs, such as Doxycycline or Rifampicin
- Alternative regimen (3): TMP/SMZ 80 mg TMP/400 mg SMZ (in a fixed ratio of 1:5)
- Note (2): TMP/SMZ should always be used in combination with another agent, such as Doxycycline, Rifampicin or Streptomycin
- 2. Complications of brucellosis
- 2.1 Spondylitis
- Continuation of Doxycycline for eight weeks or more; Surgical drainage is rarely necessary.
- 2.2 Neurobrucellosis
- Rifampicin OR Trimethoprim/sulfamethoxazole, be added to the standard regimen of Doxycycline and Streptomycin for 6-8 weeks, and possibly longer, depending on the clinical response
- 2.3 Brucella endocarditis
- Preferred regimen: Doxycycline AND an Aminoglycoside for at least eight weeks
- Note: Therapy should be continued for several weeks after surgery when valve replacement is necessary
- 3.  For children
- 3.1 less than eight years of age
- Preferred regimen: TMP/SMZ 8/40 mg/ kg/day PO bid for 6 weeks AND (Streptomycin 30 mg/kg/day IM q24h for 3 weeks OR Gentamicin 5 mg/kg/day IV/IM q24h for 7-10 days)
- Alternative regimen (1): TMP/SMZ AND Rifampicin 15 mg/kg/day PO each administered for 6 weeks
- Alternative regimen (2): Rifampicin AND an Aminoglycoside
- 3.2 eight years of age and older
- See adult treatment

# Ehrlichiosis
- Ehrlichiosis, suspected
- Preferred regimen: Doxycycline 100 mg IV q12h for 7-14 days
- Alternative regimen (1): Chloramphenicol
- Alternative regimen (2): Rifampin
- Pediatric regimen: Doxycycline 2.2 mg/kg PO bid (Children under 45 kg (100 lbs)) for 7-14 days
- Note: Patients should be treated for at least 3 days after the fever subsides and until there is evidence of clinical improvement

# Tularemia
- For treatment and prophylaxis 
- Preferred regimen: Gentamicin 5 mg/kg/day PO bid
- Alternative regimen (1): Streptomycin 2 g/day IM q12h for 10 days
- Alternative regimen (2): Ciprofloxacin 8001000 mg/day IV/PO q12h/bid for 1014 days
- Alternative regimen (3): Doxycycline 200 mg/day PO bid for at least 15 days
- Pediatric regimen: Gentamicin 56 mg/kg/day q8-12h for at least 10 days; Streptomycin 15 mg/kg PO bid (Maximum, 2 g/day) for at least 10 days; Ciprofloxacin 15 mg/kg PO bid (Maximum, 1 g/day) for at least 10 days

# Typhoid fever
- 1. Uncomplicated typhoid fever
- 1.1 Fully sensitive
- Preferred regimen (1): Ofloxacin 15 mg/kg/day for 5-7 days
- Preferred regimen (2): Ciprofloxacin 15 mg/kg/day for 5-7 days
- Alternative regimen (1): Chloramphenicol 50-75 mg/kg/day for 14-21 days
- Alternative regimen (2): Amoxicillin 75-100 mg/kg/day for 14 days
- Alternative regimen (3): TMP-SMX  8-40 mg/kg/day for 14 days
- 1.2 Multidrug resistance
- Preferred regimen (1): Fluoroquinolone 15 mg/kg/day for 5-7 days
- Preferred regimen (2): Cefixime 15-20 mg/kg/day for 7-14 days
- Alternative regimen (1): Azithromycin 8-10 mg/kg/day for 7 days
- Alternative regimen (2): Cefixime 15-20 mg/kg/day for 7-14 days
- 1.3 Quinolone resistance
- Preferred regimen (1): Azithromycin 8-10 mg/kg/day for 7 days
- Preferred regimen (2): Ceftriaxone 75 mg/kg/day for 10-14 days
- Alternative regimen: Cefixime 20 mg/kg/day for 7-14 days
- 2. Severe typhoid fever
- 2.1 Fully sensitive
- Preferred regimen: Ofloxacin 15 mg/kg/day for 10-14 days
- Alternative regimen (1): Chloramphenicol 100 mg/kg/day for 14-21 days
- Alternative regimen (2): Amoxicillin 100 mg/kg/day for 14 days
- Alternative regimen (3): TMP-SMX  8-40 mg/kg/day for 14 days
- 2.2 Multidrug resistant
- Preferred regimen: Fluoroquinolone 15 mg/kg/day for 10-14 days
- Alternative regimen (1): Ceftriaxone 60 mg/kg/day for 10-14 days
- Alternative regimen (2): Cefotaxime 80 mg/kg/day for 10-14 days
- 2.3 Quinolone resistant
- Preferred regimen (1): Ceftriaxone 60 mg/kg/day for 10-14 days
- Preferred regimen (2): Cefotaxime 80 mg/kg/day for 10-14 days
- Alternative regimen: Fluoroquinolone 20 mg/kg/day for 7-14 days

# Kawasaki syndrome
- 1. Initial treatment 
- Preferred regimen: IVIG 2 g/kg single infusion within the first 7-10 days of illness AND Aspirin 80-100 mg/kg/day qid , reduce the aspirin dose after the child has been afebrile for 48 to 72 hours, then begin low-dose aspirin (3 to 5 mg/kg/day) and maintain it until the patient shows no evidence of coronary changes by 6 to 8 weeks after the onset of illness
- Note (1): Other clinicians continue highdose aspirin until day 14 of illness and 48 to 72 hours after fever cessation
- Note (2): For children who develop coronary abnormalities, aspirin may be continued indefinitely
- 2. Treatment of Patients Who Failed to Respond to Initial Therapy (persistent or recrudescent fever  36 hours after completion of the initial IVIG infusion)
- Preferred regimen: IVIG 2 g/kg q24h for 1-3 days OR Methylprednisolone 30 mg/kg IV for 2-3 hours q24h for 1-3 days

# Leptospirosis
- 1. Severe 
- High doses of Penicillin IV
- 2. Less severe
- Preferred regimen: Amoxycillin OR Ampicillin OR Doxycycline OR Erythromycin
- Alternative regimen: Ceftriaxone OR Cefotaxime OR Quinolone
- Note (1): Treatment with effective antibiotics should be initiated as soon as the diagnosis of leptospirosis is suspected and preferably before the fifth day after the onset of illness
- Note (2): Clinicians should never wait for the results of laboratory tests before starting treatment with antibiotics because serological tests do not become positive until about a week after the onset of illness, and cultures may not become positive for several weeks.

# Rocky Mountain spotted fever
- R. rickettsii
- Preferred regimen: Doxycycline 100 mg q12h
- Alternative regimen: Chloramphenicol
- Pediatric regimen: Doxycycline 2.2 mg/kg PO bid (under 45 kg (100 lbs))
- Note: Patients should be treated for at least 3 days after the fever subsides and until there is evidence of clinical improvement; Standard duration of treatment is 7-14 days.

# Relapsing fever
- 1. Tick-Borne Relapsing Fever 
- Preferred regimen: Doxycycline 100 mg PO bid for 5-10 days
- Alternative regimen: Erythromycin 500 mg PO qid for 5-10 days
- Note: If meningitis/encephalitis present, use Ceftriaxone 2 g IV q12h for 14 days
- 2. Louse-Borne Relapsing Fever
- Preferred regimen: Tetracycline 500 mg PO single dose
- Alternative regimen: Erythromycin 500 mg PO single dose

# Tetanus
- 1. General measures
- Patients should be placed in a quiet shaded area and protected from tactile and auditory stimulation as much as possible; All wounds should be cleaned and debrided as indicated
- 2. Antitoxin and other immunotherapy
- Preferred regimen: Human TIG 500 U IM/IV as soon as possible AND Age-appropriate TT-containing vaccine, 0.5 cc IM at a separate site
- Note: patients without a history of primary TT vaccination should receive a second dose 12 months after the first dose and a third dose 612 months later
- 3. Antibiotic treatment
- Preferred regimen (1): Metronidazole 500 mg PO/IV qid/q6h
- Preferred regimen (2): Penicillin G 100,000200,000 IU/kg/day IV q6-12h
- Alternative regimen (1): Tetracyclines
- Alternative regimen (2): Macrolides
- Alternative regimen (3): Clindamycin
- Alternative regimen (4): Cephalosporins
- Alternative regimen (5): Chloramphenicol
- 4. Muscle spasm control
- Preferred regimen: Diazepam 5 mg IV OR Lorazepam 2 mg
- Note: Lorazepam should be titrated to achieve spasm control without excessive sedation and hypoventilation
- Alternative regimen (1): Magnesium sulphate 5 gm (or 75mg/kg) IV THEN 23 gm/hr until spasm control is achieved  Benzodiazepines
- Note: Monitor patellar reflex as areflexia (absence of patellar reflex) occurs at the upper end of the therapeutic range (4mmol/L). If areflexia develops, dose should be decreased
- Alternative regimen (2): Baclofen OR Dantrolene 12 mg/kg IV/PO q4h
- Alternative regimen (3): Barbiturates 100150 mg q1-4h
- Alternative regimen (4): Chlorpromazine 50150 mg IM q48h
- Pediatric regimen: Lorazepam 0.10.2 mg/kg q26h, titrating upward as needed; Barbiturates 610 mg/kg by any route; Chlorpromazine 412 mg IM q48h
- Note: As for Benzodiazepines, large amounts may be required (up to 600 mg/day); Oral preparations could be used but must be accompanied by careful monitoring to avoid respiratory depression or arrest
- 5. Autonomic dysfunction control
- Preferred regimen: Magnesium sulphate OR Morphine OR Esmolol

# Lymphadenitis
- Lymphadenitis
- Pathogen-directed antimicrobial therapy
- 1. Nocardia
- Preferred regimen: TMP-SMX 510 mg/kg/day (TMP component) IV/PO q6-12h for 3 months
- Alternative regimen (1): Sulfisoxazole 2 g PO qid for 3 months
- Alternative regimen (2): Minocycline 100-200 mg PO bid for 3 months
- 2. Bartonella henselae (cat-scratch disease)
- Preferred regimen (adult): Azithromycin 500 mg PO single dose THEN 250 mg/day for 4 days
- Preferred regimen (pediatric): Azithromycin 10 mg/kg PO single dose THEN 5 mg/kg/day for 4 days

# Sepsis, adult
- 1. Sepsis, adult
- 1.1 Empiric antimicrobial therapy
- 1.1.1 History of intravenous drug use with high prevalence of MRSA
- Perferred regimen: Vancomycin 1 g IV q12h
- 1.1.2 Sepsis associated with petechiae
- Perferred regimen: Ceftriaxone 2 g IV q12h
- 1.1.3 Biliary source
- Perferred regimen (1): Ampicillin-Sulbactam 3 g IV q6h
- Perferred regimen (2): Piperacillin-Tazobactam 3.375 g IV q4h
- Perferred regimen (3): Ticarcillin-Clavulanate 3.1 g IV q4h
- 1.1.4 Community-acquired pneumonia
- Perferred regimen: (Levofloxacin 750 mg IV q24h OR Moxifloxacin 400 mg IV q24h) AND Piperacillin-Tazobactam 3.375 g IV q4h AND Vancomycin 1 g IV q12h
- 1.1.5 Unclear infection source
- Perferred regimen: (Doripenem 500 mg IV q8h OR Ertapenem 1 g IV q24h OR Imipenem 0.5 g IV q6h OR Meropenem 1 g IV q8h) AND Vancomycin 1 g IV q12h
- 1.1.6 Low prevalence of ESBL and/or carbapenemase-producing aerobic GNB
- Perferred regimen: Piperacillin-Tazobactam 3.375 g IV q4h AND Vancomycin 1 g IV q12h
- 1.1.7 High prevalence of ESBL and/or carbapenemase-producing aerobic GNB
- Perferred regimen: Colistin 2.5 mg/kg single dose followed by 1.5 mg/kg IV q12h AND  Meropenem 1 g IV q8h AND Vancomycin 1 g IV q12h

# Sepsis, pediatric
- 1. Sepsis, pediatric
- 1.1 Empiric antimicrobial therapy
- 1.1.1 Children aged > 1 month
- Preferred regimen: (Cefotaxime 50 mg/kg IV q8h OR Ceftriaxone 100 mg/kg IV q24h) AND Vancomycin 15 mg/kg IV q6h
- Alternative regimen: Aztreonam 7.5 mg/kg IV q6h AND Linezolid 10 mg/kg IV q8h
- 1.1.2 Children aged < 1 month
- Preferred regimen: Ampicillin 25 mg/kg IV q8h AND Cefotaxime 50 mg/kg q12h  Vancomycin 15 mg/kg IV q12h (if suspecting MRSA)
- Alternative regimen: Ampicillin 25 mg/kg IV q6h AND Ceftriaxone 75 mg/kg IV q24h  Vancomycin 15 mg/kg IV q12h (if suspecting MRSA)